根治性膀胱切除术相关手术编码案例分析

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英文篇名：Case Analysis of the Coding of Surgical Procedures Related to Radical Cystectomy 作者：何玥 ; 金敏 ; 张静 ; 杨洋 ; 曾芳 ; 童时宇 ; 王珍 英文作者：He Yue;Jin Min;Zhang Jing;Yang Yang;Zeng Fang;Tong Shiyu;Wang Zhen;Department of Medical Record Management and Information Statistics,Xiangya Hospital of Central South University; 关键词：膀胱根治性切除术 ; 尿流改道 ; 回肠代膀胱术 ; 手术编码 英文关键词：Radical cystectomy;;Urinary diversion;;Ileum bladder operation;;Operation coding 中文刊名：ZGBN 英文刊名：Chinese Medical Record 机构：中南大学湘雅医院病案管理与信息统计科;中南大学湘雅医院泌尿肿瘤专科; 出版日期：2019-01-18 出版单位：中国病案 年：2019 期：v.20 基金：中南大学湘雅医院医院管理研究基金项目(2017GL01) 语种：中文; 页：ZGBN201901008 页数：4 CN：01 ISSN：11-4998/R 分类号：22-25

摘要

根治性膀胱切除术是肌层浸润性膀胱癌患者的标准治疗方法,目前常见的术式包括膀胱重建术和不可控尿流改道方案(包括输尿管腹壁造口术和回肠代膀胱术)。本文通过回顾4例膀胱恶性肿瘤患者的病案,针对3种根治性膀胱切除术的不同术式及手术步骤介绍如何按照ICD-9-CM-3原则进行手术编码,手术编码的区别以及需要注意的编码提示,强调术式和性别对手术编码的重要性。要求编码员认真阅读手术记录,及时补充新的医疗知识,与时俱进,同时和临床医师保持沟通。
        Radical cystectomy is the standard treatment for patients with muscle-invasive bladder cancer.Currently, common surgical procedures include bladder reconstruction and uncontrollable urinary diversion(including ureteroabdominal wall ostomy and ileal bladder replacement). In this paper, by reviewing the medical records of 4 patients with bladder malignancy, and aiming at the different surgical methods and procedures of 3 kinds of radical cystectomy, the author introduces how to carry out the surgical coding and the difference of surgical coding according to the principle of icd-9-cm-3, as well as the coding tips that should be paid attention to, and emphasizes the importance of surgical methods and gender for the surgical coding. The coder is required to read the surgical records carefully, timely supplement new medical knowledge, keep abreast of The Times, and maintain communication with the clinician.

引文

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