Medical classification

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Medical classification, or
medical coding, is the process of
transforming descriptions of
medical diagnoses and
procedures into universal medical
code numbers. The diagnoses and
procedures are usually taken from
a variety of sources within the
health care record, such as the
transcription of the physician's
notes, laboratory results,
radiologic results, and other
sources.

Diagnosis codes 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. These
diagnosis and procedure codes
are used by government health
programs, private health
insurance companies, workers'
compensation carriers and others
to process claims.
Medical classification systems are
used for a variety of applications
in medicine, public health and
medical informatics, including:
statistical analysis of diseases
and therapeutic actions

 reimbursement; e.g., based on

diagnosis-related groups
knowledge-based and decision
support systems
direct surveillance of epidemic
or pandemic outbreaks
There are country specific
standards and international
classification systems.
Contents
1 Classification Types
2 WHO Family of International
Classifications
o2.1 Reference classifications
o2.2 Derived classifications
o2.3 Related classifications

 3 Other medical classifications

o3.1 Diagnosis
o3.2 Procedure
o3.3 Other
3.3.1 Library classification
that have medical
components
4 ICD, SNOMED and Electronic
Health Record (EHR)
o4.1 What is SNOMED?
o4.2 What is ICD?
o4.3 SNOMED CT vs ICD
o4.4 Data Mapping of
SNOMED and ICD
5 Clinical Coding in Australia
o5.1 What is clinical coding?

o5.2 What does clinical coder

do?
o5.3 What is coded data used
for?
6 Veterinary medical coding
7 See also
8 References
9 External links
Classification Types
Many different medical
classifications exist, though they
occur into two main groupings:
Statistical classifications and
Nomenclatures.
A statistical classification
brings together similar clinical
concepts and groups them into

categories. The number of

categories is limited so that the
classification does not become
too big. An example of this is used
by the International Statistical
Classification of Diseases and
Related Health Problems (known
as ICD). ICD groups diseases of
the circulatory system into one
"chapter," known as Chapter IX,
covering codes I00I99. One of
the codes in this chapter (I47.1)
has the code title (rubric)
Supraventricular tachycardia.
However, there are several other
clinical concepts that are also
classified here. Among them are
paroxysmal atrial tachycardia,
paroxysmal junctional

tachycardia, auricular tachycardia

and nodal tachycardia.
Another feature of statistical
classifications is the provision of
residual categories for "other" and
"unspecified" conditions that do
not have a specific category in
the particular classification.
In a nomenclature there is a
separate listing and code for
every clinical concept. So, in the
previous example, each of the
tachycardia listed would have its
own code. This makes
nomenclatures unwieldy for
compiling health statistics.
Types of coding systems specific
to health care include:

 Diagnostic codes
oAre used to determine
diseases, disorders, and
symptoms
oCan be used to measure
morbidity and mortality
oExamples: ICD-9-CM, ICD-10
Procedural codes
oThey are numbers or
alphanumeric codes used to
identify specific health
interventions taken by
medical professionals.
oExamples: ICPM, ICHI
Pharmaceutical codes
oAre used to identify
medications
oExamples: AT, NDC

 Topographical codes
oAre codes that indicate a
specific location in the body
oExamples :ICD-O, SNOMED
WHO Family of International
Classifications
The World Health Organization
(WHO) maintains several
internationally endorsed
classifications designed to
facilitate the comparison of health
related data within and across
populations and over time as well
as the compilation of nationally
consistent data.[1] This "Family of
International Classifications" (FIC)
include three main (or reference)
classifications on basic
parameters of health prepared by

the organization and approved by

the World Health Assembly for
international use, as well as a
number of derived and related
classifications providing additional
details. Some of these
international standards have been
revised and adapted by various
countries for national use.
Reference classifications
International Statistical
Classification of Diseases
and Related Health
Problems (ICD)[2]
oICD-9 (9th revision,
published in 1977)
ICD-9-CM (Clinical
Modification, used in the
US)

oICD-10 (10th revision, in use

by WHO since 1994)
ICD-10-CM (Clinical
Modification, used in the
US)
ICD-10-PCS (Procedure
Coding System, used in
the US)
ICD-10-CA (used for
morbidity classification in
Canada).[3]
ICD-10-AM (used in
Australia and New
Zealand)[4]
EUROCAT - an extension
of the ICD-10 Q chapter
for congenital disorders

 International Classification
of Functioning, Disability
and Health (ICF)
International Classification
of Health Interventions
(ICHI) (previously known as
International Classification of
Procedures in Medicine)[5]
Derived classifications
Derived classifications are based
on the WHO reference
classifications (i.e. ICD and ICF).[1]
They include the following:
International Classification of
Diseases for Oncology, Third
Edition (ICD-O-3)
ICD-10 Classification of Mental
and Behavioural Disorders This publication deals

exclusively with Chapter V of

ICD-10, and is available as two
variants; the clinical
descriptions and diagnostic
guidelines,[6] and the diagnostic
criteria for research[7] (also
known as the "blue book" and
"green book" respectively).[8]
Application of the International
Classification of Diseases to
Dentistry and Stomatology, 3rd
Edition (ICD-DA)[9]
Application of the International
Classification of Diseases to
Neurology (ICD-10-NA)[10]
Related classifications
Related classifications in the
WHO-FIC are those that partially
refer to the reference

classifications, e.g. only at

specific levels.[1] They include:
International Classification of
Primary Care (ICPC)[11]
oICPC-2 PLUS
International Classification of
External Causes of Injury
(ICECI)[12]
Anatomical Therapeutic
Chemical Classification System
with Defined Daily Doses
(ATC/DDD)
Technical aids for persons with
disabilities: Classification and
terminology (ISO9999)[13]
International Classification for
Nursing Practice (ICNP)[14]
Other medical classifications

Diagnosis
The categories in a diagnosis
classification classify diseases,
disorders, symptoms and medical
signs. In addition to the ICD and
its national variants, they include:
Diagnostic and Statistical
Manual of Mental Disorders
(DSM)
oDSM-IV Codes
International Classification of
Headache Disorders 2nd
Edition (ICHD-II)[15]
International Classification of
Sleep Disorders (ICSD)
Online Mendelian Inheritance in
Man, database of genetic codes
Read codes

 Systematized Nomenclature of
Medicine - Clinical Terms
(SNoMed-CT)
Procedure
The categories in a procedure
classification classify specific
health interventions undertaken
by health professionals. In
addition to the ICHI and ICPC,
they include:
Australian Classification of
Health Interventions (ACHI)
Canadian Classification of
Health Interventions (CCI)[16]
Chinese Classification of Heath
Interventions (CCHI)
Current Procedural Terminology
(CPT)

 Health Care Procedure Coding

System (HCPCS)
ICD-10 Procedure Coding
System (ICD-10-PCS)
OPCS Classification of
Interventions and Procedures
(OPCS-4)
Other
Classification of PharmacoTherapeutic Referrals (CPR)
Logical Observation Identifiers
Names and Codes (LOINC),
standard for identifying
medical laboratory
observations
Medical Dictionary for
Regulatory Activities (MedDRA)

 Medical Subject Headings

(MeSH)
oList of MeSH codes
Nursing Interventions
Classification (NIC)
Nursing Outcomes
Classification (NOC)
TIME-ITEM, ontology of topics
in medical education
TNM Classification of Malignant
Tumors
Unified Medical Language
System (UMLS)
Victoria Ambulatory Coding
System (VACS) / Queensland
Ambulatory Coding System
(QACS), Australia[citation needed]

Library classification that

have medical components
Dewey Decimal Classification
and Universal Decimal
Classification (section 610620)
National Library of Medicine
classification
ICD, SNOMED and Electronic
Health Record (EHR)
What is SNOMED?
The Systematized Nomenclature
of Medicine (SNOMED) is the most
widely recognised nomenclature
in healthcare.[17] Its current
version, SNOMED Clinical Terms
(SNOMED CT), is intended to
provide a set of concepts and
relationships that offers a

common reference point for

comparison and aggregation of
data about the health care
process.[18] SNOMED CT is often
described as a reference
terminology.[19] SNOMED CT
contains more than 311,000
active concepts with unique
meanings and formal logic-based
definitions organised into
hierarchies.[18] SNOMED CT can be
used by anyone with an Affiliate
License, 40 low income countries
defined by the World Bank or
qualifying research, humanitarian
and charitable projects.[18]
SNOMED-CT is designed to be
managed by computer, and it is a
complex relationship concepts.[17]

What is ICD?
The International Classification of
Disease (ICD) is the most widely
recognized medical classification
maintained by the World Health
Organization (WHO).[20] Its primary
purpose is to categorise diseases
for morbidity and mortality
reporting. The United States has
used a clinical modification of ICD
(ICD-9-CM) for the additional
purposes of reimbursement. ICD10 was endorsed by WHO in 1990,
and WHO Member states began
using the classification system in
1994 for both morbidity and
mortality reporting. In the US,
however, it has only been used for
reporting mortality since 1999.

Because of the US delay in

adopting its version of ICD-10, it is
currently unable to compare
morbidity data with the rest of the
world. ICD has a hierarchical
structure, and coding in this
context, is the term applied when
representations are assigned to
the words they represent.[20]
Coding diagnoses and procedures
is the assignment of codes from a
code set that follows the rules of
the underlying classification or
other coding guidelines.
SNOMED CT vs ICD
SNOMED CT and ICD are designed
for different purposes and each
should be used for the purposes
for which they were designed.[21]

As a core terminology for the EHR,

SNOMED CT provides a common
language that enables a
consistent language that enables
a consistent way of capturing,
sharing, and aggregating health
data across specialties and sites
of care.[22] It is highly detailed
terminology designed for input
not reporting. Classification
systems such as ICD-9-CM, ICD10-CM, and ICD-10-PCS group
together similar diseases and
procedures and organise related
entities for easy retrieval.[22] They
are typically used for external
reporting requirements or other
uses where data aggregation is
advantageous, such as measuring
the quality of care monitoring

resource utilisation, or processing

claims for reimbursement.
SNOMED is clinically-based,
documents whatever is needed
for patient care and has better
clinical coverage than ICD. ICDs
focus is statistical with less
common diseases get lumped
together in catch-all categories,
which result in loss of information.
SNOMED CT is used directly by
healthcare providers during the
process of care, whereas ICD is
used by coding professionals after
the episode of care. SNOMED CT
has multiple hierarchy, whereas
there is single hierarchy for ICD.
SNOMED CT concepts are defined
logically by their attributes,

whereas only textual rules and

definitions in ICD.[22]
Data Mapping of SNOMED and ICD
SNOMED and ICD can be
coordinated. The National Library
of Medicine (NLM) maps ICD-9CM, ICD-10-CM, ICD-10-PCS, and
other classification systems to
SNOMED.[23] Data Mapping is the
process of identifying
relationships between two distinct
data models. The full value of the
health information contained in an
EHR system will only be realised if
both systems involved in the map
are up to date and accurately
reflect the current practice of
medicine.[20]
Clinical Coding in Australia

Medical coding and classification

systems are expected to become
increasingly important in the
health care sector. Together with
and as an integrated part of the
electronic health information
systems, the coding and
classification systems will be used
to improve the quality and
effectiveness of the medical
services.[24]
What is clinical coding?
Clinical coding is the translation of
written, scanned and/or electronic
clinical documentation about
patient care into code format. For
example, hypertension is
represented by the code 'I10';

general anaethesia is represented

by the code'92514-XX[1910]'.
A standardised classification
system, The International
Statistical Classification of
Diseases and Related Health
Problems, 10th Revision,
Australian Modification (ICD-10AM), is applied in all Australian
acute health facilities. It is based
on the World Health Organisation
(WHO) ICD-10 system, updated
with the Australian Classification
of Health Interventions (ACHI),
Australian Coding Standards
(ACS). Clinical coding is a
specialised skill requiring
excellent knowledge of medical
terminology and disease

processes, attention to detail, and

analytical skills.[25]
What does clinical coder do?
A clinical coder is responsible for
abstracting relevant information
from the medical record and
deciding which diagnoses and
procedures meet criteria for
coding as per Australian and State
Coding Standards. The coder then
assigns codes for these diagnoses
and procedures based on ICD-10AM conventions and standards.[25]
What is coded data used for?
The assigned codes and other
patient data are processed by
grouper software to determine a
diagnosis-related group (DRG) for

the episode of care, which is used

for funding and reimbursement.
This process allows hospital
episodes to be grouped into
meaningful categories, helping us
to better match patient needs to
health care resources.[26]
The coded information is used for
clinical governance, clinical audit
and outcome and effectiveness of
patient's care and treatment.
Statistically this information is
used to keep a track of payment
by results, cost analysis,
commissioning, etiology studies,
health trends, epidemiology
studies, clinical indicators and
case-mix planning.
Veterinary medical coding

Veterinary medical codes include

the VeNom Coding Group, the U.S.
Animal Hospital Codes, and
SNOMED.
See also
Acronyms in healthcare
Ambulatory Payment
Classification, US billing system
for outpatient services
Biological database
Classification of mental
disorders
Clinical coder
German Institute for Medical
Documentation and
Information

 Health information
management
Health informatics
Human resources for health
information system
List of international common
standards
Medical dictionary
North American Nursing
Diagnosis Association
(professional organization)
Nosology
References
1. World Health Organization.
Family of International
Classifications. Accessed 12
July 2011.

2. World Health Organization.

International Classification of
Diseases (ICD).
3. Canadian Institute for Health
Information. ICD-10-CA.
Accessed 12 July 2011.
4. New Zealand Health
Information Service. ICD-10AM. Accessed 12 July 2011.
5.

WHO. ICHI.

6. World Health Organization

ICD Blue book
7. World Health Organization
ICD Greenbook
8. "ICD-10-CM Release for 2014
now available". Dx Revision
Watch. Retrieved 30 May 2015.
9. Bezroukov V (February
1979). "The application of the

International Classification of
Diseases to dentistry and
stomatology". Community Dent
Oral Epidemiol 7 (1): 214.
doi:10.1111/j.16000528.1979.tb01180.x.
PMID 282953.
10. van Drimmelen-Krabbe JJ,
Bradley WG, Orgogozo JM,
Sartorius N (November 1998).
"The application of the
International Statistical
Classification of Diseases to
neurology: ICD-10 NA". J.
Neurol. Sci. 161 (1): 29.
doi:10.1016/S0022510X(98)00217-2.
PMID 9879674.
11. WHO. ICPC-2.
12. WHO. ICECI.

13. WHO. Technical aids for

persons with disabilities:
Classification and terminology
(ISO9999).
14. WHO. International
Classification for Nursing
Practice (ICNP).
15. Olesen, Jes (2004). "The
International Classification of
Headache Disorders: 2nd
edition". Cephalalgia. 24
(Suppl 1): 9160.
doi:10.1111/j.14682982.2003.00824.x.
PMID 14979299.
16. Canadian Classification of
Health Interventions. CCI.
17. http://www.ihtsdo.org/snome
d-ct/

18. http://www.nlm.nih.gov/rese
arch/umls/Snomed/snomed_faq
.html#what
19. http://sydney.edu.au/medicin
e/fmrc/snomed/
20. Margret k.
Amatayakul,MBA,RHIA,CHPS,CP
HIT,CPEHR&FHIMSS.
(2009).Electronic Health
Records: A Practical Guide for
Professionals and
Organizations.Chicago,America
:AHIMA
21. http://www.icd10watch.com/
blog/why-snomed-cannotreplace-icd-10-cmpcs-code-sets
22. http://ebookbrowse.com/sno
med-icd10-kwfung-pptxd371532824

23. http://www.who.int/classifica
tions/icd/snomedCTToICD10Ma
ps/en/
24. "[Medical coding and
classification systems].".
Tidsskr Nor Laegeforen 114
(6): 6946. Feb 1994.
PMID 8191453.
25. http://www.clinicalcoding.he
alth.wa.gov.au/about/
26. http://www.health.vic.gov.au
External links
WHO Family of International
Classifications official site
Medical terminologies at the
National Library of Medicine
The International Health
Terminology Standards

Development Organisation SNOMED CT

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Health informatics
Categories:
Medical classification
Nursing classification

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