The International Classification of Diseases (ICD) is a globally used medical classification used in epidemiology, health management and for clinical purposes. The ICD is maintained by the World Health Organization (WHO), which is the directing and coordinating authority for health within the United Nations System. The ICD is originally designed as a health care classification system, providing a system of diagnostic codes for classifying diseases, including nuanced classifications of a wide variety of signs, symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or disease. This system is designed to map health conditions to corresponding generic categories together with specific variations, assigning for these a designated code, up to six characters long. Thus, major categories are designed to include a set of similar diseases.
Nosology is the branch of medical science that deals with the classification of diseases. Fully classifying a medical condition requires knowing its cause, the effects it has on the body, the symptoms that are produced, and other factors. For example, influenza is classified as an infectious disease because it is caused by a virus, and it is classified as a respiratory infection because the virus infects and damages certain tissues in the respiratory tract. The more that is known about the disease, the more ways the disease can be classified nosologically.
The International Classification of Functioning, Disability and Health (ICF) is a classification of the health components of functioning and disability.
A medical classification is used to transform descriptions of medical diagnoses or procedures into standardized statistical code in a process known as clinical coding. Diagnosis classifications list diagnosis codes, which are used to track diseases and other health conditions, inclusive of chronic diseases such as diabetes mellitus and heart disease, and infectious diseases such as norovirus, the flu, and athlete's foot. Procedure classifications list procedure code, which are used to capture interventional data. These diagnosis and procedure codes are used by health care providers, government health programs, private health insurance companies, workers' compensation carriers, software developers, and others for a variety of applications in medicine, public health and medical informatics, including:
The Systematized Nomenclature of Medicine (SNOMED) is a systematic, computer-processable collection of medical terms, in human and veterinary medicine, to provide codes, terms, synonyms and definitions which cover anatomy, diseases, findings, procedures, microorganisms, substances, etc. It allows a consistent way to index, store, retrieve, and aggregate medical data across specialties and sites of care. Although now international, SNOMED was started in the U.S. by the College of American Pathologists (CAP) in 1973 and revised into the 1990s. In 2002 CAP's SNOMED Reference Terminology was merged with, and expanded by, the National Health Service's Clinical Terms Version 3 to produce SNOMED CT.
Procedure codes are a sub-type of medical classification used to identify specific surgical, medical, or diagnostic interventions. The structure of the codes will depend on the classification; for example some use a numerical system, others alphanumeric.
In health care, diagnosis codes are used as a tool to group and identify diseases, disorders, symptoms, poisonings, adverse effects of drugs and chemicals, injuries and other reasons for patient encounters. Diagnostic coding is the translation of written descriptions of diseases, illnesses and injuries into codes from a particular classification. In medical classification, diagnosis codes are used as part of the clinical coding process alongside intervention codes. Both diagnosis and intervention codes are assigned by a health professional trained in medical classification such as a clinical coder or Health Information Manager.
Logical Observation Identifiers Names and Codes (LOINC) is a database and universal standard for identifying medical laboratory observations. First developed in 1994, it was created and is maintained by the Regenstrief Institute, a US nonprofit medical research organization. LOINC was created in response to the demand for an electronic clinical care and management database and is publicly available at no cost.
SNOMED CT or SNOMED Clinical Terms is a systematically organized computer-processable collection of medical terms providing codes, terms, synonyms and definitions used in clinical documentation and reporting. SNOMED CT is considered to be the most comprehensive, multilingual clinical healthcare terminology in the world. The primary purpose of SNOMED CT is to encode the meanings that are used in health information and to support the effective clinical recording of data with the aim of improving patient care. SNOMED CT provides the core general terminology for electronic health records. SNOMED CT comprehensive coverage includes: clinical findings, symptoms, diagnoses, procedures, body structures, organisms and other etiologies, substances, pharmaceuticals, devices and specimens.
The International Classification of Primary Care (ICPC) is a classification method for primary care encounters. The ICPC-3 strives to be a person centered classification for Primary Care, building on the foundations of the ICPC-2. It includes references to existing international standards such as ICD-10, ICD-11, ICF as well as SNOMED CT clinical terminology. It provides a framework for documenting and organizing clinical data from primary care patient contacts.
Medcin, is a system of standardized medical terminology, a proprietary medical vocabulary and was developed by Medicomp Systems, Inc. MEDCIN is a point-of-care terminology, intended for use in Electronic Health Record (EHR) systems, and it includes over 280,000 clinical data elements encompassing symptoms, history, physical examination, tests, diagnoses and therapy. This clinical vocabulary contains over 38 years of research and development as well as the capability to cross map to leading codification systems such as SNOMED CT, CPT, ICD-9-CM/ICD-10-CM, DSM, LOINC, CDT, CVX, and the Clinical Care Classification (CCC) System for nursing and allied health.
The German Institute for Medical Documentation and Information, abbreviated DIMDI, was a German organization responsible for medical information classification and management. It was a government Institute of the German Federal Ministry of Health and was located in Cologne, Germany.
A clinical coder—also known as clinical coding officer, diagnostic coder, medical coder, or nosologist—is a health information professional whose main duties are to analyse clinical statements and assign standardized codes using a classification system. The health data produced are an integral part of health information management, and are used by local and national governments, private healthcare organizations and international agencies for various purposes, including medical and health services research, epidemiological studies, health resource allocation, case mix management, public health programming, medical billing, and public education.
ICD-10 is the 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD), a medical classification list by the World Health Organization (WHO). It contains codes for diseases, signs and symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or diseases. Work on ICD-10 began in 1983, became endorsed by the Forty-third World Health Assembly in 1990, and was first used by member states in 1994. It was replaced by ICD-11 on January 1, 2022.
OPCS-4, or more formally OPCS Classification of Interventions and Procedures version 4, is the procedural classification used by clinical coders within National Health Service (NHS) hospitals of NHS England, NHS Scotland, NHS Wales and Health and Social Care in Northern Ireland. It is based on the earlier Office of Population Censuses and Surveys Classification of Surgical Operations and Procedures, and retains the OPCS abbreviation from this now defunct publication.
The ICD-11 is the eleventh revision of the International Classification of Diseases (ICD). It replaces the ICD-10 as the global standard for recording health information and causes of death. The ICD is developed and annually updated by the World Health Organization (WHO). Development of the ICD-11 started in 2007 and spanned over a decade of work, involving over 300 specialists from 55 countries divided into 30 work groups, with an additional 10,000 proposals from people all over the world. Following an alpha version in May 2011 and a beta draft in May 2012, a stable version of the ICD-11 was released on 18 June 2018, and officially endorsed by all WHO members during the 72nd World Health Assembly on 25 May 2019.
Read codes are a clinical terminology system that was in widespread use in General Practice in the United Kingdom until around 2018, when NHS England switched to using SNOMED CT. Read codes are still in use in Scotland and in England were permitted for use in NHS secondary care settings, such as dentistry and mental health care until 31 March 2020. Read codes support detailed clinical encoding of multiple patient phenomena including: occupation; social circumstances; ethnicity and religion; clinical signs, symptoms and observations; laboratory tests and results; diagnoses; diagnostic, therapeutic or surgical procedures performed; and a variety of administrative items. It therefore includes but goes significantly beyond the expressivity of a diagnosis coding system.
The Clinical Care Classification (CCC) System is a standardized, coded nursing terminology that identifies the discrete elements of nursing practice. The CCC provides a unique framework and coding structure. Used for documenting the plan of care; following the nursing process in all health care settings.
OPS, the Operationen- und Prozedurenschlüssel is the German modification of the International Classification of Procedures in Medicine (ICPM). For German hospitals it is currently the official coding system for medical procedures. Apart from its use for clinical controlling and performance statistics it is a basis for inpatient claims processing within the German Diagnosis-related Groups (G-DRG) system. Yearly OPS releases are produced by DIMDI. Besides OPS, G-DRG also requires disease codes based on ICD-10-GM is.
The ICD-10 Clinical Modification (ICD-10-CM) is a set of diagnosis codes used in the United States of America. It was developed by a component of the U.S. Department of Health and Human services, as an adaption of the ICD-10 with authorization from the World Health Organization. In 2015, ICD-10-CM replaced ICD-9-CM as the federally mandated classification. Annual updates are provided.
