Abstract：Objective To review the quality of disease coding with R code as the main diagnostic code in a hospital, summarize the error types, and select typical cases for analysis and discussion, in order to provide guarantee for improving the accuracy of disease coding and carrying out DRGs payment smoothly.Methods Four hundred and thirtyseven medical records with R code of discharged patients from October 1, 2021 to December 31, 2021 were extracted, and the medical records were consulted and reviewed one by one according to the international classification of diseases.Results There were 51 coding errors with an error rate of 11.7% among the 51 cases with R coding. The erroneous medical records were divided into 4 categories according to the error type, among which 58.8% (30/51) should be classified to other chapters, 31.4% (16/51) were wrong in the selection of major codes, 7.8% (4/51) missed the coding of disease cause or main treatment (4/51), and other errors accounted for 2.0% (1/51).Conclusion The main causes of R coding errors in the hospital are coders′ failure to consult medical records, blind compliance with doctors′ choice of main codes, and lack of medical knowledge and classification rules. In order to improve coding quality, coders need to improve their professional knowledge and strengthen coding quality control.
张睿，杨帆. ICD-10中R编码应用案例分析[J]. 中国医院统计, 2022, 29(1): 51-53.
Zhang Rui, Yang Fan. Application case analysis of R coding in ICD-10. journal1, 2022, 29(1): 51-53.
