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目的通过分析ICD-10中含有.9的残余类目编码的使用情况,寻找减少残余类目误用的方法,提高编码准确性。方法对某院2015年10-11月出院的6000份病案主要诊断进行编码,对含有.9的残余类目编码进行汇总分析。结果 6000份病案中有2100(35%)份病案使用了残余类目,其中有420份(7%)残余类目编码使用不可避免,有1680份(28%)残余类目编码属于误用。结论残余类目.9编码在编码中的误用情况较为严重,编码员除了提高自身编码水平外,还应该建立与临床医师沟通机制,同时对临床医师进行疾病分类知识培训,通过多项举措的实施以减少残余类目.9的使用,提高疾病编码的准确性。?
OBJECTIVE To find out ways to reduce the misuse of residual categories and improve the coding accuracy by analyzing the usage of residual category codes containing .9 in ICD-10. Methods The main diagnosis of 6,000 cases of medical records discharged in a hospital from October to November in 2015 was coded and the residual category codes containing .9 were summarized and analyzed. As a result, 2,001 (35%) of the 6,000 medical records used remnant categories, of which 420 (7%) of them were inevitable and 1680 (28%) of them were misused. Conclusion Residual categories.9 miscoding is more serious in coding. In addition to improving their coding level, coders should also establish a communication mechanism with clinicians, train clinicians on disease classification knowledge, and adopt various measures Implemented to reduce the use of residual categories .9 to improve the accuracy of disease codes. ?