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目的规范输卵管系膜囊肿手术编码。方法采用输卵管系膜囊肿为检索词,通过病案统计管理系统检索出2007年7月-2015年3月188份病案,对其中94份行输卵管系膜囊肿手术的年份区间、手术名称、手术编码等进行统计分析。结果 2007年-2008年间输卵管系膜囊肿手术对应两个手术名称及编码,占20.21%,因编码员分类错误占6.38%。2009年-2014年间ICD-9-CM-3临床版字典库中取消输卵管系膜囊肿切除术和输卵管系膜囊肿剥除术及对应编码后,将输卵管系膜囊肿手术编码靠在输卵管病损切除术(或腹腔镜下输卵管病损切除术)和阔韧带病损切除术,分别占43.62%和17.02%。2015年1月-3月统一规范了输卵管系膜囊肿手术名称及编码,占5.32%。结论规范ICD-9-CM-3临床版字典库,提高编码人员的综合素质,规范临床医师手术名称,才能提高输卵管系膜囊肿手术编码质量。
Objective To standardize the surgical coding of tubal mesangial cysts. Methods Using tubal mesangial cysts as the search term, 188 medical records from July 2007 to March 2015 were retrieved through the medical records management system, and the year interval, operation name, surgical coding and so on of 94 cases of tubal mesangial cysts were analyzed. conduct statistical analysis. Results Between 2007 and 2008, tubal mesangial cyst surgery corresponded to two surgical names and codes, accounting for 20.21%, accounting for 6.38%. 2009-2014 year ICD-9-CM-3 clinical dictionary cancel tubal cyst excision and tubal cyst stripping and the corresponding coding, the tubal surgical coding of tubal lesions in the fallopian tube Surgery (or laparoscopic tubal lesion resection) and broad ligament lesion resection accounted for 43.62% and 17.02% respectively. From January to March 2015, the names and codes of tubal mesangial cysts were unified and standardized, accounting for 5.32%. Conclusion It is possible to improve the coding quality of the tubal mesangial cyst by standardizing the ICD-9-CM-3 clinical dictionary, improving the overall quality of the coders and regulating the clinician’s name.