外科病歷書寫注意事項 以 ICD-10PCS 為例 李君儀醫師 馬偕醫學院助理教授 馬偕紀念醫院 心臟 血管外科主任 馬偕紀念醫院品管中 心主任 馬偕紀念醫院醫教部醫療品質組組 長

Transcription

1 外科病歷書寫注意事項 以 ICD-10PCS 為例 李君儀醫師 馬偕醫學院助理教授 馬偕紀念醫院 心臟 血管外科主任 馬偕紀念醫院品管中 心主任 馬偕紀念醫院醫教部醫療品質組組 長

2 ICD-9 2

3 ICD- 9- CM 編碼 A 分類碼 B 病因 部位和表現 ICD- 10- CM 編碼 A 分類碼 B 病因 部位和嚴重度 C 範圍 第 7 碼 用於產科 外傷和傷害的原因 A B A B C

4 ICD 9 CM ICD 10 CM 13,600 codes 69,000 codes 共有 17 章 包含 3-5 碼 第 1 碼為英文或數字 英文字母只使用 E 和 V 2,3,4,5 碼必定為數字 缺乏特定性 每 1 碼的描述較簡略 共有 21 章 包含 3-7 碼 第 1 碼為數字 使用 U 以外的所有英文字母 第 2 碼必定為數字 3,4,5,6,7 碼可以為英文或數字 較具特定性 每 1 碼的描述較詳細 * 編碼的過程類似, 但是分類的方式有所不同 4

5 精確測量成效 提升臨床研究 長期照護管理 ICD-10CM ICD-10PCS 減少 錯誤 發展自動化編碼程式 較低行政成本 5

6 外科醫師注意事項 ICD-10 CM 了解分類 方式和常 用的名稱 呈現 足夠精確的資訊 症狀與相關狀況 病因的描述 因果相關性 部位與側性 時序性

7 ICD- 9 和 ICD- 10 PCS 的差異 ICD- 9 ICD- 10 PCS 3 到 5 個代碼 7 個代碼所有代碼都是數字毎 一個代碼可以字 母或數字 ICD- 10 PCS 有 7 個字 母或數字 而使得處置更加清楚明確, 讓臨床資料的價值最 大化 Root opera3on 的分類與定義 方式需與平常 用語進 行對應 過去 ICD- 9 的處置碼可能會對應到超過 一個以上的 ICD- 10 PCS 處置碼

8 ICD- 10 PCS 的架構 ICD- 10 PCS 一個處置碼包括七位碼, 每 一位碼代表 一個分類軸, 每個分類軸可以有 34 個選項 ( 數字 0-9 或字 母 A- H, J- N, and P- Z) 來代表 手術 方式的差異

9 Body Root Section Body Part Approach Device Qualifier System Operation 定義處置 / 手術的 大範圍 Medical/surgical 定義在 0 心臟外科還有 Extracorporeal Assistance and Performance à 定義在 5 其他還有注射 (3) 影像檢查(B) 等等

10 Body Root Section Body Part Approach Device Qualifier System Operation 解剖部位與系統 02 Heart and Great Vessels 03 Upper Arteries 04 Lower Arteries 05 Upper Veins 06 Lower Veins 0D Gastrointestinal System 0F Hepatobiliary System and Pancreas

11 Body Root Section Body Part Approach Device Qualifier System Operation 最複雜 而困擾的 一個碼 個別獨 立的定義 和 手術意圖有關

12 Medical/Surgical Root Opera3ons Altera=on Bypass Change Control Crea=on Destruc=on Detachment Dila=on Division Drainage Excision Ex=rpa=on Extrac=on Fragmenta=on Fusion Inser=on Inspec=on Map Occlusion ReaQachment Release Removal Repair Replacement Reposi=on Resec=on Restric=on Revision Supplement Transfer Transplanta=on

13 Body Root Section Body Part Approach Device Qualifier System Operation 特定解剖位置 和側性有關 Body System Body Part

14 Body Root Section Body Part Approach Device Qualifier System Operation 用來達到 手術部位的 方式 Open Percutaneous Percutaneous Endoscopic Via Natural or Artificial Opening Via Natural or Artificial Opening Endoscopic Via Natural or Artificial Opening with percutaneous endoscopic assistance External

15 Approach 的決策參考 是開始有切 口? Open 否 Percutaneous Endoscopic 是 經由內視鏡? 否 Percutaneous 是 經過 皮膚? 經由開 口? 否 是 經由內視鏡? 是 Via Natural or Artificial Opening Endoscopic 否 否 External 有經 皮內視鏡輔助? 否 Via Natural or Artificial Opening 是 Via Natural or Artificial Opening with Percutaneous Endoscopic Assistance

16 Approaches Open Percutaneous endoscopic

17 External Approaches

18 Approaches Percutaneous Liver biopsy

19 Approaches Endoscopic polypectomy Via Natural or Ar=ficial Opening Endoscopic Via Natural or Ar=ficial Opening with Percutaneous Endoscopic Assistance

20 Body Root Section Body Part Approach Device Qualifier System Operation 手術後仍然存在的裝置 Monitoring device Intraluminal Synthetic Autologous tissue Nonautologous tissue

21 Body Root Section Body Part Approach Device Qualifier System Operation 附加特性 移植組織的來源 以診斷為 目的的處置 其他附加資訊

22 22

23 Heart and Great Vessels 021 Bypass 025 Destruction 027 Dilation 028 Division 02B Excision 02C Extirpation 02F Fragmentation 02H Insertion 02J Inspection 02K Map 02L Occlusion 02N Release 02P Removal 02Q Repair 02R Replacement 02S Reposition 02T Resection 02U Supplement 02V Restriction 02W Revision 02Y Transplantation Respiratory System 0B1 Bypass 0B2 Change 0B5 Destruction 0B7 Dilation 0B9 Drainage 0BB Excision 0BC Extirpation 0BD Extraction 0BF Fragmentation 0BH Insertion 0BJ Inspection 0BL Occlusion 0BM Reattachment 0BN Release 0BP Removal 0BQ Repair 0BS Reposition 0BT Resection 0BU Supplement 0BV Restriction 0BW Revision 0BY Transplantation Gastrointestinal System 0D1 Bypass 0D2 Change 0D5 Destruction 0D7 Dilation 0D8 Division 0D9 Drainage 0DB Excision 0DC Extirpation 0DF Fragmentation 0DH Insertion 0DJ Inspection 0DL Occlusion 0DM Reattachment 0DN Release 0DP Removal 0DQ Repair 0DR Replacement 0DS Reposition 0DT Resection 0DU Supplement 0DV Restriction 0DW Revision 0DX Transfer 0DY Transplantation

24 改變體內管路的直徑或路徑 Bypass Dilation Occlusion Restriction 和外來物有關的 Insertion Removal Replacement Supplement Revision 修補相關的 Repair 破壞 / 拿出 身體組織的部分或全部 Destruction Excision Resection 拿出體內的固體 / 液體 / 氣體部份 Drainage Extirpation Fragmentation 放回或移動 身體組織 Reposition Transplantation 切開 身體組織 Division Release 檢查相關的 Inspection

25 分析病歷 Procedure: Right Femoro- Popliteal Above- the- Knee Bypass with Gore- Tex GraZ This pa=ent had painful cramping in his calf, due to occlusion of his superficial femoral artery. Due to severe varicose veins, a prosthe=c Gore- Tex graz was used for the conduit. Procedure: AZer placement of an epidural catheter for spinal anesthesia, the pa=ent was prepped and draped in the usual sterile fashion. An incision was made in the pa=ent s groin and the right femoral artery was exposed. An incision was approximately 2 cm about the pa=ent s knee joint to expose the popliteal artery. Gore- Tex graz length is approximated and tunneled between the two sites. The graz is sutured to the femoral artery for the proximal anastomosis and then sutured to the above knee popliteal artery for the distal anastomosis. Both wounds are closed. Root Opera=on Device Approach Origin Des=na- =on

26 用 PCS 表單確認 Bypass 041K0JL Fem-Pop Bypass with Gore-Tex

27 Subtotal gastrectomy + Billroth II 0DB60ZZ anastomosis Section 0 Medical and Surgical Body System D Gastrointestinal System Operation 1 Bypass: Altering the route of passage of the contents of a tubular body part Body Part Approach Device Qualifier 1 Esophagus, Upper 2 Esophagus, Middle 3 Esophagus, Lower 5 Esophagus 1 Esophagus, Upper 2 Esophagus, Middle 3 Esophagus, Lower 5 Esophagus 6 Stomach 9 Duodenum 6 Stomach 9 Duodenum 0D160ZA Bypass 0 Open 4 Percutaneous Endoscopic 8 Via Natural or Artificial Opening Endoscopic 7 Autologous Tissue Substitute J Synthetic Substitute K Nonautologous Tissue Substitute Z No Device 4 Cutaneous 6 Stomach 9 Duodenum A Jejunum B Ileum 3 Percutaneous J Synthetic Substitute 4 Cutaneous 0 Open 4 Percutaneous Endoscopic 8 Via Natural or Artificial Opening Endoscopic 7 Autologous Tissue Substitute J Synthetic Substitute K Nonautologous Tissue Substitute Z No Device 4 Cutaneous 9 Duodenum A Jejunum B Ileum L Transverse Colon 3 Percutaneous J Synthetic Substitute 4 Cutaneous 4 Cutaneous

28 Section 0 Medical and Surgical Body System 4 Lower Arteries Operation 7 Dilation: Expanding an orifice or the lumen of a tubular body part Body Part Approach Device Qualifier 0 Abdominal Aorta 1 Celiac Artery 2 Gastric Artery 3 Hepatic Artery 4 Splenic Artery 5 Superior Mesenteric Artery 6 Colic Artery, Right 7 Colic Artery, Left 8 Colic Artery, Middle 9 Renal Artery, Right A Renal Artery, Left B Inferior Mesenteric Artery C Common Iliac Artery, Right D Common Iliac Artery, Left E Internal Iliac Artery, Right F Internal Iliac Artery, Left H External Iliac Artery, Right J External Iliac Artery, Left K Femoral Artery, Right L Femoral Artery, Left M Popliteal Artery, Right N Popliteal Artery, Left P Anterior Tibial Artery, Right Q Anterior Tibial Artery, Left R Posterior Tibial Artery, Right S Posterior Tibial Artery, Left T Peroneal Artery, Right U Peroneal Artery, Left V Foot Artery, Right W Foot Artery, Left Y Lower Artery Na=ve vessel 的 PTA - Dila=on 0 Open 3 Percutaneous 4 Percutaneous Endoscopic 4 Intraluminal Device, Drug-eluting D Intraluminal Device Z No Device Z No Qualifier 對右髂動脈和左股動脈進 行 PTA, 其中髂動脈放 1 支 支架, 如何編碼? 047C3DZ,047L3ZZ

29 靜脈曲張腔內鐳射治療 Through a =ny incision at the knee, a small tube is placed into the greater saphenous vein. Then, a laser or radiofrequency fiber is passed through the tube into the vein. Once in place, the fiber is ac=vated, delivering very localized heat to the vein wall. In response, the vein closes down and becomes permanently blocked.

30 Occlusion - 用 PCS 表單確認 06L 06LP3ZZ

31 腹主動脈瘤接受 血管腔內 支架 血管置放 Intraluminal device Bifurcated prosthesis Root opera=on = Restric3on Device = Intraluminal device

32 用 PCS 表單確認 04V Section 0 Medical and Surgical Body System 4 Lower Arteries Operation V Restriction: Partially closing an orifice or the lumen of a tubular body part Body Part Approach Device Qualifier 0 Abdominal Aorta 0 Abdominal Aorta 1 Celiac Artery 0 Open 3 Percutaneous 4 Percutaneous Endoscopic 0 Open 3 Percutaneous 4 Percutaneous Endoscopic C Extraluminal Device Z No Device D Intraluminal Device Z No Qualifier J Temporary Z No Qualifier 04V03DZ

33 Open Right Inguinal Herniorrhaphy without mesh Section 0 Medical and Surgical Body System Y Anatomical Regions, Lower Extremities Operation Q Repair: Restoring, to the extent possible, a body part to its normal anatomic structure and function Body Part Approach Device Qualifier 0 Buttock, Right 1 Buttock, Left 5 Inguinal Region, Right 6 Inguinal Region, Left 7 Femoral Region, Right 8 Femoral Region, Left 9 Lower Extremity, Right A Inguinal Region, Bilateral B Lower Extremity, Left C Upper Leg, Right D Upper Leg, Left E Femoral Region, Bilateral F Knee Region, Right G Knee Region, Left H Lower Leg, Right J Lower Leg, Left K Ankle Region, Right L Ankle Region, Left M Foot, Right N Foot, Left 0YQ50ZZ Repair 0 Open 3 Percutaneous 4 Percutaneous Endoscopic X External Z No Device Z No Qualifier

34 Laparoscopic abdominal wall Herniorrhaphy with mesh Section 0 Medical and Surgical Body System W Anatomical Regions, General Operation U Supplement: Putting in or on biological or synthetic material that physically reinforces and/or augments the function of a portion of a body part Body Part Approach Device Qualifier 0 Head 2 Face 4 Upper Jaw 5 Lower Jaw 6 Neck 8 Chest Wall C Mediastinum F Abdominal Wall K Upper Back L Lower Back M Perineum, Male N Perineum, Female Supplement 0WUF4JZ 0 Open 4 Percutaneous Endoscopic 7 Autologous Tissue Substitute J Synthetic Substitute K Nonautologous Tissue Substitute Z No Qualifier

35 胸主動脈瘤接受主動脈切除, 並 用 人 工 血管置換 Section 0 Medical and Surgical Body System 2 Heart and Great Vessels Operation R Replacement: Putting in or on biological or synthetic material that physically takes the place and/or function of all or a portion of a body part Body Part Approach Device Qualifier 5 Atrial Septum 6 Atrium, Right 7 Atrium, Left 9 Chordae Tendineae D Papillary Muscle J Tricuspid Valve K Ventricle, Right L Ventricle, Left M Ventricular Septum N Pericardium P Pulmonary Trunk Q Pulmonary Artery, Right R Pulmonary Artery, Left S Pulmonary Vein, Right T Pulmonary Vein, Left V Superior Vena Cava W Thoracic Aorta F Aortic Valve G Mitral Valve H Pulmonary Valve F Aortic Valve G Mitral Valve H Pulmonary Valve 0 Open 4 Percutaneous Endoscopic 0 Open 4 Percutaneous Endoscopic 3 Percutaneous Replacement 7 Autologous Tissue Substitute 8 Zooplastic Tissue J Synthetic Substitute K Nonautologous Tissue Substitute 02RW0JZ 7 Autologous Tissue Substitute 8 Zooplastic Tissue J Synthetic Substitute K Nonautologous Tissue Substitute 7 Autologous Tissue Substitute 8 Zooplastic Tissue J Synthetic Substitute K Nonautologous Tissue Substitute Z No Qualifier Z No Qualifier H Transapical Z No Qualifier

36 Replacement/Repair/Supplement 用以恢復身體某些組織功能的處置 身體組織仍保留? 否 Replacement 是 身體組織有使用植入物加強? 否 Repair 是 Supplement

37 Permanent Pacemaker/AICD/CRT 置放 分成兩部分 :lead 和 generator Lead: 放到 心臟裡 面,body system 屬 heart and great vessel Generator: 放在 皮下,body system 屬 subcutaneous =ssue and fascia Section 0 Medical and Surgical Body System 2 Heart and Great Vessels Operation H Insertion: Putting in a nonbiological appliance that monitors, assists, performs, or prevents a physiological function but does not physically take the place of a body part Body Part Approach Device Qualifier 4 Coronary Vein 6 Atrium, Right 7 Atrium, Left K Ventricle, Right L Ventricle, Left 0 Open 3 Percutaneous 4 Percutaneous Endoscopic 0 Open Inser3on 0 Monitoring Device, Pressure Sensor 2 Monitoring Device 3 Infusion Device D Intraluminal Device J Cardiac Lead, Pacemaker K Cardiac Lead, Defibrillator M Cardiac Lead Z No Qualifier Permanent pacemaker: 02HK3JZ AICD: 02HK3KZ CRT: 02H43MZ Dual chamber pacemaker: 02HK3JZ, 02H63JZ

38 Generator 的部分 Section 0 Medical and Surgical Body System J Subcutaneous Tissue and Fascia Operation H Insertion: Putting in a nonbiological appliance that monitors, assists, performs, or prevents a physiological function but does not physically take the place of a body part R Subcutaneous Tissue Body and Part Fascia, Left Foot Approach Device Qualifier 0 Subcutaneous Tissue and Fascia, Scalp 6 Subcutaneous Tissue and Fascia, Chest 8 Subcutaneous Tissue and Fascia, Abdomen 0 Open 3 Percutaneous 0 Monitoring Device, Hemodynamic 2 Monitoring Device 4 Pacemaker, Single Chamber 5 Pacemaker, Single Chamber Rate Responsive 6 Pacemaker, Dual Chamber 7 Cardiac Resynchronization Pacemaker Pulse Generator 8 Defibrillator Generator 9 Cardiac Resynchronization Defibrillator Pulse Generator A Contractility Modulation Device B Stimulator Generator, Single Array C Stimulator Generator, Single Array Rechargeable D Stimulator Generator, Multiple Array E Stimulator Generator, Multiple Array Rechargeable H Contraceptive Device M Stimulator Generator N Tissue Expander P Cardiac Rhythm Related Device V Infusion Device, Pump W Vascular Access Device, Reservoir X Vascular Access Device Permanent pacemaker: 0JH604Z AICD: 0JH608Z CRT: 0JH607Z Dual chamber pacemaker: 0JH606Z Z No Qualifier

39 CVP line 置放 Section 0 Medical and Surgical Body System 5 Upper Veins Operation H Insertion: Putting in a nonbiological appliance that monitors, assists, performs, or prevents a physiological function but does not physically take the place of a body part Body Part Approach Device Qualifier 0 Azygos Vein 1 Hemiazygos Vein 3 Innominate Vein, Right 4 Innominate Vein, Left 5 Subclavian Vein, Right 6 Subclavian Vein, Left 7 Axillary Vein, Right 8 Axillary Vein, Left 9 Brachial Vein, Right A Brachial Vein, Left B Basilic Vein, Right C Basilic Vein, Left D Cephalic Vein, Right F Cephalic Vein, Left G Hand Vein, Right H Hand Vein, Left L Intracranial Vein M Internal Jugular Vein, Right N Internal Jugular Vein, Left P External Jugular Vein, Right Q External Jugular Vein, Left R Vertebral Vein, Right S Vertebral Vein, Left T Face Vein, Right V Face Vein, Left 從右鎖 骨下靜脈放置 CVP line 0 Open 3 Percutaneous 4 Percutaneous Endoscopic 3 Infusion Device D Intraluminal Device 05H533Z 0 Open 2 Monitoring Device Z No Qualifier

40 拔除 Permcath Removal Section 0 Medical and Surgical Body System 5 Upper Veins Operation P Removal: Taking out or off a device from a body part Body Part Approach Device Qualifier Y Upper Vein Y Upper Vein 0 Open 3 Percutaneous 4 Percutaneous Endoscopic X External 05PYXDZ 0 Drainage Device 2 Monitoring Device 3 Infusion Device 7 Autologous Tissue Substitute C Extraluminal Device D Intraluminal Device J Synthetic Substitute K Nonautologous Tissue Substitute 0 Drainage Device 2 Monitoring Device 3 Infusion Device D Intraluminal Device Z No Qualifier Z No Qualifier

41 PTA 另 一章 Revision 65 歲洗腎病 人, 左 手 AV GraZ 阻塞, 進 手術室在 C- arm 下進 行 graz 的 thrombectomy Section 0 Medical and Surgical Body System 3 Upper Arteries Operation W Revision: Correcting, to the extent possible, a portion of a malfunctioning device or the position of a displaced device Body Part Approach Device Qualifier Y Upper Artery 0 Open 3 Percutaneous 4 Percutaneous Endoscopic X External 0 Drainage Device 2 Monitoring Device 3 Infusion Device 7 Autologous Tissue Substitute C Extraluminal Device D Intraluminal Device J Synthetic Substitute K Nonautologous Tissue Substitute M Stimulator Lead Z No Qualifier 03WY3JZ

42 Af 接受 Maze IV opera=on Section 0 Medical and Surgical Body System 2 Heart and Great Vessels Operation 5 Destruction: Physical eradication of all or a portion of a body part by the direct use of energy, force, or a destructive agent Body Part Approach Device Qualifier 4 Coronary Vein 5 Atrial Septum 6 Atrium, Right 8 Conduction Mechanism 9 Chordae Tendineae D Papillary Muscle F Aortic Valve G Mitral Valve H Pulmonary Valve J Tricuspid Valve K Ventricle, Right L Ventricle, Left M Ventricular Septum N Pericardium P Pulmonary Trunk Q Pulmonary Artery, Right R Pulmonary Artery, Left S Pulmonary Vein, Right T Pulmonary Vein, Left V Superior Vena Cava W Thoracic Aorta 7 Atrium, Left Destruc3on 0 Open 3 Percutaneous 4 Percutaneous Endoscopic 0 Open 3 Percutaneous 4 Percutaneous Endoscopic 02560ZZ, 02570ZZ, 02570ZK Z No Device Z No Device Z No Qualifier K Left Atrial Appendage Z No Qualifier

43 The surgeon harvests the lez radial artery through an incision for use in another simultaneous procedure. What root opera=on is this? Excision

44 03BC0ZZ 用 PCS 表單確認 03B

45 Laparoscopic Cholecystectomy Section 0 Medical and Surgical Body System F Hepatobiliary System and Pancreas Operation T Resection: Cutting out or off, without replacement, all of a body part Body Part Approach Device Qualifier 0 Liver 1 Liver, Right Lobe 2 Liver, Left Lobe 4 Gallbladder G Pancreas 5 Hepatic Duct, Right 6 Hepatic Duct, Left 8 Cystic Duct 9 Common Bile Duct C Ampulla of Vater D Pancreatic Duct F Pancreatic Duct, Accessory Resec3on 0 Open 4 Percutaneous Endoscopic 0 Open 4 Percutaneous Endoscopic 7 Via Natural or Artificial Opening 8 Via Natural or Artificial Opening Endoscopic Z No Device Z No Device Z No Qualifier Z No Qualifier 0FT44ZZ

46 右頸動脈內膜剝離術 Right Caro=d Endarterectomy Root opera=on = Ex3rpa3on

47 用 PCS 表單確認 03C 03CK0ZZ Thrombectomy 編碼模式亦同

48 右側輸尿管結石接受體外震波碎石 Section 0 Medical and Surgical Body System T Urinary System Operation F Fragmentation: Breaking solid matter in a body part into pieces Body Part Approach Device Qualifier 3 Kidney Pelvis, Right 4 Kidney Pelvis, Left 6 Ureter, Right 7 Ureter, Left B Bladder C Bladder Neck D Urethra 0 Open 3 Percutaneous 4 Percutaneous Endoscopic 7 Via Natural or Artificial Opening 8 Via Natural or Artificial Opening Endoscopic X External Z No Device Z No Qualifier Fragmenta3on 0TF6XZZ

49 Chest tube drainage for lez pleural effusion Section 0 Medical and Surgical Body System B Respiratory System Operation 9 Drainage: Taking or letting out fluids and/or gases from a body part Body Part Approach Device Qualifier 1 Trachea 2 Carina 3 Main Bronchus, Right 4 Upper Lobe Bronchus, Right 5 Middle Lobe Bronchus, Right 6 Lower Lobe Bronchus, Right 7 Main Bronchus, Left 8 Upper Lobe Bronchus, Left 9 Lingula Bronchus B Lower Lobe Bronchus, Left C Upper Lung Lobe, Right D Middle Lung Lobe, Right F Lower Lung Lobe, Right G Upper Lung Lobe, Left H Lung Lingula J Lower Lung Lobe, Left K Lung, Right L Lung, Left M Lungs, Bilateral N Pleura, Right P Pleura, Left R Diaphragm, Right S Diaphragm, Left N Pleura, Right P Pleura, Left R Diaphragm, Right S Diaphragm, Left 0B9P30Z 0 Open 3 Percutaneous 4 Percutaneous Endoscopic 7 Via Natural or Artificial Opening 8 Via Natural or Artificial Opening Endoscopic 0 Open 3 Percutaneous 4 Percutaneous Endoscopic 0 Open 3 Percutaneous 4 Percutaneous Endoscopic Z No Device X Diagnostic Z No Qualifier 0 Drainage Device Z No Qualifier Z No Device X Diagnostic Z No Qualifier

50 Transplanta=on Section 0 Medical and Surgical Body System 2 Heart and Great Vessels Operation Y Transplantation: Putting in or on all or a portion of a living body part taken from another individual or animal to physically take the place and/or function of all or a portion of a similar body part Body Part Approach Device Qualifier A Heart 0 Open Z No Device 0 Allogeneic 1 Syngeneic 2 Zooplastic 02YA0Z0

51 右腳股 骨 骨折進 行內固定 Reposi=on Section 0 Medical and Surgical Body System Q Lower Bones Operation S Reposition: Moving to its normal location, or other suitable location, all or a portion of a body part Body Part Approach Device Qualifier 6 Upper Femur, Right 7 Upper Femur, Left 8 Femoral Shaft, Right 9 Femoral Shaft, Left B Lower Femur, Right C Lower Femur, Left G Tibia, Right H Tibia, Left J Fibula, Right K Fibula, Left 6 Upper Femur, Right 0 Open 3 Percutaneous 4 Percutaneous Endoscopic 4 Internal Fixation Device 5 External Fixation Device 6 Internal Fixation Device, Intramedullary B External Fixation Device, Monoplanar C External Fixation Device, Ring D External Fixation Device, Hybrid Z No Device Z No Qualifier 0QS806Z

52 病人上消化道出血進行 PES 檢查 Section 0 Medical and Surgical Body System D Gastrointestinal System Operation J Inspection: Visually and/or manually exploring a body part Body Part Approach Device Qualifier 0 Upper Intestinal Tract 6 Stomach D Lower Intestinal Tract U Omentum V Mesentery W Peritoneum Inspec=on 0 Open 3 Percutaneous 4 Percutaneous Endoscopic 7 Via Natural or Artificial Opening 8 Via Natural or Artificial Opening Endoscopic X External 0 Open 3 Percutaneous 4 Percutaneous Endoscopic X External Z No Device Z No Device Z No Qualifier Z No Qualifier 0DJ68ZZ

53 腸沾黏進行 adhesiolysis Release Section 0 Medical and Surgical Body System D Gastrointestinal System Operation N Release: Freeing a body part from an abnormal physical constraint by cutting or by the use of force Body Part Approach Device Qualifier 1 Esophagus, Upper 2 Esophagus, Middle 3 Esophagus, Lower 4 Esophagogastric Junction 5 Esophagus 6 Stomach 7 Stomach, Pylorus 8 Small Intestine 9 Duodenum A Jejunum B Ileum C Ileocecal Valve E Large Intestine F Large Intestine, Right G Large Intestine, Left H Cecum J Appendix K Ascending Colon L Transverse Colon M Descending Colon N Sigmoid Colon P Rectum 0 Open 3 Percutaneous 4 Percutaneous Endoscopic 7 Via Natural or Artificial Opening 8 Via Natural or Artificial Opening Endoscopic 0 Open 0DN80ZZ Z No Device Z No Qualifier

54 Change tracheostomy tube Section 0 Medical and Surgical Body System B Respiratory System Operation 2 Change: Taking out or off a device from a body part and putting back an identical or similar device in or on the same body part without cutting or puncturing the skin or a mucous membrane Body Part Approach Device Qualifier 0 Tracheobronchial Tree K Lung, Right L Lung, Left Q Pleura T Diaphragm X External 1 Trachea X External 0 Drainage Device Y Other Device 0 Drainage Device E Intraluminal Device, Endotracheal Airway F Tracheostomy Device Y Other Device Z No Qualifier Z No Qualifier 0B21XFZ

55 頸椎受傷接受融合手術 Fusion Section 0 Medical and Surgical Body System R Upper Joints Operation G Fusion: Joining together portions of an articular body part rendering the articular body part immobile Body Part Approach Device Qualifier 0 Occipital-cervical Joint 1 Cervical Vertebral Joint 2 Cervical Vertebral Joints, 2 or more 4 Cervicothoracic Vertebral Joint 6 Thoracic Vertebral Joint 7 Thoracic Vertebral Joints, 2 to 7 8 Thoracic Vertebral Joints, 8 or more A Thoracolumbar Vertebral Joint C Temporomandibular Joint, Right 0 Open 3 Percutaneous 4 Percutaneous Endoscopic 7 Autologous Tissue Substitute A Interbody Fusion Device J Synthetic Substitute K Nonautologous Tissue Substitute Z No Device 0 Anterior Approach, Anterior Column 1 Posterior Approach, Posterior Column J Posterior Approach, Anterior Column 0RG20J0

56 小朋友輸尿管逆流, 經內視鏡打 Deflux Section 3 Administration Body System E Physiological Systems and Anatomical Regions Operation 0 Introduction: Putting in or on a therapeutic, diagnostic, nutritional, physiological, or prophylactic substance except blood or blood products Body System / Region Approach T Substance Qualifier E Products of Conception G Upper GI H Lower GI K Genitourinary Tract N Male Reproductive E Products of Conception 3 Percutaneous 7 Via Natural or Artificial Opening 8 Via Natural or Artificial Opening Endoscopic 3 Introduc=on G Other Therapeutic Substance C Other Substance 3E0K8GC

57 懷疑左側輸尿管阻塞造成水腎進行 順行性腎盂造影 Section B Imaging Body System T Urinary System Type 0 Plain Radiography: Planar display of an image developed from the capture of external ionizing radiation on photographic or photoconductive plate Body Part Contrast Qualifier Qualifier 0 Bladder 1 Kidney, Right 2 Kidney, Left 3 Kidneys, Bilateral 4 Kidneys, Ureters and Bladder 5 Urethra 6 Ureter, Right 7 Ureter, Left 8 Ureters, Bilateral B Bladder and Urethra C Ileal Diversion Loop Sec=on:Imaging 0 High Osmolar 1 Low Osmolar Y Other Contrast Z None Z None Z None BT020ZZ

58 外科醫師注意事項 ICD- 10 PCS 了解分類與編碼邏輯 呈現 足夠精確的資訊 部位的描述 : 名稱要明確 側性 : 左側 右側 中間 雙側 手術 方式 : 依照 手術的 目的 手術途徑 : 內視鏡 自然 口 經 皮穿刺 植 入物的有無與種類 :ring 心包膜 mesh

59 如何加強編碼完整性與正確性? 溝通! 溝通! 溝通! ICD- 10 CM/PCS 結合電 子病歷系統 結構式診斷碼鍵 入 處置之結構式醫囑 結構式 手術記錄

60 醫師的 角 色 熟悉不同的診斷與處置分類模式 臨床 工作結合編碼 ICD- 10 CM: 利 用 POMR 的模式, 定義病 人住院中產 生的診斷 應 用電腦輔助編碼系統協助進 行編碼 ICD- 10 PCS: 應 用結構式醫囑 應 用結構式 手術記錄

61 感謝聆聽 敬請指教