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目的探讨手术编码中有关恶性肿瘤根治术的一些具体查找方法和编码原则。方法掌握根治术的查找方法,以“切除术”为主导词查找,按切除中某个部位查到相应的编码,再按照手术的具体范围,查找相关的附加编码。结果恶性肿瘤根治术是不定型的根治性手术,在ICD-9-CM-3的索引中,仅有少量根治术可以通过“切除术—部位—根治术”方法直接查到,绝大部分恶性肿瘤要根据手术的部位、术式、方法、性质来确定正确的编码。结论编码员即要熟练掌握手术操作原则,还要了解各类手术的轴心分类,仔细阅读手术记录,经常与临床医师沟通,并要求规范化书写手术记录和名称,力求分类编码准确,以满足医疗统计和检索的需求。
Objective To explore some specific search methods and coding principles of radical resection of malignant tumors in surgical coding. Methods To find out the way to find out the radical operation, search with the dominant word “resection ”, find the corresponding code according to the part of the resection, and then search the relevant additional codes according to the specific scope of the operation. Results Radical resection of malignant tumor was an unspecified radical surgery. In the index of ICD-9-CM-3, only a small amount of radical resection can be directly detected by the method of “resection-site-radical operation” Some malignant tumors according to the surgical site, surgical procedures, methods to determine the correct encoding. Conclusion The coder should master the principle of operation, but also understand the axial classification of various types of surgery, read the surgical records carefully, often communicate with clinicians, and require standardized written records of surgery and name, and strive to classification coding accurate to meet the medical Statistics and retrieval needs.