The importance and clinical significance of breast reconstruction’s procedure classification and coding
10.3760/cma.j.cn114453-20200817-00472
- VernacularTitle:乳房重建手术编码的重要性及临床意义
- Author:
Yang SUN
1
;
Qin SHU
;
Xiaobing XU
;
Lian XIAO
;
Sai HU
;
Shourong XU
;
Yaosong JIANG
;
Yanjiao XIN
;
Di LI
Author Information
1. 华中科技大学同济医学院附属协和医院病案统计科，武汉 430022
- Keywords:
Mammaplasty;
Clinical coding;
Diagnosis-related groups;
ICD-9-CM-3
- From:
Chinese Journal of Plastic Surgery
2021;37(7):757-762
- CountryChina
- Language:Chinese
-
Abstract:
Objective:To investigate the importance and clinical significance of breast reconstruction’s procedure classification and coding.Methods:By retrieving the medical record information system, the breast reconstruction cases with a diagnosis code (ICD-10) of C50 or Z85.3 and a procedure code (ICD-9-CM-3) of 85.33, 85.35, 85.53, 85.54, 85.55, 85.7, 85.95, or 85.96 were collected from Wuhan Union Hospital from Jan. 2016 to Dec. 2019. The reconstruction techniques and timing of the cases were counted according to the clinical procedure names in the operation notes and to the ICD codes verified by the content from operation notes and progress notes, respectively. The results were compared and analyzed by chi-square test with P<0.05 indicating statistically significant difference. Results:A total of 108 cases were included in the study. The difference between clinical procedure names and ICD codes regarding the reconstruction techniques is statistically significant ( P<0.05) with 51 clinical procedure naming ambiguities (47.2%) i. e., the names do not precisely indicate the reconstruction techniques. Similarly, the difference between clinical procedure names and ICD codes regarding the reconstruction timing is statistically significant ( P<0.05) with 29 clinical procedure name errors (26.9%). i. e., the reconstruction timing in the name does not correspond to its counterpart in reality. Conclusions:The clinical procedure names cannot accurately tell the reconstruction techniques or the timing of the procedure, affecting the correctness of the procedure coding and the diagnosis-related groups (DRGs) result. We suggest the reconstruction surgeons to learn some procedure classification and coding knowledge in a timely manner in order to enhance the correctness of the procedure names and coding and to get adapt to the medical insurance payment reform based on CHS-DRG.
