【摘要】 目的 通过对某医院呼吸系统结核ICD-10编码错误分析，提高编码准确性。方法 检索某医院病案信息系统2021年1月1日-2022年12月31日住院病案：检索诊断编码含A15、A16、A19的住院病案首页共1145例，检索HIV感染、肺尘埃沉着病、妊娠、儿童、精神障碍合并呼吸系统结核的住院病案首页共15例，编码员重新查阅核对病案资料，结合疾病编码规则，统计疾病分类错误例数，分析错误原因。结果 1145份住院病案首页中编码错误548例，错误率47.9%。编码于A15的错误率为17.9%，编码于A16的错误率高达52.7%，编码于A19的错误率为30%。错编于A15和A16的主要原因是编码员对呼吸系统结核实验室检查方法不熟悉、未认真阅读病历及实验室检查结果，未严格按照A15和A16的分类轴心(即实验室检查对结核分枝杆菌感染的证实情况)来编码。错编于A19的主要原因是未遵照ICD-10的编码规则——没有指出传染病的急慢性情况要按急性编码。HIV感染合并呼吸系统结核编码错误率为66.7%，肺尘埃沉着病合并呼吸系统结核编码错误率为71.4%，以上错误原因为未按规则合并编码。儿童合并呼吸系统结核编码错误率高达100%，错误原因是未核对ICD-10卷一的“不包括”内容。结论 呼吸系统结核编码错误率较高，错误主要原因为对结核检查方法不熟悉、对呼吸系统结核分类轴心不明确，未严格遵守编码规则及核对ICD-10卷一内容亦导致分类错误，编码员应加强理论知识及专业技能培训以提高编码准确性。更多还原

【Abstract】 Objectives Through the analysis of the ICD-10 coding error of respiratory tuberculosis in a hospital,improve the coding accuracy. Method Medical records from 2021 to 2022 were retrieved from the medical records information system of a hospital: 1145 cases with diagnostic codes including A15, A16 and A19; A total of 15 cases with HIV infection, pneumoconiosis, pregnancy, children, mental disorders with respiratory tuberculosis. Medical records were checked again, and the disease coding errors were counted and the causes of errors were analyzed in combination with disease coding rules. Results There were 548 errors in 1145 cases, with an error rate of 47.9%.The error rate was 17.9% for A15, 52.7% for A16, and 30% for A19.The main reasons for miscoding A15and A16 were that coders were not familiar with the laboratory test methods for respiratory tuberculosis, did not carefully read the medical records and laboratory test results, and did not strictly code according to the classification axis of A15 and A16(the confirmation of mycobacterium tuberculosis infection by laboratory tests).The main reason for the error in A19 was that it did not follow the coding rules of ICD-10, which did not indicate that acute and chronic conditions of infectious diseases should be coded as acute. The coding error rate of HIV infection with respiratory tuberculosis was 66.7%, and the coding error rate of pneumoconiosis with respiratory tuberculosis was 71.4%. The above error reasons were not combined coding according to the rules. The coding error rate for children with respiratory tuberculosis was up to 100%, due to the failure to check the "not included" content of ICD-10volume I. Conclusions The coding error rate of respiratory tuberculosis was relatively high. The main reasons for the errors were unfamiliar with the methods of tuberculosis examination, unclear classification axis of respiratory tuberculosis, and not strictly following the coding rules and checking the contents of ICD-10 volume I also led to classification errors. Coders should strengthen the training of theoretical knowledge and professional skills to improve the accuracy of coding.更多还原