Firstly, the development environment application of the national medical security disease diagnosis related grouping (chs-drg) is based on the settlement list data of the medical security fund, the medical security disease classification and code (ICD-10) and the medical security surgery and operation classification and code (icd-9-cm-3) of the national medical insurance version. In addition, in the process of DRG grouping, each case is diagnosed according to the discharge diagnosis (ICD-10) . the cases are grouped according to the relevant medical factors such as surgical operation (icd-9-cm-3), complications or complications, ventilator use time and age. The main operation and operation code is the core information directly used for DRG grouping and an important basis for distinguishing ADRG, as shown in the following figure:
Diagnosis intervention packet (DIP) is a combination of cases with similar disease diagnosis and similar clinical process. Taking the process of one-time treatment of the disease as the research unit, it uses the disease diagnosis (ICD-10) and treatment methods (conservative treatment and surgical operation icd-9-cm-3) in the whole sample data The basic data needed by dip includes the information of the disease coding system.
The name of surgery and operation in icd-9-cm-3 generally consists of (SCOPE) location, operation method, approach, disease nature and other elements. Each component of the name of surgical operation may affect the integrity and accuracy of coding, and coding errors will occur if you don't pay attention to it. Let's see the impact of the above elements on coding in actual filling through practical cases:
（1） The influence of anatomical site contrast coding
As the core component of surgical terminology, it must be clearly pointed out, otherwise it will be difficult to classify or will be generally classified.
Example: resection of lung cancer
Analysis: This is a typical inappropriate operation name. It does not specify the scope of resection or the operation method. It can be divided into total pneumonectomy, lobectomy or pulmonary lesion resection. The code is as follows:
Pneumonectomy 32.29 -- open, 32.2003 - thoracoscopic
Segmental pneumonectomy 32.39 -- open, 32.30 -- thoracoscopic
Lobectomy 32.49-open, 32.41-thoracoscopic
Total pneumonectomy with mediastinal lymph node dissection 32.59-open, 32.50-thoracoscopic
The correct code of icd-9-cm-3 can be correctly determined only after the surgical site and operation method are clear. (special note: in the classification of surgical operation, the left and right parts of the same organ are classified the same. In addition, when the indicated parts are too detailed and the specific part is not listed in the icd-9-cm-3 index, the amplification method similar to the classification of diseases can be used.)
（2） The effect of surgical operation on coding
Surgical operation is also the core component of the name of surgery. It is more important than the part. Without operation, it can not be classified at all. Operation is also an element that doctors can't forget to write, but it is also an element that often causes problems and can't be correctly expressed. Different operation methods have different degrees of difficulty, which directly affects the grouping of DRG / dip.
Example 1: eyelid repair
Suture of palpebral margin 085200
Eyelid reconstruction involving meibomian layer 08.7100
Eyelid reconstruction involving full thickness of palpebral margin 08.7300
Analysis: repair is often an unclear operation. It not only has suture, but also repair. Therefore, the repair of eyelid must distinguish between simple suture, repair and reconstruction. In particular, it is pointed out that reconstruction should distinguish between eyelid margin, lamellar layer or full layer.
（3） Effect of surgical approach on coding
Generally, the approach of surgical operation does not need to be pointed out, but it is required in a few cases.
Example 2: cervical fusion includes anterior approach, posterior approach, anterolateral approach and posterolateral approach
Anterior cervical fusion 81.0200 × 001
Posterior cervical fusion 81.0300 × 001
Anterolateral cervical fusion 81.0200 × 002
Posterior lateral cervical fusion 81.0300x002
（4） Influence of disease nature on codingMore recommended