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目的通过回顾性分析探讨腰椎间盘突出症手术操作分类的编码。方法利用《国际疾病分类第九次临床修订本手术与操作》(ICD-9-CM-3)和《广东省医院统计病案管理系统》手术编码字典库,从手术操作的术式和路径及所用器械或材料的不同给予ICD-9-CM-3编码。结果手术操作术式和路径及所用器械或材料不同,手术操作分类的编码亦不同。结论编码员必须认真阅读病案及手术记录,熟悉手术术式和路径,才能保证手术操作分类编码的准确性。
Objective To investigate the classification of surgical procedures of lumbar disc herniation by retrospective analysis. Methods Using the ICD-9-CM-3 Surgical and Operational Dictionary of Guangdong Province Hospital Statistical Medical Records Management System, The difference in device or material is given ICD-9-CM-3 encoding. The results of surgical procedures and the path of operation and the use of different instruments or materials, surgical classification codes are also different. Conclusion The coder must carefully read the medical records and surgical records, be familiar with the surgical procedures and paths, in order to ensure the accuracy of the classification of surgical operations coding.