Abstract:

Abstract: Objective Through this case, we can discuss the diagnosis and operation of breast cancer, which is helpful for a correct understanding of breast cancer and operation and making the correct encoding. Methods 10 breast surgery cases were selected from breast cancer department，using the international statistical classification of diseases(ICD)-10 and related health problems and surgical procedures of international classification of diseases(ICD-9-CM-3)，improve the accuracy of the coding, the causes of the wrong diagnosis and operation coding were found and analyzed. Results Main diagnosis of 2 cases of breast malignancy, full mastectomy code (unilateral / bilateral) was 85.41/85.42, revised from 1 to 2, modified radical breast cancer code (unilateral / bilateral) was 85.43/85.44, revised from 5 to 8, radical breast cancer code (unilateral / bilateral) was 85.45/85.46, revised from 3 to 0, revised breast cancer enlarged radical coding (unilateral / bilateral) 85.47/85.48, reduced from 1 to 0. Conclusion Accurate diagnosis and surgical coding must be performed according to the type and extent of mastectomy, this enables the electronic medical record audit system to better serve clinicians and coding workers

Key words: Breast cancer, Modified radical mastectomy, Coding