投影片 1

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1 類玲

2 論 ( 800 ~ 999 ) (E-code) (Fracture) (Injury) (Late effect) (Poison of drug & chemical) (Complication)

3 (Fracture of skull) 800 ~ 804 (base) (Ethmoid bone) (Occiput bone) (Sphenoid bone) (Temporal bone) (vault) (Frontal bone) (Parietal bone) ( ), 若 ( ), 省略 800 ~ ~804 Ex: Temporal bone fracture with subarachnoid ( )hemorrhage=> 801.2X fracture => skull=>base =>with=> subarachnoid hemorrhage

4 度識狀 (Consciousness) 識狀

5 - 1 度識狀 (Consciousness) ICD-9-CM 識狀 0 識狀 Unspecified state of consciousness 1 識 With no loss of consciousness 2 (1 ) 識 With brief(less than one hour) loss of consciousness 3 (1~24 ) 識 With moderate(1~24 hours) loss of consciousness 4 ( 24 ) 識復識 With prolonged (more than 24 hours) loss of consciousness and return to pre-existing conscious level

6 - 2 5 ( 24 ) 識不復識 ( Hopeless) With prolonged (more than 24 hours) loss of consciousness without return to pre-existing conscious level 6 識 With loss of consciousness of unspecified duration 9 With concussion, unspecified 識識狀 (Consciousness)

7 數識狀拉 (Glasgow) 數來 ExVxMx 錄 E(Eye) 1 ~ 4 V(Verbal) 1 ~ 5 M(Motor) 1 ~ 6 見 : ILOC=> Initial loss of consciousness LOC=> loss of consciousness

8 Q: 類六度識狀 (Consciousness) 識來 AAD 5 1 A: 識狀 (Consciousness) 來識來 AAD 5

9 Q: SDH 識 3 SDH A: 識狀 5 "5"

10 850.x (Concussion) 識 (Loss of consciousness) 識 ( Unconsciousness) 識復度裂不 851.xx 不 852 ~ 853

11 ( 不論 ) 例漏 ( Cerebrospinal fluid rhinorrhea ) 漏 ( Cerebrospinal fluid otorrhea ) 345.9x ( Epilepsy attack)

12 切 (Craniotomy) 切理切行切省略切 (Craniectomy) 切不 (Osteoplasty) (Cranioplasty) Ex:skull bone defect (old CVA craniectomy) =>

13 -1 (Fracture of vertebral column) (Spinal cord injury) 806 (Paraplegia) (Quadriplegia) 力 (Paraparesis) 力 (Quadriparesis) (Paralysis) (Spinal concussion) 神 (Nerve injury) (Injury to cauda equina) Ex:fracture of C5 with quadriplegia => E-code =>fracture =>vertebra=>with quadriplegia =>spinal cord injury =>cervical

14 -2 (Fracture of vertebral column) x ~ 805.1x Ex: fracture of C5-6 => E-code (Spinal cord injury) 952.xx Ex:spinal coed injury of T8 => E-code

15 (Compression fracture) Fracture Ex:Lumbar compression fracture due to fall from bed => E x Ex: T12 compression fracture due to osteoporosis => =>fracture =>pathologic=>vertebra

16 肋 (fracture of ribs) 肋數數 807.0x-807.1x Ex: Fracture of 4~7ribs =>807.04

17 (Fracture)-1 若 (E- code) (Close) (Open) ( 列 )

18 (Fracture)-2 不來 (1)Comminuted (3)Elevated (2)Depressed (4)Fissured 裂 (5)Fracture NOS (6)Green stich 柳狀 (7)Impacted (9)March (8)Linear (10)Simple (11)Slipped epiphysis 滑 (12)Spiral 螺

19 (Fracture)-3 (1) Compound (2) Infected (3) Missile (4) Puncture 刺 (5) With foreign body 異

28 類類不不 ex: Fracture of r t tibia, fracture- dislocation of left fibula =>

29 列 1.Skull or face ~ Pelvis or vertebral column ~ Both lower limbs lower with upper limb and lower limb(s) with rib(s) and sternum ~ Both upper limbs and upper limb with rib(s) and sternum ~ Trunk ~ 度度列

30 (Shaft) U/3( 1/3 ) M/3( 1/3) L/3( 1/3) (Upper end) (Proximal end) 離 (Lower end) (Distal end) 離

31 復復 (close reduction) 不切復復 (open reduction) 切復 (internal fixation), plate screw K-wire pin (external fixation)(external Skeletal Fixation,ESF), cast splint Hoffman s external fixation

35 復 77.xx 78.xx, 79.xx 不復 Fracture of clavicle 810.xx+ 復.9 Colle s Fracture 復.2 Smith s Fracture 復.2 Pilon Fracture 復.6 Plateau of tibia Fracture 復.6 Tuberity Fracture 復.6 Lisfranc s Fracture 復.7

36 (Dislocation)-1 異 (Displacement) (Subluxation) 不 (Congenital dislocation) 理 (Pathological dislocation)718.2 復 (Recurrent dislocation)718.3

37 (Dislocation)-2 見 (1) Complete (2) Simple (3) Partial (4) Dislocation NOS (5) Uncomplicated 見 (1) Compound (2) Infected (3) With foreign body 異 ( )

38 (Dislocation)-3 復復兩療復 79.7~79.8 復復

39 (Internal injury) :860~869 open wound With open wound: 洞見裂 ( ) infection foreign body With open wound, With open wound; 例 stab( 刺 ) injury of liver=> Blunt trauma P.259

40 (Internal injury) 見 a.blast injury open wound b.blunt trauma open wound c.contusion open wound d.rupture 裂見 e.laceration 裂見 open wound f.hematoma g.tear 裂

41 (open wound ) 870~897 : wound open 識 (Complication) 1 Complication (Delayed healing) 療 (Delayed treatment) 異留 (Foreign body) (Major infection) Open wound by site with infection Ex:open wound of back with infection =>876.1

42 (Coding of Injuries) 1.1 不立列 1.2 (abrasion) (contusion) 若更不 1.3 神度列 ( 神 ) ( ) ( ) 神神

43 (Multiple Trauma) multiple injuries 若歷 multiple injuries 若歷若兩療 ( ) 連

44 (Multiple Trauma) 類 a.head b.neck c.back d.chest e.abdomen Pelvis f.legs Feet Toes g.arms Wrist Hands 例 Laceration of forehead Multiple contusion of forearm Repair forehead laceration

45 Crushing injury 歷 : Crushing injury 來 Fracture( ),Internal injuries( ) 兩 Crushing injury Fracture( ) Internal injuries( ) Coding Clinic, ICD-9-CM Addendum, 2003, p.20

46 (Injury to blood vessels) ( ) 狀神神神神 Ex:open wound of the anterior abdominal wall with rupture of the aorta => =>injury => blood vessel=>aorta=>abdomen

47 (Late effect)-1 留狀列狀年年狀狀不年年

48 (Late effect)-2 類 905 ~ 909 (E-code) 137~ 類留狀, 不留狀例 hemiplegia due to old CVA

49 (Late effect)-3 列狀 Late Due to old Due to previous injury or illness Following previous injury or illness 留狀 (Residual) 不狀 : 留狀 (Residual)

50 (Coding of Burns)- ( ) 不度度度落度度來識

51 (Coding of Burns) 度類 947 ( ) 類

52 (Coding of Burns)- 3.1 不度列 3.2 不度 ( 類 ) 錄 3.3 (non-healing) ( ) 列來 3.5 不類錄 946( ) 錄 ( ) 類量

53 (Coding of Burns)- 3.7 料 948 度 20% (Rule of Nines) 來 3.9 ( 例 ) 療狀 ( ) (Ecode) 3.10 錄

54 類度度 0 度 20%, 948 Burn => extent

55 9% 9% 18% 18% 18% 1%

56 (Coding of Debridement of Wound, Infection or Burn) 4.1 切 (Brushing, Scrubbing, Washing) 4.2 切 (Excisional Debridement) 切 (Nonexcisional Debridement) 86.28

57 (Graft) 來行來來行異冷 86.65

58 類 -1 Graft Skin graft (FTSG) Full-thickness skin graft 離力裂 (STSG) Split-thickness skin graft 易理裂度

59 類 -2 Flap (pedicle or flap graft) 切行留來連來 (free flap) 切 86.7x

60 類 -3 Bone graft excision of bone for graft Tendon graft Hand Other site Nerve graft 04.5 Vein graft 39.58

61 不良 -1 (Adverse Effect, Poisoning and Toxic Effect) 5.1 不良不良 (E930- E949) 類不良例 (tachycardia) (delirium) (gastrointestinal hemorrhaging) (vomiting) (hypokalemia) (hepatitis) (renal failure) (respiratory failure)

62 不良 -2 (Adverse Effect, Poisoning and Toxic Effect) 5.3 量 ( ) 5.4 兩 5.5 不 ( 例量 ) 不良 ( 例 ) 濫濫

63 不良不良 ( 異.. ) 不良來狀暈 (Drug hypersensitivity ) 狀不 995.2; 狀, 狀療, 不療, digoxin dilantin 狀狀 + Ex: drug eruption due to aspirin E935.3

64 不不 ( 量 ) 不良見 Overdose, intoxication, 兩 + 狀 + ( 濫 )+ Ex:coma due to accident of valium( ) overdose => E853.2

65 療類 ex:tracheostomy complication 519.0

66 類狀 Postoperation( ) Due to surgery( ) (Complication) 996 ~ 999

67 狀 Ex:colostomy malfunction => 若類 ~ 999 ( 類說 ) 療 990 Proctitis ( )due to radiation => =>effect, adverse => radiation Colitis due to radiation =>558.1

68 ~ Breakdown(mechanical) Displacement 異 Leakage 漏 Obstruction, mechanical 塞 Perforation Protrusion

69 ~ 異 996.6x infection and inflammatory 996.7X 塞 (Embolism) (Hemorrhage) (Infection) (Inflammation) 塞 (Occlusion) (Pain) (Stenosis) (Thrombus) Ex: osteoarthritis of hip s/p THR infection => E878.1

70 996.8 Transplant failure Rejection Ex:rejection on liver transplant E878.0

71 療療刺裂裂裂裂不 674.1x 裂 674.2x 裂

72 ~ x 療異留

73 練

74 練 -1 Closed fracture of vault of skull with subdural hemorrhage ; 4hour loss of consciousness Closed fracture lateral condyle, left humerus open reduction and internal fixation Coma due to acute barbiturate( ) intoxication Attempted suicide E950.1

75 練 -2 The helmeted ( )motorcyclist suffered a road accident with chest and abdominal pain. His chest film showed right multiple rib fr with pneumohemothorax. Abd CT showed liver laceration with hemoperitoneum E819.2(accident=>motor vehicle) This 24-years old male got r t patella fr s/p ORIF with ILN at our hospital.he was admitted for removal of implant now.the procedure was done in admitted period. V54.0(admission for =>removal of ) (removal => fixation device =>internal => patella

76 練 -3 Third degree burn of thigh with infected Second degree burn of abdominal wall TBSA 9% Excision debridement The patient fracture her left patella when she suffered a fall into a hole on the public golf course.she was taken to surgery, where an open reduction and internal fixation were performed without complication. By the second postoperative day, she was ambulatory( ) on crutches and redy for discharge E883.9+E fall=>into =>hole accident=>occurring (at)(in)=>place=>public=>sport

78 類

79 類 E800-E 類 ( ) 類

80 -1 Accident(to) Assault(homicidal)(by)(in) ( 殺 ) Collision Cut 切 Explosion Fall, falling 落 Fire Foreign body 異

81 -2 Hit,hitting by injury,injured Shooting,shot Suffocation Suicide 殺

82 -1 若 2 更,, 類列. Ex1: 樓落 =>E880.9( 樓落 )+E960 ( ) EX2: Tornado 龍車 =>E908.1 Tornado+E815.0

83 -2 列 E960-E966 E968-E969 E908-E909 E800-E848 E-code

84 -1 兩不不連串

85 陸 E800-E848 E800-E848 1.Aircraft and spacecraft (E840-E845) 2.Watercraft(E830-E838) 3.Motor vehicle(e810-e825) 4.Railway(E800-E807) 5.Other road vehicles(e826-e829) Ex: 車車, 車 E800-E845 來識

86 療 -1 E870-E876 療 Misadventure 例 : 理留 E871.0

87 療 -2 E878-E879 療異, Reaction Abnormal Ex: E878.1

88 E849 說 E850-E869 E880-E928 :accident(to) occuring (at)(in) 不

89 :E Late effect of

90 -1 列索 : 殺殺

91 -2 不 E930-E949

92 異例量 (Overdose of antihistamines) (Semicoma) 狀,, 車車, 隆

93 異例 Poisioning by antiallergic and antiemetic drugs( ) Coma and stupor( ) Fracutre of intertrochanteric section of femur, closed ( 隆, ) E858.1 Accidental poisoning by primary systemic agents( ) E812.1 Other motor rehicle traffic accident involving collision with motor rehicle, passenger in motor vehicle other than motorcycle( 車車, 車 )

94 Q586 1.CVP Infection E-code E879.8 E Double lumen infection E Double lumen E879.1 E878 Surgical operation, E879 Procedure,on CVP 行, 不, CVP Infection E-code E879.8, Double lumen E879.1

95 練

96 練 Motorcyclist injured in an accidental collision with car. Close fracture, right tibia and fibula, due to fall from bicycle Patient injured because he caught in heavy farm machinery that he was operating Syncope due to hypersensitivity to antidepressant medication. Coma due to unintentional overdose of sleep pills.

97 練 -1 Motorcyclist ( 車 )injured in an accidental collision with car.e812.2 Close fracture, right tibia and fibula, due to fall from bicycle E826.1 Patient injured because he caught ( )in heavy farm machinery ( )that he was operating E919.0+E849.1 accident=>machine=>agricultural( ) accident=>occurring=>farm Syncope due to hypersensitivity to antidepressant medication E939.0 Coma due to unintentional( ) overdose of sleep pills E852.9

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