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《ICD-10-CM官方指南》中恶性肿瘤主要诊断选择相关内容（四）原创2023-08-08 09:48·DRG打工人前言ICD-10-CM Official Guidelines for Coding and Reporting FY 2023中恶性肿瘤主要诊断选择的相关描述翻译系列文章:《ICD-10-CM编码和报告的官方指南》中恶性肿瘤主要诊断选择相关内容（一）：翻译第一~三大条《ICD-10-CM编码和报告的官方指南》中恶性肿瘤主要诊断选择相关内容（二）：翻译第四~七大条《ICD-10-CM编码和报告的官方指南》中恶性肿瘤主要诊断选择相关内容（三）：翻译第八~十二大条本期翻译第十三~十四大条l. Sequencing of neoplasm codes肿瘤编码排序1) Encounter for treatment of primary malignancy因治疗原发性恶性肿瘤而就诊If the reason for the encounter is for treatment of a primary malignancy, assign the malignancy as the principal/first-listed diagnosis. The primary site is to be sequenced first, followed by any metastatic sites.如果就诊原因是治疗原发性恶性肿瘤则将恶性肿瘤作为主要/第一诊断首先对原发部位进行排序然后是任何转移部位2) Encounter for treatment of secondary malignancy因治疗继发性恶性肿瘤而就诊When an encounter is for a primary malignancy with metastasis and treatment is directed toward the metastatic (secondary) site(s) only, the metastatic site(s) is designated as the principal/first-listed diagnosis. The primary malignancy is coded as an additional code.如果就诊原因是原发性恶性肿瘤伴转移而治疗仅针对转移（继发）部位则转移部位作为主要/第一诊断原发性恶性肿瘤作为附加编码3) Malignant neoplasm in a pregnant patient妊娠合并恶性肿瘤When a pregnant patient has a malignant neoplasm, a code from subcategory O9A.1-, Malignant neoplasm complicating pregnancy, childbirth, and the puerperium, should be sequenced first, followed by the appropriate code from Chapter 2 to indicate the type of neoplasm.当妊娠患者患有恶性肿瘤时应首先使用 O9A.1- "妊娠、分娩和产褥期并发恶性肿瘤 "中的编码然后使用第 2 章中的适当编码来表示肿瘤类型4) Encounter for complication associated with a neoplasm因肿瘤并发症而就诊When an encounter is for management of a complication associated with a neoplasm, such as dehydration, and the treatment is only for the complication, the complication is coded first, followed by the appropriate code(s) for the neoplasm.如果就诊原因是为了治疗与肿瘤相关的并发症（如脱水）且治疗仅针对并发症则先对并发症进行编码然后再对肿瘤进行适当编码The exception to this guideline is anemia. When the admission/encounter is for management of an anemia associated with the malignancy, and the treatment is only for anemia, the appropriate code for the malignancy is sequenced as the principal or first-listed diagnosis followed by code D63.0, Anemia in neoplastic disease.贫血是本指南的例外情况如果入院/就诊是为了治疗与恶性肿瘤相关的贫血且治疗仅针对贫血则应将恶性肿瘤的相应编码作为主要诊断或第一诊断然后是编码 D63.0 "肿瘤性疾病中的贫血"5) Complication from surgical procedure for treatment of a neoplasm治疗肿瘤的手术并发症When an encounter is for treatment of a complication resulting from a surgical procedure performed for the treatment of the neoplasm, designate the complication as the principal/first-listed diagnosis. See the guideline regarding the coding of a current malignancy versus personal history to determine if the code for the neoplasm should also be assigned.如果就诊是为了治疗肿瘤而进行的外科手术所引起的并发症则应将并发症指定为主要/第一诊断请参阅有关当前恶性肿瘤与个人病史的编码指南以确定是否也应分配肿瘤的编码6) Pathologic fracture due to a neoplasm肿瘤导致的病理性骨折When an encounter is for a pathological fracture due to a neoplasm, and the focus of treatment is the fracture, a code from subcategory M84.5, Pathological fracture in neoplastic disease, should be sequenced first, followed by the code for the neoplasm.如果就诊原因是因肿瘤导致的病理性骨折且治疗重点是骨折则应首先使用 M84.5（肿瘤性疾病中的病理性骨折）中的编码然后再使用肿瘤的编码If the focus of treatment is the neoplasm with an associated pathological fracture, the neoplasm code should be sequenced first, followed by a code from M84.5 for the pathological fracture.如果治疗重点是伴有病理骨折的肿瘤则应首先使用肿瘤编码然后使用 M84.5 中的病理骨折编码m. Current malignancy versus personal history of malignancy当前恶性肿瘤与个人恶性肿瘤史When a primary malignancy has been excised but further treatment, such as an additional surgery for the malignancy, radiation therapy or chemotherapy is directed to that site, the primary malignancy code should be used until treatment is completed.如果原发性恶性肿瘤已被切除但仍需进一步治疗如针对该部位的额外恶性肿瘤手术、放疗或化疗则应使用原发性恶性肿瘤编码直至治疗结束When a primary malignancy has been previously excised or eradicated from its site, there is no further treatment (of the malignancy) directed to that site, and there is no evidence of any existing primary malignancy at that site, a code from category Z85, Personal history of malignant neoplasm, should be used to indicate the former site of the malignancy.当原发性恶性肿瘤先前已从其部位切除或根除没有针对该部位的（恶性肿瘤）进一步治疗且没有证据表明该部位存在任何原发性恶性肿瘤时应使用 Z85（个人恶性肿瘤病史）中的编码来表示恶性肿瘤的原发部位Codes from subcategories Z85.0 – Z85.85 should only be assigned for the former site of a primary malignancy, not the site of a secondary malignancy. Code Z85.89 may be assigned for the former site(s) of either a primary or secondary malignancy.Z85.0-Z85.85 子类别中的编码只能用于原发性恶性肿瘤的原发部位而不能用于继发性恶性肿瘤的原发部位编码 Z85.89 可用于原发性或继发性恶性肿瘤的原发部位
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