PPT檔下載

Report
ICD-10-CM/PCS介紹
台大醫院 病歷資訊管理室
疾病分類組 游斐雲
2014-10-25
1
ICD-9-CM為何要改為ICD-10-CM/PCS
醫療評估欠缺合理基礎
編碼限制影響DRG給付
與國際接軌
2
台灣導入ICD-10-CM/PCS的計畫
延至??
小全
型國
醫推
院廣
先教
驅育
計課
劃程
資配
訊合
作
業卡
,上
雙傳
軌,
作開
業發
及
建
置
•
ICD-10-CM/PCS
•DRG
報健徵全
格保求國
式局醫教
資院育
料自訓
庫院練
建參
立加
,雙
公軌
告編
申碼
IC
完培
成育
台種
灣子
中師
文資
版
初
稿
當
門
時
、
機分 住
類 診
之 、
轉 全
換 面
將。單
再 軌
擇 申
適 報
3
什麼是ICD-10-CM/PCS
• ICD-10-CM (International Statistical Classification of
Diseases and Related Health Problems,Tenth Revision,Clinical
Modification)
國際疾病與相關健康問題統計分類第十版臨床修訂
(適用於門住診疾病診斷分類)
• ICD-10-PCS (Procedure coding system) 處置代碼系統
1993年美國CMS與3M資訊公司,依ICD-9-CM第3冊發展。
(適用於住診處置分類)
4
診斷代碼格式的改變-1
項目
ICD-9-CM
ICD-10-CM
格式(Format)
XXX.XX
XXX.XXXX
長度(Length)
3-5
3-7
代碼數量
13,000 +
68,000 +
開頭字元
數字或字母
字母
例如
COPD
Femoral neck fr.
DM
Hepatitis B carrier
496
820.8
250.00
V02.61
J44.9
S72.009A
E11.9
Z22.51
5
診斷代碼格式的改變-2
ICD-9-CM
XXX.XX
Category
ICD-10-CM
XXX.XXX X
Category
Etiology
Anatomic site
Manifestation
Etiology
Anatomic site
Manifestation
Severity
Extension
6
章節編排的改變
ICD-9-CM
第1章 傳染病與寄生蟲疾病
第2章 腫瘤
第3章 內分泌、營養、代謝疾病和免疫失調
第4章 血液及造血器官疾病
第5章 精神疾患
第6章 神經系統和感覺器官的疾病
第7章 循環系統疾病
第8章 呼吸系統疾病
第9章 消化系統疾病
第10章 泌尿生殖系統疾病
第11章 妊娠、生產與產褥期併發症
第12章 皮膚與皮下組織疾病
第13章 肌肉骨骼系統與結締組織疾病
第14章 先天畸形
第15章 周產期的病況
第16章 症狀、徵兆和不明確的情況
第17章 損傷及中毒
*損傷及中毒外因分類
*補充分類
ICD-10-CM
第1章 感染症與寄生蟲疾病
第2章 腫瘤
第3章 血液、造血器官與免疫機轉的疾患
第4章 內分泌、營養與(新陳)代謝疾病
第5章 精神[心智]與行為疾患
第6章 神經系統疾病
第7章 眼與附器疾病
第8章 耳與乳突疾病
第9章 循環系統疾病
第10章 呼吸系統疾病
第11章 消化系統疾病
第12章 皮膚與皮下組織疾病
第13章 肌肉骨骼系統與結締組織疾病
第14章 泌尿生殖系統疾病
第15章 妊娠、生產與產褥期
第16章 源於周產期的病況
第17章 先天性畸形、變形與染色體異常
第18章 症狀、徵候與臨床和實驗室異常發現
第19章 傷害、中毒與外因造成的其他影響
第20章 罹病與死亡的外因
第21章 影響健康狀態與醫療保健服務接觸因素
7
Salmonella infection
依嚴重度、部位給不同代碼
A02.9
Salmonella infection
A02.0
A02.1
Salmonella enteritis
Salmonella sepsis
A02.2- Salmonella meningitis, pneumonia..
8
Tuberculosis(A15-A19)
A15
A17
A18
A19
Respiratory
Nervous system
Other system
Miliary
•
肺 (A15.0)
•
胸腔內淋巴結
(A15.4)
•
喉、氣管及支氣
管 (A15.5)
•
肋膜炎 (A15.6)
•
其他呼吸道
(A15.8)
• 腦膜炎(A17.0)
骨骼及關節,生殖
• 腦膜腦炎
泌尿系統,周邊淋
(A17.82)
巴腺,腸道、腹膜
• 腦和脊髓之結
及腸繫膜, 皮膚及
核瘤 (A17.81)
皮下組織,眼,耳,內
• 神經炎
(A17.83)
• 急性單一部位
(A19.0)
• 急性多重部位
(A19.1)
分泌腺體,心臟等
等
Old TB (B90- )
9
Sepsis
A41.9 & R65.21
Septic shock
Severe sepsis A41.9 & R65.20
Sepsis A41.9 (常見於 A40-, A41-)
SIRS R65.10 & R65.11
(是否有Acute organ dysfunction)
10
Diabetes mellitus(E08-E13)
Type I
Type II
E10
E11
Juvenile
/ Brittle
Default
Durg /
chemical
other
E08
E09
E13
Pancreatic Dz,
SteroidInduced
Due to
underlying
Malignancy
Cushing’s
Postop
Secondary
11
DM的併發症
Coma E10.11
Coma E11.11
Coma E11.641
E11.00
E11.649
E11.65
Hypo
glycermia
Hyper
glycermia
E10.10
DKA HHNK
E11.21
E11.319
E11.40
Nephro
pathy
Retino
pathy
Neuro
pathy
E11.52
gangrene
E11.628
E11.630
E11.618
ulcer
Periodo
ntitis
Arthro
pathy
12
Hypertension (I10-I15)
I10
原發性
高血壓
I11
高血壓
性
心臟病
I12
I13
I15
高血壓
性慢性
腎臟病
高血壓
性心臟
及慢性
腎臟病
續發性
高血壓
先編高血壓,另編心臟衰竭或慢性腎臟病之型態
13
心臟衰竭和慢性腎臟病之型態
Heart failure
CKD
• LV failure (I50.1)
• CKD stage1(N18.1)
• Systolic failure (I50.2-)
• CKD stage2(N18.2)
• Diastolic failure (I50.3-)
• CKD stage3(N18.3)
• Systolic & Diastolic
failure (I50.4-)
• CKD stage4(N18.4)
• RV failure (I50.9)
• ESRD (N18.6)
• CKD stage5(N18.5)
• CKD (N18.9)
14
其他高血壓疾病
代碼
名稱
注意事項
I60-I69 Hypertensive
cerebrovascular disease
先編CVA代碼
再加編高血壓碼
H35.03- Hypertensive retinopathy
需另編高血壓代碼
依入院情況排順序
妊娠暫時性高血壓,
無顯著蛋白尿
妊娠暫時性高血壓,
有顯著蛋白尿
O13
O14
R03.0
PIH without significant
proteinuria
PIH with significant
proteinuria
Elevated blood pressure
用於血壓值升高,但
無診斷高血壓
15
Acute myocardial infarction
I21
Acute
I25.2
Old MI
I22
Subsequent
I23
Complication
• STEMI依梗塞部位編碼,NSTEMI皆編於I21.4
• 離前次MI ,4週內又發生MI,I21和I22皆需編碼
• 代碼I23需合併使用I21或I22
16
Asthma (J45)
• 變項 :
– Mild –Moderate –Severe
– Intermittent –Persistent
– Acute exacerbation –Status Asthmaticus
• 例如:
– J45.40 Moderate persistent asthma
– J45.41 Moderate persistent asthma with
acute exacerbation
– J45.42 Moderate persistent asthma with
status asthmaticus
17
Trimester
• 產科代碼新增妊娠期別的描述
例如
O99.011 Anemia complicating pregnancy,
first trimester
<14週
O99.012 Anemia complicating pregnancy,
second trimester 14 ~ <28週
O99.013 Anemia complicating pregnancy,
third trimester 28週~
O99.019 Anemia complicating pregnancy,
unspecified trimester
18
Fracture 7th Character
A –Close fx
B –Open fx
type I or II
C –Open fx
type IIIA,
IIIB, IIIC
Initial
D –Close fx
G –Close fx
routine
healing
delayed
healing
E -Open fx
H –Open Fx
type I or II ,
routine
healing
K –Close fx
P –Close fx
nonunion
malunion
M –Open fx
Q –Open fx
type I or II ,
delayed
healing
type I or
II ,nonunion
type I or
II ,malunion
F –Open fx
J –Open fx
N-Open fx
type IIIA,
IIIB,
IIIC ,routine
healing
type IIIA,
IIIB, IIIC ,
delayed
healing
type IIIA,
IIIB,
IIIC ,nonuni
on
Subsequent
提供醫療照護的時機的描述
Sequela
R –Open fx
type IIIA,
IIIB,IIIC ,mal
union
S –sequela
19
Pressure ulcer
L89. X X X
1.指Skin change,edema
2
2
3
部 側 深
位 性 度
4
4
L89.500 Pressure ulcer of unspecified ankle, unstageable (無法分期)
L89.501 Pressure ulcer of unspecified ankle, stage 1
L89.502 Pressure ulcer of unspecified ankle, stage 2
L89.503 Pressure ulcer of unspecified ankle, stage 3
L89.504 Pressure ulcer of unspecified ankle, stage 4
L89.509 Pressure ulcer of unspecified ankle, unspecified stage
(未明示分期)
20 20
Skin ulcer(nonpressure)
L97. X X X
1
1
2
部 側 深
位 性 度
3
4
L97.301 ulcer of unspecified ankle limited to breakdown of skin
L97.302 ulcer of unspecified ankle with fat layer exposed
L97.303 ulcer of unspecified ankle with necrosis of muscle
L97.304 ulcer of unspecified ankle with necrosis of bone
L97.309 ulcer of unspecified ankle with unspecified severity
側性: 1-右 ,2-左
21
Respiratory failure (J96)
J96.0
Acute
J96.1
Chronic
J96.2
Acute on
chronic
J96.9
unspecified
• 第5位碼再區分
--“1”hypoxia
--“2”hypercapnia
--“9”unspecified
• P28.5 Newborn respiratory failure
• J95.821 Postprocedural respiratory failure
22
Coronary artery disease
血管型態
●
●
Native vessel
Post bypass graft(s)
合併症狀
●
Ustable angina
●
Angina with documented
-- autologous vein
-- autologous artery
-- nonautologous
biological bypass graft(s)
-- specified type
●
spasm
●
Other forms of angina
●
Unspecified angina
Transplanted heart
--of native coronary artery
-- bypass graft(s)
I25.1- I25.7- I25.823
Benign prostatic hypertrophy
• N40.0 Enlarged prostate without LUTS
• N40.1 Enlarged prostate with LUTS
另加編 lower urinary tract symptoms :
• incomplete bladder emptying
• urinary incontinence (N39.4-)
(R39.14)
• nocturia (R35.1)
• urinary obstruction (N13.8)
• straining on urination (R39.16) • urinary retention (R33.8)
• urinary frequency (R35.0)
• urinary urgency (R39.15)
• urinary hesitancy (R39.11)
• weak urinary stream (R39.12)
24
Open wound
S61. X X X X
部 異 側 就
位 物 性 診
時
機
• 明示傷口類型及有無異物
• 類型包含:
laceration, penetration,perforating,
puncture,open bite等
• 側性: 1-右 ,2-左
S61.41 Laceration without foreign body of hand
S61.42 Laceration with foreign body of hand
S61.43 Puncture wound without foreign body of hand
S61.44 Puncture wound with foreign body of hand
S61.45 Open bite of hand
• 就診時機: A- initial , D- subsequent , S-sequela
25
Cerebrovascular disease
I60-I62
I63
I65-I66
hemorrhage
Infarction
occlusion
• 部位
• 血管
- SAH
 血管
 側性- left,right
- ICH




Hemisphere
brain stem
Cerebellum
intraventricular
- SDH
 acute
 Subacute
 chronic
- EDH
Old CVA I69-
• 血管
- precerebral
- precerebral
 basilar
 carotid
 vertebral
- cerebral
 anterior
 middle
 posterior
• 側性- left,right
• 型態
 basilar
 carotid
 vertebral
- cerebral
 anterior
 middle
 posterior
• 側性
- left,right, bilateral
- embolism
- thrombosis
Occlusion併infarction編於I6326
Old CVA with late effect (sequelae)
I69.0~I69.2
hemorrhage
I69.3
Infarction
I69.8
Other
第 5 位碼
第 6 位碼
1
2
3
4
5
6
9
1
2
3
4
5
Cognitive deficits
Speech and language deficits
Monoplegia of upper limb
Monoplegia of lower limb
Hemiplegia and hemiparesis
Other paralytic syndrome
Other sequelae
right dominant side
left dominant side
right non-dominant side
left non-dominant side
bilateral
未明示dominant side, 分類規則如下 :
• For ambidextrous patients, the default should be dominant.
• If the left side is affected, the default is non-dominant.
• If the right side is affected, the default is dominant.
27
處置代碼格式的改變-1
項目
ICD-9-CM
ICD-10-PCS
格式(Format)
XX.XX
XXXXXXX
長度(Length)
3-4
固定7位(無小數點)
字元型態
數字
字母或數字
代碼數量
3,700 +
86,000 +
例如 :
Laparoscopic
cholecystectomy
51.23
0FT44ZZ
28
處置代碼格式的改變-2
• 代碼由固定7位碼構成,例如 02103D4
• 可填入的值共有34個
– 數字:0 - 9
– 字母:除了I和O以外 (因容易和數字1和0混淆)
例如在Medical and Surgical章節的7碼意義如下:
Section
章節
Character
7位碼
1
Root operation Approach
手術途徑
手術方式
2
Body system
系統分類
3
4
Body part
手術部位
5
Qualifer
修飾辭
6
7
Device
裝置物
29
處置編排的改變
ICD-9-CM
章節
第 1章
第 2章
第 3章
第 4章
第 5章
第 6章
第 7章
第 8章
第 9章
第 10章
第 11章
第 12章
第 13章
第 14章
第 15章
第 16章
內容
神經系統手術
內分泌系統手術
眼的手術
耳部手術
鼻、口、咽手術
呼吸系統手術
心血管系統手術
血液和淋巴系統手術
消化系統手術
泌尿系統手術
男性生殖器官手術
女性生殖器官手術
產科處置
肌肉骨骼系統手術
皮膚系統手術
其他及治療性處置
ICD-10-PCS
章節
內容
Medical and Surgical
Obstetrics
Placement
Administration
Measurement and Monitoring
Extracorporeal Assistance and Performance
Extracorporeal Therapies
Osteopathic
Other Procedures
Chiropractic
Imaging
Nuclear Medicine
Radiation Oncology
0
1
2
3
4
5
6
7
8
9
B
C
D
F Physical Rehabilitation and Diagnostic Audiology
G Mental Health
H Substance Abuse Treatment
30
範例:Esophagogastroduodenoscopy
with gastric biopsy
 0DB68ZX :
Character1
Section
Character2
Body System
Gastrointesti
Medical and nal System
Surgical
0
D
Character3
Root
Operation
Character4
Body Part
Character5 Character6 Character7
Approach
Device
Qualifier
Excision
Stomach
Via Natural
or Artificial
No Device Diagnostic
Opening
Endoscopic
B
6
由手術關鍵字
開始查詢索引
8
Z
X
查詢部位,途徑,裝置和特性
31
Medical and Surgical--Root operation
0- Alteration
C- Extirpation
1- Bypass
P- Removal
外力拉 D- Extraction
2- Change 出剝離 F- Fragmentation
Q- Repair
3- Control
G- Fusion
S- Reposition
4- Creation
H- Insertion
T- Resection
5- Destruction
J- Inspection
切除
V- Restriction 全部
6- Detachment
K- Map
W- Revision
7- Dilation
L- Occlusion
U- Supplement
8- Division
M- Reattachment
X- Transfer
9- Drainage 切除
B- Excision 部分
N- Release
Y- Transplantation
R- Replacement
32
Medical and Surgical--Body system
0- Central Nervous System
C- Mouth and Throat
P- Upper Bones
1- Peripheral Nervous
System
D- Gastrointestinal System
Q- Lower Bones
2- Heart and Great Vessels
F- Hepatobiliary System
and Pancreas
R- Upper Joints
3- Upper Arteries
G- Endocrine System
S- Lower Joints
4- Lower Arteries
H- Skin and Breast
T- Urinary System
5- Upper Veins
J- Subcutaneous Tissue
and Fascia
U- Female Reproductive
System
6- Lower Veins
K- Muscles
V- Male Reproductive
System
7- Lymphatic and Hemic
Systems
L- Tendons
W- Anatomical Regions,
General
8- Eye
M- Bursae and Ligaments
X- Anatomical Regions,
Upper Extremities
9- Ear, Nose, Sinus
N- Head and Facial Bones
Y- Anatomical Regions,
Lower Extremities
B- Respiratory System
33
Medical and Surgical--Approach
0 Open
開放性
3 Percutaneous
經皮
4 Percutaneous Endoscopic
經皮內視鏡
7 Via Natural or Artificial Opening
經由自然開口或人工造口
Via Natural or Artificial Opening
8 Endoscopic
經由自然開口或人工造口
內視鏡
Via Natural or Artificial Opening With
F Percutaneous Endoscopic Assistance
經由自然開口或人工造口
合併經皮內視鏡輔助
X External
經由外部
34
Medical and Surgical--Device
0-Drainage Device
C-Extraluminal Device
M-Stimulator Generator
1-Radioactive Element
D-Intraluminal Device
N-Neurostimulator Generator,
Tissue Expander
2-Monitoring Device
3-Infusion Device
E-Endotracheal Airway,Multiple Array
P-Cardiac Rhythm Related Device
Rechargeable Stimulator Generator
Q-Implantable Heart Assist System,
F-Tracheostomy Device
Biventricular External Heart Assist
System
4-Internal Fixation Device
G-Endobronchial Valve,Pessary
R-External Heart Assist System
5-External Fixation Device
H-Contraceptive Device
S-Hearing Device
6-Intramedullary Internal Fixation
Device
J-Synthetic Substitute
T-Radioactive Intraluminal Device,
7-Autologous Tissue Substitute
K-Nonautologous Tissue Substitute
U-Feeding Device
8-Spacer
Y-Other Device
V-Infusion Pump
9-Autologous Venous Tissue
L-Artificial Sphincter
W-Reservoir
A-Interbody Fusion Device
M-Bone Growth Stimulator,
Neurostimulator Lead, Stimulator X-Vascular Access Device
Lead,Cardiac Lead ,
B-Monoplanar External Fixation
Device
M-Diaphragmatic Pacemaker Lead
Y-Other Device
35
Medical and Surgical--Qualifier
1-Bypass
D-Extraction
S-Reposition
4-Creation
G-Fusion
T-Resection
5-Destruction
H-Insertion
U-Supplement
6-Detachment
L-Occlusion
V-Restriction
7-Dilation
M-Reattachment
X-Transfer
9-Drainage
N-Release
Y-Transplantation
B-Excision
Q-Repair
C-Extirpation
R-Replacement
36
Endoscopic
sigmoid colon polypectomy
• 0DBN8ZZ
Excision
37
Closed reduction radius fracture
• 0PSHXZZ(右), 0PSJXZZ(左)
Reposition
38
Repair left inguinal hernia
• 0YQ60ZZ
Repair
39
Repair
left inguinal hernia with mesh
• 0YU60JZ
Supplement
40
Delivery
• 10E0XZZ(Assisted spontaneous)
Delivery
• 10D00Z1 (C/S) ,10D00Z2(Extraperitoneal C/S)
Extraction
• 10D07Z6(Vacuum),10D07Z3(forceps,low)
Extraction
41
Episiotomy and repair
• 0W8NXZZ (剪Ep&repair)
• 0KQM0ZZ (2o裂傷 perineal repair)
Division
Repair
42
Delivery perineal laceration
0KQ
0HQ,0UQ,0WQ
2o
1o
•
•
Vulva,fourchette,
•
Pelvic floor
labia 0UQM0ZZ
•
Perineum
Perineum skin
0HQ9XZZ
•
•
muscles
Vagina muscles
Vagina mucosa
•
Vagina wall
0UQG0ZZ
•
Vulva,fourchett
e,labia
Slight perineal
診斷 : O70.0
•
Perineum skin
•
Slight perineal
診斷 : O70.1
0DQ
3o
4o
Anal sphincter
•
Anal mucosa
•
Rectal mucosa
septum
•
Anal sphincter
•
Pelvic floor
•
Rectovagina
•
Perineal
0DQR0ZZ
•
0KQM0ZZ
•
0WQN0ZZ
•
0DQ
Rectovagina
septum
muscles
•
Vaginal
muscles
僅anal sphincter tear
診斷 : O70.4
診斷 : O70.2
診斷 : O70.3
43
結紮 (Sterilization)
• 診斷代碼為Z30.2,男女性結紮皆適用。
• 處置為0UL74ZZ (Laparoscopy tube ligation)
Occlusion
分類輸卵管結紮手術,須注意側性,途徑,裝置物
44
Dilation & curettage-1
• 0UDB7ZX (診斷性)
Extraction
45
Dilation & curettage-2
• 10A07ZZ (Termination, complete abortion)
Abortion
• 入院終止妊娠,診斷編於Z33.2 Encounter for
elective termination of pregnancy
46
Dilation & curettage-3
• 10D17ZZ (Incomplete abortion後)
• 10D27ZZ (Ectopic)
Extraction
47
Remove
left femur shaft internal fixation
• 0QP904Z
Removal
48
Cataract extraction
& Insertion left IOL prosthesis
• 08RK3JZ
Replacement
當次摘除且植入
49
Extracapsular extraction of lens
• 08DJ3ZZ(右眼),08DK3ZZ(左眼)
Extraction
當次僅摘除
50
Secondary insertion of lens
• 08RJ3JZ(右眼),08RK3JZ(左眼) Replacement
當次僅植入
51
Extraction of tooth
• 0CDWXZ? ,0CDXXZ?
Extraction
52
Right internal jugular
on double lumen for H/D
• 05HM33Z
Insertion
53
Dialysis
• 5A1D00Z -單次,5A1D60Z -多次(血液透析)
Performance
• 3E1M39Z(腹膜透析)
Irrigation
54
Invasive mechanical ventilation
• 5A19?5Z
Performance
The 5th character,duration of the ventilation
• Less than 24 consecutive hours
• 24-96 consecutive hours
• Greater than 96 consecutive hours.
55
Noninvasive mechanical ventilation
• 5A09?5?
Assistance
The 7th character, type of ventilation
•
•
•
•
•
7
8
9
B
Z
Continuous positive airway pressure
Intermittent positive airway pressure
Continuous negative airway pressure
Intermittent negative airway pressure
No Qualifier
56
Debridement
Excision
• 手術部位不同,編碼不同
skin 0HB
subcutaneous Tissue and Fascia 0JB
muscle 0KB
Tendon 0LB
Bone 0NB
57
Debridement of skin
• 0HB?XZZ (Excisional debridement)
Excision
• 0HD?XZZ (Nonexcisional debridement)
Extraction
58
http://www.nhi.gov.tw/
主題專區 > 國際疾病分類第十版ICD-10-CM/PC
>我國2014年版本資料
59
60

similar documents