《中国病案》2023年第24卷第2期·27··疾病与手术分类·跟腱修补术编码浅析高子健①马志晖①*摘要跟腱修补术是跟腱损伤后的常见术式，其术式更是种类繁多。由于临床书写不规范，以及编码员自身能力的原因，导致跟腱修补术的手术编码互相混淆，产生错编或漏编。通过对跟腱修补术式的整理，列举出不同术式中的核心区别，并确定术式相关的主导词，进而查找正确的手术编码，单纯的跟腱修补是跟腱缝合术83.64，带铆钉的跟腱修补术是83.88，同种异体肌腱移植修补术是83.81，跟腱修补术伴踇长屈肌腱移位术是83.75，跟腱延长术是83.85。同时对4个跟腱修补术案例进行分析，浅析编码人员在编码过程中可能存在的问题，通过提高编码员对手术过程的掌握程度，及时更新相应的临床知识，能够意识到主导词及修饰词的重要性，加强对ICD-9-CM-3编码工具书的应用以及书中英文注释的解读，这些都会提升手术编码的准确性。关键词跟腱手术；手术编码；ICD-9-CM-3AnalysisofOrthopedicAchillesTendonSurgeryGaoZijian,MaZhihui*AbstractAchillestendonrepairisacommonoperationafterAchillestendoninjury,andtherearemanysurgicalmethods.Duetonon-standardclinicalwritingandcoders'ownability,thesurgicalcodesofAchillestendonrepairwereconfusedwitheachother,resultinginmiscodingormissingcoding.Inthispaper,bysortingoutthesurgicalmethodsofAchillestendonrepair,thecoredifferencesamongdifferentsurgicalmethodsarelisted,andtheleadingwordsrelatedtothesurgicalmethodsaredetermined,soastofindthecorrectsurgicalcode.ThesimpleAchillestendonrepairisAchillestendonsuture83.64,theAchillestendonrepairwithrivets83.88,andthetendonallograftrepair83.81.Achillestendonrepairwithhalluxflexortendontransferwas83.75,andAchillestendonlengthationwas83.85.ForfouroftheAchillestendonrepaircaseanalysis,analysesthecodermayexistintheprocessofcodingproblem,byimprovingthecoder'smasterintheoperationprocess,updatethecorrespondingclinicalknowledge,torealizetheimportanceofleadingwords,andmodifiers,andstrengthentheICD-9-CM-3codingtheinterpretationoftheuseofreferencebooksandbooksinEnglishandChineseannotation.Allofthesewillimprovetheaccuracyofsurgicalcoding.KeywordsTheAchillestendonsurgery；Theoperationcode；ICD-9-CM-3Firs...
