卫生管理信息学第37卷第6期医学信息Vol.37No.62024年3月JournalofMedicalInformationMar.2024作者简介：展定莹（1995.8-），女，甘肃靖远人，本科，技师，主要从事国际疾病分类和病案信息化管理研究术后状态编码在病案首页的正确应用展定莹渊四川省第二中医医院病案管理办公室袁四川成都610000冤摘要院随着病案首页ICD编码在医保付费尧医院管理和临床科研等的作用日益重要袁医疗行业对ICD编码准确性提出更高要求遥ICD编码准确性不仅指主要诊断和主要手术编码准确袁也包括其他诊断编码准确遥但在实际工作中对其他诊断ICD编码准确性重视较少袁不规范填写情况较多遥术后状态则是其他诊断中最常见也较为特殊的诊断描述遥本文主要探讨了术后状态的编码分类和编码应用袁侧重强调了Z89-Z90尧Z93-Z96和Z98.8及Z92.4的区别袁再用实际案例阐述了术后状态编码在病案首页的正确用法袁以期为ICD编码提供参考遥关键词院ICD编码曰术后状态曰ICD-10曰其他诊断中图分类号院R197文献标识码院BDOI院10.3969/j.issn.1006-1959.2024.06.008文章编号院1006-1959渊2024冤06-0047-05CorrectApplicationofPostoperativeStatusCodingintheFrontPageofMedicalRecordsZHANDing-ying(MedicalRecordsManagementOffice,SichuanSecondHospitalofTraditionalChineseMedicine,Chengdu610000,Sichuan,China)Abstract：WiththeincreasingimportanceofICDcodingonthefrontpageofmedicalrecordsinmedicalinsurancepayment,hospitalmanagementandclinicalresearch,themedicalindustryhasputforwardhigherrequirementsfortheaccuracyofICDcoding.TheaccuracyofICDcodingnotonlyreferstotheaccuracyofmajordiagnosisandmajorsurgicalcoding,butalsoincludestheaccuracyofotherdiagnosticcoding.However,inpracticalwork,lessattentionispaidtotheaccuracyofICDcodingforotherdiagnoses,andtherearemorenon-standardfillings.Postoperativestatusisthemostcommonandspecialdiagnosticdescriptioninotherdiagnoses.Thispapermainlydiscussesthecodingclassificationandcodingapplicationofpostoperativestatus,focusingonthedifferencesbetweenZ89-Z90,Z93-Z96,Z98.8andZ92.4,andthenexpoundsthecorrectusageofpostoperativestatuscodingonthefrontpageofmedicalrecordswithpracticalcases,inordertoprovidereferenceforICDcoding.Keywords：ICDcoding;Postoperativestatus;ICD-10;Otherdiagnos...
