ICD-10-CMPCS病歷書(shū)寫(xiě)相關(guān)注意事項(xiàng)及案例討論-臺(tái)中榮民總醫(yī)院

整型外科

ICD-10-CM/PCS教育訓(xùn)練病歷組103/07/042ICD-9-CM不能續(xù)用及面臨的問(wèn)題導(dǎo)入至今，醫(yī)療科技已有重大改變及進(jìn)步，無(wú)法正確反映當(dāng)今醫(yī)療技術(shù)和特材之差異，導(dǎo)致醫(yī)療服務(wù)得不到適當(dāng)?shù)慕o付。編碼結(jié)構(gòu)受到限制，無(wú)法因應(yīng)新增需求擴(kuò)編。無(wú)法與國(guó)際接軌，因各國(guó)大多已採(cǎi)用以ICD-10-CM為基礎(chǔ)發(fā)展臨床疾病分類。ICD-10-CM/PCS於臺(tái)中榮總之推展現(xiàn)況101年計(jì)畫(huà)案試行編碼骨科部、泌尿外科、心臟內(nèi)科、腸胃內(nèi)科、免疫風(fēng)濕科102年計(jì)畫(huà)案試行編碼胸腔內(nèi)科、胸腔外科、神經(jīng)內(nèi)科、神經(jīng)外科、新陳代謝科103年健保特約醫(yī)院ICD-10-CM/PCS編碼實(shí)作獎(jiǎng)勵(lì)方案50%出院病人以雙軌申報(bào)院內(nèi)常見(jiàn)診斷以I-9為基礎(chǔ)進(jìn)行1-10資訊化ICD-9-CM與ICD-10-CM之差異5ICD-10-CM/PCS診斷代碼數(shù)處置代碼數(shù)ICD-9-CM13,677ICD-10-CM70,000ICD-9-CM3,768ICD-10-PCS71,9245倍19倍Category類別

Etiology,anatomicsite,severity病因，解剖部位，嚴(yán)重度Extension擴(kuò)充碼XXX.XXXX第一個(gè)字元為英文字ICD-10-CM代碼結(jié)構(gòu)(診斷)UlcerunstageablestageⅠPressurepre-ulcerskinchangeslimitedtopersistentfocaledemastageⅡPressureulcerwithabrasion,blister,partialthicknessskinlossinvolvingepidermisand/ordermisstageⅢPressureulcerwithfullthicknessskinlossinvolvingdamageornecrosisofsubcutaneoustissuestageⅣPressureulcerwithnecrosisofsofttissuesthroughtounderlyingmuscle,tendon,orboneunspecifiedstage─limitedtobreakdownofskin─withfatlayerexposed─withnecrosisofmuscle─withnecrosisofbone─withunspecifiedseverityICD-10-PCS代碼結(jié)構(gòu)(處置)章節(jié)手術(shù)方式手術(shù)途徑修飾詞身體系統(tǒng)手術(shù)部位裝置物代碼由七碼構(gòu)成RootOperation在工具書(shū)都有明確的定義

整外常見(jiàn)手術(shù)方式Amputation病歷書(shū)寫(xiě)注意事項(xiàng)：Qualifier(Amputation

特殊修飾辭)的選取，目前ICD-10-PCS有其定義Amputation-Qualifier1/3BodyPartQualifierValueDefinitionUpperarmandupperleg0High:Amputationattheproximalportionoftheshaftofthehumerusorfemur高位：截肢在肱骨或股骨的骨幹近端部分1Mid:Amputationatthemiddleportionoftheshaftofthehumerusorfemur中位：截肢在肱骨或股骨的骨幹中間部分2Low:Amputationatthedistalportionoftheshaft低位：截肢在肱骨或股骨的骨幹遠(yuǎn)端部分11Amputation-Qualifier2/3BodyPartValueDefinitionThumb,finger,toe0Complete：Amputationatthemetacarpophalangeal/metatarsal-phalangealjoint完全：掌指骨/蹠趾骨關(guān)節(jié)的截肢1High：Amputationanywherealongtheproximalphalanx高位：沿著指骨近端的截肢2Mid：Amputationthroughtheproximal

interphalangealjointoranywherealongthemiddlephalanx中位：通過(guò)指間關(guān)節(jié)近端或沿著中段指骨的截肢3Low：Amputationthroughthedistal

interphalangeal

jointoranywherealongthedistalphalanx低位：通過(guò)指間關(guān)節(jié)遠(yuǎn)端或沿著遠(yuǎn)端指骨的截肢12Amputation-Qualifier3/3BodyPartQualifierValueDefinitionHandandfoot0Complete完全4Complete1stRay第一指完全5Complete2ndRay第二指完全6Complete3ndRay第三指完全7Complete4ndRay第四指完全8Complete5ndRay第五指完全9Partial1stRay第一指部分BPartial2ndRay第二指部分CPartial3ndRay第三指部分DPartial4ndRay第四指部分FPartial5ndRay第五指部分13AK&BKamputation後有案例討論1415ICD-10-CM/PCS

病歷書(shū)寫(xiě)注意事項(xiàng)及案例討論ICD-9-CMICD-10-CMFinger區(qū)分Metacarpophalangeal/TransphalangealComplete/Partial參考資料:http:///content/hand-anatomyFinger如何區(qū)分?Metacarpophalangeal/TransphalangealTransphalangealMetacarpophalangeal醫(yī)師回答：Metacarpophalangealjoints以下的指骨編碼在MetacarpophalangealAmputation如何區(qū)分Complete/Partial請(qǐng)問(wèn)Nearlytotalamputation屬於？S68.616CompletetraumatictransphalangealamputationofrightlittlefingerS68.626Partialtraumatictransphalangealamputationofrightlittlefinger醫(yī)師回答:Nearlytotal還有組織連接應(yīng)屬於partial部分與完全截肢,是以外傷處是否有軟組織相連？醫(yī)師回答:是Amputation如何區(qū)分Complete/PartialAbove-kneeamputation

Thefemurwasdividedwithanelectricsawatthelevelabout10cmfromtheupperborderofthepatella.疾病分類人員無(wú)法判斷Qualifier的選?。elow-kneeamputation

Maketwocircularincisionbelowthekneejoint10cm.疾病分類人員無(wú)法判斷Qualifier的選??！AK/Above-kneeHigh：proximalfemurMid：shaftfemurLow：distalfemurBK/Below-KneeHigh：proximaltibia/fibulaMid：shafttibia/fibulaLow：distaltibia/fibula建議BK/AK是否可比照以下書(shū)寫(xiě)方式？醫(yī)師回答:A-K通常在LowB-K通常在High手術(shù)建議書(shū)寫(xiě)方式：R’tAKamputation，distalfemur→0Y6C0Z3R’tBKamputation，proximaltibia/fibula→0Y6H0Z1

High：Theportionofthetib/fibclosesttothekneeDebridement※手術(shù)紀(jì)錄應(yīng)載明清創(chuàng)之深度及部位如：skin、muscle、subcutaneoustissueandfascia、tendon、nerve、bursaandligament、jointDeep的深度無(wú)法從procedure得知？若醫(yī)師沒(méi)有書(shū)寫(xiě)清楚可暫時(shí)由診斷來(lái)判定：Burn傷口通常是在skinPressuresore可能在bone或皮下骨髓炎通常會(huì)清到boneTRAMFlapReconstruction

前右側(cè)乳房全切除患者，入院移轉(zhuǎn)右側(cè)橫向腹直肌做為乳房重建術(shù)TRAMFlap(TransverseRectusAbdominis

Myocutaneous

flap)reconstruction由關(guān)鍵字TRAM(transverserectusabdominis

myocutaneous)flapreconstruction索引250KXK0Z6TRAMflap區(qū)分為Free或Pedicled，手術(shù)方式請(qǐng)幫忙書(shū)寫(xiě)為T(mén)RAMfreeflapTRAMpedicleflap醫(yī)師回答:本院大部分做的都是TRAMpedicleflapSTSG手術(shù)過(guò)程沒(méi)有提及有作STSG，是否有作？※若有作STSG、FTSG、Freeflap，Skingraft的取皮部位請(qǐng)載明donorsite！醫(yī)師回答：此為醫(yī)令帶入的關(guān)係並非有作！Revisionofscarcontracture＆STSG1.Revisionofscar：Excsion→有切skinRelease

→沒(méi)切skin2.此案例的STSG取皮處?醫(yī)師回答：1.Revision通常有Excsionskin2.STSG通常dornorsite一般都在大腿同側(cè)

Rotationandadvancementflap

Transfer

002022111IAdvancementflap是否都為skinflap（轉(zhuǎn)移皮瓣的最深層組織在skin）?醫(yī)師回答：Face大部分為skin其他部位請(qǐng)參考procedure內(nèi)容Advancementflap深度是否在Skin?1.Advancementflap深度在SubcutaneousTissueandFascia?

2.若起點(diǎn)為SubcutaneousTissueandFascia，第七碼要選擇被轉(zhuǎn)移的組織層是？Q1.請(qǐng)問(wèn)Localflap深度在SkinorSubcutaneousTissueandFascia?Transfer→SkinTransfer→SubcutaneousTissueandFascia