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目的分析非霍奇金淋巴瘤C82-C85编码使用情况,提高C82-C85编码准确率。方法根据《疾病和有关健康问题的国际统计分类第十次修订本》分类原则,检索某医院以C82-C85为主要编码的病案。结果检索出的137份病案中50份病案首页编码错误,错误率36.50%,其中34份病案为病理分型错误,错误率24.82%;2份病案为病理转化前后错误,错误率1.46%;6份病案为肿瘤分类原则错误,错误率4.38%;8份病案为其他错误,主要是其他类型的恶性肿瘤归入恶性淋巴瘤中,错误率5.84%。结论 C82-C85编码的正确使用需要编码员在仔细阅读病案的基础上,加强与病理科医师的沟通,明确淋巴瘤病理分型,提高C82-C85疾病分类准确率。
Objective To analyze the coding of non-Hodgkin’s lymphoma C82-C85 and improve the accuracy of C82-C85 coding. Methods According to the principle of classification according to the “Tenth Revision of International Statistical Classification of Diseases and Related Health Problems”, a medical record with C82-C85 as the main code was searched in a hospital. Results Among the 137 medical records retrieved, 50 cases of the first page of medical records were coded incorrectly and the error rate was 36.50%. Among them, 34 cases were pathological typing errors with an error rate of 24.82%. Two cases were pathological transformation errors with an error rate of 1.46%. 6 Medical records for the classification of the principle of the wrong tumor, the error rate of 4.38%; 8 medical records for other errors, mainly classified as malignant lymphoma of other types of cancer, the error rate of 5.84%. Conclusions Correct use of C82-C85 code requires the coder to carefully communicate with the pathologist to clarify the pathological classification of lymphoma and improve the classification accuracy of the C82-C85 disease based on the careful reading of the medical record.