osteoarthritis bilateralknee Ans 715 36 osteoarthritis of knee
關節病變 例: osteoarthritis ,bilateral,knee Ans: 715. 36 例: osteoarthritis of knee and hip Ans: 715. 89
關節病變 o 外傷性關節炎(traumatic arthritis): 716. 1 x 是因關節受傷後所引起之關節炎 例: traumatic arthritis ,left ankle ,due to old traumatic dislocation Ans: 716. 17 + 905. 6(late effect )+E 929. X
關節病變 例: Gout arthritis with tophi Gout tophi若是在joint 建議編 274. 0即可, 若Gout tophi生長之部位在skin或soft tissure 則建議編 274. 0+274. 8 X。 病管協會Q&A編號 655
常見處置 全髋關節置換術(total hip replacement ,THR ) 代碼: 81. 51 半髋關節置換術(partial hip replacement ) 代碼: 81. 52 常見置換型態: 雙極式人 關節(Bipolar prosthesis ) 奧斯汀-摩里人 關節(Austin-Moore´s prosthesis ) 關鍵字:replacement
常見處置 例: A patient was a victim of right hip OA, admitted and received right hip total hip replacement (THR). When condition was stable then discharged. 診斷: 715. 35 處置: 81. 51
常見處置 例: The 52 -year –old male patient was a victim of partial hip replacement s/p 2 years ago This time he was complained hip pain and x-ray showed prosthetic loosening. After admitted revision total hip replacement was performed 診斷: 996. 4 + E 878. 1 處置: 81. 53 n complication→mechanical→device→orthopedic, internal
常見處置 例: Removal of infected hip prosthesis with subsequent readmission fro replacement of prosthesis 診斷: 996. 66 + E 878. 1 處置: 80. 05 n removal→foreign→joint structures-see also arthrotomy
常見處置 o arthroplasty: 內含以下處置 n n n n . debridment. brusectomy. ligament division and abrasion. synovectomy. excision plica. Remove of loose body. bone was abraded with a shaved
常見處置 arthroscopy: 80. 2 x Arthroscopic shaving and drilly: 80. 8 x 病管協會會訊第十三期, p 22 arthroscopic menisectomy: 80. 6 Coding clinic , 1993, 1 Q, p 23
常見處置 例:The patient OA Knee and loose body in right knee OP:Arthroscopy debridement & shaving , remove loose body及 arthroplasty Ans: 715. 36+717. 6+ 81. 47+80. 26
背部病變 o 代碼範圍: 720 -724 Back pain Lumbago or low back pain : 724. 2 Back pain not otherwise specified : 724. 5 Psychogenic back pain: 307. 89 若確知造成back pain之原因,此back pain 是屬於該病因之病徵時,則不再加編背痛 之代碼。
背部病變 o 椎間盤突出(herniation of interventral disc HIVD)代碼: 722. XX 編碼時須注意是否有合併脊髓病變 n HIVD with myelopathy: 722. 7 x Traumatic HIVD視為dislocation by site 關鍵字:herniation
背部病變 例: herniation interventral disc,L 4 -5, laminectomy with excision of intervertebral disc,L 4 -5 Ans: 722. 10+80. 51
常見處置 o o o Laminectomy 03. 09 Diskectomy 80. 51 Decompression 03. 09 Fusion 81. 0 x Laminectomy併diskectomy及fusion ,若部位 相同則03. 09可省略不編
常見處置 o Spinal fusion surgery 脊椎融合術 n Posterolateral fusion (PLF) Posterior lumbar interbody fusion (PLIF) Anterior lumbar interbody fusion(PLIF) Anterior spinal fusion (ALIF) Posterior spinal fusion Fusion 手術包含bone graft 及internal fixation,但 若醫師有明示取骨處則應加編 77. 7 x
常見處置 例: L 4 -5 spinal stenosis & HIVD & rheumatic arthritis 1. L 4 -5 laminectomy 2. PLIF (posterior lumbar interbody fusion ) 3. L 4 -5 discectomy 4. chip autognostic bone graft (from laminectomy) into L 4 -5 disc Ans: 722. 10+724. 02+714. 0 81. 08+80. 51
骨軟骨病變及後天肌肉骨髂畸形 例: osteomyelitis of left distal femur DM, type 2 poor control Ans: 250. 82+730. 25+731. 8 n diabetic with →osteomyelitis
骨軟骨病變及後天肌肉骨髂畸形 o 骨質疏鬆症(osteoporosis) : 733. 0 x n 第五位碼是以致病原因分類,如 老年性或醫源性骨質疏鬆 Drug induced osteoporosis: 733. 09 use additional E code to indentify drug
骨軟骨病變及後天肌肉骨髂畸形 例: senile osteoporosis→ senile→ 733. 01
骨折 編碼原則: 一、骨折可分為close or open 1、close fracture : (1)comminuted 粉碎性 (3)elevated 舉起 (5)fracture NOS未明示 (7)impacted嵌入性 (9)march前進性 (11)lipped epiphysis 骼滑脫 (2)depressed 凹陷性 (4)fissured裂縫 (6)green stich 柳條狀 (8)linear線性 (10)simple單純性 (12)spiral 螺旋形性
骨折 2、open fracture : (1)compound 複雜性 (2)infected 感染性 (3)missile 投射性 (4)puncture 穿刺性性 (5)with foreign body 異物
骨折 二 、Malunion or Nonunion of fracture (癒合不良或未癒合性骨折) 為骨折所造成之殘存狀況 以 733. 81或 733. 82為主要診斷, 再加上後遺 症(late effect)代碼及E-code Delay union編碼上可被視為nonunion o 關鍵字: Malunion or Nonunion
骨折 例: nonunion of fracture , left femoral neck fracture s/p Ans: 733. 82+905. 3+E-code
骨折 三. 診斷未明示為close or open fracture , 則以 close fracture 編碼 四. 同一部位之骨折有close and open fracture 時, 則只編open fracture 五. open fracture with tendon , capsule rupture 編open fracture 即可 六. Multiple fracture: 804、819、827、828,當 資料不足時方可使用,否則須分編碼
骨折 例: left tibia and fibual open fracture with tenden rupture Ans: 823. 92 Coding Clinic 1993, 2 Q, Page 7
骨折 例: Tibia PCL avulsion close fracture該如何編 碼? Ans: 823. 80 +844. 2 n close fracture ligament rupture兩者皆code Q&A編號 732
骨折 九. crushing injury 與骨折同時並存時,編碼應 以crushing injury為主診 斷,Fracture(800829) 或Internal injuries(860. 0 -869. 1)等為附加 診斷。 Coding Clinic, ICD-9 -CM Addendum, 2003, p. 20 病管協會公告
骨折 例:right upper leg crushing injury with right femur shaft fracture op: 1. Rotation flap graft 2. ORIF Ans: 928. 00+821. 01+86. 70+79. 35+E-code
骨折 例: pathological fracture due to metastatic carcinoma of bone ; ovary five years ago Ans: 733. 14+198. 5+V 10. 4
骨折 例: open tibia shaft fracture ORIF+Debridement tibia bone Ans: 823. 30+79. 36+79. 66+E-code o debridement performed on an open fracture site is assigned to the 79. 60 -79. 69 category Coding Clinic 1995. 3 Q. P 12
骨折手術 o Reduction of fracture : 79. 0 -79. 5 n n n 1. humerus 、(shoulder 、elbow 、olecram fossa ) 2. radius 、 ulna (colles’s 、olecram) 3. carpals 、metacarpals 6. tibia 、fibula (patella 、ankle 、knee) 9. other specified bone (clavicle)
脫臼 代碼範圍: 830 -839 脫臼分為: close or open 一. close dislocation: (1). complete完全性 (2 ). simple單純性 (3 ). dislocation NOS未明示 (4). uncomplication 無合併症 (5). partial部份
脫臼 二. open dislocation (1)compound複雜性 (2)infected 感染性 (3)with foreign body異物
脫臼 六. 包括:移位(displacement ) 半脫臼(subluxation) 不包括:先天性脫臼 (congenital dislocation)754. 0 -755. 8 病理性脫臼 (pathological dislocation)718. 2 x 復發性脫臼 (recurrent dislocation)718. 3 x
扭傷 o 代碼範圍: 840 -848 表關節囊( joint capsule)、韌帶(ligment)、肌 肉(muscle)與肌鍵(tendon)之損傷,(包括 sprain 、strain 、tear 、laceration 、rupture) 若合併開放傷口之肌鍵損傷,則編於 880 -884, 890 -894
扭傷 例: right hand laceration wound with tendon rupture OP:repair wound and tendon Ans: 882. 2+82. 86 wound open→hand→with tendon→ 882. 2
例題 例: 診斷:failed back syndrome (post L 1 -3 with junctional problem L 3/4) 手術:PLIF (posterior lumbar interbody fusion )及. L 4 -5 discectomy Ans: 722. 83+81. 08+80. 51 key word :posttlaminectomy syndrome →lumbar region→ 722. 83 協會Q&A 293
例題 例:The patient dizziness and fell down,致右肩 痛入急診, 於急診會骨科, 並使用三角巾固 定, 於新陳代謝科收入院 診斷:hypoglycemia cause unknown right humeral head avulsion fracture small infraction of brain gastric ulcer
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