标题：阑尾低级别黏液性肿瘤 ICD-10编码探究

      作者：严惠莲，廖定轲，王洁容，王永杰，赵雁梨    中山大学肿瘤防治中心病案统计科，广东 广州 510060

      卷次： 2024年35卷3期

      【摘要】 目的 分析我院阑尾低级别黏液性肿瘤 ICD-10编码现状及问题，以期提高交界性肿瘤编码的准确率以及医院按病种分值付费(DIP)的入组率。方法 从病案信息系统调取2018—2022年主要诊断编码为阑尾低级别黏液性肿瘤的首次住院病案，获得病案共263份，对疾病编码进行逐一核查。结果 263份低级别黏液性肿瘤病案中，形态码编码正确153份，形态码编码正确率为58.17%；无转移的病案共91份，形态码编码正确82份，正确率为90.11%；有转移的病案共172份，形态码编码正确71份，正确率为41.28%。结论 阑尾低级别黏液性肿瘤的形态学编码正确率偏低，对DIP的入组造成一定影响。编码人员应加强 IDC-10编码和相关医学知识的学习，不断提高编码人员的专业技术水平和综合素质，从而提高病案形态学编码的正确率和DIP的入组率。
      【关键词】 阑尾；低级别黏液性肿瘤；ICD-10编码；按病种分值付费
      【中图分类号】 R739.93 【文献标识码】 A 【文章编号】 1003—6350（2024）03—0403—04

Study on ICD-10 coding of low-grade appendiceal mucinous neoplasms.
YAN Hui-lian, LIAO Ding-ke, WANGJie-rong, WANG Yong-jie, ZHAO Yan-li. Department of Medical Record Statistics, Sun Yat-sen University Affiliated CancerHospital, Guangzhou 510060, Guangdong, CHINA
【Abstract】 Objective To study the present situation and problems of ICD-10 coding for low-grade appendi-ceal mucinous neoplasms in Sun Yat-sen University Affiliated Cancer Hospital, so as to improve the accuracy of codingfor borderline tumors and the admission rate of DIP in hospitals. Methods From 2018 to 2022, the first hospitalizationmedical records with the main diagnosis code of low-grade appendiceal mucinous neoplasms were retrieved from themedical record information system, and 263 medical records were obtained. The medical record codes were checked oneby one. Results Among the 263 medical records, 153 cases were correctly coded with morphological code (with cor-rect rate of 58.17%); there were 91 medical records without metastasis, 82 of which were correctly coded with morpho-logical code (accounting for 90.11%); there were 172 medical records with metastasis, 71 of which were correctly coded(41.28%). Conclusion The correct rate of morphological code of low-grade appendiceal mucinous neoplasms is low,which has some influence on the inclusion of DIP. Coders should strengthen the study of IDC-10 coding and relatedmedical knowledge, and constantly improve the professional technical level and comprehensive quality of coders, so asto improve the correct rate of medical record morphological coding and the enrollment rate of DIP.
      【Key words】 Appendices; Low-grade mucinous neoplasms; ICD-10 coding; Diagnosis intervention packet