中英文对照版《医疗保障基金结算清单填写规范》
1.主要诊断定义：经医疗机构诊治确定的导致患者本次住院就医主要原因的疾病（或健康状况）。
The principal diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS) as “that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.”
2.主要诊断一般应该是：
（1）消耗医疗资源最多。
（2）对患者健康危害最大。
（3）影响住院时间最长。
3.除下列规则中特殊约定的要求外，原则上“入院病情”为“4”的诊断不应作为主要诊断。
4.一般情况下，有手术治疗的患者的主要诊断要与主要手术治疗的疾病相一致。
5.急诊手术术后出现的并发症，应视具体情况根据原则 2 正确选择主要诊断。
6.择期手术后出现的并发症，应作为其他诊断填写，而不应作为主要诊断。
7.择期手术前出现的并发症，应视具体情况根据原则 2 正确选择主要诊断。
8.当住院是为了治疗手术和其它治疗的并发症时，该并发症作为主要诊断。当该并发症被编在 T80-T88 系列时，由于编码在描述并发症方面缺少必要的特性，需要另编码对该并发症进行说明。
When the admission is for treatment of a complication resulting from surgery or other medical care, the complication code is sequenced as the principal diagnosis. If the complication is classified to the T80-T88 series and the code lacks the necessary specificity in describing the complication, an additional code for the specific complication should be assigned.
9.当诊断不清时，主要诊断可以是疾病、损伤、中毒、体征、症状、异常发现，或者其它影响健康状态的因素。
10.当症状、体征和不确定情况有相关的明确诊断时，该诊断应作为主要诊断。而 ICD-10 第十八章中的症状、体征和不确定情况则不能作为主要诊断。
Codes for symptoms, signs, and ill-defined conditions from Chapter 18 are not to be used as principal diagnosis when a related definitive diagnosis has been established.
11.当有明确的临床症状和相关的疑似诊断时，优先选择明确的临床症状做主要诊断。疑似的诊断作为其他诊断。
12.如果以某个疑似的诊断住院，出院时诊断仍为“疑似”的不确定诊断，选择该疑似诊断作为主要诊断，编码时应按照确定的诊断进行编码。
If the diagnosis documented at the time of discharge is qualified as “probable,” “suspected,” “likely,” “questionable,” “possible,” or “still to be ruled out,” “compatible with,” “consistent with,” or other similar terms indicating uncertainty, code the condition as if it existed or was established.
13.极少情况下，会有 2 个或 2 个以上疑似诊断的情况，如：“…不除外、或…”（或类似名称），如果诊断都可能存在，且无法确定哪个是更主要的情况下，选其中任一疑似诊断作为主要诊断，将其它疑似诊断作为其他诊断。
In those rare instances when two or more contrasting or comparative diagnoses are documented as “either/or” (or similar terminology), they are coded as if the diagnoses were confirmed and the diagnoses are sequenced according to the circumstances of the admission. If no further determination can be made as to which diagnosis should be principal, either diagnosis may be sequenced first.
14.如果确定有2个或2个以上诊断同样符合主要诊断标准，在编码指南无法提供参考的情况下，应视具体情况根据原则 2 正确选择主要诊断。
In the unusual instance when two or more diagnoses equally meet the criteria for principal diagnosis as determined by the circumstances of admission, diagnostic workup and/or therapy provided, and the Alphabetic Index, Tabular List, or another coding guidelines does not provide sequencing direction, any one of the diagnoses may be sequenced first.
15.由于各种原因导致原诊疗计划未执行时：
（1）未做其它诊疗情况下出院的，仍选择拟诊疗的疾病为主要诊断，并将影响患者原计划未执行的原因写入其他诊断。
（2）当针对某种导致原诊疗计划未执行的疾病（或情况）做了相应的诊疗时，选择该疾病（或情况）作为主要诊断，拟诊疗的疾病为作为其他诊断。
Sequence as the principal diagnosis the condition, which after study occasioned the admission to the hospital, even though treatment may not have been carried out due to unforeseen circumstances.
16.从急诊留观室留观后入院的，当患者因为某个疾病（或情况）被急诊留观，且随后因为同一疾病（或情况）在同一家医院住院，选择导致急诊留观的疾病（或情况）为主要诊断。
1. Admission Following Medical Observation
When a patient is admitted to an observation unit for a medical condition, which either worsens or does not improve, and is subsequently admitted as an inpatient of the same hospital for this same medical condition, the principal diagnosis would be the medical condition which led to the hospital admission.
2. Admission Following Post-Operative Observation
When a patient is admitted to an observation unit to monitor a condition (or complication) that develops following outpatient surgery, and then is subsequently admitted as an inpatient of the same hospital, hospitals should apply the Uniform Hospital Discharge Data Set (UHDDS) definition of principal diagnosis as 'that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.'
17.当患者在门诊手术室接受手术，并且继而入住同一家医院变为住院病人时，要遵从下列原则选择主要诊断：
（1）如果因并发症入院，选择该并发症为主要诊断。
（2）如果住院的原因是与门诊手术无关的另外原因，选择这个另外原因为主要诊断。
When a patient receives surgery in the hospital's outpatient surgery department and is subsequently admitted for continuing inpatient care at the same hospital, the following guidelines should be followed in selecting the principal diagnosis for the inpatient admission:
· If the reason for the inpatient admission is a complication, assign the complication as the principal diagnosis.
· If no complication, or other condition, is documented as the reason for the inpatient admission, assign the reason for the outpatient surgery as theprincipal diagnosis.
· If the reason for the inpatient admission is another condition unrelated to the surgery, assign the unrelated condition as the principal diagnosis.
18.多部位烧伤，以烧伤程度最严重部位的诊断为主要诊断。同等烧伤程度的情况下，选择烧伤面积最大部位的诊断为主要诊断。
Sequence first the code that reflects the highest degree of burn when more than one burn is present.
19.多部位损伤，选择明确的最严重损伤和/或主要治疗的疾病诊断为主要诊断。
The code for the most serious injury, as determined by the provider and the focus of treatment, is sequenced first.
20.中毒的患者，选择中毒诊断为主要诊断，临床表现为其他诊断。如果有药物滥用或药物依赖的诊断，应写入其他诊断。
When coding a poisoning or reaction to the improper use of a medication (e.g., overdose, wrong substance given or taken in error, wrong route of administration), first assign the appropriate code from categories T36-T50. Use additional code(s) for all manifestations of poisonings. If there is also a diagnosis of abuse or dependence of the substance, the abuse or dependence is assigned as an additional code.
21.产科的主要诊断是指产科的主要并发症或合并疾病。没有任何并发症或合并疾病分娩的情况下，选择 O80 或 O84 为主要诊断。
22.当患者住院的目的是为了进行康复，选择患者需要康复治疗的问题作为主要诊断；如果患者入院进行康复治疗的原发疾病已经不存在了，选择相应的后续治疗作为主要诊断。
When the purpose for the admission/encounter is rehabilitation, sequence first the code for the condition for which the service is being performed. If the condition for which the rehabilitation service is being provided is no longer present, report the appropriate aftercare code as the first-listed or principal diagnosis, unless the rehabilitation service is being provided following an injury.
23.肿瘤：
（1）当住院治疗是针对恶性肿瘤时，恶性肿瘤才有可能成为主要诊断。
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.
（2）当对恶性肿瘤进行外科手术切除（包括原发部位或继发部位），即使做了术前和/或术后放疗或化疗时，选择恶性肿瘤为主要诊断。
When an episode of care involves the surgical removal of a neoplasm, primary or secondary site, followed by adjunct chemotherapy or radiation treatment during the same episode of care, the code for the neoplasm should be assigned as principal or first-listed diagnosis.
（3）即使患者做了放疗或化疗，但是住院的目的是为了明确肿瘤诊断（如恶性程度、肿瘤范围），或是为了确诊肿瘤进行某些操作（如：穿刺活检等），主要诊断仍选择原发（或继发）部位的恶性肿瘤。
When the reason for admission/encounter is to determine the extent of the malignancy, or for a procedure such as paracentesis or thoracentesis, the primary malignancy or appropriate metastatic site is designated as the principal or first-listed diagnosis, even though chemotherapy or radiotherapy is administered.
（4）如果患者本次专门为恶性肿瘤进行化疗、放疗、免疫治疗而住院时，选择恶性肿瘤化疗（编码 Z51.1）、放疗（编码Z51.0）或免疫治疗（编码 Z51.8）为主要诊断，恶性肿瘤作为其他诊断。如果患者在一次住院中接受了不止一项的上述治疗，则可以使用超过一个的编码，应视具体情况根据原则 2 正确选择主要诊断。
If a patient admission/encounter is solely for the administration of chemotherapy, immunotherapy or external beam radiation therapy assign code Z51.0, Encounter for antineoplastic radiation therapy, or Z51.11, Encounter for antineoplastic chemotherapy, or Z51.12, Encounter for antineoplastic immunotherapy as the first-listed or principal diagnosis. If a patient receives more than one of these therapies during the same admission more than one of these codes may be assigned, in any sequence.
（5）当治疗是针对继发部位的恶性肿瘤时，以继发部位的恶性肿瘤为主要诊断。如果原发肿瘤依然存在，原发肿瘤作为其他诊断。如果原发恶性肿瘤在先前已被切除或根除，恶性肿瘤个人史作为其他诊断，用来指明恶性肿瘤的原发部位。
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.
（6）当只是针对恶性肿瘤和/或为治疗恶性肿瘤所造成的并发症进行治疗时，选择该并发症作为主要诊断，恶性肿瘤作为其他诊断首选。如果同时有多个恶性肿瘤，按照肿瘤恶性程度的高低顺序书写。
When an encounter is for management of a complication associated with a neoplasm, such as dehydration, and the ICD-10-CM Official Guidelines for Coding and treatment is only for the complication, the complication is coded first, followed by the appropriate code(s) for the neoplasm.
A 恶性肿瘤引起的贫血，如果患者为治疗恶性肿瘤相关的贫血而入院，且仅对贫血进行了治疗，应选肿瘤疾病引起的贫血作为主要诊断（D63.0*肿瘤引起的贫血），恶性肿瘤作为其他诊断。
When 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 the appropriate code for the anemia (such as code D63.0, Anemia in neoplastic
disease).
B 化疗、放疗和免疫治疗引起的贫血，当患者为了治疗因化疗、放疗和免疫治疗引起的贫血而住院时，且仅对贫血进行了治疗，选择贫血作为主要诊断，相关的肿瘤诊断作为其他诊断。
When the admission/encounter is for management of an anemia associated with an adverse effect of the administration of chemotherapy or immunotherapy and the only treatment is for the anemia, the anemia code is sequenced first followed by the appropriate codes for the neoplasm and the adverse effect.
C 当患者为了接受化疗、放疗和免疫治疗而入院，治疗中产生了并发症，如：难以控制的恶心、呕吐或脱水，仍选择化疗、放疗和免疫治疗为主要诊断，并发症作为其他诊断。
When a patient is admitted for the purpose of external beam radiotherapy, immunotherapy or chemotherapy and develops complications such as uncontrolled nausea and vomiting or dehydration, the principal or first-listed diagnosis is Z51.0, Encounter for antineoplastic radiation therapy, or Z51.11, Encounter for antineoplastic chemotherapy, or Z51.12, Encounter for antineoplastic immunotherapy followed by any codes for the complications.
D 当患者因为恶性肿瘤引起的并发症住院治疗时（如脱水），且仅对该并发症（如脱水）进行了治疗（静脉补液），选择该并发症（如脱水）作为主要诊断，相关的肿瘤诊断作为其他诊断。
When the admission/encounter is for management of dehydration due to the malignancy and only the dehydration is being treated (intravenous rehydration), the dehydration is sequenced first, followed by the code(s) for the malignancy.
（7）未特指部位的广泛转移恶性肿瘤
未特指部位的广泛转移恶性肿瘤使用编码 C80，该诊断只有在患者有了转移病灶且不知道原发和继发部位时使用。当有已知继发部位肿瘤的诊断时，应分别逐一诊断。
Disseminated malignant neoplasm, unspecified, is for use only in those cases where the patient has advanced metastatic disease and no known primary or secondary sites are specified. It should not be used in place of assigning codes for the primary site and all known secondary sites.
（8）妊娠期间的恶性肿瘤
当妊娠者患有恶性肿瘤，选择妊娠、分娩及产褥期并发恶性肿瘤（099.8）作为主要诊断，ICD-10 第二章中的适当编码作为其他诊断，用来明确肿瘤的类型。
When a pregnant woman 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.
（9）肿瘤患者住院死亡时，应根据上述要求，视本次住院的具体情况正确选择主要诊断。