ICD-10 - CM/PCS 介紹

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ICD-10-CM/PCS 介紹

台大醫院病歷資訊管理室疾病分類組游斐雲

2014-10-25

與國際接軌

醫療評估欠缺合理基礎

編碼限制影響 DRG給付

ICD-9-CM 為何要改為 ICD-10-CM/PCS

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http://research.ncku.edu.tw/re/articles/c/20080509/images/080327022158tIYxVj.jpg

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培育種子師資

完成台灣中文版初稿

全國教育訓練

徵求醫院自院參加雙軌編碼

健保局資料庫建立，公告申

報格式

全國推廣教育課程

小型醫院先驅計劃

配合IC

卡上傳，開發及建

置資訊作業，雙軌作業

•

門、住診、全面單軌申報

ICD

-10-CM

/PCS

。

•D

RG

分類之轉換將再擇

適當時機

延至 ??

台灣導入 ICD-10-CM/PCS 的計畫

什麼是 ICD-10-CM/PCS

• ICD-10-CM (International Statistical Classification of Diseases and Related Health Problems,Tenth Revision,Clinical Modification)

國際疾病與相關健康問題統計分類第十版臨床修訂 ( 適用於門住診疾病診斷分類 )

• ICD-10-PCS (Procedure coding system) 處置代碼系統 1993 年美國 CMS 與 3M 資訊公司，依 ICD-9-CM 第 3 冊

發展。 ( 適用於住診處置分類 )

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診斷代碼格式的改變 -1項目 ICD-9-CM ICD-10-CM

格式 (Format) XXX.XX XXX.XXXX

長度 (Length) 3 - 5 3 - 7

代碼數量 13,000 + 68,000 +

開頭字元數字或字母字母例如COPDFemoral neck fr.DMHepatitis B carrier

496820.8250.00V02.61

J44.9S72.009AE11.9Z22.51

診斷代碼格式的改變 -2ICD-9-CM

XXX.XX

ICD-10-CM

XXX.XXX X

CategoryEtiologyAnatomic siteManifestation

CategoryEtiologyAnatomic siteManifestationSeverity Extension

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章節編排的改變ICD-9-CM

第 1 章傳染病與寄生蟲疾病第 2 章腫瘤第 3 章內分泌、營養、代謝疾病和免疫失調第 4 章血液及造血器官疾病第 5 章精神疾患第 6 章神經系統和感覺器官的疾病第 7 章循環系統疾病第 8 章呼吸系統疾病第 9 章消化系統疾病第 10 章泌尿生殖系統疾病第 11 章妊娠、生產與產褥期併發症第 12 章皮膚與皮下組織疾病第 13 章肌肉骨骼系統與結締組織疾病第 14 章先天畸形第 15 章周產期的病況第 16 章症狀、徵兆和不明確的情況第 17 章損傷及中毒

＊損傷及中毒外因分類＊補充分類

ICD-10-CM第 1 章感染症與寄生蟲疾病第 2 章腫瘤第 3 章血液、造血器官與免疫機轉的疾患第 4 章內分泌、營養與 ( 新陳 ) 代謝疾病第 5 章精神 [ 心智 ] 與行為疾患第 6 章神經系統疾病第 7 章眼與附器疾病第 8 章耳與乳突疾病第 9 章循環系統疾病第 10 章呼吸系統疾病第 11 章消化系統疾病第 12 章皮膚與皮下組織疾病第 13 章肌肉骨骼系統與結締組織疾病第 14 章泌尿生殖系統疾病第 15 章妊娠、生產與產褥期第 16 章源於周產期的病況第 17 章先天性畸形、變形與染色體異常第 18 章症狀、徵候與臨床和實驗室異常發現第 19 章傷害、中毒與外因造成的其他影響第 20 章罹病與死亡的外因第 21 章影響健康狀態與醫療保健服務接觸因素

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Salmonella infection

Salmonella infection

Salmonella enteritis

Salmonella sepsis

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A02.9

A02.0

A02.1

依嚴重度、部位給不同代碼

A02.2- Salmonella meningitis, pneumonia..

Tuberculosis(A15-A19)

骨骼及關節 , 生殖泌尿系統 , 周邊淋巴腺 , 腸道、腹膜及腸繫膜 , 皮膚及皮下組織 , 眼 ,

耳 , 內分泌腺體 ,

心臟等等

• 急性單一部位

(A19.0)

• 急性多重部位

(A19.1)

A15 A17 A18 A19Nervous system Other system MiliaryRespiratory

• 肺 (A15.0)

• 胸腔內淋巴結 (A15.4)

• 喉、氣管及支氣管 (A15.5)

• 肋膜炎 (A15.6)

• 其他呼吸道 (A15.8)

Old TB (B90- )

• 腦膜炎(A17.0)

• 腦膜腦炎(A17.82)

• 腦和脊髓之結核瘤 (A17.81)

• 神經炎(A17.83)

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Sepsis

SIRS

Sepsis

Severe sepsis

Septic shock

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A41.9 ( 常見於 A40-, A41-)

A41.9 & R65.20

A41.9 & R65.21

R65.10 & R65.11

( 是否有 Acute organ dysfunction)

Diabetes mellitus(E08-E13)

Type I

E10

Juvenile / Brittle

E11

Default

Due to underlying

E08

Pancreatic Dz, MalignancyCushing’s

Durg /chemical

E09

Steroid-Induced

other

E13

PostopSecondary

Type II

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DM 的併發症

12

ulcer

HHNKDKA

gangrene

Nephropathy

Retinopathy

Neuropathy

Arthropathy

Periodontitis

Hypoglycermia

Hyperglycermia

E10.10 E11.00 E11.649 E11.65

E11.21 E11.319 E11.40

E11.52 E11.628 E11.630 E11.618

Coma E11.641Coma E10.11 Coma E11.11

Hypertension (I10-I15)

I10

原發性高血壓

I11

高血壓性

心臟病

I12

高血壓性慢性腎臟病

I13

高血壓性心臟及慢性腎臟病

I15

續發性高血壓

先編高血壓 , 另編心臟衰竭或慢性腎臟病之型態

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心臟衰竭和慢性腎臟病之型態Heart failure

• LV failure (I50.1)

• Systolic failure (I50.2-)

• Diastolic failure

(I50.3-)

• Systolic & Diastolic

failure (I50.4-)

• RV failure (I50.9)

CKD

• CKD stage1(N18.1)





• ESRD (N18.6)

• CKD (N18.9)

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其他高血壓疾病

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代碼名稱注意事項

I60-I69 Hypertensive cerebrovascular disease

先編 CVA 代碼再加編高血壓碼

H35.03-

Hypertensive retinopathy 需另編高血壓代碼依入院情況排順序

O13 PIH without significant proteinuria

妊娠暫時性高血壓 ,無顯著蛋白尿

O14 PIH with significant proteinuria

妊娠暫時性高血壓 ,有顯著蛋白尿

R03.0 Elevated blood pressure 用於血壓值升高 ,但無診斷高血壓

Acute myocardial infarction

I21

Acute

I22

Subsequent

I23

Complication

I25.2Old MI

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• STEMI 依梗塞部位編碼 ,NSTEMI 皆編於I21.4

• 離前次 MI ,4 週內又發生 MI,I21 和 I22 皆需編碼

• 代碼 I23 需合併使用 I21 或 I22

Asthma (J45)• 變項 :

– Mild –Moderate –Severe– Intermittent –Persistent– Acute exacerbation –Status Asthmaticus

• 例如 : – J45.40 Moderate persistent asthma – J45.41 Moderate persistent asthma with acute exacerbation – J45.42 Moderate persistent asthma with status asthmaticus

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1818

Trimester• 產科代碼新增妊娠期別的描述例如

O99.011 Anemia complicating pregnancy, first trimester <14 週

O99.012 Anemia complicating pregnancy, second trimester 14 ~ <28 週

O99.013 Anemia complicating pregnancy, third trimester 28 週 ~

O99.019 Anemia complicating pregnancy, unspecified trimester

Fracture 7th Character

A –Close fx

D –Close fx

routine healing

G –Close fx

delayed healing

K –Close fx

nonunion

B –Open fx

type I or II

E -Open fx

type I or II , routine

healing

H –Open Fx

type I or II , delayed healing

M –Open fx

type I or II ,nonunion

C –Open fx

type IIIA, IIIB, IIIC

F –Open fx

type IIIA, IIIB,

IIIC ,routine healing

J –Open fx

type IIIA, IIIB, IIIC , delayed healing

N-Open fx

type IIIA, IIIB,

IIIC ,nonunion

Initial Subsequent

P –Close fx

malunion

Q –Open fx

type I or II ,malunion

R –Open fx

type IIIA, IIIB,IIIC ,ma

lunion

Sequela S –sequela

提供醫療照護的時機的描述 19

2020

Pressure ulcer

2

3

4

4

2 L89. X X X

部位

深度

側性

L89.500 Pressure ulcer of unspecified ankle, unstageable ( 無法分期 )

L89.501 Pressure ulcer of unspecified ankle, stage 1




L89.509 Pressure ulcer of unspecified ankle, unspecified stage

（未明示分期）

1. 指 Skin change,edema

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2121

Skin ulcer(nonpressure)

1

2

3

4

1 L97. X X X

部位

深度

側性

L97.301 ulcer of unspecified ankle limited to breakdown

of skin

L97.302 ulcer of unspecified ankle with fat layer exposed

L97.303 ulcer of unspecified ankle with necrosis of muscle

L97.304 ulcer of unspecified ankle with necrosis of bone

L97.309 ulcer of unspecified ankle with unspecified

severity

側性 : 1- 右 ,2- 左

Respiratory failure (J96)J96.0 J96.1 J96.2 J96.9

ChronicAcute on chronic

unspecifiedAcute

• 第 5 位碼再區分 --“1”hypoxia

--“2”hypercapnia

--“9”unspecified

• P28.5 Newborn respiratory failure

• J95.821 Postprocedural respiratory failure

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Coronary artery disease血管型態

● Native vessel

● Post bypass graft(s) -- autologous vein

-- autologous artery

-- nonautologous

biological bypass graft(s)

-- specified type

● Transplanted heart --of native coronary artery

-- bypass graft(s)

I25.1- I25.7- I25.8-

合併症狀● Ustable angina

● Angina with documented

spasm

● Other forms of angina

● Unspecified angina

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Benign prostatic hypertrophy

• N40.0 Enlarged prostate without LUTS

• N40.1 Enlarged prostate with LUTS

另加編 lower urinary tract symptoms :

• incomplete bladder emptying (R39.14)

• urinary incontinence (N39.4-)

• nocturia (R35.1) • urinary obstruction (N13.8)

• straining on urination (R39.16)

• urinary retention (R33.8)

• urinary frequency (R35.0) • urinary urgency (R39.15)

• urinary hesitancy (R39.11)• weak urinary stream

(R39.12)

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2525

Open wound

S61. X X X X

部位

側性

異物

S61.41 Laceration without foreign body of hand

S61.42 Laceration with foreign body of hand

S61.43 Puncture wound without foreign body of hand

S61.44 Puncture wound with foreign body of hand

S61.45 Open bite of hand

就診時機

• 明示傷口類型及有無異物• 類型包含 :

laceration,

penetration,perforating,

puncture,open bite 等• 側性 : 1- 右 ,2- 左

• 就診時機 : A- initial , D- subsequent , S-sequela

Cerebrovascular disease

• 部位 - SAH

血管側性 - left,right

- ICH Hemisphere brain stem Cerebellum intraventricul

ar - SDH

acute Subacute chronic

- EDH

• 血管 - precerebral

basilar carotid vertebral

- cerebral anterior middle posterior

• 側性 - left,right• 型態 - embolism - thrombosis

hemorrhage Infarction occlusion

I63 I65-I66I60-I62

Old CVA I69-

• 血管 - precerebral

basilar carotid vertebral

- cerebral anterior middle posterior

• 側性 - left,right, bilateral

Occlusion 併 infarction 編於I63-

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Old CVA with late effect (sequelae)

hemorrhage Infarction OtherI69.3 I69.8I69.0~I69.2

第 5 位碼 1 Cognitive deficits 2 Speech and language deficits 3 Monoplegia of upper limb 4 Monoplegia of lower limb 5 Hemiplegia and hemiparesis 6 Other paralytic syndrome 9 Other sequelae

第 6 位碼 1 right dominant side 2 left dominant side 3 right non-dominant side 4 left non-dominant side 5 bilateral

未明示 dominant side, 分類規則如下 : • For ambidextrous patients, the default should be dominant. • If the left side is affected, the default is non-dominant. • If the right side is affected, the default is dominant.

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2828

處置代碼格式的改變 -1項目 ICD-9-CM ICD-10-PCS

格式 (Format) XX.XX XXXXXXX

長度 (Length) 3 - 4 固定 7 位 ( 無小數點 )

字元型態數字字母或數字

代碼數量 3,700 + 86,000 +

例如 :Laparoscopic cholecystectomy

51.23 0FT44ZZ

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Body system系統分類

Body part手術部位

Device裝置物

Section章節

Root operation手術方式

Approach手術途徑

Qualifer修飾辭

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處置代碼格式的改變 -2• 代碼由固定 7 位碼構成，例如 02103D4• 可填入的值共有 34個

– 數字： 0 - 9– 字母：除了 I 和 O以外 (因容易和數字 1 和 0混淆 )

例如在Medical and Surgical章節的 7 碼意義如下 :

Character7 位碼 1 2 3 4 5 6 7

處置編排的改變ICD-9-CM ICD-10-PCS

章節內容第1章神經系統手術第2章內分泌系統手術第3章眼的手術第4章耳部手術第5章鼻、口、咽手術第6章呼吸系統手術第7章心血管系統手術第8章血液和淋巴系統手術第9章消化系統手術第10章泌尿系統手術第11章男性生殖器官手術第12章女性生殖器官手術第13章產科處置第14章肌肉骨骼系統手術第15章皮膚系統手術第16章其他及治療性處置

章節內容0 Medical and Surgical1 Obstetrics2 Placement3 Administration4 Measurement and Monitoring5 Extracorporeal Assistance and Performance6 Extracorporeal Therapies7 Osteopathic8 Other Procedures9 ChiropracticB ImagingC Nuclear MedicineD Radiation OncologyF Physical Rehabilitation and Diagnostic Audiology

G Mental HealthH Substance Abuse Treatment

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範例 :Esophagogastroduodenosc

opy with gastric biopsy

0DB68ZX :

Character1Section

Character2Body

System

Character3Root

Operation

Character4Body Part

Character5

Approach

Character6

Device

Character7

Qualifier

Medical and

Surgical

Gastrointestinal System

Excision Stomach

Via Natural or Artificial Opening

Endoscopic

No Device

Diagnostic

0 D B 6 8 Z X

由手術關鍵字開始查詢索引查詢部位 , 途徑 , 裝置和

特性

Medical and Surgical--Root operation

0- Alteration C- Extirpation P- Removal

1- Bypass D- Extraction Q- Repair

2- Change F- Fragmentation R- Replacement

3- Control G- Fusion S- Reposition

4- Creation H- Insertion T- Resection

5- Destruction J- Inspection V- Restriction

6- Detachment K- Map W- Revision

7- Dilation L- Occlusion U- Supplement

8- Division M- Reattachment X- Transfer

9- Drainage N- Release Y- Transplantation

B- Excision 　　32

切除部分

切除全部

外力拉出剝離

Medical and Surgical--Body system

0- Central Nervous System C- Mouth and Throat P- Upper Bones

1- Peripheral Nervous System

D- Gastrointestinal System Q- Lower Bones

2- Heart and Great VesselsF- Hepatobiliary System and Pancreas

R- Upper Joints

3- Upper Arteries G- Endocrine System S- Lower Joints

4- Lower Arteries H- Skin and Breast T- Urinary System

5- Upper VeinsJ- Subcutaneous Tissue and Fascia

U- Female Reproductive System

6- Lower Veins K- MusclesV- Male Reproductive System

7- Lymphatic and Hemic Systems

L- TendonsW- Anatomical Regions, General

8- Eye M- Bursae and LigamentsX- Anatomical Regions, Upper Extremities

9- Ear, Nose, Sinus N- Head and Facial BonesY- Anatomical Regions, Lower Extremities

B- Respiratory System 　　33

Medical and Surgical--Approach

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0 Open 開放性

3 Percutaneous 經皮

4 Percutaneous Endoscopic 經皮內視鏡

7 Via Natural or Artificial Opening 經由自然開口或人工造口

8 Via Natural or Artificial Opening Endoscopic

經由自然開口或人工造口內視鏡

F Via Natural or Artificial Opening With Percutaneous Endoscopic Assistance

經由自然開口或人工造口合併經皮內視鏡輔助

X External 經由外部

Medical and Surgical--Device

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0-Drainage Device C-Extraluminal Device M-Stimulator Generator

1-Radioactive Element D-Intraluminal DeviceN-Neurostimulator Generator, Tissue Expander

2-Monitoring DeviceE-Endotracheal Airway,Multiple Array Rechargeable Stimulator Generator

P-Cardiac Rhythm Related Device

3-Infusion Device F-Tracheostomy Device

Q-Implantable Heart Assist System, Biventricular External Heart Assist System

4-Internal Fixation Device G-Endobronchial Valve,Pessary R-External Heart Assist System

5-External Fixation Device H-Contraceptive Device S-Hearing Device

6-Intramedullary Internal Fixation Device

J-Synthetic Substitute T-Radioactive Intraluminal Device,

7-Autologous Tissue Substitute K-Nonautologous Tissue Substitute U-Feeding Device

8-Spacer Y-Other Device V-Infusion Pump

9-Autologous Venous Tissue L-Artificial Sphincter W-Reservoir

A-Interbody Fusion Device

M-Bone Growth Stimulator, Neurostimulator Lead, Stimulator Lead,Cardiac Lead ,

X-Vascular Access Device

B-Monoplanar External Fixation Device

M-Diaphragmatic Pacemaker Lead Y-Other Device

Medical and Surgical--Qualifier

1-Bypass D-Extraction S-Reposition

4-Creation G-Fusion T-Resection

5-Destruction H-Insertion U-Supplement

6-Detachment L-Occlusion V-Restriction

7-Dilation M-Reattachment X-Transfer

9-Drainage N-Release Y-Transplantation

B-Excision Q-Repair

C-Extirpation R-Replacement

36

Endoscopic sigmoid colon polypectomy

• 0DBN8ZZ

37

Excision

Closed reduction radius fracture

• 0PSHXZZ( 右 ), 0PSJXZZ( 左 )

38

Reposition

Repair left inguinal hernia• 0YQ60ZZ

39

Repair

Repair left inguinal hernia with

mesh• 0YU60JZ

40

Supplement

Delivery• 10E0XZZ(Assisted spontaneous)

• 10D00Z1 (C/S) ,10D00Z2(Extraperitoneal C/S)

• 10D07Z6(Vacuum),10D07Z3(forceps,low)

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Delivery

Extraction

Extraction

Episiotomy and repair• 0W8NXZZ (剪 Ep&repair)

• 0KQM0ZZ (2o裂傷 perineal repair)

42

Division

Repair

Delivery perineal laceration

• Anal

sphincter

0DQR0ZZ

• Rectovagina

septum

• Pelvic floor

• Perineal

muscles

• Vaginal

muscles

• Anal mucosa

• Rectal

mucosa

• Anal

sphincter

• Rectovagina

septum

0HQ,0UQ,0WQ 0KQ 0DQ 0DQ2o 3o 4o1o

• Pelvic floor

• Perineum

muscles

0KQM0ZZ

• Vagina

muscles

• Vagina wall

• Vulva,fourchet

te,labia

• Perineum skin

• Slight perineal

• Vulva,fourchett

e,labia

0UQM0ZZ

• Perineum skin

0HQ9XZZ

• Vagina mucosa

0UQG0ZZ

• Slight perineal

0WQN0ZZ

43

診斷 : O70.0

診斷 : O70.1

診斷 : O70.2

診斷 : O70.3

僅 anal sphincter

tear 診斷 : O70.4

結紮 (Sterilization)• 診斷代碼為 Z30.2 ，男女性結紮皆適用。• 處置為 0UL74ZZ (Laparoscopy tube

ligation)

分類輸卵管結紮手術，須注意側性 , 途徑 , 裝置物44

Occlusion

Dilation & curettage-1• 0UDB7ZX ( 診斷性 )

45

Extraction

Dilation & curettage-2• 10A07ZZ (Termination, complete abortion)

• 入院終止妊娠 , 診斷編於 Z33.2 Encounter for elective termination of pregnancy

46

Abortion

Dilation & curettage-3• 10D17ZZ (Incomplete abortion後 ) • 10D27ZZ (Ectopic)

47

Extraction

Remove left femur shaft internal

fixation• 0QP904Z

48

Removal

Cataract extraction

& Insertion left IOL prosthesis• 08RK3JZ

49

當次摘除且植入

Replacement

Extracapsular extraction of lens • 08DJ3ZZ( 右眼 ),08DK3ZZ( 左眼 )

50

當次僅摘除

Extraction

Secondary insertion of lens • 08RJ3JZ( 右眼 ),08RK3JZ( 左眼 )

51

當次僅植入

Replacement

Extraction of tooth

• 0CDWXZ? ,0CDXXZ?

52

Extraction

Right internal jugular

on double lumen for H/D• 05HM33Z

53

Insertion

Dialysis• 5A1D00Z - 單次 ,5A1D60Z - 多次 ( 血液透析 )

• 3E1M39Z( 腹膜透析 )

54

Irrigation

Performance

Invasive mechanical

ventilation • 5A19?5Z

The 5th character,duration of the ventilation

• Less than 24 consecutive hours• 24-96 consecutive hours • Greater than 96 consecutive hours.

55

Performance

Noninvasive mechanical

ventilation • 5A09?5?

The 7th character, type of ventilation • 7 Continuous positive airway pressure • 8 Intermittent positive airway pressure • 9 Continuous negative airway pressure • B Intermittent negative airway pressure • Z No Qualifier

56

Assistance

Debridement• 手術部位不同 , 編碼不同 skin 0HB subcutaneous Tissue and Fascia 0JB muscle 0KB Tendon 0LB Bone 0NB

57

Excision

Debridement of skin• 0HB?XZZ (Excisional debridement)

• 0HD?XZZ (Nonexcisional debridement)

58

Excision

Extraction

http://www.nhi.gov.tw/ 主題專區 >

國際疾病分類第十版 ICD-10-CM/PC >我國2014年版本資料

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http://www.nhi.gov.tw/webdata/webdata.aspx?menu=17&menu_id=1027&webdata_id=4565&WD_ID=1027

http://www.nhi.gov.tw/webdata/webdata.aspx?menu=17&menu_id=1027&WD_ID=1042&webdata_id=4591



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謝謝聆聽

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ICD-10 - CM/PCS 介紹