PowerPoint 簡報

Size: px

Start display at page:

Download "PowerPoint 簡報"

骨灏籍
7 years ago
Views:

1 內科病歷書寫注意事項以 ICD-10-CM/PCS 為例台大醫院內科部主治醫師資訊室醫療資訊執行長病歷資訊管理室顧問醫師品質管理中心顧問醫師郭律成

2 何謂疾病分類疾病分類為一專業, 有疾病分類師證照醫師養成教育中, 缺乏此相關之學習依據病歷紀錄內容, 將診斷與處置加以編碼 WHO 於 1994 年用 42 種語言公佈 ICD-10 International Classification of Diseases 10 th Revision CM: Clinical Modification PCS: Procedure Coding System

3 時程美國原宣布疾病分類系統原訂於 2014 年 10 月 1 日以 ICD-10-CM/PCS 編碼美國國會通過延後一年施行 2015 年 10 月 1 日起施行我國健保署於 2016 年起, 以 ICD-10- CM/PCS 分類系統編碼

4 為何要導入 ICD-10-CM/PCS ICD-9-CM 將因缺乏維護單位而走入歷史 ICD-9-CM 已使用超過 30 年, 對病人照護的診斷以及處置手術都無法精確的描述, 且編碼結構受限, 無法因應新增需求擴編不正確的或有限的資料或資料不夠詳細等問題, 都將影響醫療診斷處置嚴重度與品質

5 第十版碼數為第九版的 5~22 倍第十版疾病碼處置碼位碼數 :3-7 字母數字碼位碼數 :7 字母數字碼代碼數 :68,000 代碼數 :90,000 疾病碼處置碼位碼數 :3-5 數字碼位碼數 :3-4 數字碼代碼數 :13,500 代碼數 :4,000 第九版

6 ICD-10-CM 之格式第 1 個字元為英文字母, 接著為 2 位數字接 1 個小數點, 小數點後接數字 X X X X X X X Category ( 類別 ) Etiology, anatomic site, severity ( 病因, 解剖部位, 嚴重度 ) Extension 擴充

7 ICD-10-PCS 之格式 ICD-10-PCS 一個處置碼包括七位碼, 每一位碼代表一個分類軸, 每一個分類軸可以多至 34 個選項章節手術方式手術途徑修飾詞系統分類手術部位裝置物

ICD10-CM 特性 - Severity 疾病的嚴重度的描述例如 Decubitus ulcer (Pressure ulcer) ICD-9CM ICD-10CM 707.0 Decubitus ulcer L89.000 Pressure ulcer of unspecified elbow, unstageable L89.

8 ICD10-CM 特性 - Severity 疾病的嚴重度的描述例如 Decubitus ulcer (Pressure ulcer) ICD-9CM ICD-10CM Decubitus ulcer L Pressure ulcer of unspecified elbow, unstageable L Pressure ulcer of unspecified elbow, stage 1 L Pressure ulcer of unspecified elbow, stage 2 L Pressure ulcer of unspecified elbow, stage 3 L Pressure ulcer of unspecified elbow, stage 4 L Pressure ulcer of unspecified elbow, unspecified stage

$) Cerebral infarction Dislocations Extremity atherosclerosis Fractures Injury Joint effusion, pain Pressure ulcers Sprains Tears 例如 Displaced transverse fracture of$

9 ICD10-CM 特性 - Laterality (side) 增加了側性的代碼描述在 Arthritis Cancers, neoplasms (breast, lung, bones, etc.) Cerebral infarction Dislocations Extremity atherosclerosis Fractures Injury Joint effusion, pain Pressure ulcers Sprains Tears 例如 Displaced transverse fracture of shaft of humerus, right arm, initial encounter for closed fracture. Rt. Lt.

10 ICD-10-CM 優於 ICD-9-CM 之特性明確性 : 罕見疾病疾病名稱 Gaucher's disease 高雪氏症中文 ICD-9- CM ICD-10- CM E75.22 Fabry disease Fabry 氏症 E75.21 Sialidosis 涎酸酵素缺乏症 E77.1 Adrenoleukodystrophy 腎上腺腦白質失養症 E Mucolipidosis 黏脂質症 E77.0 Cerebrotendinous Xanthomatosis 腦腱性黃瘤症 E75.5

ICD-10-PCS 優於 ICD-9-CM 之特性 Completeness( 完整性 ) ICD-9-CM ICD-10-PCS 0SR90J5 開放性右側髖關節置換術, 使用金屬對聚乙烯合成替代物 81.

11 ICD-10-PCS 優於 ICD-9-CM 之特性 Completeness( 完整性 ) ICD-9-CM ICD-10-PCS 0SR90J5 開放性右側髖關節置換術, 使用金屬對聚乙烯合成替代物個代碼全髖關節置換術 0SR90J6 開放性右側髖關節置換術, 使用金屬對金屬合成替代物 0SR90J7 開放性右側髖關節置換術, 使用陶瓷對陶瓷合成替代物 0SR90J8 開放性右側髖關節置換術, 使用陶瓷對聚乙烯合成替代物 0SR90JZ 開放性右側髖關節置換術, 使用合成替代物 0SR90KZ 開放性右側髖關節置換術, 使用非自體移植組織替代物

12 ICD-10-CM/PCS 可精確的辨識診斷及處置碼 : 治療過程及醫療耗用程度可以更精確呈現提供研究更多且更正確的資料, 並使研究成果能與國際接軌並做跨國比較 ICD-10-CM/PCS 對醫療機構之病歷管理疾病分類健保申報資訊系統與臨床照護運作等作業息息相關, 實施前若不做周全的準備, 將衝擊醫院的運作及影響健保給付欲成功導入 ICD-10 系統, 除了醫院政策支持外, 必須靠資訊單位臨床單位及病歷管理單位三方面的協同合作

13 減少對臨床作業的衝擊 ICD-10 CM/PCS 實施, 雖然記載足夠的訊息是必要的, 但不能為此而影響臨床作業或做不必要的文書工作 ICD-10 工作團隊分析現行紀錄不足以編碼情形, 找出問題所在點, 才能提出合宜對策, 以減少對臨床作業的衝擊

14 ICD-10-CM/PCS 相關資料

15 台大醫院各次專科前十大診斷處置 ICD-10-CM/PCS 編碼問題收集病歷書寫正確對應 ICD-10 病歷書寫應注意事項或編碼疑慮診斷 / 處置診斷處置診斷處置佔率 83.3% 75.4% 16.7% 24.6%

16 無法正確編碼分析無法正確編碼醫師病歷紀錄不完整疾分人員專業不足無法正確解讀病歷疾分人員不熟悉 ICD-10 編碼規則

17 明確之診斷尚未確定之診斷診斷用語暫時診斷 (preliminary diagnosis) 預先診斷 (provisional diagnosis) 臨時診斷 (tentative diagnosis) 臆斷 (impression) 有印象猜測之義, 主觀的因素, 應少用為宜以症狀作為診斷胸痛發燒視力模糊心悸... Rule out (R/O): 無法用於 ICD-10 編碼字面上, rule out 是指排除某種疾病, 但卻常被使用為應考慮某種疾病 To be ruled out versus To be considered

18 案例

19 Chronic kidney disease, CKD 診斷名稱 ICD-9 CM ICD-10 CM CKD, stage Unspecified disorder of kidney and ureter N18.1 Chronic kidney disease, stage 1 CKD, stage 2 N18.2 Chronic kidney disease, stage 2 CKD, stage 3 N18.3 Chronic kidney disease, stage 3 CKD, stage 4 N18.4 Chronic kidney disease, stage 4 CKD, stage N18.5 Chronic kidney disease, stage 5 Chronic renal failure ESRD N18.6 End stage renal disease N18.9 Chronic kidney disease, unspecified

20 Chronic kidney disease, CKD

21 Chronic kidney disease, CKD

22 Heart failure

23 Urosepsis ICD-10 CM ICD-9 CM

24 Urosepsis?

25 Pressure sore ICD-10 CM ICD-9 CM Pressure sore 需區分部位側性期別

26 Pressure sore 沒有側性及 stage

27 Pressure sore 部位? 側性? Stage?

28 Pressure sore

29 Nosocomial infection ICD-10 CM ICD-9 CM 沒有 nosocomial infection 代碼

30 Nosocomial infection

31 Crohn's Disease ICD-9 CM ICD-10 CM

32 Crohn's Disease

33 Lymphoma

34 Gastric cancer

36 BPH 編碼可能與健保開立相關藥物有關

37 Myocardial infarction

38 DM

39 Dry eye

40 Glaucoma

41 Thoracentesis ICD-9 1 個代碼當次 tapping 後留有 chest tube Thoracentesis 34.91

42 Thoracentesis 那一側?

43 Thoracentesis

44 Percutaneous transluminal coronary angioplasty (PTCA) ICD-9-CM Coronary arteries are classified by number of coronary arteries or anatomic name of a coronary ICD-10-PCS Coronary arteries are classified by number of distinct sites treated, rather than number of coronary arteries or anatomic name of a coronary

45 PTCA ICD-10-PCS

ICD-9-CM與ICD-10-PCS處置碼的差異 ICD-9-CM 處置碼 1. 36.05 Multiple vessel PTCA or coronary atherectomy performed during the same operation, with or without mention of thrombolytic agent 2. 36.06 Insertion of coronary artery stent(s) 3.

46 ICD-9-CM與ICD-10-PCS處置碼的差異 ICD-9-CM 處置碼 Multiple vessel PTCA or coronary atherectomy performed during the same operation, with or without mention of thrombolytic agent Insertion of coronary artery stent(s) Left heart cardiac catheterization Coronary arteriography using two catheters ICD-10-PCS Z Dilation of Coronary Artery, Two Sites with Drug-eluting Intraluminal Device, Percutaneous Approach Dilation of Coronary Artery, One Site, Bifurcation, with Drug-eluting Intraluminal Device, Percutaneous 3. 4A023N7 Measurement of Cardiac Sampling and Pressure, Left Heart, Percutaneous Approach 4. B2111ZZ Fluoroscopy of Multiple Coronary Arteries 46 using Low Osmolar Contrast

47 PTCA CAD, 3VD, s/p POBAS with DES to LAD (2 sites, one in bifurcation [LM-LAD-LCX]) and RCA (one site) 47

49 Liver biopsy ICD-9 CM ICD-10 PCS

50 Liver biopsy

51 Liver biopsy S a.4b 肝左葉 S 肝右葉

52 Chemotherapy

53 Transfusion

55 支氣管鏡 Right side bronchial tree : No endobronchial lesion, fair mucosa, scanty sputum Left side brochial tree : No endobronchial lesion, fair mucosa, scanty sputum Bronchoscopic Diagnosis : 1. Several endotracheal tumors with mildly erosive mucosa 2. Scanty sputum 3. Radial EBUS showed concentric peribronchial lesion at RB3 Specimens :? 1. Transbronchail biopsy*4 to RB3 for pathology 2. Entracheal biopsy*4 to for pathology 3. Bronchial washing to RB3 cytology; bacterial, TB & fungal culture 檢查處置 Body Part 選取 RB1- RB3 Right upper RB4- RB5 Right middle RB6-RB10 Right Lower LB1- LB5 Left Upper LB6-LB10 Left Lower 不需改變醫師書寫習慣, 疾分人員再教育即可

56 支氣管鏡 & 切片

57 = Bronchoscopic biopsy, open-lung biopsy, VATS biopsy 0BB58ZX or 0BB68ZX?

58 何處做切片? RM 是何縮寫? (right main bronchus? right middle lobe bronchus?)

66 復健在 ICD-9 無細碼, 但在 ICD-10 分得很細

68 不明確 (unspecified) 之診斷編碼 ICD 10 診斷名稱說明 J18.9 Pneumonia, unspecified organism 如有培養出菌種, 應書寫於出院診斷 C67.9 Malignant neoplasm of bladder, unspecified I50.9 D49.0 C C Heart failure, unspecified (congestive heart failure) Neoplasm of unspecified behavior of digestive system Malignant neoplasm of unspecified site of right female breast Malignant neoplasm of unspecified site of left female breast C11.9 Malignant neoplasm of nasopharynx, unspecified M35.9 Systemic involvement of connective tissue, unspecified I63.9 Cerebral infarction, unspecified C16.9 Malignant neoplasm of stomach, unspecified Trigone, dome, lateral wall, anterior wall, posterior wall, neck, ureteric orifice, rachus, overlapping sites 先分 Systolic heart failure 及 Diastolic heart failure, 再細分為急性慢性診斷為消化系統的 tumor, 如已有病理報告, 應更新出院診斷分 nipple and areola, central portion, upper-inner quadrant, upper-outer quadrant, lower-outer quadrant 等 superior wall posterior wall lateral wall anterior wall overlapping sites 1.Vascular territory 2.Thrombosis, Embolism Cardia, fundus, body, pyloric antrum, pylorus, lesser curvature, greater curvature, overlapping sites

69 研擬病歷紀錄不足解決方案病歷紀錄不足系統性問題非系統性問題資訊系統輔助回饋及教育訓練

70 結論病歷紀錄完整正確是臨床人員的職責 ICD-10 CM/PCS 實施, 雖然記載足夠的訊息是必要的, 但不能為此而影響臨床作業或做不必要的文書工作 ICD-10 工作團隊分析現行紀錄不足以編碼情形, 找出問題所在點, 才能提出合宜對策, 以減少對臨床作業的衝擊

危疾指引這份指引可助您了解自己危疾保單內所承保的疾病及療程每種受保的危疾均會加以及我們更會扼要地列出各種除外責任及所須長短我們凡在這份指引中提及專科醫

危疾指引這份指引可助您了解自己危疾保單內所承保的疾病及療程每種受保的危疾均會加以及我們更會扼要地列出各種除外責任及所須長短我們凡在這份指引中提及專科醫危疾指引永明危疾保險驕陽永明, 人生更燦爛危疾指引這份指引可助您了解自己危疾保單內所承保的疾病及療程每種受保的危疾均會加以及我們更會扼要地列出各種除外責任及所須長短我們凡在這份指引中提及專科醫生, 皆指在所索