RESUMEN
Interventional therapy for hepatic malignant tumours primarily includes cardiovascular system surgery,diges-tive system surgery,and various diagnostic and therapeutic procedures.Referring to the"International Classification of Diseases,Ninth Edition,Clinical Modification,ICD-9-CM-3"(2011 revision),the relevant surgical procedure codes on the front page of the case are contained mainly in the 9th chapter for cardiovascular system surgery,the 11th chapter for digestive system surgery,and the 18th chapter for various diagnostic and therapeutic procedures and other related chapters on diagnostic and therapeutic procedures.It has become a challenge for the history coders to complete the first page of interventional surgery cases by reviewing the surgery records,extracting the surgical steps,and then identifying the appropriate surgery codes and their sequencing.Accord-ing to the current classification of interventional therapy for hepatic malignant tumors,it is suggested to conduct the search and re-trieval using the keywords like"arteriography""embolization""perfusion""implantation""destruction"and"ablation".
RESUMEN
In the case of intracranial hemorrhage,coders tend to ignore the cause of intracranial hemorrhage in the cod-ing,whether it is spontaneous intracranial hemorrhage or intracranial hemorrhage caused by trauma,and the coding of the two is completely different in ICD-10.The former is classified as I60-I62 while the latter is classified as S06.Different etiology will also enter different DRG groups when DRG is included.When determining the cause,the site of intracranial hemorrhage should be determined whether it is subarachnoid hemorrhage,or epidural/subdural hemorrhage or cerebral parenchymal hemorrhage,be-cause different bleeding sites have different codes in ICD-9-CM-3 when performing blood removal in cranial swelling.The classifi-cation of epidural hematoma removal was on 01.24,subdural or subarachnoid hematoma removal was on 01.31,and intracerebral parenchymal hematoma removal was on 01.39.The removal of intracranial hematoma is usually divided into cone craniotomy,skull trepanation and drainage and traditional craniotomy according to different operation methods.The operation process of these three operations is obviously different,and coders need to understand the characteristics of the three operations to achieve accurate classification.In the DRG grouping,the disease code is different from the surgical code and the DRG group will be different.Through understanding the definition and etiology of intracranial hematoma removal,the coding ideas of intracranial hematoma re-moval were analyzed,so as to improve the professional ability of coders and ensure the accuracy of DRG data.
RESUMEN
Objective To study the problems encountered in the coding of cataract surgeries. Methods Medical record statistical system was used to retrieve 213 such patients discharged from a hospital between January and June 2016. ICD-9-CM-3 coding principle was called into play to analyze the form completion and coding of major surgeries, along with errors found in them. Results Study of the 213 medical records identified 12 errors of surgery form completion from the surgeons′medical record homepages, accounting for 5. 6% of all. With reference to ICD-9-CM-3, 188 errors were found from the surgical coding made by encoders, accounting for 88. 3% of all. 10 copies were missing with surgery coding, accounting for 4. 7%. 13 coding errors were found in major surgical choices, accounting for 6. 1%. Conclusions Failure of the encoders in their command of coding rules for cataract surgery tops the rest as the main reason for the error of surgical coding. Encoders should make effective use of the ICD-9-CM-3 manual, and master both clinical knowledge, professional skill and coding ability.