「慢性傷口」常用ICD10碼

游朝慶醫師

     今年，每家醫院應該都已改用ICD10來coding 疾病碼，然而搜尋了網路，卻不見有人做成速查表，都是要錢的，因此便參考各家的版本自己做，覺得還是要配合顏色比較好查。

   先放上一般的表格，以方便大家修改使用(可貼上word，改12號字體，邊界調為最窄，正好一頁)。並放上PDF及照片檔，方便直接列印使用。開放版權，免費使用。

    若內容有錯，請留言告知。 之後會再陸續放上我常用的。

☆壓傷Pressure injury L89.(0/1/2/3/4/5/6/8/9)(0/1/2)(0/1/2/3/4/9)

第4位(部位):0.elbow 1.back 2.hip 3.buttock 4.多處相連 5.ankle 6.heel 8.head 9.未明示 第5位(側性):0:未明示,1.右側2.左側 第5位在背部時:0.未明示1.右上2.左上3.右下4.左下5.sacrum 第6位(深度):0.unstageable,DTI,1.第1期stage1,2.stage2,3.stage3,4.stage4,9.healed,healing,未明 @兩側時則同時編寫左側及右側兩個代碼 @若有gangrene(I96)先code, @可+code B95菌種碼

Elbow: L89.0(0/1/2)(0/1/2/3/4/9) back:L89.1(0/1/2/3/4/5)(0/1/2/3/4/9) Hip:L89.2(0/1/2)(0/1/2/3/4/9) buttock: L89.3(0/1/2)(0/1/2/3/4/9) Contiguous site Back,buttock,hip多處相連:L89.4(0/1/2/3/4/5)(5為unstageable) Ankle: L89.5(0/1/2)(0/1/2/3/4/9), heel: L89.6(0/1/2)(0/1/2/3/4/9) head: L89.8(1/9)(0/1/2/3/4/9) 1頭部 9頭其他處 未明示L89.9(0/1/2/3/4/5)(5為unstageable) Necrotizing Fasciitis M72.6(+B95,B96菌), osteomyelitis, Sacrum M46.28 Diaper dermatitis: L22, buttock erosion L98.411, erythema intertrigo: L30.4

☆下肢潰瘍Skin ulcer : L97.(1/2/3/4/5/8/9)(0/1/2)(1/2/3/4/9) 適用靜脈潰瘍及糖尿病下肢潰瘍

第4位(部位): 1.thigh 2.calf 3.ankle 4.heel,midfoot 5.forefoot(other part of foot) 8.其他lower leg 9未明 第5位(側性):0.未明1.右 2.左 第6位(深度):1.skin 2. Fat 3.muscle 4.bone 9.未明

Thigh:L97.1(0/1/2)(1/2/3/4/9) calf:L97.2(0/1/2)(1/2/3/4/9) ankle:L97.3(0/1/2)(1/2/3/4/9) heel,midfoot: L97.4(0/1/2)(1/2/3/4/9) forefoot或其他:L97.5(0/1/2)(1/2/3/4/9) 其他lower leg: L97.8(0/1/2)(1/2/3/4/9) 未明示L97.9(0/1/2)(1/2/3/4/9)

☆靜脈潰瘍Stasis ulcer 無靜脈曲張 : I87.2 + L97.(1/2/3/4/5/8/9)(0/1/2)(1/2/3/4/9), 同下肢潰瘍

雖然I87.31(1/2/3/9)此碼本身就有ulcer(正式仍建議用I87.2)，但仍需L97碼以表示傷口位置及深度

venous insufficiency: I87.2 Venous stasis ulcer: I87.31(1/2/3/9)(右/左/雙側/未明)(少用) Venous hypertension with inflammation I87.32(1/2/3/9) (右/左/雙側/未明) , Venous ulcer with inflammation I87.33(1/2/3/9), venous hypertension with other C/C I87.39(1/2/3/9) Stasis dermatitis: I83.1(0/1/2)(未明/右/左) (varicose vein with inflammation, lipodermatosclerosis) Atrophie blanche: L95.0, Postinflammatory hyperpigmentation L81.0, other hyperpigmentation:L81.4, hyperkeratosis:L85.9, Dermatitis (eczematous):L30.9, Eczema:L30.8, swelling R22.4(0/1/2/3), phlebitis I80.0(1/2/3), DVT:I82.40(1/2/3/9),

☆靜脈潰瘍Stasis ulcer並靜脈曲張:I83.0(0/1/2)(1/2/3/4/5/8/9)+L97.(1/2/3/4/5/8/9)(0/1/2)(1/2/3/4/9)

Varicose vein with ulcer: I83.0(0/1/2)(1/2/3/4/5/8/9) (未明/右/左) varicose vein with inflammation: I83.1(0/1/2) (未明/右/左)，無ulcer varicose vein with ulcer with inflammation: I83.2(0/1/2)(1/2/3/4/5/8/9) varicose vein with pain I83.81(1/2/3/9),右/左/雙側/未明, varicose vein with C/C I83.89(1/2/3/9) Asymptomatic varicose vein: I83.9(0/1/2/3), 未明/右/左/雙側

☆糖尿病下肢潰瘍Diabetic foot/leg ulcer L97.(1/2/3/4/5/8/9)(0/1/2)(1/2/3/4/9) + E11.621

L97.(1/2/3/4/5/8/9)(0/1/2)(1/2/3/4/9)(foot ulcer)+ E11.621(DM with ulcer)(+Z79.4長期使用insulin) Necrotizing Fasciitis:M72.6(+B95,B96菌), osteomyelitis, Foot: M86.17(1/2/9), gangrene: I96 PAOD: I74.3, I70.20(1/2/3/8/9), claudication: I70.21(1/2/3/8/9), cyanosis:R23.0, ecchymosis:R23.3, Callus/corn:L84, wart: B07.8, Tinea pedis:B35.3, nail ingrowth: L60.0, onychia: L03.3(1/2), ankle gout:M10.07(1/2), ankle pain:M79.57(1/2), foot pain:M79.67(1/2/3), toe pain: M79.67(4/5/6)

傷口大師 游朝慶醫師 製作 105/10/15

下列為pdf的檔案

https://drive.google.com/open?id=0B9H7t0tfiL5vN0gyYkpVdkVmSWM

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