The Impact of standardization of surgical procedure names on the accuracy of ICD-9-CM-3 coding
10.3969/j.issn.1671-332X.2025.06.019
- VernacularTitle:手术操作名称规范性对ICD-9-CM-3编码准确性的影响
- Author:
Suhua FENG
1
;
Jian WU
1
;
Meiling CHEN
1
;
Chuling ZHENG
1
;
Caifang LIU
1
Author Information
1. 广州医科大学附属清远医院//清远市人民医院 广东清远 511518
- Publication Type:Journal Article
- Keywords:
Surgical operation name;
ICD-9-CM-3;
Medical record homepage;
Surgical code
- From:
Modern Hospital
2025;25(6):894-896,901
- CountryChina
- Language:Chinese
-
Abstract:
Objective To investigate and analyze the various reasons that affect the accuracy of ICD-9-CM-3 classifica-tion coding,identify key factors,and propose improvement strategies to enhance the accuracy and standardization level of surgical operation coding.Methods Using case analysis method,various factors affecting the accurate coding of ICD-9-CM-3 were sys-tematically listed and analyzed in detail.Through specific examples,this article analyzes the non-standard behavior of clinical physicians in writing surgical operation names,as well as the problems of coders relying on doctors to write,ignoring coding rules,and not fully reading medical records and surgical records during the coding process.It further explores how these factors lead to surgical classification errors.Results The main reasons affecting the accuracy of ICD-9-CM-3 coding include:lack of standardization in writing surgical operation names by clinical physicians,and failure to provide detailed descriptions of key ele-ments of the surgery;The coder overly relied on the doctor's written content during the coding process,failed to strictly follow the coding rules,and did not fully and deeply read and analyze medical records and surgical records,resulting in errors and devia-tions in surgical classification.Conclusion Each component of the surgical procedure name is an important factor affecting the accuracy of coding.Ensuring the completeness and accuracy of surgical operation names is crucial for improving the precision of ICD-9-CM-3 coding.In order to improve the quality of coding,clinical physicians need to enhance writing standards,while cod-ers need to strengthen their professional knowledge learning,strictly abide by coding rules,and comprehensively and meticulously review medical records and surgical records to achieve precise classification and coding of surgical operations.
