A medical classification is used to transform descriptions of medical
diagnoses
Diagnosis is the identification of the nature and cause of a certain phenomenon. Diagnosis is used in many different disciplines, with variations in the use of logic, analytics, and experience, to determine "cause and effect". In systems enginee ...
or
procedures
Procedure may refer to:
* Medical procedure
* Instructions or recipes, a set of commands that show how to achieve some result, such as to prepare or make something
* Procedure (business), specifying parts of a business process
* Standard opera ...
into standardized statistical code in a process known as
clinical coding
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 standard codes using a classification ...
. Diagnosis classifications list
diagnosis code
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 w ...
s, which are used to track
disease
A disease is a particular abnormal condition that negatively affects the structure or function of all or part of an organism, and that is not immediately due to any external injury. Diseases are often known to be medical conditions that a ...
s and other health conditions, inclusive of chronic diseases such as
diabetes mellitus
Diabetes, also known as diabetes mellitus, is a group of metabolic disorders characterized by a high blood sugar level ( hyperglycemia) over a prolonged period of time. Symptoms often include frequent urination, increased thirst and increased ap ...
and
heart disease
Cardiovascular disease (CVD) is a class of diseases that involve the heart or blood vessels. CVD includes coronary artery diseases (CAD) such as angina and myocardial infarction (commonly known as a heart attack). Other CVDs include stroke, hea ...
, and infectious diseases such as
norovirus
Norovirus, sometimes referred to as the winter vomiting disease, is the most common cause of gastroenteritis. Infection is characterized by non-bloody diarrhea, vomiting, and stomach pain. Fever or headaches may also occur. Symptoms usually deve ...
, the
flu
Influenza, commonly known as "the flu", is an infectious disease caused by influenza viruses. Symptoms range from mild to severe and often include fever, runny nose, sore throat, muscle pain, headache, coughing, and fatigue. These symptom ...
, and
athlete's foot
Athlete's foot, known medically as ''tinea pedis'', is a common skin infection of the feet caused by a fungus. Signs and symptoms often include itching, scaling, cracking and redness. In rare cases the skin may blister. Athlete's foot fungus m ...
. Procedure classifications list
procedure code
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 alph ...
, 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
Medicine is the science and practice of caring for a patient, managing the diagnosis, prognosis, prevention, treatment, palliation of their injury or disease, and promoting their health. Medicine encompasses a variety of health care pract ...
,
public health
Public health is "the science and art of preventing disease, prolonging life and promoting health through the organized efforts and informed choices of society, organizations, public and private, communities and individuals". Analyzing the det ...
and
medical informatics
Health informatics is the field of science and engineering that aims at developing methods and technologies for the acquisition, processing, and study of patient data, which can come from different sources and modalities, such as electronic hea ...
, including:
* statistical analysis of diseases and therapeutic actions
* reimbursement (e.g., to process claims in
medical billing
Medical billing is a payment practice within the United States healthcare system. The process involves a healthcare provider obtaining insurance information from a patient and filing, following up on and appealing claims with health insurance co ...
based on
diagnosis-related group
Diagnosis-related group (DRG) is a system to classify hospital cases into one of originally 467 groups, with the last group (coded as 470 through v24, 999 thereafter) being "Ungroupable". This system of classification was developed as a collaborat ...
s)
* knowledge-based and
decision support system
A decision support system (DSS) is an information system that supports business or organizational decision-making activities. DSSs serve the management, operations and planning levels of an organization (usually mid and higher management) and h ...
s
* direct surveillance of epidemic or pandemic outbreaks
There are country specific standards and international classification systems.
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
(known as ICD). ICD-10 groups diseases of the circulatory system into one "chapter," known as Chapter , covering codes I00–I99. One of the codes in this chapter (I47.1) has the code title (
rubric
A rubric is a word or section of text that is traditionally written or printed in red ink for emphasis. The word derives from the la, rubrica, meaning red ochre or red chalk, and originates in Medieval illuminated manuscripts from the 13th cent ...
) ''
Supraventricular tachycardia
Supraventricular tachycardia (SVT) is an umbrella term for fast heart rhythms arising from the upper part of the heart. This is in contrast to the other group of fast heart rhythms – ventricular tachycardia, which start within the lower cham ...
''. However, there are several other clinical concepts that are also classified here. Among them are paroxysmal
atrial tachycardia
Atrial tachycardia is a type of heart rhythm problem in which the heart's electrical impulse comes from an ectopic pacemaker (that is, an abnormally located cardiac pacemaker) in the upper chambers ( atria) of the heart, rather than from the sino ...
, paroxysmal
junctional tachycardia
Junctional tachycardia is a form of supraventricular tachycardia characterized by involvement of the AV node. It can be contrasted to atrial tachycardia. It is a tachycardia associated with the generation of impulses in a focus in the region of ...
, 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
Nomenclature (, ) is a system of names or terms, or the rules for forming these terms in a particular field of arts or sciences. The principles of naming vary from the relatively informal naming conventions, conventions of everyday speech to the i ...
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
** Are used to determine diseases, disorders, and symptoms
** Can be used to measure morbidity and mortality
** Examples:
ICD-9-CM
The International Classification of Diseases (ICD) is a globally used diagnostic tool for epidemiology, health management and clinical purposes. The ICD is maintained by the World Health Organization (WHO), which is the directing and coordinating ...
,
ICD-10
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, ...
,
ICD-11
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 He ...
*
Procedural codes
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 alph ...
** They are numbers or alphanumeric codes used to identify specific health interventions taken by medical professionals.
** Examples:
CPT,
HCPCS The Healthcare Common Procedure Coding System (HCPCS, often pronounced by its acronym as "hick picks") is a set of health care procedure codes based on the American Medical Association's Current Procedural Terminology (CPT).
History
The acronym ''H ...
,
ICPM,
ICHI
The International Classification of Health Interventions (ICHI) is a system of classifying procedure codes being developed by the World Health Organization (WHO). It is currently available as a beta 3 release. The components for clinical documentat ...
*
Pharmaceutical code Pharmaceutical codes are used in medical classification to uniquely identify medication. They may uniquely identify an active ingredient, drug system (including inactive ingredients and time-release agents) in general, or a specific pharmaceutical ...
s
** Are used to identify medications
** Examples:
ATC,
NDC,
ICD-11
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 He ...
*
Topographical code
In medicine, "topographical codes" (or "topography codes") are codes that indicate a specific location in the body.
Examples
Only the first of these is a system dedicated only to topography. The others are more generalized systems that contain t ...
s
** Are codes that indicate a specific location in the body
** Examples :
ICD-O
The International Classification of Diseases for Oncology (ICD-O) is a domain-specific extension of the International Statistical Classification of Diseases and Related Health Problems for tumor diseases. This classification is widely used by canc ...
,
SNOMED
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, pro ...
,
ICD-11
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 He ...
WHO Family of International Classifications
The
World Health Organization
The World Health Organization (WHO) is a specialized agency of the United Nations responsible for international public health. The WHO Constitution states its main objective as "the attainment by all peoples of the highest possible level of h ...
(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.
This "Family of International Classifications" (FIC) include three main (or reference) classifications on basic parameters of
health
Health, according to the World Health Organization, is "a state of complete physical, mental and social well-being and not merely the absence of disease and infirmity".World Health Organization. (2006)''Constitution of the World Health Organiza ...
prepared by the organization and approved by the
World Health Assembly
The World Health Assembly (WHA) is the forum through which the World Health Organization (WHO) is governed by its 194 member states. It is the world's highest health policy setting body and is composed of health ministers from member states.
T ...
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
*
(ICD)
**
ICD-10
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, ...
(10th revision, in use by WHO since 1994)
**
ICD-11
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 He ...
(11th revision)
*
(ICF)
*
International Classification of Health Interventions
The International Classification of Health Interventions (ICHI) is a system of classifying procedure codes being developed by the World Health Organization (WHO). It is currently available as a beta 3 release. The components for clinical documentat ...
(ICHI)
Derived classifications
Derived classifications are based on the WHO reference classifications (i.e. ICD and ICF).
They include the following:
* ''
International Classification of Diseases for Oncology
The International Classification of Diseases for Oncology (ICD-O) is a domain-specific extension of the International Statistical Classification of Diseases and Related Health Problems for tumor diseases. This classification is widely used by canc ...
'', Third Edition (ICD-O-3)
* ''The ICD-10 Classification of Mental and Behavioural Disorders'' – This publication deals exclusively with Chapter of ICD-10,
and is available as two variants;
**''Clinical descriptions and diagnostic guidelines'', also known as the blue book.
**''Diagnostic criteria for research,'' also known as the green book.
* ''Application of the International Classification of Diseases to Dentistry and Stomatology'', 3rd Edition (ICD-DA)
* ''Application of the International Classification of Diseases to Neurology'' (ICD-10-NA)
*
EUROCAT is an extension of the ICD-10 Chapter , which covers
congenital disorders
A birth defect, also known as a congenital disorder, is an abnormal condition that is present at birth regardless of its cause. Birth defects may result in disabilities that may be physical, intellectual, or developmental. The disabilities can ...
.
National versions
Several countries have developed their own version of WHO-FIC publications, which go beyond a local language translation. Many of these are based on the ICD:
*
ICD-9-CM
The International Classification of Diseases (ICD) is a globally used diagnostic tool for epidemiology, health management and clinical purposes. The ICD is maintained by the World Health Organization (WHO), which is the directing and coordinating ...
was the US' adaptation of ICD-9 and was maintained for use until September 2015. Starting on October 1, 2015, the
Centers for Medicare and Medicaid Services
The Centers for Medicare & Medicaid Services (CMS), is a federal agency within the United States Department of Health and Human Services (HHS) that administers the Medicare program and works in partnership with state governments to administer M ...
(CMMS) granted physicians a one-year grace period to begin using
ICD-10-CM
The ICD-10 Clinical Modification (ICD-10-CM) is a modification of the ICD-10, authorized by the World Health Organization, used as a source for diagnosis codes in the United States of America. It replaces the earlier ICD-9-CM.
Adoption
Adoption ...
, or they would be denied Medicare Part B claims.
*
ICD-10-CM
The ICD-10 Clinical Modification (ICD-10-CM) is a modification of the ICD-10, authorized by the World Health Organization, used as a source for diagnosis codes in the United States of America. It replaces the earlier ICD-9-CM.
Adoption
Adoption ...
was developed by the US'
Centers for Medicare and Medicaid Services
The Centers for Medicare & Medicaid Services (CMS), is a federal agency within the United States Department of Health and Human Services (HHS) that administers the Medicare program and works in partnership with state governments to administer M ...
(CMS) and the
National Center for Health Statistics
The National Center for Health Statistics (NCHS) is a U.S. government agency that provides statistical information to guide actions and policies to improve the public health of the American people. It is a unit of the Centers for Disease Control ...
(NCHS), and has been in use in the US since October 2015replacing ICD-9-CM.
*ICD-10-AM was published by Australia's National Centre for Classification in Health in 1998 and has since been adopted by a number of other countries.
Related classifications
Related classifications in the WHO-FIC are those that partially refer to the reference classifications, e.g. only at specific levels.
They include:
*
International Classification of Primary Care
The International Classification of Primary Care (ICPC) is a classification method for primary care encounters. It allows for the classification of the patient’s reason for encounter (RFE), the problems/diagnosis managed, primary or general heal ...
(ICPC)
**
ICPC-2 PLUS ICPC-2 PLUS is an extended terminology classified to ICPC-2 International Classification of Primary Care, which aids data entry, retrieval and analysis. ICPC-2 PLUS takes into account the frequency distribution of problems seen in primary health car ...
*
Anatomical Therapeutic Chemical Classification System
The Anatomical Therapeutic Chemical (ATC) Classification System is a drug classification system that classifies the active ingredients of drugs according to the organ or system on which they act and their therapeutic, pharmacological and chemical ...
with Defined Daily Doses (ATC/DDD)
* ''Assistive products — Classification and terminology'' (ISO9999:2022). WHO adopted ISO9999 as a related classification in 2003,
however, the
International Organization for Standardization
The International Organization for Standardization (ISO ) is an international standard development organization composed of representatives from the national standards organizations of member countries. Membership requirements are given in Ar ...
(ISO) remains responsible for maintaining ISO9999.
*''International Classification for Nursing Practice'' (ICNP)
Historic FIC classifications
ICD versions before ICD-9 are not in use anywhere.
ICD-9
The International Classification of Diseases (ICD) is a globally used diagnostic tool for epidemiology, health management and clinical purposes. The ICD is maintained by the World Health Organization (WHO), which is the directing and coordinating ...
was published in 1977, and superseded by ICD-10 in 1994. The last version of ICD-10 was published in 2019, and it was replaced by ICD-11 on 1 January 2022.
35 of the 194 member states have made the transition to the latest version of the ICD.
The
International Classification of Procedures in Medicine
The International Classification of Health Interventions (ICHI) is a system of classifying procedure codes being developed by the World Health Organization (WHO). It is currently available as a beta 3 release. The components for clinical documentat ...
(ICPM) is a
procedural classification that has not updated since 1989, and will be replaced by
ICHI
The International Classification of Health Interventions (ICHI) is a system of classifying procedure codes being developed by the World Health Organization (WHO). It is currently available as a beta 3 release. The components for clinical documentat ...
.
National adaptions of the ICPM includes
OPS-301, which is the official German procedural classification.
International Classification of External Causes of Injury The International Classification of External Causes of Injury (ICECI) is a medical classification providing codes for external injuries. It is designed to aid professionals and researchers in the statistical tracking and prevention of injury.
Firs ...
(ICECI) was last updated in 2003 and, with the development
ICD-11
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 He ...
, is no longer maintained. The concepts of ICECI are represented within ICD-11 as extension codes.
Other medical classifications
Diagnosis
The categories in a diagnosis classification classify
disease
A disease is a particular abnormal condition that negatively affects the structure or function of all or part of an organism, and that is not immediately due to any external injury. Diseases are often known to be medical conditions that a ...
s, disorders, symptoms and medical signs. In addition to the
ICD and its national variants, they include:
* ''
Diagnostic and Statistical Manual of Mental Disorders
The ''Diagnostic and Statistical Manual of Mental Disorders'' (DSM; latest edition: DSM-5-TR, published in March 2022) is a publication by the American Psychiatric Association (APA) for the classification of mental disorders using a common langua ...
'' (DSM)
**
DSM-IV Codes
DSM-IV codes are the classification found in the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision, also known as ''DSM-IV-TR'', a manual published by the American Psychiatric Association (APA) that includes almost a ...
**
DSM-5
The ''Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition'' (DSM-5), is the 2013 update to the ''Diagnostic and Statistical Manual of Mental Disorders'', the taxonomic and diagnostic tool published by the American Psychiatric ...
* ''International Classification of Headache Disorders'' 2nd Edition (ICHD-II)
*
International Classification of Sleep Disorders
The International Classification of Sleep Disorders (ICSD) is "a primary diagnostic, epidemiological and coding resource for clinicians and researchers in the field of sleep and sleep medicine". The ICSD was produced by the American Academy of Sle ...
(ICSD)
*
Online Mendelian Inheritance in Man
Online Mendelian Inheritance in Man (OMIM) is a continuously updated catalog of human genes and genetic disorders and traits, with a particular focus on the gene-phenotype relationship. , approximately 9,000 of the over 25,000 entries in OMIM r ...
, database of genetic codes
*
*
Read codes
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 are permitted ...
*
SNOMED CT
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 mo ...
Procedure
The categories in a procedure classification classify specific health interventions undertaken by
health professionals
A health professional, healthcare professional, or healthcare worker (sometimes abbreviated HCW) is a provider of health care treatment and advice based on formal training and experience. The field includes those who work as a nurse, physician (suc ...
. In addition to the
ICHI
The International Classification of Health Interventions (ICHI) is a system of classifying procedure codes being developed by the World Health Organization (WHO). It is currently available as a beta 3 release. The components for clinical documentat ...
and
ICPC, they include:
*
Australian Classification of Health Interventions
The International Classification of Health Interventions (ICHI) is a system of classifying procedure codes being developed by the World Health Organization (WHO). It is currently available as a beta 3 release. The components for clinical documentat ...
(ACHI)
*
Canadian Classification of Health Interventions (CCI)
[Canadian Classification of Health Interventions. CCI](_blank)
*
Current Procedural Terminology
The Current Procedural Terminology (CPT) code set is a procedural code set developed by the American Medical Association (AMA). It is maintained by the CPT Editorial Panel. The CPT code set describes medical, surgical, and diagnostic services and ...
(CPT)
*
Health Care Procedure Coding System The Healthcare Common Procedure Coding System (HCPCS, often pronounced by its acronym as "hick picks") is a set of health care procedure codes based on the American Medical Association's Current Procedural Terminology (CPT).
History
The acronym ''H ...
(HCPCS)
*
ICD-10 Procedure Coding System
The ICD-10 Procedure Coding System (ICD-10-PCS) is an international system of medical classification used for procedural coding. The Centers for Medicare and Medicaid Services, the agency responsible for maintaining the inpatient procedure code se ...
(ICD-10-PCS)
*
OPCS Classification of Interventions and Procedures (OPCS-4)
Drugs
Drugs are often grouped into drug classes. Such classifications include:
*
RxNorm
RxNorm is US-specific terminology in medicine that contains all medications available on the US market. It can also be used in personal health records applications. RxNorm is part of Unified Medical Language System (UMLS) terminology and is maint ...
*
Anatomical Therapeutic Chemical Classification System
The Anatomical Therapeutic Chemical (ATC) Classification System is a drug classification system that classifies the active ingredients of drugs according to the organ or system on which they act and their therapeutic, pharmacological and chemical ...
*Medical Reference Terminology
*
National Pharmaceutical Product Index
The National Pharmaceutical Product Index or NAPPI is a comprehensive database of pharmaceutical codes for medical products classification used in South Africa
South Africa, officially the Republic of South Africa (RSA), is the southernm ...
National Drug File-Reference Terminology (NDF-RT)
National Drug File-Reference Terminology was a terminology maintained by the
Veterans Health Administration
The Veterans Health Administration (VHA) is the component of the United States Department of Veterans Affairs (VA) led by the Under Secretary of Veterans Affairs for Health that implements the healthcare program of the VA through a national ...
(VHA). It groups drug concepts into classes. It was part of RxNorm until March 2018.
Medication Reference Terminology (MED-RT)
Medication Reference Terminology (MED-RT) is a terminology created and maintained by
Veterans Health Administration
The Veterans Health Administration (VHA) is the component of the United States Department of Veterans Affairs (VA) led by the Under Secretary of Veterans Affairs for Health that implements the healthcare program of the VA through a national ...
in the
United States
The United States of America (U.S.A. or USA), commonly known as the United States (U.S. or US) or America, is a country primarily located in North America. It consists of 50 states, a federal district, five major unincorporated territorie ...
. In 2018, it replaced NDF-RT that was used during 2005–2017. Med-RT is not included in RxNorm but is included in National Library of Medicine's
UMLS Metathesaurus. Prior 2017, NDF-RT was included in RxNorm. The first release of MED-RT was in the spring of 2018.
The United States Food and Drug Administration requires in its Manual of Policies and Procedures (MaPP) 7400.13 dated July 18, 2013 and updated on July 25, 2018, that MED-RT be used for selecting an established pharmacologic class (EPC) for the Highlights of Prescribing Information in drug labeling. Each EPC text phrase is associated with a term known as an EPC concept. EPC concepts use a standardized format derived from the U.S. Department of Veterans Affairs, Veterans Health Administration (VHA) Medication Reference Terminology (MED-RT). Each EPC concept also has a unique standardized alphanumeric identifier code, used as the machine-readable tag for the concept. These codes enable SPL indexing. The exact EPC text phrase used in INDICATIONS AND USAGE in Highlights might not be identical to the wording used to describe the EPC concept, because the standardized language used for the EPC concept might not be considered sufficiently clear to the readers of the labeling. Each active moiety also may be assigned MOA, PE, and CS standardized indexing concepts, which are also linked to unique standardized alphanumeric identifier codes. MOA, PE, and CS standardized indexing concepts may or may not be related to the therapeutic effect of the active moiety for a particular indication, but they should still be scientifically valid and clinically meaningful. Even if the MOA, PE, and CS standardized indexing concepts are not known with certainty to be related to the therapeutic effect, they may still be useful for identifying drug interactions and permitting other safety assessments for a moiety based upon appropriate and relevant considerations, such as enzyme inhibition and enzyme induction. MOA, PE, and CS concepts are maintained in a standardized format as part of the MED-RT hierarchy. https://www.fda.gov/media/86437/download
The United States Food and Drug Administration Study Data Technical Conformance Guide dated July 2020 states, "6.5 Pharmacologic Class 6.5.1 Medication Reference Terminology 6.5.1.1 General Considerations The Veterans Administration's Medication Reference Terminology (MED-RT) should be used to identify the pharmacologic class(es) of all active investigational substances that are used in a study (either clinical or nonclinical). This information should be provided in the SDTM TS domain when a full TS is indicated. The information should be provided as one or more records in TS, where TSPARMCD= PCLAS. Pharmacologic class is a complex concept that is made up of one or more component concepts: mechanism of action (MOA), physiologic effect (PE), and chemical structure (CS).51 The established pharmacologic class is generally the MOA, PE, or CS term that is considered the most scientifically valid and clinically meaningful. Sponsors should include in TS (the full TS) the established pharmacologic class of all active moieties of investigational products used in a study. FDA maintains a list of established pharmacologic classes of approved moieties.52 If the established pharmacologic class is not available for an active moiety, then the sponsor should discuss the appropriate MOA, PE, and CS terms with the review division. For unapproved investigational active moieties where the pharmacologic class is unknown, the PCLAS record may not be available." https://www.fda.gov/media/136460/download
The United States Food and Drug Administration publishes a Data Standards Catalog that lists the data standards and terminologies that FDA supports for use in regulatory submissions to better enable the evaluation of safety, effectiveness, and quality of FDA-regulated products. In addition, the FDA has the statutory and regulatory authority to require certain standards and terminologies and these are identified in the Catalog with the date the requirement begins and, as needed, the date the requirement ends, and information sources. The submission of data using standards or terminologies not listed in the Catalog should be discussed with the Agency in advance. Where the Catalog expresses support for more than one standard or terminology for a specific use, the sponsor or applicant may select one to use or can discuss, as appropriate, with their review division. Version 7.0 of the FDA Data Standards Catalog dated 03-15-2021, specifies that MED-RT was a required terminology by the White House Consolidated Health Informatics Initiative in various Federal Register Notices beginning as early as May 6, 2004, for NDAs, ANDAs, and certain BLAs beginning on December 17, 2016, and for certain IND's beginning on December 17, 2017. https://www.fda.gov/media/85137/download
Medical Devices
*
Global Medical Device Nomenclature
Global Medical Device Nomenclature (GMDN) is a system of internationally agreed generic descriptors used to identify all medical device products. This nomenclature is a naming system for products which include those used for the diagnosis, preventi ...
(GMDN), the standard international naming system for medical devices.
[IMDRF UDI Guidance Unique Device Identification (UDI) of Medical Devices 9.2.8](_blank)
Other
*
Classification of Pharmaco-Therapeutic Referrals
The ''Classification of Pharmaco-Therapeutic Referrals'' (''CPR'') is a taxonomy focused on defining and grouping together situations requiring a referral from pharmacists to physicians (and vice versa) regarding the pharmacotherapy used by the ...
(CPR)
*
Logical Observation Identifiers Names and Codes
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 me ...
(LOINC), standard for identifying medical laboratory observations
*
MEDCIN, point-of-care terminology, intended for use in Electronic Health Record (EHR) systems
*
Medical Dictionary for Regulatory Activities
A subscription-based product of the International Council for Harmonisation of Technical Requirements for Pharmaceuticals for Human Use (ICH), MedDRA or Medical Dictionary for Regulatory Activities is a clinically validated international medical te ...
(MedDRA)
*
Medical Subject Headings
Medical Subject Headings (MeSH) is a comprehensive controlled vocabulary for the purpose of indexing journal articles and books in the life sciences. It serves as a thesaurus that facilitates searching. Created and updated by the United States N ...
(MeSH)
**
List of MeSH codes
The following is a list of the codes for MeSH (Medical Subject Headings), a comprehensive controlled vocabulary for the purpose of indexing journal articles and books in the life sciences. It is a product of the United States National Library of ...
*
Nursing Interventions Classification The Nursing Interventions Classification (NIC) is a care classification system which describes the activities that nurses perform as a part of the planning phase of the nursing process associated with the creation of a nursing care plan.
The NIC p ...
(NIC)
*
Nursing Outcomes Classification The Nursing Outcomes Classification (NOC) is a classification system which describes patient outcomes sensitive to nursing intervention. The NOC is a system to evaluate the effects of nursing care as a part of the nursing process. The NOC contains ...
(NOC)
*
TIME-ITEM, ontology of topics in medical education
*
TNM Classification of Malignant Tumors
*
Unified Medical Language System
The Unified Medical Language System (UMLS) is a compendium of many controlled vocabularies in the biomedical sciences (created 1986). It provides a mapping structure among these vocabularies and thus allows one to translate among the various termin ...
(UMLS)
* Victoria Ambulatory Coding System (VACS) / Queensland Ambulatory Coding System (QACS), Australia
Library classification that have medical components
*
Dewey Decimal Classification
The Dewey Decimal Classification (DDC), colloquially known as the Dewey Decimal System, is a proprietary library classification system which allows new books to be added to a library in their appropriate location based on subject.
Section 4.1 ...
and
Universal Decimal Classification
The Universal Decimal Classification (UDC) is a bibliographic and library classification representing the systematic arrangement of all branches of human knowledge organized as a coherent system in which knowledge fields are related and inter-link ...
(section 610–620)
*
National Library of Medicine classification The National Library of Medicine (NLM) classification system is a library indexing system covering the fields of medicine and preclinical basic sciences. The NLM classification is patterned after the Library of Congress (LC) Classification system ...
ICD, SNOMED and Electronic Health Record (EHR)
SNOMED
The Systematized Nomenclature of Medicine (
SNOMED
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, pro ...
) is the most widely recognised nomenclature in healthcare.
Its current version, SNOMED Clinical Terms (
SNOMED CT
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 mo ...
), 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.
SNOMED CT is often described as a reference terminology. SNOMED CT contains more than 311,000 active concepts with unique meanings and formal logic-based definitions organised into hierarchies.
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.
SNOMED CT is designed to be managed by computer, and it is a complex relationship concepts.
ICD
The International Classification of Disease (
ICD) is the most widely recognized medical classification. Maintained by the
World Health Organization
The World Health Organization (WHO) is a specialized agency of the United Nations responsible for international public health. The WHO Constitution states its main objective as "the attainment by all peoples of the highest possible level of h ...
(
WHO
Who or WHO may refer to:
* Who (pronoun), an interrogative or relative pronoun
* Who?, one of the Five Ws in journalism
* World Health Organization
Arts and entertainment Fictional characters
* Who, a creature in the Dr. Seuss book '' Horton He ...
),
[Margret K. Amatayakul, MBA, RHIA, CHPS, CPHIT, CPEHR&FHIMSS.(2009).Electronic Health Records: A Practical Guide for Professionals and Organizations.Chicago, America:AHIMA] its primary purpose is to categorise diseases for morbidity and mortality reporting. However the coded data is often used for other purposes too; including reimbursement practices such as
medical billing
Medical billing is a payment practice within the United States healthcare system. The process involves a healthcare provider obtaining insurance information from a patient and filing, following up on and appealing claims with health insurance co ...
. ICD has a hierarchical structure, and coding in this context, is the term applied when representations are assigned to the words they represent.
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. The current version of the ICD,
ICD-10
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, ...
, was endorsed by
WHO
Who or WHO may refer to:
* Who (pronoun), an interrogative or relative pronoun
* Who?, one of the Five Ws in journalism
* World Health Organization
Arts and entertainment Fictional characters
* Who, a creature in the Dr. Seuss book '' Horton He ...
in 1990. WHO Member states began using the ICD-10 classification system from 1994 for both morbidity and mortality reporting. The exception was the US, who only began using it for reporting mortality in 1999 whilst continuing to use
ICD-9-CM
The International Classification of Diseases (ICD) is a globally used diagnostic tool for epidemiology, health management and clinical purposes. The ICD is maintained by the World Health Organization (WHO), which is the directing and coordinating ...
for morbidity reporting. The US only adopted its version of ICD-10 in October 2015. The delay meant it was unable to compare US morbidity data with the rest of the world during this period. The next major version of the ICD,
ICD-11
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 He ...
, was ratified by the 72nd
World Health Assembly
The World Health Assembly (WHA) is the forum through which the World Health Organization (WHO) is governed by its 194 member states. It is the world's highest health policy setting body and is composed of health ministers from member states.
T ...
on 25 May 2019, and member countries have been able to report data using ICD-11 codes since 1 January 2022.
ICD-11
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 He ...
is a fully digital product with integration of clinical terminology and classification. It allows documentation at any level of detail. It includes extension codes, a terminology system, with medicaments, chemicals, infections agents, histopathology, anatomy and mechanisms, objects and animals, and other elements that serve to describe sources of injury or harm.
Comparison
SNOMED CT
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 mo ...
and
ICD where originally designed for different purposes and each should be used for the purposes for which they were designed. As a core terminology for the
EHR, SNOMED CT and
ICD-11
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 He ...
provide a common language that enables a consistent way of capturing, and sharing health data across specialities and sites of care. SNOMED is a highly detailed terminology designed for input not reporting, without a specific use case.
ICD-11
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 He ...
and SNOMED, are clinically based, and document whatever is needed for patient care. In contrast to SNOMED, ICD-11 allows full clinical documentation while permitting internationally agreed statistical aggregation for specific
use case
In software and systems engineering, the phrase use case is a polyseme with two senses:
# A usage scenario for a piece of software; often used in the plural to suggest situations where a piece of software may be useful.
# A potential scenario ...
s. The foundation of ICD-11 together with the
WHO Classification of Health Interventions (ICHI) and the
WHO Classification for Functioning, Disability and Health (ICF), comprising also the WHO lists of anatomy, substances and more, are a complete ecosystem for lossless documentation in digital records and at the same time they address specific usecases for data aggregation in a multilingual, freely usable way. SNOMED CT and ICD are used directly by healthcare providers during the process of care, in addition, ICD can be also used for coding after the episode of care, in lower technology environments. SNOMED CT has multiple hierarchy, whereas there is single primary hierarchy for ICD-11 with alternative multiple hierarchies. SNOMED CT concepts are defined logically by their attributes, as is the case in ICD-11, that in addition has textual rules and definitions.
Data Mapping
SNOMED
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, pro ...
and
ICD can be coordinated. The
National Library of Medicine
The United States National Library of Medicine (NLM), operated by the United States federal government, is the world's largest medical library.
Located in Bethesda, Maryland, the NLM is an institute within the National Institutes of Health. Its ...
(NLM) maps ICD-9-CM, ICD-10-CM, ICD-10-PCS, and other classification systems to SNOMED.
Data Mapping is the process of identifying relationships between two distinct data models.
Veterinary medical coding
Veterinary medical codes include the
VeNom Coding Group, the U.S. Animal Hospital Codes, and the
Veterinary Extension to SNOMED CT (VetSCT).
See also
*
Acronyms in healthcare
Acronyms are very commonly used in healthcare settings. They are formed from the lead letters of words relating to medications, organisations, procedures and diagnoses. They come from both English and Latin roots. Acronyms have been described as ja ...
*
Ambulatory Payment Classification
APCs or Ambulatory Payment Classifications are the United States government's method of paying for facility outpatient services for the Medicare (United States) program. A part of the Federal Balanced Budget Act of 1997 made the Centers for Medica ...
, US billing system for outpatient services
*
Biological database
Biological databases are libraries of biological sciences, collected from scientific experiments, published literature, high-throughput experiment technology, and computational analysis. They contain information from research areas including genom ...
*
Classification of mental disorders
The classification of mental disorders is also known as psychiatric nosology or psychiatric taxonomy. It represents a key aspect of psychiatry and other mental health professional, mental health professions and is an important issue for people wh ...
*
Clinical coder
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 standard codes using a classification ...
*
German Institute for Medical Documentation and Information
The German Institute for Medical Documentation and Information (german: Deutsches Institut für Medizinische Dokumentation und Information), abbreviated DIMDI, was a German organization responsible for medical information classification and managem ...
*
Health information management
Health information management (HIM) is information management applied to health and health care. It is the practice of analyzing and protecting digital and traditional medical information vital to providing quality patient care. With the widespr ...
*
Health informatics
Health informatics is the field of science and engineering that aims at developing methods and technologies for the acquisition, processing, and study of patient data, which can come from different sources and modalities, such as electronic hea ...
*
Human resources for health information system
*
List of international common standards
A list of international common and basic technical standards, which have been established worldwide and are related by their frequent and widespread use. These standards are conventionally accepted as best practice and used globally by industry a ...
*
Medical dictionary
A medical dictionary is a lexicon for words used in medicine. The three major medical dictionaries in the United States are ''Stedman's'', ''Taber's'', and ''Dorland's''. Other significant medical dictionaries are distributed by Elsevier. Dicti ...
*
North American Nursing Diagnosis Association
NANDA International (formerly the North American Nursing Diagnosis Association) is a professional organization of nurses interested in standardized nursing terminology, that was officially founded in 1982 and develops, researches, disseminates an ...
(professional organization)
*
Nosology
Nosology () is the branch of medical science that deals with the classification of diseases. Fully classifying a medical condition requires knowing its cause (and that there is only one cause), the effects it has on the body, the symptoms that ...
*
Pathology Messaging Implementation Project
Pathology Messaging Implementation Project (PMIP) is the project that introduced universal delivery of electronic pathology results to GPs in Great Britain. The standard used by the British National Health Service (NHS) to transmit pathology order ...
References
External links
WHO Family of International Classificationsofficial site
The International Health Terminology Standards Development Organisation – SNOMED CT
{{Health informatics
Nursing classification