ICD-10PCS 與病歷書寫李君儀醫師偕醫學院助理教授偕紀念醫院臟管外科主任偕紀念醫院品管中主任偕紀念醫院醫教部醫療品質組組

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1 ICD-10PCS 與病歷書寫李君儀醫師偕醫學院助理教授偕紀念醫院臟管外科主任偕紀念醫院品管中主任偕紀念醫院醫教部醫療品質組組

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3 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 3

4 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個代碼可以字或數字 ICD-10 PCS 有 7 個字或數字使得處置更加清楚明確, 讓臨床資料的價值最化過去 ICD-9 的處置碼可能會對應到超過個以上的 ICD-10 PCS 處置碼 Root opera2on 的分類與定義式需與平常語進對應

5 ICD-10 PCS 的架構 ICD-10 PCS 個處置碼包括七位碼, 每位碼代表個分類軸, 每個分類軸可以有 34 個選項 ( 數字 0-9 或字 A-H, J-N, and P-Z) 來代表術式的差異章節手術方式手術途徑修飾詞系統分類手術部位裝置物

6 Body Root Section Body Part Approach Device Qualifier System Operation 定義處置 / 術的範圍 Medical/surgical 定義在 0 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

7 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

8 Body Root Section Body Part Approach Device Qualifier System Operation 最複雜困擾的個碼個別獨的定義和術意圖有關

Fragmenta;on Fusion Inser;on Inspec;on Map Occlusion ReaPachment Release Removal

9 Medical/Surgical Root Opera2ons 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 ReaPachment Release Removal Repair Replacement Reposi;on Resec;on Restric;on Revision Supplement Transfer Transplanta;on

10 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

11 Body Root Section Body Part Approach Device Qualifier System Operation 來達到術部位的式 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

12 Approach 的決策參考是開始有切? Open 否 Percutaneous Endoscopic 是經由內視鏡? 否 Percutaneous 是經過膚? 經由開? 否是經由內視鏡? 是 Via Natural or Artificial Opening Endoscopic 否否 External 有經內視鏡輔助? 否 Via Natural or Artificial Opening 是 Via Natural or Artificial Opening with Percutaneous Endoscopic Assistance

13 Approaches Open Percutaneous endoscopic

14 Approaches Percutaneous Liver biopsy

15 External Approaches

16 Approaches Endoscopic polypectomy Via Natural or Ar;ficial Opening Endoscopic Via Natural or Ar;ficial Opening with Percutaneous Endoscopic Assistance

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

18 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的的處置其他附加資訊

19 19

20 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

21 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 放回或移動體組織 Reposition Transplantation 切開體組織 Division Release 檢查相關的 Inspection

22 Non-Coronary Body Part FROM Downstream route Qualifier TO Bypass Altering the route of passage of the contents of a tubular body part ICD-10-PCS Official Guidelines for Coding Coronary Sites Body Part Qualifier Coronary Artery NUMBER OF SITES FROM 註 : 摘取管另外編碼 Excision for graft B3.9 If an autograft is obtained from a different body part in order to complete the objective of the procedure, a separate procedure is coded. Example: Coronary bypass with excision of saphenous vein graft, excision of saphenous vein is coded separately.

23 病歷紀錄需要可以被分析 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

24 PCS 表單確認 Bypass 041K0JL Right Fem-Pop Bypass with Gore-Tex

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

25 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

26 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 PTA, 其中髂動脈放 1 架, 如何編碼? 047C3DZ,047L3ZZ

27 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.

28 Occlusion - PCS 表單確認 06L 右腳大隱靜脈靜脈曲張接受雷射血管腔內手術封閉大隱靜脈 06LP3ZZ

29 腹主動脈瘤接受管腔內架管置放 Intraluminal device Bifurcated prosthesis Root opera;on = Restric2on Device = Intraluminal device

30 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

31 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

Open Right Inguinal Herniorrhaphy 0YQ50ZZ without mesh Section 0 Medical and Surgical Body System Y Anatomical Regions, Lower Extremities Operation Q Repair: Restoring, to the extent possible, a body

32 Open Right Inguinal Herniorrhaphy 0YQ50ZZ 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 Repair 0 Open 3 Percutaneous 4 Percutaneous Endoscopic X External Z No Device Z No Qualifier

Laparoscopic abdominal wall Herniorrhaphy with mesh Section 0 Medical and Surgical Body System W Anatomical Regions, General Operation U Supplement:

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

33 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

胸主動脈瘤接受主動脈切除, 並管置換 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

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

34 胸主動脈瘤接受主動脈切除, 並管置換 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

35 Permanent Pacemaker/AICD/CRT 置放分成兩部分 :lead 和 generator Lead: 放到臟裡,body system 屬 heart and great vessel Generator: 放在下,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 Inser2on 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

36 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

37 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

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

38 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 05PYX3Z 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

39 PTA 另章 Revision 65 歲洗腎病, 左 AV GraZ 阻塞, 進術室在 C-arm 下進 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

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

40 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 Destruc2on 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

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

42 PCS 表單確認 03B Excision 03BC0ZZ

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

43 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 Resec2on 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

44 右頸動脈內膜剝離術 Right Caro;d Endarterectomy Root opera;on = Ex2rpa2on

45 PCS 表單確認 03C Ex2rpa2on 03CK0ZZ Thrombectomy 編碼模式亦同

46 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 Fragmenta2on 0TF6XZZ

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

47 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

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

48 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

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

49 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

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

50 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

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

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

51 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

52 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

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

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

53 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

小朋友輸尿管逆流, 經內視鏡打 Deflux Section 3 Administration Body System E Physiological Systems and Anatomical

physiological, or prophylactic substance except blood or blood products Body System / Region

N Male Reproductive E Products of Conception Introduc;on 3 Percutaneous 7 Via Natural or Artificial

54 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 Introduc;on 3 Percutaneous 7 Via Natural or Artificial Opening 8 Via Natural or Artificial Opening Endoscopic 3 G Other Therapeutic Substance C Other Substance 3E0K8GC

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

radiation on photographic or photoconductive plate Body Part Contrast Qualifier Qualifier 0

5 Urethra 6 Ureter, Right 7 Ureter, Left 8 Ureters, Bilateral B Bladder and Urethra C Ileal

55 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

56 外科醫師注意事項 ICD-10 PCS 了解分類與編碼邏輯在病歷上呈現夠精確的資訊部位的描述 : 名稱要明確側性 : 左側右側中間雙側術式 : 依照術的的術途徑 : 內視鏡然經穿刺植物的有無與種類 :ring 包膜 mesh

57 如何加強編碼完整性與正確性? 溝通! 溝通! 溝通! ICD-10 CM/PCS 結合電病歷系統結構式診斷碼鍵處置之結構式醫囑結構式術記錄

58 感謝聆聽敬請指教

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

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外科病歷書寫注意事項以 ICD-10PCS 為例李君儀醫師 2016.10.1. 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 ICD-9 2 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

ICD-10PCS 與病歷書寫 李君儀醫師 偕醫學院助理教授 偕紀念醫院 臟 管外科主任 偕紀念醫院品管中 主任 偕紀念醫院醫教部醫療品質組組

ICD-10PCS 與病歷書寫李君儀醫師偕醫學院助理教授偕紀念醫院臟管外科主任偕紀念醫院品管中主任偕紀念醫院醫教部醫療品質組組