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国际阻塞性肺病疾病分类编码:是否反映了适当的临床记录?

International classification of disease coding for obstructive lung disease: does it reflect appropriate clinical documentation?

机构信息

Division of Pulmonary Medicine, St. Francis Hospital-The Heart Center, 100 Port Washington Blvd, Roslyn, NY 11576, USA.

出版信息

Chest. 2010 Jul;138(1):188-92. doi: 10.1378/chest.09-1342.

Abstract

International Classification of Disease coding is widely used by physicians, hospitals, health-care payers, and governments to assess the health of populations and as a means of reimbursement for medical care based on diagnosis and severity of illness. The current classification system, International Classification of Diseases, 9th ed (ICD-9), will soon be replaced by International Classification of Diseases, 10th ed (ICD-10). When the codes that relate to COPD and asthma are examined, the clinical relevance of the categories in International Classification of Disease coding must be questioned. In the future, a more simplified terminology that is consistent with clinical usage could improve accuracy and ease of coding. At present, however, clinicians should become familiar with the present ICD-9 and future ICD-10 codes so that their descriptions of illnesses in the medical records more accurately reflect current coding terminology.

摘要

国际疾病分类编码被医生、医院、医疗保健支付者和政府广泛用于评估人群的健康状况,并根据诊断和疾病严重程度来支付医疗费用。目前的分类系统,国际疾病分类第 9 版(ICD-9),即将被国际疾病分类第 10 版(ICD-10)取代。当检查与 COPD 和哮喘相关的代码时,必须质疑国际疾病分类编码中类别的临床相关性。在未来,更简化的、与临床使用一致的术语可以提高准确性和编码的便利性。然而,目前临床医生应该熟悉目前的 ICD-9 和未来的 ICD-10 代码,以便他们在病历中更准确地描述疾病,反映当前的编码术语。

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