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

台灣導入ICD-10-CM/PCS的計畫 延至?? 培育種子師資 完成台灣中文版初稿 全國教育訓練 徵求醫院自院參加雙軌編碼 健保局資料庫建立，公告申報格式 全國推廣教育課程 小型醫院先驅計劃 配合IC卡上傳，開發及建置資訊作業，雙軌作業 門、住診、全面單軌申報ICD-10-CM/PCS。 DRG分類之轉換將再擇適當時機 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) 新興疾病、健康問題及醫療技術的日新月異； 分類代碼的整合需求； ICD-9-CM受限於代碼的擴充，不敷使用；

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

XXX.XX XXX.XXX X 診斷代碼格式的改變-2 ICD-9-CM ICD-10-CM Category Etiology Anatomic site Manifestation Category Etiology Anatomic site Manifestation Severity Extension 6

章節編排的改變 ICD-9-CM ICD-10-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 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 Salmonella infection Salmonella enteritis Salmonella sepsis 依嚴重度、部位給不同代碼 A02.9 A02.0 A02.1 A02.2- Salmonella meningitis, pneumonia..

Tuberculosis(A15-A19) A15 A17 A18 A19 Old TB (B90- ) Respiratory 骨骼及關節,生殖泌尿系統,周邊淋巴腺,腸道、腹膜及腸繫膜, 皮膚及皮下組織,眼,耳,內分泌腺體,心臟等等 急性單一部位 (A19.0) 急性多重部位 (A19.1) 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) 腦膜腦炎(A17.82) 腦和脊髓之結核瘤 (A17.81) 神經炎(A17.83) Old TB (B90- ) 9

Sepsis Septic shock Severe sepsis Sepsis SIRS A41.9 & R65.21 A41.9 (常見於 A40-, A41-) 嚴重敗血症(Severe sepsis) 最少需編寫2個代碼，第1個代碼表示原始病因的系統性感染 接著編寫嚴重敗血症(Severe sepsis)代碼 R65.2-，另相關的急性器官功能障礙亦須編為附加代碼 R65.10 & R65.11 (是否有Acute organ dysfunction)

Diabetes mellitus(E08-E13) Type I E10 Juvenile / Brittle E11 Default Due to underlying E08 Pancreatic Dz, Malignancy Cushing’s Durg / chemical E09 Steroid-Induced other E13 Postop Secondary Type II 11

DM的併發症 DKA HHNK ulcer Nephro Retino Neuro pathy pathy pathy Arthro Coma E10.11 Coma E11.11 Coma E11.641 E10.10 E11.00 E11.649 E11.65 DKA HHNK Hypo glycermia Hyper glycermia E11.21 E11.319 E11.40 Nephro pathy Retino pathy Neuro pathy E11.630 E11.618 E11.52 E11.628 ulcer Arthro pathy gangrene Periodo ntitis

Hypertension (I10-I15) I10 I11 I12 I13 I15 先編高血壓,另編心臟衰竭或慢性腎臟病之型態 原發性高血壓 I11 高血壓性 心臟病 I12 高血壓性慢性腎臟病 I13 高血壓性心臟及慢性腎臟病 I15 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) Systolic failure (I50.2-) Diastolic failure (I50.3-) Systolic & Diastolic failure (I50.4-) RV failure (I50.9) • CKD stage1(N18.1) • CKD stage2(N18.2) • CKD stage3(N18.3) • CKD stage4(N18.4) • CKD stage5(N18.5) • ESRD (N18.6) • 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 O13 PIH without significant proteinuria 妊娠暫時性高血壓,無顯著蛋白尿 O14 PIH with significant proteinuria 妊娠暫時性高血壓,有顯著蛋白尿 R03.0 Elevated blood pressure 用於血壓值升高,但無診斷高血壓

Acute myocardial infarction Subsequent I23 Complication I25.2 Old MI 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

Asthma (J45) 變項 : 例如: – 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 提供醫療照護的時機的描述 A –Close fx D –Close fx routine healing G –Close fx delayed healing K –Close fx nonunion B –Open fx type I or II E -Open fx type I or II , routine healing H –Open Fx type I or II , delayed healing M –Open fx type I or II ,nonunion C –Open fx type IIIA, IIIB, IIIC F –Open fx type IIIA, IIIB, IIIC ,routine healing J –Open fx type IIIA, IIIB, IIIC , delayed healing N-Open fx type IIIA, IIIB, IIIC ,nonunion Initial Subsequent P –Close fx malunion Q –Open fx type I or II ,malunion R –Open fx type IIIA, IIIB,IIIC ,malunion Sequela S –sequela 提供醫療照護的時機的描述 19

Pressure ulcer L89. X X X 部位 側性 深度 1.指Skin change,edema 2 L89. X X X 1.指Skin change,edema 2 3 部位 側性 深度 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) 1 L97. X X X 1 2 部位 側性 深度 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) Acute on chronic unspecified Acute Chronic 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 合併症狀 ● Native vessel ● Post bypass graft(s) -- autologous vein -- autologous artery -- nonautologous biological bypass graft(s) -- specified type ● Transplanted heart --of native coronary artery -- bypass graft(s) I25.1- I25.7- I25.8- ● Ustable angina ● Angina with documented spasm ● Other forms of angina ● Unspecified angina 23

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 (R39.14) urinary incontinence (N39.4-) 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 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 部位 異物 側性 就診時機 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 - SAH 血管 側性- left,right - ICH Hemisphere brain stem Cerebellum intraventricular - SDH acute Subacute chronic - EDH 血管 - precerebral basilar carotid vertebral - cerebral anterior middle posterior 側性- left,right 型態 - embolism - thrombosis 血管 - precerebral basilar carotid vertebral - cerebral anterior middle posterior 側性 - left,right, bilateral Old CVA I69- Occlusion併infarction編於I63- 26

Old CVA with late effect (sequelae) I69.0~I69.2 I69.3 I69.8 hemorrhage Infarction Other 第 5 位碼 1 Cognitive deficits 2 Speech and language deficits 3 Monoplegia of upper limb 4 Monoplegia of lower limb 5 Hemiplegia and hemiparesis 6 Other paralytic syndrome 9 Other sequelae 第 6 位碼 1 right dominant side 2 left dominant side 3 right non-dominant side 4 left non-dominant side 5 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: Body system 系統分類 Body part 手術部位 Device 裝置物 Section 章節 Root operation 手術方式 Approach 手術途徑 Qualifer 修飾辭 Character 7位碼 1 2 3 4 5 6 7 29

處置編排的改變 ICD-9-CM ICD-10-PCS 30

範例:Esophagogastroduodenoscopy with gastric biopsy 0DB68ZX : Character1 Section Character2 Body System Character3 Root Operation Character4 Body Part Character5 Approach Character6 Device Character7 Qualifier Medical and Surgical Gastrointestinal System Excision Stomach Via Natural or Artificial Opening Endoscopic No Device Diagnostic D B 6 8 Z X 由手術關鍵字 開始查詢索引 查詢部位,途徑,裝置和特性

Medical and Surgical--Root operation 0- Alteration C- Extirpation P- Removal 1- Bypass D- Extraction Q- Repair 2- Change F- Fragmentation R- Replacement 3- Control G- Fusion S- Reposition 4- Creation H- Insertion T- Resection 5- Destruction J- Inspection V- Restriction 6- Detachment K- Map W- Revision 7- Dilation L- Occlusion U- Supplement 8- Division M- Reattachment X- Transfer 9- Drainage N- Release Y- Transplantation B- Excision 外力拉出剝離 切除全部 切除部分

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 6- Lower Veins K- Muscles V- Male Reproductive 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

Medical and Surgical--Approach 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 8 Endoscopic 內視鏡 F Via Natural or Artificial Opening With Percutaneous Endoscopic Assistance 合併經皮內視鏡輔助 X External 經由外部

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 E-Endotracheal Airway,Multiple Array Rechargeable Stimulator Generator P-Cardiac Rhythm Related Device 3-Infusion Device F-Tracheostomy Device Q-Implantable Heart Assist System, 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 Lead,Cardiac Lead , X-Vascular Access Device B-Monoplanar External Fixation M-Diaphragmatic Pacemaker Lead

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

Endoscopic sigmoid colon polypectomy 0DBN8ZZ Excision

Closed reduction radius fracture 0PSHXZZ(右), 0PSJXZZ(左) Reposition

Repair left inguinal hernia 0YQ60ZZ Repair

Repair left inguinal hernia with mesh 0YU60JZ Supplement

Delivery Delivery Extraction Extraction 10E0XZZ(Assisted spontaneous) 10D00Z1 (C/S) ,10D00Z2(Extraperitoneal C/S) 10D07Z6(Vacuum),10D07Z3(forceps,low) Delivery Extraction Extraction

Episiotomy and repair Division Repair 0W8NXZZ (剪Ep&repair) 0KQM0ZZ (2o裂傷 perineal repair) Repair

Delivery perineal laceration 0KQ 0DQ 0DQ 0HQ,0UQ,0WQ Anal sphincter 0DQR0ZZ Rectovagina septum Pelvic floor Perineal muscles Vaginal muscles Anal mucosa Rectal mucosa 1o 2o 3o 4o Vulva,fourchette,labia 0UQM0ZZ Perineum skin 0HQ9XZZ Vagina mucosa 0UQG0ZZ Slight perineal 0WQN0ZZ Pelvic floor Perineum muscles 0KQM0ZZ Vagina muscles Vagina wall Vulva,fourchette,labia Perineum skin Slight perineal 僅anal sphincter tear診斷 : O70.4 診斷 : O70.0 診斷 : O70.1 診斷 : O70.2 診斷 : O70.3 43

分類輸卵管結紮手術，須注意側性,途徑,裝置物 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

Dilation & curettage-1 0UDB7ZX (診斷性) Extraction

Dilation & curettage-2 Abortion 10A07ZZ (Termination, complete abortion) 入院終止妊娠,診斷編於Z33.2 Encounter for elective termination of pregnancy Abortion

Dilation & curettage-3 Extraction 10D17ZZ (Incomplete abortion後) 10D27ZZ (Ectopic) Extraction

Remove left femur shaft internal fixation 0QP904Z Removal

Cataract extraction & Insertion left IOL prosthesis 08RK3JZ Replacement 當次摘除且植入

Extracapsular extraction of lens 08DJ3ZZ(右眼),08DK3ZZ(左眼) Extraction 當次僅摘除

Secondary insertion of lens 08RJ3JZ(右眼),08RK3JZ(左眼) Replacement 當次僅植入

Extraction of tooth Extraction 0CDWXZ? ,0CDXXZ?

Right internal jugular on double lumen for H/D Insertion 05HM33Z

Dialysis 5A1D00Z -單次,5A1D60Z -多次(血液透析) 3E1M39Z(腹膜透析) Irrigation Performance Irrigation

Invasive mechanical ventilation 5A19?5Z The 5th character,duration of the ventilation Less than 24 consecutive hours 24-96 consecutive hours Greater than 96 consecutive hours. Performance

Noninvasive mechanical ventilation The 7th character, type of ventilation 7 Continuous positive airway pressure 8 Intermittent positive airway pressure 9 Continuous negative airway pressure B Intermittent negative airway pressure Z No Qualifier Assistance 資料來源:http://fhima.org/documents/therespiratorysystem.pdf

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 Excision Extraction 0HB?XZZ (Excisional debridement) 0HD?XZZ (Nonexcisional debridement) Excision Extraction

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

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