【摘要】 通过对脑梗死临床诊断流程的分析,结合具体病例探讨脑梗死的ICD-10编码。对脑梗死进行疾病分类,首先要明确脑梗死的分期,急性期分类于I63类目,非急性期则分类于I69.3。类目I63是双轴心分类,按责任血管可分为入脑前动脉、大脑动脉、大脑静脉、其他和未特指,按病因可分为血栓形成、栓塞、未特指的闭塞或狭窄、其他和未特指。临床应用最为广泛的脑梗死病因分型是TOAST分型。大动脉粥样硬化型可分类于I63.0、I63.2、I63.3或I63.5。心源性栓塞型可分类于I63.1或I63.4。小动脉闭塞型可分类于I63.8。其他明确病因型可分类于I63.6或I63.8。不明原因型可分类于I63.9。明确急性脑梗死的病因分型后,编码员需认真阅读病案,进一步确定其责任血管才能准确进行疾病分类。更多还原

【Abstract】 This article discusses the ICD-10 coding of cerebral infarction by analyzing clinical diagnosis process and several specific cases of the disease. In the classification of cerebral infarction, clinical stage of disease should be considered firstly. Acute stage of cerebral infarction is classified at category I63. And non-acute stage cerebral infarction is classified at I69.3. Category I63 is a biaxial classification. According to the classification axis of responsible vessel,it can be divided into precerebral arteries, cerebral arteries, cerebral venous, other and unspecified. And according to the classification axis of etiology, it can be divided into thrombosis, embolism, unspecified occlusion or stenosis, other and unspecified. The trial of Org 10172 in acute strcke treatment(TOAST)classification is the most widely used etiological categories of acute cerebral infarction in clinical practice.Acute cerebral infarction due to large artery atherosclerosis can be classified at I63.0, I63.2, I63.3 or I63.5.Due to cardioembolism can be classified at I63.1 or I63.4. Due to small-artery occlusion can be classified at I63.8. Due to other determined cause can be classified at I63.6 or I63.8. Due to undetermined cause can be classified at I63.9. In order to classify acute cerebral infarction correctly, clinical coders should carefully read medical records to further determine the responsible vessels after determining the etiology.更多还原