IG:HL7 diagnosis: Unterschied zwischen den Versionen

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==Introduction==
 
==Introduction==
 
===Introduction===
 
===Introduction===
===Scope===
 
  
==Diagnosis Types==
+
Documentation of diagnoses is an essential part of many workflows in healthcare systems.
 +
 
 +
The ways of documenting a diagnosis may depend on the purpose such as medical, statistical,
 +
research-related, legal or administrative purposes.
 +
 
 +
This guideline focusses on the structured electronic documentation of diagnoses for the following applications:
 +
 
 +
====[[Bild:Flag_de.svg|border|27px]] Germany====
  
==Common Diagnosis Descriptions==
+
Fields of application for diagnosis documentation in Germany are e.g.
 +
* Capturing a diagnosis for the purpose of billing an  ICD-10-GM code under Federal German Code SGB V
 +
** under law §301 for in-patients
 +
** under law §295 for out-patients /ambulatory care
 +
** under law §140 for integrated care plans ("IGV-MVZ")
 +
* Cause-of-death statistics based on ICD-10 WHO
 +
* Quality assurance as of law §137 SGB V and related hospital quality reports
 +
* Infectious disease reporting as required under Infektionsschutz-Gesetz
 +
* Epidemiology and cancer registers (using ICD-O), including further classification of tumor diseases (1)
 +
* Expertise by payor for the purpose of retirement plans and statutory insurances (using e.g. ICF)
 +
* Medical documentation in healthcare such as referral letters, admission letters, sick-leave-notes, prescriptions, in-patient EHRs
 +
* Clinical studies (MedDRA, WHO-Art)
 +
* Payor Risk Compensation as of "Risikostrukturausgleich" ruling
 +
* Product detail information for medication, such as indications, counter-indications amd sideeffects ("UAW")
  
==Diagnosis Model in HL7 V3==
+
Administrative documentation of diagnoses will be required for justifying the billing of therapy such as treatment/procedures.
  
===Summary===
+
Since Jan 1st 2000 the classification ICD-10 GM as mandatory for diagnosis encoding in both ambulatory and in-patient care,
 +
especially for lump sum billing as ruled under G-DRG (German Diagnosis Related Groups).
  
Diagnoses represented in HL7 V3 shall useu the class Observation, which is modelled as shown in fig. 1.
+
Primary care data and routine care data may not just be used for billing but also for further purposes.
 +
Only standardized guidelines support multiple use of such data.  
  
Detailed descriptions of classes and data types in this model can be found in the related HL7 V3 documentation and Data Type Guidelines.
+
Statistical processing of diagnostic data may e.g. be used for quality assurance and for research,
 +
with diagnoses typically being encoded using classifications, like ICD-10, but also ICD-O and ICF.
  
The following sections specifiy how diagnosis attributes shall be mapped into the Observation model.
+
For future integrated applications which process structured electronic diagnoses to support medical decision-making processes,
 +
advanced terminologies may have to be used, like e.g. the alphabetical index into ICD and medication/substance directories.
  
===Plain Text===
+
Note 1 TNM- and the UICC-System proved to be insufficient for grading tumors of the central nervous systems because of their low metastasis and the weak relationship between tumor size and its aggressiveness. [Louis 2007]. Therefore we will apply the WHO-Grading (see 6.8)
value.originalText diagnosis as a plain text
 
ST[0..1]
 
Plain text descriptions of the specific diagnosis shall be stored in the subelement originalText of element value. If it is not necessary to specify a text or should this text not be available, the @nullFlavour attribute shall be used. This element shall explain the reason why there is no plain text. A value of "NAV" states that no coded text is available (yet). More values are described in the HL7 documentation.
 
  
The attribute @language of subelement originalText may be used to specify the language of the prosaic diagnosis text.
+
===Scope===
  
 +
Scope of this document is an elementary specification of how to represent diagnoses using HL7 V3 messages and documents.
  
<syntaxhighlight lang="xml">
+
Diagnoses exactly map from symptoms (diagnostic signs) to terms for diseases.
<!-- structured representation of diagnosis -->
 
  <observation moodCode="EVN" classCode="OBS">
 
    ...
 
    <value xsi:type="CD" nullFlavor="NAV">
 
      <originalText>Rektumkarzinom mit Höhenlokalisation ab Anokutanlinie/Linea dentata
 
      </originalText>
 
    </value>
 
  </observation>
 
</syntaxhighlight>
 
  
===Diagnosis Code and Text===
+
A a principle HL7 represents diagnoses as observations made by a doctor at a patient, which means that diagnostic data will be modelled using the HL7 Observation class, independent of the V3 model being used.
value Diagnosis Code CD[0..1]
 
Representing a diagnosis via a code and its associated text shall be done va the value element (in the model: an attribute of the Observation class).
 
  
The XML attribute @code shall store the diagnosis code and @displayname shal store the associated diagnosis text.
+
The goal is to have a model-independent specifiation of how to map relevant diagnostic data into the class Observation.
  
Such a structured representation of e.g. an ICD10 coded diagnosis looks like this:
+
This document is based on using a structured diagnosis.
  
The XML attribute @codeSystem shall store the OID for the specific ICD-10-GM version being used and the @codeSystemName attribute shall store the plain text name of the coding system and version.
+
* Chapter 3 explains attributes of diagnostic data
 +
* Chapter 4 explains the use of the Observation class
 +
* Chapter 5 focusses on the representation of encoded diagnoses, with section 5.1 mentioning specialties of ICD-10 encding especially in the context of German requirements
 +
* Chapter 6 specifies the representation of diagnoses in tumor documentation.
 +
* Chapter 7 includes examples representations of diagnosis from vrious fields of application.
  
 +
==Diagnosis Types==
  
<syntaxhighlight lang="xml">
+
===Clarification===
  <!-- structured representation of diagnosis -->
+
 
  <observation moodCode="EVN" classCode="OBS">
+
In HL7 Version 3 the term classification of diagnoses means the type or kind of diagnosis, like e.g. "Admission Diagnosis" or "Referral Diagnosis". For clarity, we will use the term "type of diagnosis" in the following text.
  ...
+
 
    <!-- ICD-Code of a diagnosis -->
+
===Types of Diagnoses in Ambulatory Care===
    <value xsi:type="CD" code="I01.0"
+
 
      displayName="Akute rheumatische Perikarditis"
+
====[[Bild:Flag_de.svg|border|27px]] Germany====
      codeSystem="1.2.276.0.76.5.311" codeSystemName="icd10gm2006"/>
+
The federal association (KBV) of regional statutory billing associations (KV)
    ...
+
for out-patient/ambulatory care in Germany published the so-called KVDT data set as the mandatory format for billing.
  </observation>
+
It combines billing data (ADT, not to be confused with the HL7 ADT data), the rehab billing data (KADT)
</syntaxhighlight>
+
and the statistical data (STDT) of a GPO reporting to its assigned (regional) KV.
 +
Part of the KVDT data set is  a diagnosis specification with the following types of diagnosis
 +
 
 +
Billing Diagnosis - current diagnosis being the basis for billing
 +
Continued Diagnosis - diagnoses that are valid for more than three quarters (of a year).
  
===Diagnosis Type===
+
Despite these billing diagnoses it is also allowed to send continued diagnoses (more than one quarter)
 +
which are related to the services billed.
 +
Using the record attribute 6001 ("ICD-10-code") for continued diagnoses is not permitted,
 +
instead the attribute 3673 ("continued diagnosis") shall store the ICD-10-code, combined with
 +
attribute 3674 ("reliability - continued diagnosis") and
 +
optionally the attributes 3675("side localization - continued diagnosis")
 +
or , attribute 3676 ("explanation - continued diagnosis") may be used.
 +
Either attributes 6001 or 3673 shall be used.
  
code classification code CD CW[1..1]
+
===Types of Diagnoses for Inpatient Care===
The XML attribute shall specifiy the classification code using the attribute @codeSystem for storing the OID of that coding system (also see Annex <10>)
 
  
<syntaxhighlight lang="xml">
+
====[[Bild:Flag_de.svg|border|27px]] Deutschland====
<!-- structured representation of diagnosis -->
 
  <observation moodCode="EVN" classCode="OBS">
 
    <code code="DX" codeSystem="1.2.276.0.76.5.342"/>
 
    ...
 
  </observation>
 
</syntaxhighlight>
 
  
===Diagnosis Date===
+
The (Federal German Code SGB V) billing law § 301 SGB V states the diagnosis specifications which shall be sent by hospitals
author.time Diagnosis Date IVL<TS>[0..1]
+
to payors. Based on that law, the data transfer guidance „Datenuebermittlung nach §301“ of the federal hospital association DKG
The diagnsis date shall specify when the diagnosis was made as the time in the clinical process which is not necessarily the documentation date.
+
has been published. This guidance defines different record types (e.g. admission record, discharge record) which also include diagnosis specifications, as given by the following table:
The diagnosis date shall be represented using the author instance which shall be connected via Participation to the current Observation instance.
 
Instances of author contain a model attribute time of type IVL<TS>.
 
Detailed information regarding the person giving the diagnosis shall be modelled using an instance of assignedEntity.
 
  
<syntaxhighlight lang="xml">
+
{| class="hl7table"
<!-- structured representation of diagnosis -->
+
!Record type
  <observation moodCode="EVN" classCode="OBS">
+
!Segment: Name
    ...
+
!Diagnosis
    <author>
+
|-
      <!-- Diagnosedatum -->
+
|Admission Record
      <time value="20100111"/>
+
|EAD
      <assignedAuthor>
+
|Admission Diagnosis
        ...
+
|-
      </assignedAuthor>
+
|Indicator for Continuation
    </author>
+
|DAU
    ...
+
|Continued Diagnosis - justiyfing sick leave
  </observation>
+
|-
</syntaxhighlight>
+
|Indicator for Continuation
 +
|FAB
 +
|Diagnosis by specialized clinical department
 +
|-
 +
|Discharge Record
 +
|DAU
 +
|Continued Diagnosis - justiyfing sick leave
 +
|-
 +
|Discharge Record
 +
|ETL
 +
|Discharge Diagnosis
 +
|-
 +
|Discharge Record
 +
|NDG
 +
|Concurrent Diagnosis
 +
|-
 +
|Discharge Record
 +
|FAB
 +
|Diagnosis by specialized clinical department
 +
|-
 +
|Outpatient Procedure
 +
|RZA
 +
|Referral diagnosis
 +
|-
 +
|Outpatient Procedure
 +
|BDG
 +
|Treatment diagnosis
 +
|}
 +
 
 +
As a result this guidance distinguishes the following types of diagnoses under §301 SGB V:
 +
* Admission Diagnosis
 +
* Inpatient Admission Diagnosis
 +
* Special Department Diagnosis
 +
* Continued Diagnosis (with sick leave)
 +
* Discharge Diagnosis
 +
* Special Department Diagnosis Extension
 +
* Referral Diagnosis
 +
* Treatment Diagnosis
 +
 
 +
Main diagnoses and concurrent diagnoses (as defined by medical aspects) as well as primary and secondary diagnoses shall be represented via additional attributes.
 +
 
 +
Regarding further diagnosis types please see Annex A
 +
 
 +
==Common Diagnosis Descriptions==
 +
 
 +
===Introduction===
 +
This chapter gives the attributes that are common parts of a structured diagnosis specification which are required for processing an electronic diagnosis information.  
 +
 
 +
===Plain-Text Description===
 +
This attribute describes the diagnosis through  prosaic text, hate.g. may be entered via a text entry field by the medical professional.
 +
This plain text description should be a mandatory part of medical documentation.
  
===Documentation Date===
+
Example: Allergic asthma
dataEnterer.time documentation date TS [1..1]
 
  
The documentation is the date when the diagnosis has been entered by e.g. a clinician. The data value is mapped to an instance dataEnterer which is related via a Particpation to the Observation instance (see fig. 1 Observation Model).
+
Note that plain-text descriptions will not necessarily match the associated text of diagnosis codes, like the ones from the systematic classification ICD-10.
  
The dataEnterer class has an model attribute time of type TS, such that in XML  the data value will be mapped into an element time and an XML attribute @value.
 
  
In case there is no dataEnterer instance, the participation relation with its model attribute typeCode=ENT also manages a participationRole instance representing the data entering person that would otherwise be modelled through a instance of dataEnterer.
+
===Diagnosis Code===
 +
For the purposes of administrative and statistical processing, diagnoses are being encoded by encoding systems.
 +
E.g. ICD-10 is mandatory under billing according to (Federal German Code) SGB V §391 and §295.
  
<syntaxhighlight lang="xml">
+
Further systematic encoding systems are e.g. „Alpha-ID“, SNOMED CT and ID MACS.
<!-- structured representation of diagnosis -->
+
 
  <observation classCode="OBS" moodCode="EVN" negationInd="true">
+
Example: J45.0
  ...
+
 
  <!-- documentation date -->
+
=== Diagnosis Code – Catalog Text===
    <participant typeCode="ENT">
+
The catalog text is the associated text for a given diagnosis code. It does not have to match the plain text and can be rendered by an automated system - based on a given diagnosis code.
      <time value="20060606"/>
+
 
      <participantRole>
+
Example: Predominantly allergic asthma
        ...
+
 
      </participantRole>
+
===Diagnosis Type===
    </participant>
+
 
    ...
+
The diagnosis type further specifies the type of a diagnosis and will be given in an encoded form.
  </observation>
+
Examples may be "referral diagnosis", "admission diagnosis", "discharge diagnosis" etc.
</syntaxhighlight>
+
 
 +
===Diagnosis Date===
 +
This attribute describes date and time when a medical professional made the given diagnosis.
  
===Diagnosis Time Interval===
+
===Documentation Date===
effectiveTime diagnosis time interval IVL<TS>[0..1]
+
This attribute describes date and time when the diagnosis was documented.
  
The model attribute effectiveTime of class Observation specifies the time interval for which the specified is (or, has been) clinically relevant.
+
Note that when there is no need to distinguish both dates, the diagnosis date shall be used.
  
In XML, the sub-element low shall specify the begin data and sub-element high shall specifiy the end date. Dates for low or high may also be specified without the other.
+
===Specification of the Clinically-Relevant Time of a Diagnosis===
 +
This attribute is a time interval specified by a start time and end time information giving the time in which the patient suffered from the specified disease.
  
<syntaxhighlight lang="xml">
+
Giving only a start date documents the time since when the patient had that diagnosis.
<!-- structured representation of diagnosis -->
 
  <observation moodCode="EVN" classCode="OBS">
 
    ...
 
    <effectiveTime>
 
      <low value="20050127"/>
 
    </effectiveTime>
 
    ...
 
    </observation>
 
</syntaxhighlight>
 
  
===Diagnosis Confidence===
+
The start date may be different from the diagnosis date.
  
value.qualifier diagnosis confidence CR [0..1]
+
Date information in diagnoses may be with different precision.
  
the diagnosis confidence shall be represented in the model attribute value using a sub-element qualifier.
+
Examples: Diabetes since 2006
 +
or Fracture of Femur on March 12th, 2007
  
<syntaxhighlight lang="xml">
+
===Diagnosis Reliability===
  <!-- structured representation of diagnosis -->
+
This attribute describes the reliability of the specific diagnosis.
  <observation moodCode="EVN" classCode="OBS">
 
    ...
 
    <value xsi:type="CD" nullFlavor="NI">
 
      <originalText>......</originalText>
 
      <!--diagnosis confidence -->
 
      <qualifier>
 
        <name code="8" codeSystem="2.16.840.1.113883.3.7.1.0"/>
 
        <value code="G" codeSystem="2.16.840.1.113883.3.7.1.8"/>
 
      </qualifier>
 
    </value>
 
  </observation>
 
</syntaxhighlight>
 
  
XML attribut @code in name shall specify the name of the diagnosis confidence qualifier, based on the table given below.
+
====[[Bild:Flag_de.svg|border|27px]] Germany====
XML attribut @codeSystem shall specify the OID of the system giving these qualifier names.
 
The diagnosis confidence shall be specified using XML attribute @code in the XML element value.
 
  
For out-patient care (§ 295 SGB V, Germany) diagnosis confidence attributes are mandatory, while for in-patient care (§ 301 SGB V)
+
For billing under ambulatory/out-patient care (under Federal German Code SGB V) defined
they are forbidden i.e. must not be specified. (Source: DIMDI)
+
attributes (suffices A, G, V or Z) are compulsory while such attributes are not allowed for
 +
in-patient billing (under Federal German Code SGB V).
  
{| class=wikitable
+
===Localization===
! Code as of §295 SGB V
 
! Implementation
 
! Meaning
 
! Explanation
 
|-
 
|G
 
|
 
|certain
 
|diagnosis validated
 
|-
 
|V
 
|uncertaintyCode=UN
 
|suspicious
 
|suspicion diagnosis
 
|-
 
|Z
 
|
 
|state after
 
|an earlier diagnosis is related
 
|-
 
|A
 
|negationInd=true
 
|excluded
 
|this diagnosis has been excluded (use negationInd in Level 3)
 
|-
 
|}
 
  
Table 2: Vocabulary Domain for Confidence/Reliability
+
The localization attribute specifies in which body site (topography) the disease was diagnosed.
Codesystem: Sciphox (OID: 2.16.840.1.113883.3.7.1.8)
+
 
 +
Both plain text or encoded terms are allowed.
 +
 
 +
An example is the ICD-O site code for tumor documentation.
 +
 
 +
As a suffix the side may be used.
 +
 
 +
===Explanations===
 +
 
 +
This attribute allows medical professionals to document detailed explanations using a plain text.
 +
 
 +
===Reasons for Exceptions===
 +
 
 +
This plain-attribute may be required to justify a diagnosis e.g. in the context of billing.
 +
 
 +
==Diagnosis Model in HL7 V3==
 +
 
 +
===Summary===
 +
 
 +
Diagnoses represented in HL7 V3 shall useu the class Observation, which is modelled as shown in fig. 1.
 +
 
 +
Detailed descriptions of classes and data types in this model can be found in the related HL7 V3 documentation and Data Type Guidelines.
  
In tumor documentation the validation of diagnosis is also documented by specifying the 8superior) way of diagnosis. This information shall also be specified through the qualifier:
+
The following sections specifiy how diagnosis attributes shall be mapped into the Observation model.
  
{| class=wikitable
+
===Plain Text===
!Code
+
value.originalText diagnosis as a plain text
!Implementation
+
ST[0..1]
!Meaning
 
!Explanation
 
|-
 
|k
 
|
 
|clinically
 
|
 
|-
 
|z
 
|
 
|zytologically
 
|
 
|-
 
|h
 
|
 
|histologically
 
|
 
|-
 
|a
 
|
 
|autoptically
 
|
 
|-
 
|d
 
|
 
|DCO
 
|Death certificate only.
 
|-
 
|
 
|nullFlavor = OTH
 
|Other
 
|
 
|-
 
|
 
|nullFlavor = NI
 
|unknown
 
|
 
|}
 
  
Table 3: Vocabulary Domain for Diagnosis procedure in tumor documentation
+
Plain text descriptions of the specific diagnosis shall be stored in the subelement originalText of element value. If it is not necessary to specify a text or should this text not be available, the @nullFlavour attribute shall be used. This element shall explain the reason why there is no plain text. A value of "NAV" states that no coded text is available (yet). More values are described in the HL7 documentation.
Codesystem: (OID: 1.2.276.0.76.5.418)
 
  
===Localization===
+
The attribute @language of subelement originalText may be used to specify the language of the prosaic diagnosis text.
  
targetSiteCode Lokalisation
 
CD CWE [0..1]
 
  
Localization of diagnoses shall be specified using the model attribute  targetSiteCode.
+
<syntaxhighlight lang="xml">
For localizations given as plain text the sub-element originalText of targetSiteCode shall be used.
+
<!-- structured representation of diagnosis -->
In case no localization code is available, the XML attribute @nullFlavor shall
 
be specified.
 
 
 
 
 
<syntaxhighlight lang="xml">
 
<!-- structured representation of diagnosis -->
 
 
   <observation moodCode="EVN" classCode="OBS">
 
   <observation moodCode="EVN" classCode="OBS">
 
     ...
 
     ...
     <targetSiteCode nullFlavor="NI">
+
     <value xsi:type="CD" nullFlavor="NAV">
       <originalText>Oberhalb des rechten Knöchels</originalText>
+
       <originalText>Rektumkarzinom mit Höhenlokalisation ab Anokutanlinie/Linea dentata
     </targetSiteCode>
+
      </originalText>
    ...
+
     </value>
 
   </observation>
 
   </observation>
 
</syntaxhighlight>
 
</syntaxhighlight>
  
If a structured code is available, then model attribute targetSiteCode shall have a code sub-element with the code being specified in XML attribute @code
+
===Diagnosis Code and Text===
and the coding system being specified using XML attribute @codeSystem.
+
 
 +
value Diagnosis Code CD[0..1]
 +
 
 +
Representing a diagnosis via a code and its associated text shall be done va the value element (in the model: an attribute of the Observation class).
 +
 
 +
The XML attribute @code shall store the diagnosis code and @displayname shall store the associated diagnosis text.
 +
 
 +
Such a structured representation of e.g. an ICD10 coded diagnosis looks like this:
  
 +
The XML attribute @codeSystem shall store the OID for the specific ICD-10-GM version being used and the @codeSystemName attribute shall store the plain text name of the coding system and version.
  
Optionally the XML attribute @displayName may be used to specifiy a plain text for the code and @codeSystemName may be used for the name of the coding system.
 
  
 
<syntaxhighlight lang="xml">
 
<syntaxhighlight lang="xml">
<!-- structured representation of diagnosis -->
+
  <!-- structured representation of diagnosis -->
 
   <observation moodCode="EVN" classCode="OBS">
 
   <observation moodCode="EVN" classCode="OBS">
 +
  ...
 +
    <!-- ICD-Code of a diagnosis -->
 +
    <value xsi:type="CD" code="I01.0"
 +
      displayName="Akute rheumatische Perikarditis"
 +
      codeSystem="1.2.276.0.76.5.311" codeSystemName="icd10gm2006"/>
 
     ...
 
     ...
    <targetSiteCode code="299058009" codeSystem="2.16.840.1.113883.6.96"
+
   </observation>
    codeSystemName="SNOMED CT" displayName="kleiner Finger">
 
      <qualifier>
 
        <name code="78615007" codeSystem="2.16.840.1.113883.6.96"
 
              codeSystemName="SNOMED CT" displayName="mit Seitenlokalisation"/>
 
        <value code="24028007" codeSystem="2.16.840.1.113883.6.96"
 
              codeSystemName="SNOMED CT" displayName="rechts"/>
 
      </qualifier>
 
    </targetSiteCode>
 
    ...
 
   </observation>
 
 
</syntaxhighlight>
 
</syntaxhighlight>
  
Note: The localization codes suggested by the German health Ministry (BMG) shall only be used together with diagnoses encoded in ICD 10 (German).
+
===Diagnosis Type===
 +
 
 +
code classification code CD CW[1..1]
  
Additional codes for the side localization may be used in out-patient care as well as in-patient care(see 4).
+
The XML attribute shall specifiy the classification code using the attribute @codeSystem for storing the OID of that coding system (also see Annex <10>)
  
In tumor documentation further codes shall be use for the side localization:
+
<syntaxhighlight lang="xml">
 +
<!-- structured representation of diagnosis -->
 +
  <observation moodCode="EVN" classCode="OBS">
 +
    <code code="DX" codeSystem="1.2.276.0.76.5.342"/>
 +
    ...
 +
  </observation>
 +
</syntaxhighlight>
  
 +
===Diagnosis Date===
 +
author.time Diagnosis Date IVL<TS>[0..1]
  
 +
The diagnsis date shall specify when the diagnosis was made as the time in the clinical process which is not necessarily the documentation date.
 +
The diagnosis date shall be represented using the author instance which shall be connected via Participation to the current Observation instance.
 +
Instances of author contain a model attribute time of type IVL<TS>.
 +
Detailed information regarding the person giving the diagnosis shall be modelled using an instance of assignedEntity.
  
{| class=wikitable
+
<syntaxhighlight lang="xml">
! Code
+
<!-- structured representation of diagnosis -->
! Implementation
+
  <observation moodCode="EVN" classCode="OBS">
! Meaning
+
    ...
! Explanation
+
    <author>
! Common Diagnoses
+
      <!-- Diagnosedatum -->
! Tumor Diagnoses
+
      <time value="20100111"/>
|-
+
      <assignedAuthor>
| R
+
        ...
|
+
      </assignedAuthor>
| Right
+
    </author>
| side localization right
+
    ...
| X
+
  </observation>
| X
+
</syntaxhighlight>
|-
+
 
| L
+
===Documentation Date===
|
+
dataEnterer.time documentation date TS [1..1]
| Left
+
 
| side localization left
+
The documentation is the date when the diagnosis has been entered by e.g. a clinician. The data value is mapped to an instance dataEnterer which is related via a Particpation to the Observation instance (see fig. 1 Observation Model).
| X
 
| X
 
|-
 
| B
 
|
 
| both side
 
| diagnosed on both sides
 
| X
 
| X
 
|-
 
| M
 
|
 
| middle line
 
| middle line zone - 1 inch left or right from middle line
 
|
 
| X
 
|-
 
|
 
|nullFlavor = NA
 
|system disease
 
|in the sense of 'not applicable'
 
|
 
|X
 
|-
 
|
 
|nullFlavor = UNK
 
|unknown
 
|
 
| X
 
| X
 
|-
 
|}
 
  
Table 4: Vocabulary Domain for Localization
+
The dataEnterer class has an model attribute time of type TS, such that in XML  the data value will be mapped into an element time and an XML attribute @value.
Coding System: (OID: 1.2.276.0.76.5.412)
 
  
4 DIMDI
+
In case there is no dataEnterer instance, the participation relation with its model attribute typeCode=ENT also manages a participationRole instance representing the data entering person that would otherwise be modelled through a instance of dataEnterer.
5 Literatur: Basisdokumentation für Tumorkranke 5. Auflage 1999; Dudeck et al
 
  
 +
<syntaxhighlight lang="xml">
 +
<!-- structured representation of diagnosis -->
 +
  <observation classCode="OBS" moodCode="EVN" negationInd="true">
 +
  ...
 +
  <!-- documentation date -->
 +
    <participant typeCode="ENT">
 +
      <time value="20060606"/>
 +
      <participantRole>
 +
        ...
 +
      </participantRole>
 +
    </participant>
 +
    ...
 +
  </observation>
 +
</syntaxhighlight>
  
The side localization is used for diagnosis documentation for common and also for tumor documentation, but with differeent value sets, which are defined as follows:
+
===Diagnosis Time Interval===
 
+
effectiveTime diagnosis time interval IVL<TS>[0..1]
{| class=wikitable
 
! Value Set
 
! Explanation
 
! OID
 
|-
 
| Common, based on ICD-10
 
| 2.16.840.1.113883.3.7.1.7
 
|-
 
| Tumor Documentation
 
| 1.2.276.0.76.11.10
 
|-
 
|}
 
  
Table 5: Value Sets for Localization
+
The model attribute effectiveTime of class Observation specifies the time interval for which the specified is (or, has been) clinically relevant.
  
===Explanations===
+
In XML, the sub-element low shall specify the begin data and sub-element high shall specifiy the end date. Dates for low or high may also be specified without the other.
  
text explanation of diagnosis ST [0..1]
+
<syntaxhighlight lang="xml">
 
+
<!-- structured representation of diagnosis -->
Any explaining text shall be represented using the XML attribute text.
+
  <observation moodCode="EVN" classCode="OBS">
 +
    ...
 +
    <effectiveTime>
 +
      <low value="20050127"/>
 +
    </effectiveTime>
 +
    ...
 +
    </observation>
 +
</syntaxhighlight>
 +
 
 +
===Diagnosis Reliability===
  
A structured representation will look like this:
+
value.qualifier diagnosis reliability CR [0..1]
  
 +
the diagnosis reliability shall be represented in the model attribute value using a sub-element qualifier.
  
 
<syntaxhighlight lang="xml">
 
<syntaxhighlight lang="xml">
<!-- structured representation of diagnosis -->
+
  <!-- structured representation of diagnosis -->
 
   <observation moodCode="EVN" classCode="OBS">
 
   <observation moodCode="EVN" classCode="OBS">
     <value xsi:type="CD" code="J45.0" codeSystem="1.2.276.0.76.5.311"
+
    ...
      displayName="Vorwiegend allergisches Asthma bronchiale">
+
     <value xsi:type="CD" nullFlavor="NI">
       <originalText>Allergisches Asthma</originalText>
+
      <originalText>......</originalText>
 +
      <!--diagnosis reliability -->
 +
      <qualifier>
 +
        <name code="8" codeSystem="2.16.840.1.113883.3.7.1.0"/>
 +
        <value code="G" codeSystem="2.16.840.1.113883.3.7.1.8"/>
 +
       </qualifier>
 
     </value>
 
     </value>
    <text>Intermittierend, seit der Jugend</text>
 
 
   </observation>
 
   </observation>
 
</syntaxhighlight>
 
</syntaxhighlight>
  
===Reasons for Exceptions===
+
XML attribut @code in name shall specify the name of the diagnosis reliability qualifier, based on the table given below.
 +
XML attribut @codeSystem shall specify the OID of the system giving these qualifier names.
 +
The diagnosis reliability shall be specified using XML attribute @code in the XML element value.
  
value Reasons for Exceptions ST [0..1]
+
====[[Bild:Flag_de.svg|border|27px]] Germany====
  
Billling-related exceptions shall be encoded using the @value attribute of an extra Observation instance being related via an ActRelation-Ship instance to the original describing instance of Observation.
+
For out-patient care (§ 295 SGB V, Germany) diagnosis reliability attributes are mandatory, while for in-patient care (§ 301 SGB V) they are forbidden i.e. must not be specified. (Source: DIMDI)
  
A structured representation will look like this:
+
{| class="hl7table"
 
+
! Code as of §295 SGB V
<syntaxhighlight lang="xml">
+
! Implementation
<!-- structured representation of diagnosis -->
+
! Meaning
  <observation moodCode="EVN" classCode="OBS">
+
! Explanation
    ...
+
|-
    <!-- reason for exception-->
+
|G
      <entryRelationship typeCode="RSON">
+
|
        <observation moodCode="EVN" classCode="OBS">
+
|certain
          <code nullFlavor="UNK"/>
+
|diagnosis validated
          <value xsi:type="ED">...........</value>
+
|-
        </observation>
+
|V
      </entryRelationship>
+
|uncertaintyCode=UN
    ...
+
|suspicious
  </observation>
+
|suspicion diagnosis
</syntaxhighlight>
+
|-
 +
|Z
 +
|
 +
|state after
 +
|an earlier diagnosis is related
 +
|-
 +
|A
 +
|negationInd=true
 +
|excluded
 +
|this diagnosis has been excluded (use negationInd in Level 3)
 +
|-
 +
|}
  
XML attribute @typeCode shall have the value RSON (= reason) specifying an exception for billing purposes.
+
Table 2: Vocabulary Domain for Reliability
 +
Codesystem: Sciphox (OID: 2.16.840.1.113883.3.7.1.8)
  
===Using more Attributes of Observation===
+
In tumor documentation the validation of diagnosis is also documented by specifying the (superior) way of diagnosis. This information shall also be specified through the qualifier:
  
This section describes more model attributes of Observation that may play a role in describing diagnoses.
+
{| class="hl7table"
 
+
!Code
====Attribute 'id'====
+
!Implementation
id diagnosis identificator SET <II>[0..1]
+
!Meaning
 
+
!Explanation
The model attribute id should be used to identify the instance of a diagnosis - which is recommended for computer-based processing of diagnoses in order to refer to the clinical specification of that diagnosis.
+
|-
 
+
|k
In XML representations the XML attribute @extension shall store the diagnosis identifier while the XML attribute @root should specify the OID of the diagnosis database.
+
|
 
+
|clinically
In case changes or deletions have to be communicated for this diagnosis instance, this id will provide reference.
+
|
 
+
|-
====Attribute 'classCode'====
+
|z
@classCode classCode <= OBS
+
|
XML attribute shall be 'OBS' - specifiying Observation as the main type of the Act instance used for documenting the diagnosis.
+
|zytologically
 
+
|
In XML an attribute @classCode of the element Observation represents the model attribute 'classCode' of class Observation.
+
|-
 
+
|h
====Attribute 'moodCode'====
+
|
@moodCode Mood Code <= EVN
+
|histologically
Attribute @moodCode specifies how to interpret the containing Act instance.
+
|
 +
|-
 +
|a
 +
|
 +
|autoptically
 +
|
 +
|-
 +
|d
 +
|
 +
|DCO
 +
|Death certificate only.
 +
|-
 +
|
 +
|nullFlavor = OTH
 +
|Other
 +
|
 +
|-
 +
|
 +
|nullFlavor = NI
 +
|unknown
 +
|
 +
|}
  
When using an Observation to specify a diagnosis, the @moodCode shall have the value EVN, indicating that the Observation documents an earlier action.
+
Table 3: Vocabulary Domain for Diagnosis procedure in tumor documentation
 +
Codesystem: (OID: 1.2.276.0.76.5.418)
  
====Attribute 'negationInd'====
+
===Localization===
  
@negationInd Negation Indicator BL [0..1]
+
targetSiteCode Lokalisation
 +
CD CWE [0..1]
  
The optional attribute @negationInd is of data type BL with values 'true' or 'false'.
+
Localization of diagnoses shall be specified using the model attribute  targetSiteCode.
 
+
For localizations given as plain text the sub-element originalText of targetSiteCode shall be used.
Specifying a 'true' value states that the specified diagnosis has been excluded.
+
In case no localization code is available, the XML attribute @nullFlavor shall
 
+
be specified.
@negationInd is optional, the default is 'false'. If not specified, the receiving system will interpret the diagnosis as specified.
 
 
 
====Attribute 'statusCode'====
 
 
 
statusCode Statuscode <= completed
 
 
 
This attribute can be use to represent the state of the containing Act, which can be in states like e.g. "new", "active" or "cancelled". As diagnoses are considered the documentation of an action already completed, the fixed value "completed" shall be used in XML attribute @code of sub-element statusCode.
 
  
 
====An Example====
 
 
A small example shows all of the above attributes:
 
  
 
<syntaxhighlight lang="xml">
 
<syntaxhighlight lang="xml">
   <observation classCode="OBS" moodCode="EVN" negationInd="true">
+
<!-- structured representation of diagnosis -->
  …
+
   <observation moodCode="EVN" classCode="OBS">
  <statusCode code="completed"/>
+
    ...
  …
+
    <targetSiteCode nullFlavor="NI">
 +
      <originalText>Oberhalb des rechten Knöchels</originalText>
 +
    </targetSiteCode>
 +
    ...
 
   </observation>
 
   </observation>
 
</syntaxhighlight>
 
</syntaxhighlight>
  
==Representation of Diagnosis in specific Codesystems==
+
If a structured code is available, then model attribute targetSiteCode shall have a code sub-element with the code being specified in XML attribute @code
===ICD-10-GM-coded Diagnoses===
+
and the coding system being specified using XML attribute @codeSystem.
  
The „International Statistical Classification of Diseases” (ICD) is a
 
classification system for diseases and related health issues. It has a hierarchical structure. As the german localized version ICD-10-GM is a varient of the ICD-10 released by WHO.
 
  
Diseases are specified through alphanumeric codes. Each disease has a unique code and vice versa.
+
Optionally the XML attribute @displayName may be used to specifiy a plain text for the code and @codeSystemName may be used for the name of the coding system.  
The majority of codes are so-called primary diagnosis keys, i.e.they contain all information to encode a given diagnosis.
 
  
ICD also provides the ability to specify secondary keys for additional information. Such secondary keys must only be used together with a primary diagnosis and are marked through asterisk (*) or exclamation (!) as additional codes .
+
<syntaxhighlight lang="xml">
 +
<!-- structured representation of diagnosis -->
 +
  <observation moodCode="EVN" classCode="OBS">
 +
    ...
 +
    <targetSiteCode code="299058009" codeSystem="2.16.840.1.113883.6.96"
 +
    codeSystemName="SNOMED CT" displayName="kleiner Finger">
 +
      <qualifier>
 +
        <name code="78615007" codeSystem="2.16.840.1.113883.6.96"
 +
              codeSystemName="SNOMED CT" displayName="mit Seitenlokalisation"/>
 +
        <value code="24028007" codeSystem="2.16.840.1.113883.6.96"
 +
              codeSystemName="SNOMED CT" displayName="rechts"/>
 +
      </qualifier>
 +
    </targetSiteCode>
 +
    ...
 +
  </observation>
 +
</syntaxhighlight>
  
Primary diagnosis codes either have no prefix or a cross (+).
+
Note: The localization codes suggested by the German health Ministry (BMG) shall only be used together with diagnoses encoded in ICD 10 (German).
  
Example.: E14.30+, H28.0* ICD-10 Code for “Diabetes mellitus with cataract“
+
Additional codes for the side localization may be used in out-patient care as well as in-patient care(see 4).
  
====Terms of ICD-10 Codes====
+
In tumor documentation further codes shall be use for the side localization:
ICD-10-GM will be used for encoding diagnoses in both in-patient and ambulatory care. In-patient diagnosis encoding additionally has to adhere to the German coding guidelines (§ 301, Deutsche Codierrichtlinien) and the extensions authorized by the Health Ministry (BMG).
 
  
For ambulatory care, the WHO-Table with BMG-extension is to be used.
 
  
=====Secondary Codes=====
 
  
ICD-10 GM distinguishes between primary codes and secundary codes.
+
{| class="hl7table"
 
+
! Code
Primary codes are codes without suffix or with a cross(+).
+
! Implementation
 
+
! Meaning
Secondary codes are those codes with an asterisk (*) or an exclam (!).
+
! Explanation
 
+
! Common Diagnoses
In oorder to explain their meaning we will translate some quotes of „Basiswissen Kodieren“ [Basic Encoding Knowledge  by DIMDI,www.dimdi.de]
+
! Tumor Diagnoses
 
+
|-
"The code for etiology (cause, origin) of a disease shall be marked qith a cross (+)
+
| R
and its manifestation with an asterisk (*) - with the cross-code being the primary code
+
|
and the asterisk-code never being used alone."
+
| Right
 
+
| side localization right
Another translated quote:
+
| X
 
+
| X
„ Asterisk codes shall only be those that are marked as explicitly permitted in ICD-10 for the asterisk-suffix."
+
|-
 
+
| L
 
+
|
„ Provided that the secondary code is permitted for asterisk, any other code describing the underlying disease may be used as primary code with the cross-suffix."
+
| Left
 
+
| side localization left
„... Some Codes are being marked with an exclam (!) indicating that therse are further descriptions or definitions of the severity. Such codes must not be used alone“ (without primary code).
+
| X
 
+
| X
As a result, each diagnosis must at least have a primary code and optionally secondary codes.
+
|-
 
+
| B
Each primary/secondary code is the alphanumeric string given by ICD-10 code followed by the suffix, either (†, *, !)
+
|
 
+
| both side
=====Side Localization=====
+
| diagnosed on both sides
 +
| X
 +
| X
 +
|-
 +
| M
 +
|
 +
| middle line
 +
| middle line zone - 1 inch left or right from middle line
 +
|
 +
| X
 +
|-
 +
|
 +
|nullFlavor = NA
 +
|system disease
 +
|in the sense of 'not applicable'
 +
|
 +
|X
 +
|-
 +
|
 +
|nullFlavor = UNK
 +
|unknown
 +
|
 +
| X
 +
| X
 +
|-
 +
|}
 +
 
 +
Table 4: Vocabulary Domain for Localization
 +
Coding System: (OID: 1.2.276.0.76.5.412)
  
Regarding the encoding of side localizations, we translated a section from „ICD-10-
+
4 DIMDI
Bekanntmachung des BMGS“ ("ICD-10 Communications of the German Health Ministry", 2004)
+
5 Literatur: Basisdokumentation für Tumorkranke 5. Auflage 1999; Dudeck et al
  
„..for the application of ICD-10-GM the following holds:
 
When encoding the side localization, the following suffices may be used:
 
– right: R
 
– left: L
 
– both sides: B ...“
 
[BMGS, 2004]
 
  
As a result, for each ICD-10 code, an independent side localization suffix can be appended.
+
The side localization is used for diagnosis documentation for common and also for tumor documentation, but with differeent value sets, which are defined as follows:
Note: primary code and secondary code can have different side localizations.
 
  
Example:
+
{| class="hl7table"
C50.4 R  Mamma Ca - right
+
! Value Set
J91* L  Pleural effusion in conditions classified elsewhere - left
+
! Explanation
 +
! OID
 +
|-
 +
| Common, based on ICD-10
 +
| 2.16.840.1.113883.3.7.1.7
 +
|-
 +
| Tumor Documentation
 +
| 1.2.276.0.76.11.10
 +
|-
 +
|}
  
For tumor documentation the extended table is valid.
+
Table 5: Value Sets for Localization
  
=====Confidence of Diagnoses=====
+
===Explanations===
  
 +
text explanation of diagnosis ST [0..1]
  
... Für die Anwendung der ICD-10-GM nach § 295 SGB V (ambulanter Bereich) gilt
+
Any explaining text shall be represented using the XML attribute text.
zusätzlich Folgendes:
 
Zur Angabe der Diagnosesicherheit ist eines der nachgenannten Zusatzkennzeichen
 
anzugeben (obligatorische Anwendung
 
– für eine ausgeschlossene Diagnose: A
 
– für eine Verdachtsdiagnose: V
 
– für einen symptomlosen Zustand nach der betreffenden Diagnose: Z
 
– für eine gesicherte Diagnose: G...“ [BMGS, 2004]
 
Das heißt, wird eine Diagnose im Rahmen einer „Abrechnung ärztlicher Leistungen“
 
(§295 SGB V) angegeben, ist neben der Angabe des ICD-10 Codes, die Angabe der
 
Diagnosesicherheit zwingend erforderlich. Im stationären Bereich dürfen diese Angaben
 
nicht verwendet werden.
 
(siehe Änderung zu 3.9)
 
  
====Mapping of ICD-10-coded Diagnoses into HL7 v3====
+
A structured representation will look like this:
  
  
Structured representations of ICD10-encoded diagnoses must support primary and secondary codes, code extensions, side localizations and confidence.
+
<syntaxhighlight lang="xml">
The primary code represents the main disease.
+
<!-- structured representation of diagnosis -->
The secondary code extends the primary code and is either used to describe manifestations in organs ("asterisk") or the cause (etiology, e.g. which bacteria) of the main disease ("exclamation")
+
  <observation moodCode="EVN" classCode="OBS">
In order to represent this dependency, an additional oberservation instance will be connected via the ActRelationship to that Observation instance containing the primary code.
+
    <value xsi:type="CD" code="J45.0" codeSystem="1.2.276.0.76.5.311"
 
+
      displayName="Vorwiegend allergisches Asthma bronchiale">
So we have the following basic structure for ICD10-encoded diagnoses:
+
      <originalText>Allergisches Asthma</originalText>
 +
    </value>
 +
    <text>Intermittierend, seit der Jugend</text>
 +
  </observation>
 +
</syntaxhighlight>
  
[[Datei:figure2.jpg]]
+
===Reasons for Exceptions===
Figure 2: Class Diagram of ICD-10 Diagnoses in HL7 v3
 
  
The attribute typeCode in the ActRelationship shall represent the code extension
+
value Reasons for Exceptions ST [0..1]
  
The related Observation instance (connected via the ActRelationship) has MFST (Manifestation) as its typeCode in order to represent 'asterisk"-codes.
+
Billling-related exceptions shall be encoded using the @value attribute of an extra Observation instance being related via an ActRelation-Ship instance to the original describing instance of Observation.
  
Exclamation-Code extensions  are being represented as Observation instances connected via ActRelationships with typeCode CAUS (Cause).
+
A structured representation will look like this:
 
 
The resulting XML structure of an ICD-10 encodeded diagnosis looks like this:
 
  
 
<syntaxhighlight lang="xml">
 
<syntaxhighlight lang="xml">
<!-- Structured Representation of Diagnosis-->
+
<!-- structured representation of diagnosis -->
  <observation moodCode="EVN" classCode="OBS">
+
  <observation moodCode="EVN" classCode="OBS">
      …
+
    ...
      <!-- Primary Code-->
+
    <!-- reason for exception-->
      <value xsi:type="CD" code=" E14.30" codeSystem=" 1.2.276.0.76.5.311"/>
+
       <entryRelationship typeCode="RSON">
       <entryRelationship typeCode="MFST">
+
        <observation moodCode="EVN" classCode="OBS">
        <observation moodCode="EVN" classCode="OBS">
+
          <code nullFlavor="UNK"/>
        …
+
          <value xsi:type="ED">...........</value>
            <!-- Secondary Code-->
+
        </observation>
            <value xsi:type="CD" code=" H28.0" codeSystem=" 1.2.276.0.76.5.311"/>
+
       </entryRelationship>
        </observation>
+
    ...
       </entryRelationship>
+
  </observation>
  </observation>
 
 
</syntaxhighlight>
 
</syntaxhighlight>
  
In this case the containing ActRelationship instance is of class entryRelationship-
+
XML attribute @typeCode shall have the value RSON (= reason) specifying an exception for billing purposes.
repesented by an element of that name.
 
  
Attribute @typeCode has MFST as a fixed value for representing an asterisk code.
+
===Using more Attributes of Observation===
  
value.@code ICD-Code
+
This section describes more model attributes of Observation that may play a role in describing diagnoses.
ST [1..1]
 
XML-Attribute @code shall store the specific ICD-10 Code.
 
  
value.@codeSystem OID of ICD-Codeset
+
====Attribute 'id'====
UID [1..1]
+
id diagnosis identificator SET <II>[0..1]
XML-Attribute @codeSystem shall keep the OID of the ICD-10 Version being used.
 
The appendix gives hints towards versions being used in practice.
 
  
value.@codeSystemName Name of ICD-10 Version
+
The model attribute id should be used to identify the instance of a diagnosis - which is recommended for computer-based processing of diagnoses in order to refer to the clinical specification of that diagnosis.
ST [0..1]
 
XML-Attribute @codeSystemName may store the Name of the used ICD-10 Version.
 
  
value.@displayName ICD-Code Text
+
In XML representations the XML attribute @extension shall store the diagnosis identifier while the XML attribute @root should specify the OID of the diagnosis database.
ST [0..1]
 
XML-Attribute @displayName may store the verbose text of the ICD-Code.
 
  
OIDs and names of ICD-10 versions may be obtained from DIMDI (www.dimdi.de)
+
In case changes or deletions have to be communicated for this diagnosis instance, this id will provide reference.
  
=====Representation of Side Localisation=====
+
====Attribute 'classCode'====
 +
@classCode classCode <= OBS
  
value.qualifier Side Localisation
+
XML attribute shall be 'OBS' - specifiying Observation as the main type of the Act instance used for documenting the diagnosis.
CR [0..1]
 
  
The side localisation code shall be represented using the child element qualifier of the value element, as it refines the specification of that diagnosis code (as decided by HL7 DE TC meeting on 2005-09-01, minutes item 1.3.2).
+
In XML an attribute @classCode of the element Observation represents the model attribute 'classCode' of class Observation.
  
An example representation looks like this:
+
====Attribute 'moodCode'====
 +
@moodCode Mood Code <= EVN
  
<syntaxhighlight lang="xml">
+
Attribute @moodCode specifies how to interpret the containing Act instance.
<!-- Structured Representation of a Diagnosis -->
 
  <observation moodCode="EVN" classCode="OBS">
 
      <code code="DX" codeSystem=""/>
 
      <!-- Primary code-->
 
      <value xsi:type="CD" code="E14.30" codeSystem="1.2.276.0.76.5.311">
 
        <qualifier>
 
            <name code="7" codeSystem="2.16.840.1.113883.3.7.1.0"/>
 
            <value code="L" codeSystem="2.16.840.1.113883.3.7.1.7"/>
 
        </qualifier>
 
      </value>
 
      <entryRelationship typeCode="CAUS">
 
        <observation moodCode="EVN" classCode="OBS">
 
            <code/>
 
            <!-- Sekundary code-->
 
            <value xsi:type="CD" code="H28.0" codeSystem="1.2.276.0.76.5.311">
 
              <qualifier>
 
                  <name code="7" codeSystem="2.16.840.1.113883.3.7.1.0"/>
 
                  <value code="B" codeSystem="2.16.840.1.113883.3.7.1.7"/>
 
              </qualifier>
 
            </value>
 
        </observation>
 
      </entryRelationship>
 
  </observation>
 
</syntaxhighlight>
 
  
Child element 'name' within element 'qualifier' defines the type of qualifier.
+
When using an Observation to specify a diagnosis, the @moodCode shall have the value EVN, indicating that the Observation documents an earlier action.
  
Therefore, in order to express a qualifier for side localisation, the fixed value „7“ from code system OID 2.16.840.1.113883.3.7.1.0 shall be used:
+
====Attribute 'negationInd'====
 +
 
 +
@negationInd Negation Indicator BL [0..1]
 +
 
 +
The optional attribute @negationInd is of data type BL with values 'true' or 'false'.
 +
 
 +
Specifying a 'true' value states that the specified diagnosis has been excluded.
 +
 
 +
@negationInd is optional, the default is 'false'. If not specified, the receiving system will interpret the diagnosis as specified.
 +
 
 +
====Attribute 'statusCode'====
 +
 
 +
statusCode Statuscode <= completed
 +
 
 +
This attribute can be use to represent the state of the containing Act, which can be in states like e.g. "new", "active" or "cancelled". As diagnoses are considered the documentation of an action already completed, the fixed value "completed" shall be used in XML attribute @code of sub-element statusCode.
 +
 
 +
 
 +
====An Example====
 +
 
 +
A small example shows all of the above attributes:
  
 
<syntaxhighlight lang="xml">
 
<syntaxhighlight lang="xml">
  <qualifier>
+
  <observation classCode="OBS" moodCode="EVN" negationInd="true">
      <name code="7" codeSystem="2.16.840.1.113883.3.7.1.0"/>
+
  …
      <value code="L" codeSystem="2.16.840.1.113883.3.7.1.7"/>
+
  <statusCode code="completed"/>
  </qualifier>
+
  …
 +
  </observation>
 
</syntaxhighlight>
 
</syntaxhighlight>
  
=====Representation of Diagnosis Confidence=====
+
==Representation of Diagnosis in specific Codesystems==
  
value.qualifier Diagnosis Confidence
+
===ICD-10-GM-coded Diagnoses===
CR [0..1]
 
  
The Diagnosis Confidence can be considered an extension to the ICD-10 code, shall be represented by the child element qualifier of the value element.
+
The „International Statistical Classification of Diseases” (ICD) is a
 +
classification system for diseases and related health issues. It has a hierarchical structure. As the german localized version ICD-10-GM is a varient of the ICD-10 released by WHO.
  
<syntaxhighlight lang="xml">
+
Diseases are specified through alphanumeric codes. Each disease has a unique code and vice versa.
<!-- Structured Representation of a diagnosis-->
+
The majority of codes are so-called primary diagnosis keys, i.e.they contain all information to encode a given diagnosis.
  <observation moodCode="EVN" classCode="OBS">
+
 
      <code code="" codeSystem=""/>
+
====[[Bild:Flag_de.svg|border|27px]] Germany====
      <!-- Primary code-->
 
      <value xsi:type="CD" code="E14.30" codeSystem="1.2.276.0.76.5.311">
 
        <qualifier>
 
            <name code="8" codeSystem="2.16.840.1.113883.3.7.1.0"/>
 
            <value code="G" codeSystem="2.16.840.1.113883.3.7.1.8"/>
 
        </qualifier>
 
      </value>
 
      <entryRelationship typeCode="CAUS">
 
        <observation moodCode="EVN" classCode="OBS" negationInd="true">
 
            <code/>
 
            <!-- Secondary code-->
 
            <value xsi:type="CD" code="H28.0" codeSystem="1.2.276.0.76.5.311">
 
              <qualifier>
 
                  <name code="8" codeSystem="2.16.840.1.113883.3.7.1.0"/>
 
                  <value code="A" codeSystem="2.16.840.1.113883.3.7.1.8"/>
 
              </qualifier>
 
            </value>
 
        </observation>
 
      </entryRelationship>
 
  </observation>
 
</syntaxhighlight>
 
  
Child element 'name' within element 'qualifier' defines the type of qualifier.
+
ICD also provides the ability to specify secondary keys for additional information. Such secondary keys must only be used together with a primary diagnosis and are marked through asterisk (*) or exclamation (!) as additional codes .
  
Therefore, in order to express a qualifier for diagnosis confidence, the fixed value '8' from code system OID 2.16.840.1.113883.3.7.1.0 shall be used:
+
Primary diagnosis codes either have no prefix or a cross (+).
  
Child element 'value' within 'qualifier shall store the respective confidence value.
+
Example.: E14.30+, H28.0* ICD-10 Code for “Diabetes mellitus with cataract“
  
Possible values are listed in Table 2.
+
====Terms of ICD-10 Codes====
 +
ICD-10-GM will be used for encoding diagnoses in both in-patient and ambulatory care. In-patient diagnosis encoding additionally has to adhere to the German coding guidelines (§ 301, Deutsche Codierrichtlinien) and the extensions authorized by the Health Ministry (BMG).
  
<syntaxhighlight lang="xml">
+
For ambulatory care, the WHO-Table with BMG-extension is to be used.
  <observation classCode="OBS" moodCode="EVN">
 
      ...
 
      <value xsi:type="CD" code="A25.1" codeSystem="1.2.276.0.76.5.311" codeSystemName="icd10gm2006">
 
        <qualifier>
 
            <name code="8" codeSystem="2.16.840.1.113883.3.7.1.0"/>
 
            <value code="G" codeSystem="2.16.840.1.113883.3.7.1.8"/>
 
        </qualifier>
 
      </value>
 
  </observation>
 
</syntaxhighlight>
 
  
When representing an EXCLUDED diagnosis the attribute @negationInd shall be specified as  „true“.
+
=====Secondary Codes=====
  
===Specifying a Diagnosis using a Thesaurus Index===
+
ICD-10 GM distinguishes between primary codes and secundary codes.
  
One more way of specifying a diagnosis is by using an index referring to an entry in a medical thesaurus.
+
Primary codes are codes without suffix or with a cross(+).
  
 +
Secondary codes are those codes with an asterisk (*) or an exclam (!).
  
====Example: Mapping an Alpha-ID-coded Diagnosis====
+
In oorder to explain their meaning we will translate some quotes of „Basiswissen Kodieren“ [Basic Encoding Knowledge  by DIMDI,www.dimdi.de]
  
As an example, the diagnostic thesaurus „Alphabetische Verzeichnis zur ICD-10 GM“ (alphabetic directory of ICD-10 GM) is being used in Germany.
+
"The code for etiology (cause, origin) of a disease shall be marked with a cross (+)
 +
and its manifestation with an asterisk (*) - with the cross-code being the primary code
 +
and the asterisk-code never being used alone."
  
This directory allows to locate a verbose description of ICD-10 terms and to find the corresponding ICD-10 GM code.
+
Another translated quote:
  
The so-called Alpha-ID has been developed to process entries of that alphabetic directory.
+
„ Asterisk codes shall only be those that are marked as explicitly permitted in ICD-10 for the asterisk-suffix."
  
It is an identification number for each textual entry in the "alphabetic directory".
 
  
In order to find this alpha-ID, a mapping file has been provided by DIMDI (www.dimdi.de).
+
„ Provided that the secondary code is permitted for asterisk, any other code describing the underlying disease may be used as primary code with the cross-suffix."
  
The Alpha-ID is needed because in medical documentation, the descriptions of diagnoses need to be more differentiated than what ICD-10 codes actually can express.
+
„... Some Codes are being marked with an exclam (!) indicating that therse are further descriptions or definitions of the severity. Such codes must not be used alone“ (without primary code).
  
Using the alpha-ID allows for a much finer granularity of diagnosis descriptions.[DIMDI,Alpha_Id].
+
As a result, each diagnosis must at least have a primary code and optionally secondary codes.
  
As an example the ICD-10 Code “A01.0 Typhus caused by Salmonella typhi“ encodes multiple diagnoses such as „liver typhus“, „lung typhus“ and many more.
+
Each primary/secondary code is the alphanumeric string given by ICD-10 code followed by the suffix, either (†, *, !)
  
By using the Alpha-Id it is possible to specify the specific type of typhus, like e.g. „liver typhus“ as„I18721“ and „lung typhus“ as „I21312“.
+
=====Side Localization=====
  
  1;I22457;A01.0;;;Darmtyphus
+
Regarding the encoding of side localizations, we translated a section from „ICD-10-
  1;I75303;A01.0;;;Eberth-Krankheit
+
Bekanntmachung des BMGS“ ("ICD-10 Communications of the German Health Ministry", 2004)
  1;I71406;A01.0;;;Enteritisches Fieber
 
  1;I22466;A01.0;;;Enterotyphus
 
  1;I22467;A01.0;;;Febris enterica
 
  1;I17704;A01.0;;;Gallenblasentyphus
 
  1;I71415;A01.0;;;Gastroenteritisches Fieber
 
  0;I78350;A01.0;;;Gastrointestinale Perforation bei Typhus
 
  1;I17794;A01.0;;;Gehirntyphus
 
  1;I21313;A01.0;;;Hauttyphus
 
  1;I22455;A01.0;;;Ileotyphus
 
  1;I94981;A01.0;;;Infektion durch Bacterium typhosum
 
  1;I73671;A01.0;;;Infektion durch Eberthella typhosa
 
  1;I22458;A01.0;;;Infektion durch Salmonella typhi
 
  1;I18721;A01.0;;;Lebertyphus
 
  1;I21312;A01.0;;;Lungentyphus
 
  1;I96251;A01.0;;;Lymphadenitis mesenterialis durch Salmonella typhi
 
  1;I66509;A01.0;;;Posttyphoider Abszess
 
  1;I22456;A01.0;;;Status typhoides
 
  1;I22463;A01.0;;;Typhoenteritis
 
  1;I71447;A01.0;;;Typhogastrisches Fieber
 
  1;I22462;A01.0;;;Typhoides Fieber
 
  1;I31416;A01.0;;;Typhomanie
 
  1;I22464;A01.0;;;Typhoperitonitis
 
  1;I22454;A01.0;;;Typhus
 
  1;I22461;A01.0;;;Typhus abdominalis
 
  1;I73926;A01.0;;;Typhusinfektion
 
  
Figure 3: Excerpt from mapping file „icd10gm2009_alphaid_edv_ascii20081006.txt“
+
„..for the application of ICD-10-GM the following holds:
 +
When encoding the side localization, the following suffices may be used:
 +
– right: R
 +
– left: L
 +
– both sides: B ...
 +
[BMGS, 2004]
  
 +
As a result, for each ICD-10 code, an independent side localization suffix can be appended.
 +
Note: primary code and secondary code can have different side localizations.
  
 +
Example:
 +
C50.4 R  Mamma Ca - right
 +
J91* L  Pleural effusion in conditions classified elsewhere - left
  
Figure 4 shows an excerpt of the metafile which defines the fields of the mapping file for the Alpha-Id.
+
For tumor documentation the extended table is valid.
  
Each record consists of six fields, each being separated by a semicolon.
+
=====Reliability of Diagnoses=====
  
The fields in each record contain the following data:
 
  
  Field 1: Validity (0-not valid, 1-valid)
+
„... When using ICD-10-GM according to § 295 SGB V (ambulatory sector) additionally the following holds:
  Field 2: Stable Identification with prefix I or T ("Alpha-Identifikationsnummer")
+
For encoding the diagnosis reliability one of the follwing suffices must be used:
  Field 3: Primary key (with cross)
+
– for an excluded diagnosis: A
  Field 4: Asterisk key (with asterisk)
+
– for a suspected diagnosis: V
  Field 5: Additional key (with exclamation)
+
– for state (without symptoms) after the given diagnosis: Z
  Field 6: Related text
+
– for a validated diagnosis: G“
 +
[BMGS, 2004, translated by author]
  
Figure 4: Excerpt from Alpha-ID metafile „icd10gm_alphaid_edv_ascii_liesmich.txt“
+
As a result, ambulatory diagnoses used in the context of „Abrechnung ärztlicher Leistungen“
 +
(billing of medical services, fixed term in the German statutory GP system acc. to german federal regulation §295 SGB V)
 +
the specification of diagnosis reliability is mandatory.
  
 +
For in-patient care these suffices MUST NOT be used.
  
A structured representation of a thesaurus uses the @value attribute of class Observation and an example instance lloks like this:
+
====Mapping of ICD-10-coded Diagnoses into HL7 v3====
  
<syntaxhighlight lang="xml">
+
Structured representations of ICD10-encoded diagnoses must support primary and secondary codes, code extensions, side localizations and reliability .
  <observation moodCode="EVN" classCode="OBS">
+
The primary code represents the main disease.
  …
+
The secondary code extends the primary code and is either used to describe manifestations in organs ("asterisk") or the cause (etiology, e.g. which bacteria) of the main disease ("exclamation")
  <value xsi:type="CD" code="I2173" codeSystem="1.2.276.0.76.5.309" codeSystemName="alphaid2006"/>
+
In order to represent this dependency, an additional oberservation instance will be connected via the ActRelationship to that Observation instance containing the primary code.
  ...
 
  </observation>
 
</syntaxhighlight>
 
  
value.@code Alpha-Id
+
So we have the following basic structure for ICD10-encoded diagnoses:
ST [1..1]
 
XML-Attribute @code stores the index referring to an enty in the „Alphabetisches
 
Verzeichnis“
 
  
value.@codeSystem OID ofAlpha-ID
+
[[Bild:Figure2.jpg|border|27px]]
UID [1..1]
 
XML-Attribute @codeSystem stores the OID of the Alpha-ID Version being used.
 
  
value.@displayName Alpha-Id Text
+
Figure 2: Class Diagram of ICD-10 Diagnoses in HL7 v3
ST [0..1]
 
XML-Attribute @displayName may be used to display a text related to the current Alpha-Id
 
  
value.@codeSystemName Name of Alpha-ID Version
+
The attribute typeCode in the ActRelationship shall represent the code extension
ST [0..1]
 
XML-Attribut @codeSystemName represents the Name of the coding system, in our case alphaid2006.
 
  
OID and name of ICD-10 Version can be obtained from DIMDI (www.dimdi.de)
+
The related Observation instance (connected via the ActRelationship) has MFST (Manifestation) as its typeCode in order to represent 'asterisk"-codes.
  
===Diagnosis Specification using Identifiers in a Nomenclature===
+
Exclamation-Code extensions  are being represented as Observation instances connected via ActRelationships with typeCode CAUS (Cause).
  
One way of specififying a diagnosis is to use the code representing a diagnostic term in some medical nomenclature.
+
The resulting XML structure of an ICD-10 encodeded diagnosis looks like this:
  
A well-known nomenclature in medicine is SNOMED-CT ("systematic nomenclature of medicine - clinical terms")
+
<syntaxhighlight lang="xml">
 +
<!-- Structured Representation of Diagnosis-->
 +
  <observation moodCode="EVN" classCode="OBS">
 +
      …
 +
      <!-- Primary Code-->
 +
      <value xsi:type="CD" code=" E14.30" codeSystem=" 1.2.276.0.76.5.311"/>
 +
      <entryRelationship typeCode="MFST">
 +
        <observation moodCode="EVN" classCode="OBS">
 +
        …
 +
            <!-- Secondary Code-->
 +
            <value xsi:type="CD" code=" H28.0" codeSystem=" 1.2.276.0.76.5.311"/>
 +
        </observation>
 +
      </entryRelationship>
 +
  </observation>
 +
</syntaxhighlight>
  
Compared to ICD-10 it has more concepts for diagnoses and mostly does not classify.
+
In this case the containing ActRelationship instance is of class entryRelationship-
 +
repesented by an element of that name.
  
In general using a term of a nomenclature often preserves more information than using a term of a classification.
+
Attribute @typeCode has MFST as a fixed value for representing an asterisk code.
  
Classification is selecting a common representation for a set of concepts that are (under some aspect) considered similar.
+
value.@code ICD-Code
 +
ST [1..1]
 +
XML-Attribute @code shall store the specific ICD-10 Code.
 +
 
 +
value.@codeSystem OID of ICD-Codeset
 +
UID [1..1]
 +
XML-Attribute @codeSystem shall keep the OID of the ICD-10 Version being used.
 +
The appendix gives hints towards versions being used in practice.
 +
 
 +
value.@codeSystemName Name of ICD-10 Version
 +
ST [0..1]
 +
XML-Attribute @codeSystemName may store the Name of the used ICD-10 Version.
  
As a result, classification reduces information, which is demonstrated by the following examples
+
value.@displayName ICD-Code Text
 +
ST [0..1]
 +
XML-Attribute @displayName may store the verbose text of the ICD-Code.
 +
 
 +
OIDs and names of ICD-10 versions may be obtained from DIMDI (www.dimdi.de)
 +
 
 +
=====Representation of Side Localisation=====
  
I.e. as a part of clinical documentation of diagnosis the encoding using alpha-id or some identifier in a nomenclature would be preferred over using a classification like e.g. ICD-10.
+
value.qualifier Side Localisation
 +
CR [0..1]
  
The example shows concepts all being represented through the same ICD-10 code Q92.8 for 'Other specified trisomies and partial trisomies of autosomes'.
+
The side localisation code shall be represented using the child element qualifier of the value element, as it refines the specification of that diagnosis code (as decided by HL7 DE TC meeting on 2005-09-01, minutes item 1.3.2).
  
A simple comparison of codes from nomenclatures gives an example of missing clarity and precision of the ICD-10 classification.
+
An example representation looks like this:
  
{| class=wikitable
+
<syntaxhighlight lang="xml">
!Diagnosis
+
<!-- Structured Representation of a Diagnosis -->
!ICD-10 Code
+
  <observation moodCode="EVN" classCode="OBS">
!Alpha-ID
+
      <code code="DX" codeSystem=""/>
!Snomed CT
+
      <!-- Primary code-->
!ID MACS
+
      <value xsi:type="CD" code="E14.30" codeSystem="1.2.276.0.76.5.311">
|-
+
        <qualifier>
|Imbalanced Insertion
+
            <name code="7" codeSystem="2.16.840.1.113883.3.7.1.0"/>
|Q92.8
+
            <value code="L" codeSystem="2.16.840.1.113883.3.7.1.7"/>
|I87548
+
        </qualifier>
|254262003
+
      </value>
|M002405-D62839-58
+
      <entryRelationship typeCode="CAUS">
|-
+
        <observation moodCode="EVN" classCode="OBS">
|Trisomy 22
+
            <code/>
|Q92.8
+
            <!-- Sekundary code-->
|I81282
+
            <value xsi:type="CD" code="H28.0" codeSystem="1.2.276.0.76.5.311">
|205655003
+
              <qualifier>
|M001897-D55549-58
+
                  <name code="7" codeSystem="2.16.840.1.113883.3.7.1.0"/>
|-
+
                  <value code="B" codeSystem="2.16.840.1.113883.3.7.1.7"/>
|Trisomy 20
+
              </qualifier>
|Q92.8
+
            </value>
|I81283
+
        </observation>
|53346000
+
      </entryRelationship>
|M002406-D55530-58
+
  </observation>
|-
+
</syntaxhighlight>
|Partial Trisomy a.n.k.
 
|Q92.8
 
|I81284
 
|133849008
 
|M001D1C-C78409-58
 
|}
 
  
Table 6: Diagnoses in different coding systems
+
Child element 'name' within element 'qualifier' defines the type of qualifier.
  
 +
Therefore, in order to express a qualifier for side localisation, the fixed value „7“ from code system OID 2.16.840.1.113883.3.7.1.0 shall be used:
  
=====Precoordinated and Postcoordinated Concepts of a Nomenclature=====
+
<syntaxhighlight lang="xml">
 +
  <qualifier>
 +
      <name code="7" codeSystem="2.16.840.1.113883.3.7.1.0"/>
 +
      <value code="L" codeSystem="2.16.840.1.113883.3.7.1.7"/>
 +
  </qualifier>
 +
</syntaxhighlight>
  
For specifiying a diagnosis using a terminology there are two fundamental approaches:
+
=====Representation of Diagnosis Reliability =====
  
The pre-coordinated approach selects a fixed term among a comprehensive list with representations for all possible concepts.
+
value.qualifier Diagnosis Reliability
 +
CR [0..1]
  
The list of all pre-coordinated terms limits the set of concepts which can be represented.
+
The diagnosis reliability can be considered an extension to the ICD-10 code, shall be represented by the child element qualifier of the value element.
  
The post-coordinated approach constructs each term out of (more or less independently) encoded aspects of the concept to be represented.
+
<syntaxhighlight lang="xml">
 
+
<!-- Structured Representation of a diagnosis-->
The resulting term is the combination of the encoded aspects of the given concept.
+
  <observation moodCode="EVN" classCode="OBS">
 
+
      <code code="" codeSystem=""/>
ICD-10 is a good example of a pre-coordinated terminology, as it lists all the terms for the concepts it can represent.
+
      <!-- Primary code-->
 
+
      <value xsi:type="CD" code="E14.30" codeSystem="1.2.276.0.76.5.311">
The cross-asterisk extension to ICD-10 is an example of post-coordination.
+
        <qualifier>
 +
            <name code="8" codeSystem="2.16.840.1.113883.3.7.1.0"/>
 +
            <value code="G" codeSystem="2.16.840.1.113883.3.7.1.8"/>
 +
        </qualifier>
 +
      </value>
 +
      <entryRelationship typeCode="CAUS">
 +
        <observation moodCode="EVN" classCode="OBS" negationInd="true">
 +
            <code/>
 +
            <!-- Secondary code-->
 +
            <value xsi:type="CD" code="H28.0" codeSystem="1.2.276.0.76.5.311">
 +
              <qualifier>
 +
                  <name code="8" codeSystem="2.16.840.1.113883.3.7.1.0"/>
 +
                  <value code="A" codeSystem="2.16.840.1.113883.3.7.1.8"/>
 +
              </qualifier>
 +
            </value>
 +
        </observation>
 +
      </entryRelationship>
 +
  </observation>
 +
</syntaxhighlight>
  
More info can be found under the Terminfo project [Terminfo] of HL7 International.
+
Child element 'name' within element 'qualifier' defines the type of qualifier.
  
====Diagnosis by Thesaurus Index or Term within a Nomenclature====
+
Therefore, in order to express a qualifier for diagnosis reliability, the fixed value '8' from code system OID 2.16.840.1.113883.3.7.1.0 shall be used:
  
A term in a nomenclature is specified through the @value attribute of class Observation.
+
Child element 'value' within 'qualifier shall store the respective reliability value.
  
An example (SNOMED CT) of the structured representation looks like this:
+
Possible values are listed in Table 2.
  
 
<syntaxhighlight lang="xml">
 
<syntaxhighlight lang="xml">
   <observation moodCode="EVN" classCode="OBS">
+
   <observation classCode="OBS" moodCode="EVN">
  ...
+
      ...
  <value  
+
      <value xsi:type="CD" code="A25.1" codeSystem="1.2.276.0.76.5.311" codeSystemName="icd10gm2006">
      xsi:type="CD" code="314888007"  
+
        <qualifier>
      codeSystem="2.16.840.1.113883.6.96"
+
            <name code="8" codeSystem="2.16.840.1.113883.3.7.1.0"/>
      codeSystemName="SNOMED CT"
+
            <value code="G" codeSystem="2.16.840.1.113883.3.7.1.8"/>
      displayName="Typ-II-Diabetes with diabetic cataract"/>
+
        </qualifier>
  ...
+
      </value>
 
   </observation>
 
   </observation>
 
</syntaxhighlight>
 
</syntaxhighlight>
  
=====Attribute value.@code Index or Term in Nomenclature=====
+
When representing an EXCLUDED diagnosis the attribute @negationInd shall be specified as  „true“.
CD CWE [1..1]
+
 
The XML attribute @code keeps the index referring to an entry in a thesaurus or nomenclature.
+
===Specifying a Diagnosis using a Thesaurus Index===
  
=====Attribute value.@codeSystem OID of Nomenclature=====
+
One more way of specifying a diagnosis is by using an index referring to an entry in a medical thesaurus.
UID [1..1]
 
The XML attribute @codeSystem stores the OID of the thesaurus or nomenclature.
 
  
=====Attribute value.@displayName Text=====
 
ST [0..1]
 
Through the XML attribute @displayName a plain text related to the index can be given.
 
  
=====Attribute value.@codeSystemName Name of Nomenclature=====
+
====Example: Mapping an Alpha-ID-coded Diagnosis====
[0..1]
 
The XML attribut @codeSystemName describes the name of the thesausrus or nomenclature.
 
  
==Representation of Cancer Diagnosis==
+
=====[[Bild:Flag_de.svg|border|27px]] Germany=====
===Introduction===
 
In this chapter, diagnostic aspects of documentation of tumor diseases will be described.
 
Different aspects of diagnostical descriptions of tumor diseases are described by ICD-O (Oncology)
 
and by further classifications to document the expansion (tumor spread) or diseases stage, respectively, the latter
 
one mostly being classified by the TNM-System.
 
  
Especially for hemato oncological diseases (Leukemias and Lymphomas), other systems (e.g. Ann-Arbor-Classification) are used.
+
As an example, the diagnostic thesaurus „Alphabetische Verzeichnis zur ICD-10 GM“ (alphabetic directory of ICD-10 GM) is being used in Germany.
TNM-System discribes:
 
  
* Expansion of primary tumor (extent or, spread in distant organs repectively)
+
This directory allows to locate a verbose description of ICD-10 terms and to find the corresponding ICD-10 GM code.
* Affection of lymph nodes in lymph flow area
 
* Existence of distant metastases.
 
  
For non-TNM–-classifiable diseases or in addition to the TNM-System there are a number of further classification systems:
+
The so-called Alpha-ID has been developed to process entries of that alphabetic directory.
* Ann Arbor
+
 
* Rai
+
It is an identification number for each textual entry in the "alphabetic directory".
* Binet
+
 
* CML-Phasen
+
In order to find this alpha-ID, a mapping file has been provided by DIMDI (www.dimdi.de).
* FAB
+
 
* Durie and Salmon
+
The Alpha-ID is needed because in medical documentation, the descriptions of diagnoses need to be more differentiated than what ICD-10 codes actually can express.
* Gleason-Score
+
 
 +
Using the alpha-ID allows for a much finer granularity of diagnosis descriptions.[DIMDI,Alpha_Id].
  
Discriptions can be found here:
+
As an example the ICD-10 Code “A01.0 Typhus caused by Salmonella typhi“ encodes multiple diagnoses such as „liver typhus“, „lung typhus“ and many more.  
http://www.med.uni-giessen.de/akkk/gtds/grafisch/doku/bd5f.htm
 
http://www.tumorzentren.de/tl_files/dokumente/adt_basis.pdf
 
  
This list probably will be always incomplete because of the medical progress.
+
By using the Alpha-Id it is possible to specify the specific type of typhus, like e.g. „liver typhus“ as„I18721“ and „lung typhus“ as „I21312“.
  
===ICD-O===
+
  1;I22457;A01.0;;;Darmtyphus
Third Edition of ICD-O [DIMDI, WHO] is the topical one. ICD-O consists of two axes, Topography- and Morphology-Axis.
+
  1;I75303;A01.0;;;Eberth-Krankheit
In ICD-O, tumor can be classified by
+
  1;I71406;A01.0;;;Enteritisches Fieber
* Site
+
  1;I22466;A01.0;;;Enterotyphus
* Tissue Structure (Histology)
+
  1;I22467;A01.0;;;Febris enterica
* Biological behaviour (Dignity)
+
  1;I17704;A01.0;;;Gallenblasentyphus
* Tissue  grading (mostly in two or four stages)
+
  1;I71415;A01.0;;;Gastroenteritisches Fieber
In this case, tissue structure and tissue grading is redundant.
+
  0;I78350;A01.0;;;Gastrointestinale Perforation bei Typhus
Precisely:
+
  1;I17794;A01.0;;;Gehirntyphus
The first four digits of morphology-code describe tissue-type.
+
  1;I21313;A01.0;;;Hauttyphus
The fifth one describes biological behaviour (dignity-code):
+
  1;I22455;A01.0;;;Ileotyphus
* /0 = benign
+
  1;I94981;A01.0;;;Infektion durch Bacterium typhosum
* /1 = neoplasm with uncertain or unknown behaviour
+
  1;I73671;A01.0;;;Infektion durch Eberthella typhosa
* /2 = Cancer in situ
+
  1;I22458;A01.0;;;Infektion durch Salmonella typhi
* /3 = malignant, primary tumor
+
  1;I18721;A01.0;;;Lebertyphus
* /6 = malignant, metastasis (not used in tumor documentation)
+
  1;I21312;A01.0;;;Lungentyphus
* /9 = malignant, uncertain wether primary tumor or a metastatic
+
  1;I96251;A01.0;;;Lymphadenitis mesenterialis durch Salmonella typhi
The sixth digit describes grading, differentiation or phenotype (Histology/Pathology):
+
  1;I66509;A01.0;;;Posttyphoider Abszess
* 1 = Grade I, well differentiated (Low grade)
+
  1;I22456;A01.0;;;Status typhoides
* 2 = Grade II, moderately differentiated (Intermediate grade)
+
  1;I22463;A01.0;;;Typhoenteritis
* 3 = Grade III, poorly differentiated (High grade)
+
  1;I71447;A01.0;;;Typhogastrisches Fieber
* 4 = Grade IV, undifferentiated (High grade)
+
  1;I22462;A01.0;;;Typhoides Fieber
* 9 = Grade IX, grade cannot be assessed
+
  1;I31416;A01.0;;;Typhomanie
For Leukemias and Lymphomas, the sixth digit signifies the immunophenotype
+
  1;I22464;A01.0;;;Typhoperitonitis
* 5 = T-Cell
+
  1;I22454;A01.0;;;Typhus
* 6 = B-Cell, Pre-B-Cell, B-Ancestor-Cell
+
  1;I22461;A01.0;;;Typhus abdominalis
* 7 = Null-Cell, Not-T-Cell-Not-B-Cell
+
  1;I73926;A01.0;;;Typhusinfektion
* 8 = NK-Cell, Natural Killer Cell
+
 
* 9 = Determination of Cell Type was not accomplished, not specified or not applicable
+
Figure 3: Excerpt from mapping file „icd10gm2009_alphaid_edv_ascii20081006.txt“
  
TNM System describes
 
* Expansion of primary tumor (extent repectivly spread in distant organs)
 
* Affection of lymph nodes in lymph flow area
 
* Exisistence of distant metastasis
 
  
For the topography axis, there exists an (hierarchical) enlargement, the ‘localisation key’ (Wagner, G. (HRSG.): Tumorlokalisationsschlüssel, 5. Auflage, Springer Verlag, Berlin, Heidelberg, New York, Tokyo 1993), which can supply at some positions clinical relevant differentiation.
 
The morphology axis is composed of a four-digit code for tissue basic structure, a characteristic number for dignity and an additional grading item.
 
The key itself does not contain all possible combinations of histology and dignity, but points out those ones, for whome exist special discriptions.
 
Vice versa not all combinations of basic structure and dignity are possible (so there is no ‘benign leukemia’). Not either there is a grading system available for all kinds of tumor. For some ones, additional information (for Example ‘Cell-line’) is used at the corresponding position.
 
  
====Tumor Localization====
+
Figure 4 shows an excerpt of the metafile which defines the fields of the mapping file for the Alpha-Id.
For Tumor-Coding first of all, the site is important. It will be classified by the Topography -Axis of ICD-O. Topographical -Codes of ICD-10 are based on chapter II (Neoplasm –C 00 – C 97) of ICD-10.
 
However, some of the topographical Codes of ICD-10 (Codes) are not used, because their content is discribed by histology- and digit-Codes of ICD-O. (e.g. Differentiation in situ/ infiltrated, melanoma vs. scin cancer).
 
  
====Tumor Histology and Dignity ====
+
Each record consists of six fields, each being separated by a semicolon.
Furthermore, in ICD-O, tumor morphology i.e. tissue structure (histology) and biological behavior (dignity) is discribed by special Codes.
 
Tumor histology is coded by a four-digit number, which is assumed of the morphology-axis of Standardized Nomenclature of Patholoy (SNOP). Dignity-Code is attendant on morphology-Code, seperated by /.
 
Examples:
 
* 8060/0 squamous epithelium - papillomatose
 
* 8070/2 squamous epithelium – cancer in situ undifferentiated
 
* 8070/3 squamous epithelium – cancer undifferentiated
 
* 8070/6 squamous epithelium – cancer metastasis undifferentiated
 
  
====Tumor Grading====
+
The fields in each record contain the following data:
Grading is derived from the comparison of primary tissue with the neoplasm of this tissue.
 
There are five grading-degrees (s.o.) and further three degrees for Malignant Lymphoma.
 
Registration of tumor grading is also provided in TNM.
 
  
====Qualifier of Tumor Formula====
+
  Field 1: Validity (0-not valid, 1-valid)
ICD-O –Codes can be specified by the following qualifier:
+
  Field 2: Stable Identification with prefix I or T ("Alpha-Identifikationsnummer")
+
  Field 3: Primary key (with cross)
Here ICD-O provides additionally the following codes for Lymphoma, which specify the Cell line:
+
  Field 4: Asterisk key (with asterisk)
B-Cell, T-Cell, Null-Cell Lymphoma.
+
  Field 5: Additional key (with exclamation)
ICD-O uses the Codes 1 – 9.
+
  Field 6: Related text
A detailled System is discribed in Chapter 9 under 9.5.2 and 9.53.
 
  
====Example====
+
Figure 4: Excerpt from Alpha-ID metafile „icd10gm_alphaid_edv_ascii_liesmich.txt“
 
GRAPHIC IS MISSING
 
  
DisplayName is only available in correlation to qualifiers. According to ICD-O-3 formation rule there are much more discriptions possible as ICD-Catalog proposes.
 
  
 +
A structured representation of a thesaurus uses the @value attribute of class Observation and an example instance lloks like this:
  
===TNM Classification===
+
<syntaxhighlight lang="xml">
 +
  <observation moodCode="EVN" classCode="OBS">
 +
  …
 +
  <value xsi:type="CD" code="I2173" codeSystem="1.2.276.0.76.5.309" codeSystemName="alphaid2006"/>
 +
  ...
 +
  </observation>
 +
</syntaxhighlight>
  
The TNM classification describes the expansion (spread) of the tumor , i.e. stadium and prognosis of the disease.
+
value.@code Alpha-Id
 +
ST [1..1]
 +
XML-Attribute @code stores the index referring to an enty in the „Alphabetisches
 +
Verzeichnis“
  
As a special feature, the TNM classification uses the same notation for all tumors but supports different interpretations for different entities.
+
value.@codeSystem OID ofAlpha-ID
 +
UID [1..1]
 +
XML-Attribute @codeSystem stores the OID of the Alpha-ID Version being used.
  
As an example, a T3 for mamma carcinoma has a different interpretation then the stomach carcinoma.
+
value.@displayName Alpha-Id Text
 
+
ST [0..1]
The current edition is 7th which is valid since January 2010, which is a reason why many TNM-6- codes may still be in use.
+
XML-Attribute @displayName may be used to display a text related to the current Alpha-Id
Therefore all TNM-codes should have a version identifier, because
 
non translatable differences are in the different editions.
 
  
A simple overview can be found in  http://de.wikipedia.org/wiki/TNM.
+
value.@codeSystemName Name of Alpha-ID Version
 +
ST [0..1]
 +
XML-Attribut @codeSystemName represents the Name of the coding system, in our case alphaid2006.
  
 +
OID and name of ICD-10 Version can be obtained from DIMDI (www.dimdi.de)
  
The T category will be used for the expansion of the primary tumor,
+
===Diagnosis Specification using Identifiers in a Nomenclature===
where the stages T0, Tis, T1-T4 und TX are being used, the "higher"
 
the number, the more progress is being diagnosed and the more adverse the prognosis.
 
  
T0 stands for "no primary tumor found" (e.g. because being
+
One way of specififying a diagnosis is to use the code representing a diagnostic term in some medical nomenclature.
eradicated by therapy)
 
Tis stands for a very early (non-infiltrating) stage tumor
 
(Tumor in situ) and
 
TX stands for a diagnosis which can not judge the stage because of missing data
 
  
For some tumors subcategories like e.g. T2a, T2b have been defined.
+
A well-known nomenclature in medicine is SNOMED-CT ("systematic nomenclature of medicine - clinical terms")
  
 +
Compared to ICD-10 it has more concepts for diagnoses and mostly does not classify.
  
The N-category classifies the affection of lymphatic nodes - usingN0, N1-N3, NX, where N0 means "no lymphatic node affected".
+
In general using a term of a nomenclature often preserves more information than using a term of a classification.
  
For some tumors, thisexclusion ("N0") requires the examination of a minimum amount of nodes.
+
Classification is selecting a common representation for a set of concepts that are (under some aspect) considered similar.
  
The higher the N category the more severe is the lymphatic node affection.
+
As a result, classification reduces information, which is demonstrated by the following examples
  
If no sufficient data is available NX is being diagnosed.
+
I.e. as a part of clinical documentation of diagnosis the encoding using alpha-id or some identifier in a nomenclature would be preferred over using a classification like e.g. ICD-10.
  
 +
The example shows concepts all being represented through the same ICD-10 code Q92.8 for 'Other specified trisomies and partial trisomies of autosomes'.
  
The M category describes the existence of distant metastases, with the vallues of M0 (no metastases detectable), M1 (metastases detectable) and MX (insufficient data).
+
A simple comparison of codes from nomenclatures gives an example of missing clarity and precision of the ICD-10 classification.
  
 +
{| class="hl7table"
 +
!Diagnosis
 +
!ICD-10 Code
 +
!Alpha-ID
 +
!Snomed CT
 +
!ID MACS
 +
|-
 +
|Imbalanced Insertion
 +
|Q92.8
 +
|I87548
 +
|254262003
 +
|M002405-D62839-58
 +
|-
 +
|Trisomy 22
 +
|Q92.8
 +
|I81282
 +
|205655003
 +
|M001897-D55549-58
 +
|-
 +
|Trisomy 20
 +
|Q92.8
 +
|I81283
 +
|53346000
 +
|M002406-D55530-58
 +
|-
 +
|Partial Trisomy a.n.k.
 +
|Q92.8
 +
|I81284
 +
|133849008
 +
|M001D1C-C78409-58
 +
|}
  
The TNM can be used according to clinical criteria (preoperative, cTNM) and according to the pathology findings (pTNM).
+
Table 6: Diagnoses in different coding systems
 
 
For many patients one single diagnoss will be made, either a cTNM or a pTNM, such that this type of finding must be distinguished.
 
  
This preoperative ("c" or no prefix) / pathology ("p") attribute can be captured independently for each of the T N M categories.
 
  
Therefore the typically used pTNM often meanes pTpNcM, because the spread of a timur can best be diagnosed through surgery while
+
=====Precoordinated and Postcoordinated Concepts of a Nomenclature=====
lymphatic spread only by pathology.
 
  
The prefix "r" describes remaining tumors (after non-disease intervals) and a prefix "y" if the classification was assessed after systemic or radiation treatment (ycTNM, ypTNM etc.).
+
For specifiying a diagnosis using a terminology there are two fundamental approaches:
  
For multiple  Primary tumors the suffix "m" (or the number of tumors) will be put after the T-category value(T2(m), T2(5)).
+
The pre-coordinated approach selects a fixed term among a comprehensive list with representations for all possible concepts.
  
 +
The list of all pre-coordinated terms limits the set of concepts which can be represented.
  
Therefore a complete TNM formula looks like this:
+
The post-coordinated approach constructs each term out of (more or less independently) encoded aspects of the concept to be represented.
  
There are voluntary components e.g. the certainty-Faktor (C-Factor)
+
The resulting term is the combination of the encoded aspects of the given concept.
  
Other components require pathology lab examination (L-, V- or Pn-Category)
+
ICD-10 is a good example of a pre-coordinated terminology, as it lists all the terms for the concepts it can represent.
* y-Symbol (y or empty, disgnosis after systematic or xray treatment)
 
* r-Symbol (r or empty, remainder)
 
* p/c/a-Symbol for pT-category (clinical or pathological)
 
* T-Category
 
* (m) for multiple localizations or number of tumors
 
* C-Factor for T-Category (certainty)
 
  
* L-Category
+
The cross-asterisk extension to ICD-10 is an example of post-coordination.
* V-Category
 
* Pn-Category
 
* p/c/a-Symbol for pN-Category (clinical or pathological)
 
* N-Category
 
* C-Factor for N-Category (certainty)
 
  
* p/c/a-Symbol für pM-Category
+
More info can be found under the Terminfo project [Terminfo] of HL7 International.
* M-Category
 
* C-Factor for M-Category (certainty)
 
* S-Kategorie (serological values, only for testicle tumors)
 
* UICC-Stadium (Grading via UICC 0 and I-IV together with
 
letter A, B and C for further classification).
 
  
For some tumors further modifiers are being documented as a suffix
+
====Diagnosis by Thesaurus Index or Term within a Nomenclature====
(mostly in parenthenses) like e.g. (sn), (mol-),(mol+).
 
  
In addition, the TNM supplement introduces innovative or "under test" extensions, which raises doubts whether ta full control of TNM entries.
+
A term in a nomenclature is specified through the @value attribute of class Observation.
  
Typical T-Categories (without pre-/suffices) are being listed in chapter "Sites"
+
An example (SNOMED CT) of the structured representation looks like this:
  
Typical N-Categories (without pre-/suffices) are being listed in chapter "Nodes".
+
<syntaxhighlight lang="xml">
 +
  <observation moodCode="EVN" classCode="OBS">
 +
  ...
 +
  <value
 +
      xsi:type="CD" code="314888007"
 +
      codeSystem="2.16.840.1.113883.6.96"
 +
      codeSystemName="SNOMED CT"
 +
      displayName="Typ-II-Diabetes with diabetic cataract"/>
 +
  ...
 +
  </observation>
 +
</syntaxhighlight>
  
Typical M-Categories (without pre-/suffices) are being listed in chapter "Metastases".
+
=====Attribute value.@code Index or Term in Nomenclature=====
 +
CD CWE [1..1]
 +
The XML attribute @code keeps the index referring to an entry in a thesaurus or nomenclature.
  
9 Reference: DKFZ
+
=====Attribute value.@codeSystem OID of Nomenclature=====
 +
UID [1..1]
 +
The XML attribute @codeSystem stores the OID of the thesaurus or nomenclature.
  
====Qualifiers of the Tumor Formula====
+
=====Attribute value.@displayName Text=====
Despite values for T,N and M the TNM formula may also contain various qualifiers.
+
ST [0..1]
The following table gives an overview which qualifiers can be used for which information and where they are being used.
+
Through the XML attribute @displayName a plain text related to the index can be given.
This is case-sensitive!
 
  
a Autoptical
+
=====Attribute value.@codeSystemName Name of Nomenclature=====
c Clinical
+
[0..1]
C C-Faktor (certainty)
+
The XML attribut @codeSystemName describes the name of the thesausrus or nomenclature.
G histopathological Grading
 
L Lymphatic vessel invasion
 
m multiple Tumors
 
M distant metastases
 
N Regional lymphatic node metastases
 
p pathological
 
Pn perineural Invasion
 
r Rezidiv tumor
 
R Residual tumor after treatment
 
sn Sentinel-Lymphatic nodes
 
Stage Anatomic Stage-Grouping
 
T Expansion (spreading) of Primary tumor
 
V Venous invasion
 
y Classifikation after initial multi-modal Therapy
 
  
===Ann Arbor Classification===
+
==Representation of Cancer Diagnosis==
 
+
===Introduction===
For lymphoma the TNM-classification does not make sense and therefore theso-called Ann-Arbor
+
In this chapter, diagnostic aspects of documentation of tumor diseases will be described.
classification will be applied.
+
Different aspects of diagnostical descriptions of tumor diseases are described by ICD-O (Oncology)
 +
and by further classifications to document the expansion (tumor spread) or diseases stage, respectively, the latter
 +
one mostly being classified by the TNM-System.  
  
In this system, the stages I-IV are being distinguished, with an additional suffix letter
+
Especially for hemato oncological diseases (Leukemias and Lymphomas), other systems (e.g. Ann-Arbor-Classification) are used.
- A meaning "no general symptoms"
+
TNM-System discribes:
- B "with general symptoms"
 
- E "extra-lymphatic organ affected"
 
- S "spleen affected"
 
  
As with TNM, the Ann-Arbor classification distinguishes between cliniclal (cS) and pathological (pS) grading.
+
* Expansion of primary tumor (extent or, spread in distant organs repectively)
 +
* Affection of lymph nodes in lymph flow area
 +
* Existence of distant metastases.
  
According to Durie & Salmon tere are gradings from I to III or the
+
For non-TNM–-classifiable diseases or in addition to the TNM-System there are a number of further classification systems:
grades according to SWOG from 1-4 for the "Multiple Myeloma".
+
* Ann Arbor
 +
* Rai
 +
* Binet
 +
* CML-Phasen
 +
* FAB
 +
* Durie and Salmon
 +
* Gleason-Score
  
===FIGO Stages===
+
Discriptions can be found here:
 +
http://www.med.uni-giessen.de/akkk/gtds/grafisch/doku/bd5f.htm
 +
http://www.tumorzentren.de/tl_files/dokumente/adt_basis.pdf
  
FIGO stages ignificantly overlap with the TNM classification, especially on the T-axis.
+
This list probably will be always incomplete because of the medical progress.
  
Therefore no details are being given here.
+
===ICD-O===
 
+
Third Edition of ICD-O [DIMDI, WHO] is the topical one. ICD-O consists of two axes, Topography- and Morphology-Axis.
===Gleason Score===
+
In ICD-O, tumor can be classified by
 
+
* Site
The so-called Gleason-Score serves to classify the prostate carcinoma.
+
* Tissue Structure (Histology)
The total numeric value is the sum of two indicators for
+
* Biological behaviour (Dignity)
• loss of differentiation (1-5)
+
* Tissue  grading (mostly in two or four stages)
• growth pattern (1-5)
+
In this case, tissue structure and tissue grading is redundant.
 +
Precisely:
 +
The first four digits of morphology-code describe tissue-type.
 +
The fifth one describes biological behaviour (dignity-code):
 +
* /0 = benign
 +
* /1 = neoplasm with uncertain or unknown behaviour
 +
* /2 = Cancer in situ
 +
* /3 = malignant, primary tumor
 +
* /6 = malignant, metastasis (not used in tumor documentation)
 +
* /9 = malignant, uncertain wether primary tumor or a metastatic
 +
The sixth digit describes grading, differentiation or phenotype (Histology/Pathology):
 +
* 1 = Grade I, well differentiated (Low grade)
 +
* 2 = Grade II, moderately differentiated (Intermediate grade)
 +
* 3 = Grade III, poorly differentiated (High grade)
 +
* 4 = Grade IV, undifferentiated (High grade)
 +
* 9 = Grade IX, grade cannot be assessed
 +
For Leukemias and Lymphomas, the sixth digit signifies the immunophenotype
 +
* 5 = T-Cell
 +
* 6 = B-Cell, Pre-B-Cell, B-Ancestor-Cell
 +
* 7 = Null-Cell, Not-T-Cell-Not-B-Cell
 +
* 8 = NK-Cell, Natural Killer Cell
 +
* 9 = Determination of Cell Type was not accomplished, not specified or not applicable
  
Resulting values range from 2 to 10 (also see Scores & Assessment DSTU).
+
TNM System describes
 +
* Expansion of primary tumor (extent repectivly spread in distant organs)
 +
* Affection of lymph nodes in lymph flow area
 +
* Exisistence of distant metastasis
  
Furthermore there is a more recent Gleason classification (according to Dhom,
+
For the topography axis, there exists an (hierarchical) enlargement, the ‘localisation key’ (Wagner, G. (HRSG.): Tumorlokalisationsschlüssel, 5. Auflage, Springer Verlag, Berlin, Heidelberg, New York, Tokyo 1993), which can supply at some positions clinical relevant differentiation.
Müller and Helpap [Helpap 2002, Helpap2007]), which also requires to specify
+
The morphology axis is composed of a four-digit code for tissue basic structure, a characteristic number for dignity and an additional grading item.
the procedure (esp. the two degrees) being used.
+
The key itself does not contain all possible combinations of histology and dignity, but points out those ones, for whome exist special discriptions.
 +
Vice versa not all combinations of basic structure and dignity are possible (so there is no ‘benign leukemia’). Not either there is a grading system available for all kinds of tumor. For some ones, additional information (for Example ‘Cell-line’) is used at the corresponding position.
  
===Papanikolaou===
+
====Tumor Localization====
 +
For Tumor-Coding first of all, the site is important. It will be classified by the Topography -Axis of ICD-O. Topographical -Codes of ICD-10 are based on chapter II (Neoplasm –C 00 – C 97) of ICD-10.
 +
However, some of the topographical Codes of ICD-10 (Codes) are not used, because their content is discribed by histology- and digit-Codes of ICD-O. (e.g. Differentiation in situ/ infiltrated, melanoma vs. scin cancer).
  
The so-called Pap-Test [Pap] is based on colored cell samples from the cervix and is used as an early indocator for cervical cancers.
+
====Tumor Histology and Dignity ====
 +
Furthermore, in ICD-O, tumor morphology i.e. tissue structure (histology) and biological behavior (dignity) is discribed by special Codes.
 +
Tumor histology is coded by a four-digit number, which is assumed of the morphology-axis of Standardized Nomenclature of Patholoy (SNOP). Dignity-Code is attendant on morphology-Code, seperated by /.
 +
Examples:
 +
* 8060/0 squamous epithelium - papillomatose
 +
* 8070/2 squamous epithelium – cancer in situ undifferentiated
 +
* 8070/3 squamous epithelium – cancer undifferentiated
 +
* 8070/6 squamous epithelium – cancer metastasis undifferentiated
  
===WHO Grading===
+
====Tumor Grading====
 +
Grading is derived from the comparison of primary tissue with the neoplasm of this tissue.
 +
There are five grading-degrees (s.o.) and further three degrees for Malignant Lymphoma.
 +
Registration of tumor grading is also provided in TNM.
  
The so-called WHO Grading serves as an individual progonossi on the one hand
+
====Qualifier of Tumor Formula====
and also is an indicator towards further treatment on the other hand.
+
ICD-O –Codes can be specified by the following qualifier:
 +
 +
Here ICD-O provides additionally the following codes for Lymphoma, which specify the Cell line:
 +
B-Cell, T-Cell, Null-Cell Lymphoma.
 +
ICD-O uses the Codes 1 – 9.
 +
A detailled System is discribed in Chapter 9 under 9.5.2 and 9.53.
  
Tumors of WHO Grade I and II in most cases can be treated by surgery alone,
+
====Example====
while tumors with WHO Grading III and IV normally need additional treatment
+
by radiation or chemotherapie after surgery.
+
GRAPHIC IS MISSING
  
The grading looks like this:
+
DisplayName is only available in correlation to qualifiers. According to ICD-O-3 formation rule there are much more discriptions possible as ICD-Catalog proposes.
  
{| class=wikitable
 
! Code
 
! Codename
 
! Meaning
 
|-
 
|I
 
|
 
|benign,slow growth of tumor, very good prognosis
 
|-
 
|II
 
|
 
|still benign, slow growth of tumor,tendency to recur
 
|-
 
|III
 
|
 
|malignant,actively producing abnormal cells,tends to recur
 
|-
 
|IV
 
|
 
|very malignant,fast growth,needs systemic therapy, bad prognosis
 
|}
 
  
Table 9: WHO Grading (OID 1.2.276.0.76.5.394)
+
===TNM Classification===
  
The fourth edition of the "World Health Organization (WHO)
+
The TNM classification describes the expansion (spread) of the tumor , i.e. stadium and prognosis of the disease.
Classification of tumours of the central nervous system" (2007) lists all
 
relevant tumor entities.
 
  
Also see "Brain Tumor Basics" (http://www.abta.org/sitefiles/sitepages/524309b806778d4f7b79044d97f324ea.pdf)
+
As a special feature, the TNM classification uses the same notation for all tumors but supports different interpretations for different entities.
  
===Conclusion===
+
As an example, a T3 for mamma carcinoma has a different interpretation than the stomach carcinoma.
  
The following data of tumors can be represented by these respective classifications (through values and/or modifiers)
+
The current edition is 7th which is valid since January 2010, which is a reason why many TNM-6- codes may still be in use.
 +
Therefore all TNM-codes should have a version identifier, because
 +
non translatable differences are in the different editions.
  
 +
A simple overview can be found in  http://de.wikipedia.org/wiki/TNM.
  
{| class=wikitable
 
! Concept
 
! Classification
 
|-
 
|Tumor localisation
 
|ICD-O
 
|-
 
|Morphology + dignity
 
|ICD-O
 
|-
 
|Tissue differentiation ICD-O
 
|ICD-O/TNM
 
|-
 
|type of stage codes (c,p,r,y)
 
|TNM/Ann-Arbor
 
|-
 
|T Code + C Factor, multiplicity
 
|TNM
 
|-
 
|M Code + C Factor, multiplicity
 
|TNM
 
|-
 
|N Code + C Factor, multiplicity
 
|TNM
 
|-
 
|Residual Tumor
 
|TNM
 
|-
 
|stage grouping
 
|TNM/Ann-Arbor/Durie&Salmon/SWOG
 
|-
 
|}
 
  
==Cancer Diagnosis in HL7 V3==
+
The T category will be used for the expansion of the primary tumor,
 +
where the stages T0, Tis, T1-T4 und TX are being used, the "higher"
 +
the number, the more progress is being diagnosed and the more adverse the prognosis.
  
= Representation for specific Use Cases =
+
T0 stands for "no primary tumor found" (e.g. because being
 +
eradicated by therapy)
 +
Tis stands for a very early (non-infiltrating) stage tumor
 +
(Tumor in situ) and
 +
TX stands for a diagnosis which can not judge the stage because of missing data
 +
 
 +
For some tumors subcategories like e.g. T2a, T2b have been defined.
 +
 
 +
 
 +
The N-category classifies the affection of lymphatic nodes - usingN0, N1-N3, NX, where N0 means "no lymphatic node affected".
 +
 
 +
For some tumors, this exclusion ("N0") requires the examination of a minimum amount of nodes.
 +
 
 +
The higher the N category the more severe is the lymphatic node affection.
 +
 
 +
If no sufficient data is available NX is being diagnosed.
 +
 
 +
 
 +
The M category describes the existence of distant metastases, with the vallues of M0 (no metastases detectable), M1 (metastases detectable) and MX (insufficient data).
  
= Terminology =
 
== Introduction ==
 
This chapter separates codes in use from normative specifications, in order to allow updates to such codes without having to rewrite the normative part. Therefore this chapter is just informative. Current codes have to be requested.
 
{|
 
|-
 
!Due to pending third-party copy rights regarding some of the the following tables, the textual descriptions may not be given here such that the respective fields remain empty.
 
|}
 
  
== Overview of Value Sets ==
+
The TNM can be used according to clinical criteria (preoperative, cTNM) and according to the pathology findings (pTNM).
{| class=wikitable
+
 
! Value Sets
+
For many patients one single diagnoss will be made, either a cTNM or a pTNM, such that this type of finding must be distinguished.
! OID
+
 
! Short Term
+
This preoperative ("c" or no prefix) / pathology ("p") attribute can be captured independently for each of the T N M categories.
! German
+
 
! English
+
Therefore the typically used pTNM often meanes pTpNcM, because the spread of a timur can best be diagnosed through surgery while
|-
+
lymphatic spread only by pathology.
|Tumors
+
 
|1.2.276.0.76.11.1
+
The prefix "r" describes remaining tumors (after non-disease intervals) and a prefix "y" if the classification was assessed after systemic or radiation treatment (ycTNM, ypTNM etc.).
|uicctumor
+
 
|ValueSet für Tumore in der Tumordokumentation
+
For multiple  Primary tumors the suffix "m" (or the number of tumors) will be put after the T-category value(T2(m), T2(5)).
|ValueSet for tumors in the cancer documentation
+
 
|-
+
 
|Nodes
+
Therefore a complete TNM formula looks like this:
|1.2.276.0.76.11.2
+
 
|uiccodes
+
There are voluntary components e.g. the certainty-Faktor (C-Factor)
|ValueSet für Knoten in der Tumordokumentation
+
 
|ValueSet for nodes in the cancer documentation
+
Other components require pathology lab examination (L-, V- or Pn-Category)
|-
+
* y-Symbol (y or empty, disgnosis after systematic or xray treatment)
|Metastases
+
* r-Symbol (r or empty, remainder)
|1.2.276.0.76.11.3
+
* p/c/a-Symbol for pT-category (clinical or pathological)
|uiccmetastasen
+
* T-Category
|ValueSet für Metastasen in der Tumordokumentation
+
* (m) for multiple localizations or number of tumors
|ValueSet for metastases in the cancer documentation
+
* C-Factor for T-Category (certainty)
|-
+
 
|ResidualTumor
+
* L-Category
|1.2.276.0.76.11.4
+
* V-Category
|uiccresidualtumor
+
* Pn-Category
|ValueSet für Residualtumor in der Tumordokumentation
+
* p/c/a-Symbol for pN-Category (clinical or pathological)
|ValueSet for residual tumor in the cancer documentation
+
* N-Category
|-
+
* C-Factor for N-Category (certainty)
|Stage Classification
+
 
|1.2.276.0.76.11.5
+
* p/c/a-Symbol für pM-Category
|uiccstages
+
* M-Category
|ValueSet für die Stadiengruppier ung in der Tumordokumentation
+
* C-Factor for M-Category (certainty)
|ValueSet for stages in the cancer documentation
+
* S-Kategorie (serological values, only for testicle tumors)
|-
+
* UICC-Stadium (Grading via UICC 0 and I-IV together with
|Venous Invasion
+
letter A, B and C for further classification).
|1.2.276.0.76.11.6
+
 
|uiccveneninvasion
+
For some tumors further modifiers are being documented as a suffix
|ValueSet für die Veneninvasion in der Tumordokumentation
+
(mostly in parenthenses) like e.g. (sn), (mol-),(mol+).  
|ValueSet for venous invasion in the cancer documentation
 
|-
 
|Lymphatic Invasion
 
|1.2.276.0.76.11.7
 
|uicclymphsysteminvasion
 
|ValueSet für die Lymphsysteminvasion in der Tumordokumentation
 
|ValueSet for the lymphatic system invasion in the cancer documentation
 
|-
 
|Perineural Invasion
 
|1.2.276.0.76.11.8
 
|uiccneuralscheideninvasion
 
|ValueSet für die Neuralscheideninvasion in der Tumordokumentation
 
|ValueSet for the perineural invasion in the cancer documentation
 
|-
 
|TNM Qualifier
 
|1.2.276.0.76.11.9
 
|uicctnmqualifier
 
|ValueSet für die TNM-Qualifier in der Tumordokumentation
 
|ValueSet for tnm qualifier in the cancer documentation
 
|-
 
|TNM Localisation for Tumor Documentation
 
|1.2.276.0.76.11.10
 
|uicclocalisation
 
|ValueSet für die TNM-Seitenlokalisation in der Tumordokumentation
 
|ValueSet for tnm localisation in the cancer documentation
 
|}
 
Table 12: Value Sets
 
  
UICC 5. Edition (OID 2.16.840.1.113883.15.8)
+
In addition, the TNM supplement introduces innovative or "under test" extensions, which raises doubts whether ta full control of TNM entries.
UICC 6. Edition (OID 2.16.840.1.113883.15.7)
 
UICC 7. Edition (OID 2.16.840.1.113883.15.6)
 
  
 +
Typical T-Categories (without pre-/suffices) are being listed in chapter "Sites"
  
== Overview of Coding Schemata ==
+
Typical N-Categories (without pre-/suffices) are being listed in chapter "Nodes".
  
{| class=wikitable
+
Typical M-Categories (without pre-/suffices) are being listed in chapter "Metastases".
!Vocabulary Domain/Coding System
+
 
!OID
+
9 Reference: DKFZ
!Short Term
+
 
|-
+
====Qualifiers of the Tumor Formula====
|ICD10GM
+
Despite values for T,N and M the TNM formula may also contain various qualifiers.
|
+
The following table gives an overview which qualifiers can be used for which information and where they are being used.
|
+
This is case-sensitive!
|-
+
 
|ICD­10 GM Version 2012
+
* a Autoptical
|1.2.276.0.76.5.409
+
* c Clinical
|icd10gm2012
+
* C C-Factor (certainty)
|-
+
* G histopathological Grading
|ICD­10 GM Version 2011
+
* L Lymphatic vessel invasion
|1.2.276.0.76.5.388
+
* m multiple Tumors
|icd10gm2011
+
* M distant metastases
|-
+
* N Regional lymphatic node metastases
|ICD­10 GM Version 2010
+
* p pathological
|1.2.276.0.76.5.384
+
* Pn perineural Invasion
|icd10gm2010
+
* r Rezidiv tumor
|-
+
* R Residual tumor after treatment
|ICD­10 GM Version 2009
+
* sn Sentinel-Lymphatic nodes
|1.2.276.0.76.5.356
+
* Stage Anatomic Stage-Grouping
|icd10gm2009
+
* T Expansion (spreading) of Primary tumor
|-
+
* V Venous invasion
|ICD­10 GM Version 2008
+
* y Classification after initial multi-modal Therapy
|1.2.276.0.76.5.330
+
 
|icd10gm2008
+
===Ann Arbor Classification===
|-
+
 
|ICD­10 GM Version 2007
+
For lymphoma the TNM-classification does not make sense and therefore theso-called Ann-Arbor
|1.2.276.0.76.5.318
+
classification will be applied.
|icd10gm2007
+
 
|-
+
In this system, the stages I-IV are being distinguished, with an additional suffix letter
|ICD­10 GM Version 2006
+
* A meaning "no general symptoms"
|1.2.276.0.76.5.311
+
* B "with general symptoms"
|icd10gm2006
+
* E "extra-lymphatic organ affected"
|-
+
* S "spleen affected"
|ICD­O
+
 
|
+
As with TNM, the Ann-Arbor classification distinguishes between clinical (cS) and pathological (pS) grading.
|
+
 
 +
According to Durie & Salmon tere are gradings from I to III or the
 +
grades according to SWOG from 1-4 for the "Multiple Myeloma".
 +
 
 +
===FIGO Stages===
 +
 
 +
FIGO stages ignificantly overlap with the TNM classification, especially on the T-axis.
 +
 
 +
Therefore no details are being given here.
 +
 
 +
===Gleason Score===
 +
 
 +
The so-called Gleason-Score serves to classify the prostate carcinoma.
 +
The total numeric value is the sum of two indicators for
 +
• loss of differentiation (1-5)
 +
• growth pattern (1-5)
 +
 
 +
Resulting values range from 2 to 10 (also see Scores & Assessment DSTU).
 +
 
 +
Furthermore there is a more recent Gleason classification (according to Dhom,
 +
Müller and Helpap [Helpap 2002, Helpap2007]), which also requires to specify
 +
the procedure (esp. the two degrees) being used.
 +
 
 +
===Papanikolaou===
 +
 
 +
The so-called Pap-Test [Pap] is based on colored cell samples from the cervix and is used as an early indocator for cervical cancers.
 +
 
 +
===WHO Grading===
 +
 
 +
The so-called WHO Grading serves as an individual progonosis on the one hand
 +
and also is an indicator towards further treatment on the other hand.
 +
 
 +
Tumors of WHO Grade I and II in most cases can be treated by surgery alone,
 +
while tumors with WHO Grading III and IV normally need additional treatment
 +
by radiation or chemotherapie after surgery.  
 +
 
 +
The grading looks like this:
 +
 
 +
{| class="hl7table"
 +
! Code
 +
! Codename
 +
! Meaning
 
|-
 
|-
|ICD­O­3
+
|I
|2.16.840.1.113883.6.43.1
+
|  
|icd­o­3
+
|benign,slow growth of tumor, very good prognosis
 
|-
 
|-
|ICD­O­DA­1978
+
|II
|n.a.
 
 
|
 
|
 +
|still benign, slow growth of tumor,tendency to recur
 
|-
 
|-
|ICD­O­DA­2002
+
|III
|n.a.
 
 
|
 
|
 +
|malignant,actively producing abnormal cells,tends to recur
 
|-
 
|-
|TNM
+
|IV
|
 
 
|
 
|
 +
|very malignant,fast growth,needs systemic therapy, bad prognosis
 +
|}
 +
 +
Table 9: WHO Grading (OID 1.2.276.0.76.5.394)
 +
 +
The fourth edition of the "World Health Organization (WHO)
 +
Classification of tumours of the central nervous system" (2007) lists all
 +
relevant tumor entities.
 +
 +
Also see "Brain Tumor Basics" (http://www.abta.org/sitefiles/sitepages/524309b806778d4f7b79044d97f324ea.pdf)
 +
 +
===Conclusion===
 +
 +
The following data of tumors can be represented by these respective classifications (through values and/or modifiers)
 +
 +
 +
{| class="hl7table"
 +
! Concept
 +
! Classification
 
|-
 
|-
|C­Faktor
+
|Tumor localisation
|1.2.276.0.76.5.341
+
|ICD-O
|c­faktor­tumor
 
 
|-
 
|-
|TNM 5. Edition
+
|Morphology + dignity
|2.16.840.1.113883.15.8
+
|ICD-O
|tnm5
 
 
|-
 
|-
|TNM 6. Edition
+
|Tissue differentiation ICD-O
|2.16.840.1.113883.15.7
+
|ICD-O/TNM
|tnm6
 
 
|-
 
|-
|TNM 7. Edition
+
|type of stage codes (c,p,r,y)
|2.16.840.1.113883.15.6
+
|TNM/Ann-Arbor
|tnm7
 
 
|-
 
|-
|Dignity
+
|T Code + C Factor, multiplicity
|1.2.276.0.76.5.335
+
|TNM
|dignitaet­tumor
 
 
|-
 
|-
|Cell­ Type
+
|M Code + C Factor, multiplicity
|1.2.276.0.76.5.413
+
|TNM
|
 
 
|-
 
|-
|Validity R­Classification
+
|N Code + C Factor, multiplicity
|1.2.276.0.76.5.414
+
|TNM
|
 
 
|-
 
|-
|Existence of Residual Tumor  
+
|Residual Tumor
|1.2.276.0.76.5.415
+
|TNM
|
 
 
|-
 
|-
|Tumor Diagnoses
+
|stage grouping
|1.2.276.0.76.5.334
+
|TNM/Ann-Arbor/Durie&Salmon/SWOG
|tumordiagnosen
 
 
|-
 
|-
|Grading
+
|}
|1.2.276.0.76.5.336
+
 
|grading_tumor
+
==Cancer Diagnosis in HL7 V3==
|-
+
 
|­Localisation of Metastases
+
=== Representing Cancer Diagnoses in HL7 ===
|1.2.276.0.76.5.401
+
 
|
+
Tumor diagnoses shall be represented in HL7 V3 according to the following schema:
 +
A centralised instance of Observation shall specify the ICD-O code in the 'value' model-attribute
 +
with Dignity and (differentiation) grading in its 'qualifier' sub-element.
 +
 
 +
Further details shall be represented in more Observation-instances being connected via
 +
supporting ActRelationShip instances with typeCode:=SPRT .  
 +
 
 +
The CertaintyFactor shall be in the 'qualifier' sub-element of the model-attribute 'value'
 +
but only for those Observation instances which represent a T-, N- or M-Classification.
 +
 
 +
Multiplicity shall be in one more Observation instance related (supporting ActRelationShip)
 +
to that Observation instance representing the T-Classifier.
 +
 
 +
==== Tree View of HL7-based Representation of Cancer Diagnosis ====
 +
 
 +
<syntaxhighlight lang="text">
 +
+- ICD-O (Dignity, Grading)
 +
+- T-Category (c, p, r, y)
 +
| +- Multiplicity
 +
+- N-Category (c, p, sn)
 +
| +- Number of nodes examined and marked positive
 +
+- M-Category (c, p)
 +
+- Residual Tumor
 +
+- Grading
 +
+- Cell Type
 +
+- Lymphatic Invasion
 +
+- Venous Invasion
 +
+- Perineural Invasion
 +
+- Staging
 +
+- Ann-Arbor
 +
+- Gleason-Score
 +
</syntaxhighlight>
 +
 
 +
{| class="hl7table"
 +
!Code
 +
!Codename
 +
!Class / Path
 +
!Representation (Observation or Qualifier)
 +
|-
 +
|DF
 +
|Differenzierungsgrad
 +
|Observation (ICD-O)
 +
|qualifier.@name
 
|-
 
|-
|Scores
+
|DN
|
+
|Dignität
|
+
|Observation (ICD-O)
 +
|qualifier.@name
 
|-
 
|-
|Gleason­Score
+
|T
|
+
|T
|
+
|support-Observation
 +
|Observation/value.@code
 
|-
 
|-
|Gleason­Score: Loss of Differentiation
+
|M
|1.2.276.0.76.5.402
+
|M
|
+
|support-Observation
 +
|Observation/value.@code
 
|-
 
|-
|Gleason­Score: Growth Pattern
+
|N
|1.2.276.0.76.5.403
+
|N
|
+
|support-Observation
 +
|Observation/value.@code
 
|-
 
|-
|Gleason­Score: Grading
+
|MP
|1.2.276.0.76.5.404
+
|Multiplicity
|
+
|support-Observation
 +
(T)-support-Observation
 +
|Observation/value.@code
 
|-
 
|-
|Ann­Arbor
+
|CF
|1.2.276.0.76.5.405
+
|Certainty Factor
|
+
|support-Observation(T or N or M)
 +
|qualifier.@name
 
|-
 
|-
|Papanikolaou: Grading
+
|RS
|1.2.276.0.76.5.406
+
|Residual tumor
|
+
|support-Observation
 +
|Observation/value.@code
 
|-
 
|-
|Alpha­ID
+
|GR
|
+
|Grading
|
+
|support-Observation
 +
|Observation/value.@code
 
|-
 
|-
|Alpha­ID 2012
+
|LI
|1.2.276.0.76.5.408
+
|Lymphatic invasion
|alphaid2012
+
|support-Observation
 +
|Observation/value.@code
 
|-
 
|-
|Alpha­ID 2011
+
|VI
|1.2.276.0.76.5.387
+
|Venous invasion
|alphaid2011
+
|support-Observation
 +
|Observation/value.@code
 
|-
 
|-
|Alpha­ID 2010
+
|SG
|1.2.276.0.76.5.383
+
|Staging
|alphaid2010
+
|support-Observation
 +
|Observation/value.@code
 
|-
 
|-
|Alpha­ID 2009
+
|AA
|1.2.276.0.76.5.355
+
|Ann-Arbor-Classification
|alphaid2009
+
|support-Observation
 +
|Observation/value.@code
 +
|}
 +
Table 10: Codes for Tumor Diagnoses (OID 1.2.276.0.76.5.334)
 +
 
 +
=== Example ===
 +
 
 +
<syntaxhighlight lang="xml">
 +
<observation classCode="OBS" moodCode="EVN">
 +
  ...
 +
  <value xsi:type="CD" code="8070" codeSystem="2.16.840.1.113883.6.43.1"
 +
    displayName="Plattenepithelkarzinom"
 +
    codeSystemName="icd-o-3">
 +
    <qualifier>
 +
      <!-- Dignity -->
 +
      <name code="335" codeSystem="2.16.840.1.113883.3.7.1.0"/>
 +
      <value code="0" codeSystem="1.2.276.0.76.5.335"/>
 +
    </qualifier>
 +
    <qualifier>
 +
      <!-- Differentiation/Grading -->
 +
      <name code="336" codeSystem="2.16.840.1.113883.3.7.1.0"/>
 +
      <value code="1" codeSystem="1.2.276.0.76.5.336"/>
 +
    </qualifier>
 +
  </value>
 +
  <!-- Tumor formula -->
 +
  <entryRelationship typeCode="SPRT">
 +
    <observation moodCode="EVN" classCode="OBS">
 +
      <!-- T-Code -->
 +
      <value xsi:type="CD" code="T1" codeSystem="2.16.840.1.113883.15.8" codeSystemName=" tnm5"/>
 +
        <qualifier>
 +
          <name code="341" codeSystem="2.16.840.1.113883.3.7.1.0"/>
 +
          <value code="C2" codeSystem="1.2.276.0.76.5.341"/>
 +
        </qualifier>
 +
      </value>
 +
    </observation>
 +
  </entryRelationship>
 +
  <entryRelationship typeCode="SPRT">
 +
    <observation moodCode="EVN" classCode="OBS">
 +
    <!-- N-Code -->
 +
      <value xsi:type="CD" code="N2" codeSystem="2.16.840.1.113883.15.8" codeSystemName="tnm5"/>
 +
      </value>
 +
    </observation>
 +
  </entryRelationship>
 +
  <entryRelationship typeCode="SPRT">
 +
    <observation moodCode="EVN" classCode="OBS">
 +
    <!-- M-Code -->
 +
      <value xsi:type="CD" code="M0" displayName="Fernmetastasen nicht vorhanden"
 +
        codeSystem="2.16.840.1.113883.15.8" codeSystemName="tnm5"/>
 +
      </value>
 +
    </observation>
 +
  </entryRelationship>
 +
</observation>
 +
</syntaxhighlight>
 +
 
 +
= Representation for specific Use Cases =
 +
 
 +
== Introduction ==
 +
The following sections present examples for structured diagnosis representations in selected applications.
 +
 
 +
== GP/Ambulatory Billing Diagnosis (Germany) ==
 +
 +
This example shows a so-called "KVDT Record"  according to §295 (German Federal Code SGB V) with a diagnosis to be represented through HL7 version 3.
 +
 
 +
Diagnosis fields in the current KVDT record:
 +
 
 +
{| class="hl7table"
 +
!FK
 +
!Usage
 +
!Field Name
 +
!Field Type
 +
!Conditions
 +
!Explanations
 
|-
 
|-
|Alpha­ID 2008
+
|6001
|1.2.276.0.76.5.329
+
|n
|alphaid2008
+
|ICD-Code
 +
|m
 +
|
 +
Rule 486
 +
Rule 488
 +
Rule 489
 +
Rule 490
 +
Rule 492
 +
| see chapter 7
 
|-
 
|-
|Alpha­ID 2007
+
|6003
|1.2.276.0.76.5.316
+
|1
|alphaid2007
+
|Diagnosis Reliability
 +
|m
 +
|Rule 484
 +
| see chapter 7
 
|-
 
|-
|Alpha­ID 2006
+
|6004
|1.2.276.0.76.5.309
+
|1
|alphaid2006
+
|Side Localization
 +
|k
 +
|
 +
| see chapter 7
 
|-
 
|-
|MeSH
+
|6006
|
+
|n
 +
|Diagnosis Explanations
 +
|k
 
|
 
|
 +
| see chapter 7
 
|-
 
|-
|MeSH
+
|6008
|2.16.840.1.113883.6.177.5
+
|n
|MSHGER
+
|Diagnosis Exception Case
 +
|m
 +
|Rule 491
 
|-
 
|-
|Snomed CT
+
|3673
 +
|n
 +
|Continued Diagnosis (ICD-Code)
 +
|m
 
|
 
|
 +
Rule 486
 +
Rule 488
 +
Rule 489
 +
Rule 490
 +
Rule 492
 
|
 
|
 
|-
 
|-
|SNOMED CT
+
|3674
|2.16.840.1.113883.6.96
+
|1
|SNOMED CT
+
|Diagnosis Reliability/
 +
Continued Diagnosis
 +
|m
 +
|
 +
|
 
|-
 
|-
|ID Macs
+
|3675
 +
|1
 +
|Side Localization
 +
Continued Diagnosis
 +
|k
 
|
 
|
 
|
 
|
 
|-
 
|-
|ID Macs
+
|3676
|1.2.276.0.76.5.305
+
|n
|id_macs
+
|Diagnosis Explanation
|-
+
Continued Diagnosis
 +
|k
 
|
 
|
 
|
 
|
 +
|-
 +
|3677
 +
|n
 +
|Diagnosis Exception Case
 +
Continued Diagnosis
 +
|m
 +
|Regel 491
 
|
 
|
 
|-
 
|-
|Typing Diagnosis
 
|1.2.276.0.76.5.342
 
 
|}
 
|}
Table 13: Coding Schemata
+
Table 11: GP/Ambulatory Billing Diagnoses (Germany) ref 10,11
  
== Diagnosis Types In Germany ==
+
Multiple ICD-10 codes may be specified - without a (mandatory) check of its medical validity
The following codes are being used for typing of diagnoses.
+
but with at least one primary ICD-10 code being required.
This table is a pragmatic collection of the current state-of-the-art in german systems. An international classification is not available at this time.  
 
  
{| class=wikitable
+
With each code, a ide localization, a diagnosis reliability, diagnosis explanations
!Code  
+
and exception cases may be specified.
!Meaning
+
 
 +
Control code 6001 indicates a (current) billing diagnosis, while
 +
control code 3673 indicates a continued diagnosis.
 +
 
 +
* 10 FK: Field (control) code
 +
* 11 m = MANDATORY, k = OPTIONAL
 +
 
 +
=== Example in HL7-V3:===
 +
 
 +
<syntaxhighlight lang="xml">
 +
<!-- Diagnose (Abrechnungsdiagnose) 6001-->
 +
<!-- :A17.0+;G01*;;Tuberkulöse Meningitis Gesichert Rechts-->
 +
<!-- Diagnose 1***************************************************************-->
 +
 +
<observation classCode="OBS" moodCode="EVN">
 +
  <!-- Code für Abbrechungsdiagnose 6001-->
 +
  <code code="XXX_DX" codeSystem="2.16.840.1.113883.5.4"/>
 +
  <!-- Diagnoseerläuterung 6006**********************************************-->
 +
  <text/>
 +
  <!-- Primärcode 6001*******************************************************-->
 +
  <value xsi:type="CD" code="A17.0" codeSystem="1.2.276.0.76.5.311"
 +
    codeSystemName="icd10gm2006">
 +
    <!-- Diagnosesicherheit 6003-->
 +
    <qualifier>
 +
      <name code="DSH" codeSystem="111.111.1.1.1"/>
 +
      <value code="G" codeSystem="1.2.276.0.76.3.1.1.5.1.21"/>
 +
    </qualifier>
 +
    <!-- Seitenlokalisation 6004-->
 +
    <qualifier>
 +
      <name code="SL" codeSystem="111.111.1.1.1"/>
 +
      <value code="R" codeSystem="1.2.276.0.76.3.1.1.5.1.22"/>
 +
    </qualifier>
 +
  </value>
 +
  <!-- Ausnahmetatbestand zu Primärcode**************************************-->
 +
  <entryRelationship typeCode="RSON">
 +
    <observation classCode="OBS" moodCode="EVN">
 +
      <code nullFlavor="NI"/>
 +
      <value xsi:type="ST">…</value>
 +
    </observation>
 +
  </entryRelationship>
 +
  <entryRelationship typeCode="MFST">
 +
  <!-- Sekundärcode 6001*************************************************-->
 +
    <observation classCode="OBS" moodCode="EVN">
 +
      <code code="XXX_DX" codeSystem="2.16.840.1.113883.5.4"/>
 +
      <!-- Diagnoseerläuterung 6006**************************************-->
 +
      <text>Diagnoseerläuterung</text>
 +
      <value xsi:type="CD" code="G01" codeSystem="1.2.276.0.76.5.311" codeSystemName="icd10gm2006">
 +
        <!-- Diagnosesicherheit 6003-->
 +
        <qualifier>
 +
          <name code="DSH" codeSystem="2.16.840.1.113883.3.7.1.0"/>
 +
          <value code="G" codeSystem="1.2.276.0.76.3.1.1.5.1.21"/>
 +
        </qualifier>
 +
        <!-- Seitenlokalisation 6004-->
 +
        <qualifier>
 +
          <name code="SL" codeSystem="2.16.840.1.113883.3.7.1.0"/>
 +
          <value code="R" codeSystem="1.2.276.0.76.3.1.1.5.1.22"/>
 +
        </qualifier>
 +
      </value>
 +
      <!-- Ausnahmebegründung zum Sekundärcode 6008***********************-->
 +
      <entryRelationship typeCode="RSON">
 +
        <observation classCode="OBS" moodCode="EVN">
 +
          <code nullFlavor="NI"/>
 +
          <value xsi:type="ST">…</value>
 +
        </observation>
 +
      </entryRelationship>
 +
    </observation>
 +
  </entryRelationship>
 +
</observation>
 +
</syntaxhighlight>
 +
 
 +
==Diagnosis in the Referral Letter / Medical Documentation==
 +
The Implementation Guideline „Arztbrief“ (www.hl7.de) as well as related documents lists various examples
 +
of how to represent diagnoses via HL7 V3/CDA Release 2
 +
(see [CDAr2Arztbrief]).
 +
 
 +
= Terminology =
 +
== Introduction ==
 +
This chapter separates codes in use from normative specifications, in order to allow updates to such codes without having to rewrite the normative part. Therefore this chapter is just informative. Current codes have to be requested.
 +
{|
 
|-
 
|-
|DX
+
!Due to pending third-party copy rights regarding some of the the following tables, the textual descriptions may not be given here such that the respective fields remain empty.
|Diagnosis, not specified any further
+
|}
 +
 
 +
== Overview of Value Sets ==
 +
 
 +
{| class="hl7table"
 +
! Value Sets
 +
! OID
 +
! Short Term
 +
! German
 +
! English
 
|-
 
|-
| RFFDX
+
|Tumors
|Referral Diagnosis
+
|1.2.276.0.76.11.1
 +
|uicctumor
 +
|ValueSet für Tumore in der Tumordokumentation
 +
|ValueSet for tumors in the cancer documentation
 
|-
 
|-
| ENTDX
+
|Nodes
|Entry Diagnosis
+
|1.2.276.0.76.11.2
 +
|uiccodes
 +
|ValueSet für Knoten in der Tumordokumentation
 +
|ValueSet for nodes in the cancer documentation
 
|-
 
|-
| TRFDX
+
|Metastases
|Transfer Diagnosis
+
|1.2.276.0.76.11.3
 +
|uiccmetastasen
 +
|ValueSet für Metastasen in der Tumordokumentation
 +
|ValueSet for metastases in the cancer documentation
 
|-
 
|-
| ADMDX
+
|ResidualTumor
|Admittance Diagnosis
+
|1.2.276.0.76.11.4
 +
|uiccresidualtumor
 +
|ValueSet für Residualtumor in der Tumordokumentation
 +
|ValueSet for residual tumor in the cancer documentation
 
|-
 
|-
| CDDX
+
|Stage Classification
|Clinical Department’s Diagnosis
+
|1.2.276.0.76.11.5
 +
|uiccstages
 +
|ValueSet für die Stadiengruppier ung in der Tumordokumentation
 +
|ValueSet for stages in the cancer documentation
 
|-
 
|-
|   CDXDX
+
|Venous Invasion
|Clinical Department’s extra Diagnosis
+
|1.2.276.0.76.11.6
 +
|uiccveneninvasion
 +
|ValueSet für die Veneninvasion in der Tumordokumentation
 +
|ValueSet for venous invasion in the cancer documentation
 
|-
 
|-
|   CDTDX
+
|Lymphatic Invasion
|Clinical Department’s Treatment Diagnosis
+
|1.2.276.0.76.11.7
 +
|uicclymphsysteminvasion
 +
|ValueSet für die Lymphsysteminvasion in der Tumordokumentation
 +
|ValueSet for the lymphatic system invasion in the cancer documentation
 
|-
 
|-
|   CDDISDX
+
|Perineural Invasion
|Clinical Department’s Discharge Diagnosis
+
|1.2.276.0.76.11.8
 +
|uiccneuralscheideninvasion
 +
|ValueSet für die Neuralscheideninvasion in der Tumordokumentation
 +
|ValueSet for the perineural invasion in the cancer documentation
 
|-
 
|-
|   CDADMDX
+
|TNM Qualifier
|Clinical Department’s Admittance Diagnosis
+
|1.2.276.0.76.11.9
 +
|uicctnmqualifier
 +
|ValueSet für die TNM-Qualifier in der Tumordokumentation
 +
|ValueSet for tnm qualifier in the cancer documentation
 
|-
 
|-
| SUCCDX
+
|TNM Localisation for Tumor Documentation
|Successive Diagnosis (with continuing sick leave)
+
|1.2.276.0.76.11.10
|-
+
|uicclocalisation
| DISDX
+
|ValueSet für die TNM-Seitenlokalisation in der Tumordokumentation
|Discharge Diagnosis
+
|ValueSet for tnm localisation in the cancer documentation
|-
+
|}
|  TDX
+
Table 12: Value Sets
|Transfer Diagnosis
+
 
 +
UICC 5. Edition (OID 2.16.840.1.113883.15.8)
 +
UICC 6. Edition (OID 2.16.840.1.113883.15.7)
 +
UICC 7. Edition (OID 2.16.840.1.113883.15.6)
 +
 
 +
 
 +
== Overview of Coding Schemata ==
 +
 
 +
{| class="hl7table"
 +
!Vocabulary Domain/Coding System
 +
!OID
 +
!Short Term
 
|-
 
|-
| PERMDX
+
|ICD10GM
|Permanent Diagnosis
+
|
 +
|
 
|-
 
|-
|   APERMDX
+
|ICD­10 GM Version 2012
|Anamnestic Permanent Diagnosis
+
|1.2.276.0.76.5.409
 +
|icd10gm2012
 
|-
 
|-
|   BPERMDX
+
|ICD­10 GM Version 2011
|Treatment-related Permanent Diagnosis
+
|1.2.276.0.76.5.388
 +
|icd10gm2011
 
|-
 
|-
|   EMERDX
+
|ICD­10 GM Version 2010
|Emergency-related Diagnosis
+
|1.2.276.0.76.5.384
 +
|icd10gm2010
 
|-
 
|-
| REIMDX
+
|ICD­10 GM Version 2009
|Reimbursement Diagnosis
+
|1.2.276.0.76.5.356
 +
|icd10gm2009
 
|-
 
|-
| POSTOPDX
+
|ICD­10 GM Version 2008
|Post-operative Diagnosis
+
|1.2.276.0.76.5.330
 +
|icd10gm2008
 
|-
 
|-
| PREOPDX
+
|ICD­10 GM Version 2007
|Pre-operative Diagnosis
+
|1.2.276.0.76.5.318
 +
|icd10gm2007
 
|-
 
|-
| ADR
+
|ICD­10 GM Version 2006
|UAW ­Observed Unwanted Side Effects
+
|1.2.276.0.76.5.311
 +
|icd10gm2006
 
|-
 
|-
| ADRPD
+
|ICD­O
|UAW Main Disease
+
|
 +
|
 
|-
 
|-
| ADRCCD
+
|ICD­O­3
|UAW Side Disease  
+
|2.16.840.1.113883.6.43.1
 +
|icd­o­3
 
|-
 
|-
| IFSGDX
+
|ICD­O­DA­1978
|If–G ­Diagnoses
+
|n.a.
 +
|
 
|-
 
|-
| IFSGSUSPDX
+
|ICD­O­DA­2002
|If–G ­Suspicious Diagnoses
+
|n.a.
 +
|
 
|-
 
|-
| IFSGDD
+
|TNM
|If–G ­Differential Diagnoses
+
|
 +
|
 
|-
 
|-
| COD
+
|C­Faktor
|Cause of Death (fatal disease)
+
|1.2.276.0.76.5.341
 +
|c­faktor­tumor
 
|-
 
|-
| CCCOND
+
|TNM 5. Edition
|Accompanying Diseases
+
|2.16.840.1.113883.15.8
 +
|tnm5
 
|-
 
|-
| EXTCS
+
|TNM 6. Edition
|External Cause
+
|2.16.840.1.113883.15.7
 +
|tnm6
 
|-
 
|-
| NEO
+
|TNM 7. Edition
|Neoblasts
+
|2.16.840.1.113883.15.6
 +
|tnm7
 
|-
 
|-
| UAE
+
|Dignity
|Unwanted Medication Event
+
|1.2.276.0.76.5.335
 +
|dignitaet­tumor
 
|-
 
|-
|   UAW
+
|Cell­ Type
|Unwanted Medication Effect12
+
|1.2.276.0.76.5.???
 +
|
 
|-
 
|-
| CAREDX
+
|Validity R­Classification
|Care Diagnosis
+
|1.2.276.0.76.5.???
 +
|
 
|-
 
|-
| SYMDX
+
|Existence of Residual Tumor
|Symptom
+
|1.2.276.0.76.5.???
 +
|
 
|-
 
|-
| OTHDX
+
|Tumor Diagnoses
|Miscellaneous Diagnosis
+
|1.2.276.0.76.5.334
|}
+
|tumordiagnosen
Table 14: Diagnosis Types (OID 1.2.276.0.76.5.342)
 
 
 
== ICD-O Codes ==
 
=== Dignity ===
 
Dignity refers to a tumor property related to their biological behavior in the body. 13
 
{| class=wikitable
 
!Meaning
 
!Code
 
 
|-
 
|-
|0
+
|Grading
|benign
+
|1.2.276.0.76.5.336
 +
|grading_tumor
 
|-
 
|-
|1
+
|­Localisation of Metastases
|Neoplasm with uncertain or unknown behaviour
+
|1.2.276.0.76.5.401
 +
|
 
|-
 
|-
|2
+
|Scores
|Carcinoma in situ
+
|
 +
|
 
|-
 
|-
|3
+
|Gleason­Score
|malign, Primary Tumor
+
|
 +
|
 
|-
 
|-
|6
+
|Gleason­Score: Loss of Differentiation
|malign, Metastasis
+
|1.2.276.0.76.5.402
 +
|
 
|-
 
|-
|9
+
|Gleason­Score: Growth Pattern
|malign, not differentiated between Primary Tumor or Metastasis
+
|1.2.276.0.76.5.403
|}
+
|
Table 15: Dignity Codes (OID 1.2.276.0.76.5.335)
 
 
 
12 In this case, a cause has to be documented along with the diagnosis – but that is not covered in this implementation guide. It also has to be clarified whether such diagnosis is equal to “suspicious for”.
 
13 DIMDI www.dimdi.de ICD10GM, ICDO3
 
 
 
 
 
 
=== Grade of Differentiation/Grading ===
 
The following table lists possible gradings. The entity column lists to what tumor entities these grades apply. ref.14
 
{| class=wikitable
 
!Code
 
!Description
 
!German
 
!Entity
 
 
|-
 
|-
|0
+
|Gleason­Score: Grading
|Primary acquired melanosis
+
|1.2.276.0.76.5.404
 
|
 
|
|Malignant Melanoma of Conjunctiva
 
 
|-
 
|-
|1
+
|Ann­Arbor
|well differentiated
+
|1.2.276.0.76.5.405
|Gut differenziert
+
|
|all but Prostata, Malignant Melanoma of Conjunctiva
 
 
|-
 
|-
 +
|Papanikolaou: Grading
 +
|1.2.276.0.76.5.406
 
|
 
|
|Well differentiated (slight anaplasia) (Gleason 2­4)
 
|
 
|Prostata
 
 
|-
 
|-
 +
|Alpha­ID
 
|
 
|
|Malignant melanoma arising from a naevus
 
 
|
 
|
|Malignant Melanoma of Conjunctiva
 
 
|-
 
|-
|2
+
|Alpha­ID 2012
|moderately differentiated
+
|1.2.276.0.76.5.408
|Mäßig differenziert
+
|alphaid2012
|all but Prostata, Malignant Melanoma of Conjunctiva
 
 
|-
 
|-
|
+
|Alpha­ID 2011
|Moderately differentiated (moderate anaplasia) (Gleason 5–6)
+
|1.2.276.0.76.5.387
|
+
|alphaid2011
|Prostata
 
 
|-
 
|-
|
+
|Alpha­ID 2010
|Malignant melanoma arising from primary acquired melanosis
+
|1.2.276.0.76.5.383
|
+
|alphaid2010
|Malignant Melanoma of Conjunctiva
 
 
|-
 
|-
|3
+
|Alpha­ID 2009
|poorly differentiated
+
|1.2.276.0.76.5.355
|Schlecht differenziert
+
|alphaid2009
|all but Prostata, Penis, Kidney, Renal Pelvis and Ureter, Urinary Bladder, Urethra, Malignant Melanoma of Conjunctiva
+
|-
 +
|Alpha­ID 2008
 +
|1.2.276.0.76.5.329
 +
|alphaid2008
 
|-
 
|-
|
+
|Alpha­ID 2007
|Malignant melanoma arising de novo
+
|1.2.276.0.76.5.316
|
+
|alphaid2007
|Malignant Melanoma of Conjunctiva
 
 
|-
 
|-
|3­4
+
|Alpha­ID 2006
|Poorly differentiated/ undifferentiated (marked anaplasia) (Gleason 7– 10)
+
|1.2.276.0.76.5.309
|
+
|alphaid2006
|Prostata
 
 
|-
 
|-
 +
|MeSH
 
|
 
|
|Poorly differentiated/ undifferentiated
 
 
|
 
|
|Penis, Kidney, Renal Pelvis and Ureter, Urinary Bladder, Urethra
 
 
|-
 
|-
|4
+
|MeSH
|undifferentiated
+
|2.16.840.1.113883.6.177.5
|Undifferenziert
+
|MSHGER
|all but Prostata, Penis, Kidney, Renal Pelvis and Ureter, Urinary Bladder, Urethra, Malignant Melanoma of Conjunctiva
 
 
|-
 
|-
|9
+
|Snomed CT
 
|
 
|
 
|
 
|
|Grading not performed, not given or not applicable
 
 
|-
 
|-
|L
+
|SNOMED CT
|low malignity  (G1­G2)
+
|2.16.840.1.113883.6.96
|Niedriggradig maligne (G1­G2)
+
|SNOMED CT
 +
|-
 +
|ID Macs
 +
|
 
|
 
|
 
|-
 
|-
|M
+
|ID Macs
|intermediate malignity (G2­G3)
+
|1.2.276.0.76.5.305
|Mittelgradig maligne (G2­G3)
+
|id_macs
 +
|-
 
|
 
|
|-
 
|H
 
|high malignity (G3­G4)
 
|Hochgradig maligne (G3G4)
 
 
|
 
|
|-
 
|B
 
|Borderline
 
|Grenzfall
 
 
|
 
|
 
|-
 
|-
|X
+
|Typing Diagnosis
|grade of differentiation cannot be assessed
+
|1.2.276.0.76.5.342
|Differenzierungs­grad nicht be­stimmbar
 
 
|}
 
|}
 +
Table 13: Coding Schemata
  
{|
+
== Diagnosis Types In Germany ==
 +
The following codes are being used for typing of diagnoses.
 +
This table is a pragmatic collection of the current state-of-the-art in german systems. An international classification is not available at this time.
 +
 
 +
{| class="hl7table"
 +
!Code
 +
!Meaning
 
|-
 
|-
!This Grading may either be a qualifier in a containing ICDO or be documented as a component in a stand-alone code.
+
|DX
|}
+
|Diagnosis, not specified any further
Table 16:Grade of Differentiation/Gradings (OID 1.2.276.0.76.5.336)
 
14 DIMDI www.dimdi.de ICD-O-3
 
 
 
 
 
=== Cell Type ===
 
This qualifier identifies the immune phenotype related to a lymphoma.
 
{| class=wikitable
 
!Code
 
!Meaning
 
!Explanation  
 
 
|-
 
|-
|T
+
| RFFDX
|T­ cell type
+
|Referral Diagnosis
|affects T ­lymphocytes
 
 
|-
 
|-
|B
+
| ENTDX
|B­ cell type
+
|Entry Diagnosis
|affects B lymphocytes
 
 
|-
 
|-
|N  
+
| TRFDX
|Null cell type
+
|Transfer Diagnosis
|[[NHL]]  Th0, null cell type lymphoma (and T-cell)
 
 
|-
 
|-
|K
+
| ADMDX
|Natural­ Killer cell type  
+
|Admittance Diagnosis
|affects NK­ cells: rare lymphoma, mostly in nose or of nasal type
 
 
|-
 
|-
|X
+
| CDDX
|
+
|Clinical Department’s Diagnosis
|not determineable (undifferentiated lymphoma)
+
|-
 +
|    CDXDX
 +
|Clinical Department’s extra Diagnosis
 
|-
 
|-
|9
+
|   CDTDX
|
+
|Clinical Department’s Treatment Diagnosis
|affected cell type determination not performed, not specified or not applicable
 
 
|-
 
|-
|U
+
|   CDDISDX
|
+
|Clinical Department’s Discharge Diagnosis
|unknown, nullFlavor=UNK
 
|}
 
Table 17: Lymphoma-Affected Cell Type (OID 1.2.276.0.76.5.413)
 
 
 
=== Validity of R Classification ===
 
This qualifier documents the focus of the Residual¬ Classification15.
 
{| class=wikitable
 
!Code
 
!Meaning
 
!Explanation  
 
 
|-
 
|-
|L
+
|   CDADMDX
|locoregionary tumor
+
|Clinical Department’s Admittance Diagnosis
|nearby tumor(s)
 
 
|-
 
|-
|M
+
| SUCCDX
|distant metastasis
+
|Successive Diagnosis (with continuing sick leave)
|distant secondary tumors
 
 
|-
 
|-
|G
+
| DISDX
|overall phenomenon
+
|Discharge Diagnosis
|
+
|-
|}
+
|  TDX
Table 18: Validity of R-Classifikation (OID 1.2.276.0.76.5.414)
+
|Transfer Diagnosis
15 Altmann based on TNM V7, Giessen, 2010
+
|-
 
+
|  PERMDX
=== Existence of Residual Tumor ===
+
|Permanent Diagnosis
This qualifier indicates, where a Residual Tumor exists ref. 16.
 
{| class=wikitable
 
!Code
 
!Meaning
 
!Explanation
 
 
|-
 
|-
|L
+
|   APERMDX
|locoregionary tumor
+
|Anamnestic Permanent Diagnosis
|nearby tumor(s)
 
 
|-
 
|-
|F
+
|   BPERMDX
|distant metastasis
+
|Treatment-related Permanent Diagnosis
|distant secondary tumors
 
 
|-
 
|-
|B
+
|   EMERDX
|both
+
|Emergency-related Diagnosis
|
 
 
|-
 
|-
|U
+
| REIMDX
|unknown
+
|Reimbursement Diagnosis
|nullFlavor=UNK
 
|}
 
Existence of residual Tumor
 
 
 
16 Dudeck J. Basisdokumentation für Tumorerkrankte. Giessen. 1999.
 
 
 
== Codes for TNM-Classification ==
 
{{NoteBox|The TNM classification according to UICC is being a codesystem as a whole. Therefore all tables share the same OID for documentation purposes.
 
 
 
An easy way to handle this is the definition of value sets, each with the respective permitted values.
 
Each code may only be used in some documentation if the respective UICC edition is checkmarked in our table– which states that the respective code is a part of that edition.}}
 
 
 
=== Tumors ===
 
This section lists known T-Categories ref. 17 (without representing possible extensions). Descriptions vary with the related entity. Codes shall be used along with tumor diagnosis, as one code may have different meanings. (e.g. T1 may refer to 23 cm or 24 cm).
 
{| class=wikitable
 
!Code
 
!Description
 
!Explanation
 
!5.
 
!6.
 
!7.
 
 
|-
 
|-
|Ta
+
| POSTOPDX
|
+
|Post-operative Diagnosis
|
 
|X
 
|X
 
|X
 
 
|-
 
|-
|Tis
+
| PREOPDX
|Carcinoma in situ
+
|Pre-operative Diagnosis
|non invasive
 
|X
 
|X
 
|X
 
 
|-
 
|-
|T0
+
| ADR
|No evidence of primary tumour
+
|UAW ­Observed Unwanted Side Effects
|
+
|-
|
+
| ADRPD
|X
+
|UAW Main Disease
|X
 
 
|-
 
|-
|T1
+
| ADRCCD
|
+
|UAW Side Disease  
|
 
|X
 
|X
 
|X
 
 
|-
 
|-
|T1mic
+
| IFSGDX
|
+
|If–G ­Diagnoses
|micro invasion
 
|X
 
|X
 
|X
 
 
|-
 
|-
|T1a
+
| IFSGSUSPDX
|
+
|If–G ­Suspicious Diagnoses
|
 
|X
 
|X
 
|X
 
 
|-
 
|-
|T1a1
+
| IFSGDD
|
+
|If–G ­Differential Diagnoses
|
 
|X
 
|X
 
|X
 
 
|-
 
|-
|T1a2
+
| COD
|
+
|Cause of Death (fatal disease)
|
 
|X
 
|X
 
|X
 
 
|-
 
|-
|T1b
+
| CCCOND
|
+
|Accompanying Diseases
|
 
|X
 
|X
 
|X
 
 
|-
 
|-
|T1b1
+
| EXTCS
|
+
|External Cause
|
 
|X
 
|X
 
|X
 
 
|-
 
|-
|T1b2
+
| NEO
|
+
|Neoblasts
|
 
|X
 
|X
 
|X
 
 
|-
 
|-
|T1c
+
| UAE
|
+
|Unwanted Medication Event
|
 
|X
 
|X
 
|X
 
 
|-
 
|-
|T1d
+
|   UAW
|
+
|Unwanted Medication Effect12
|
 
|
 
|
 
|X
 
 
|-
 
|-
|T2
+
| CAREDX
|
+
|Care Diagnosis
|
 
|X
 
|X
 
|X
 
 
|-
 
|-
|T2a
+
| SYMDX
|
+
|Symptom
|
 
|X
 
|X
 
|X
 
 
|-
 
|-
|T2a1
+
| OTHDX
|
+
|Miscellaneous Diagnosis
|
+
|}
|
+
Table 14: Diagnosis Types (OID 1.2.276.0.76.5.342)
|
+
 
|X
+
== ICD-O Codes ==
 +
=== Dignity ===
 +
Dignity refers to a tumor property related to their biological behavior in the body. 13
 +
{| class="hl7table"
 +
!Meaning
 +
!Code
 
|-
 
|-
|T2a2
+
|0
|
+
|benign
|
 
|
 
|
 
|X
 
 
|-
 
|-
|T2b
+
|1
|
+
|Neoplasm with uncertain or unknown behaviour
|
 
|X
 
|X
 
|X
 
 
|-
 
|-
|T2c
+
|2
|
+
|Carcinoma in situ
|
 
|X
 
|X
 
|X
 
 
|-
 
|-
|T2d
+
|3
 +
|malign, Primary Tumor
 +
|-
 +
|6
 +
|malign, Metastasis
 +
|-
 +
|9
 +
|malign, not differentiated between Primary Tumor or Metastasis
 +
|}
 +
Table 15: Dignity Codes (OID 1.2.276.0.76.5.335)
 +
 
 +
12 In this case, a cause has to be documented along with the diagnosis – but that is not covered in this implementation guide. It also has to be clarified whether such diagnosis is equal to “suspicious for”.
 +
13 DIMDI www.dimdi.de ICD10GM, ICDO3
 +
 +
 
 +
 
 +
=== Grade of Differentiation/Grading ===
 +
The following table lists possible gradings. The entity column lists to what tumor entities these grades apply. ref.14
 +
{| class="hl7table"
 +
!Code
 +
!Description
 +
!German
 +
!Entity
 +
|-
 +
|0
 +
|Primary acquired melanosis
 
|
 
|
 +
|Malignant Melanoma of Conjunctiva
 +
|-
 +
|1
 +
|well differentiated
 +
|Gut differenziert
 +
|all but Prostata, Malignant Melanoma of Conjunctiva
 +
|-
 
|
 
|
 +
|Well differentiated (slight anaplasia) (Gleason 2­4)
 
|
 
|
 +
|Prostata
 +
|-
 
|
 
|
|X
+
|Malignant melanoma arising from a naevus
 +
|
 +
|Malignant Melanoma of Conjunctiva
 +
|-
 +
|2
 +
|moderately differentiated
 +
|Mäßig differenziert
 +
|all but Prostata, Malignant Melanoma of Conjunctiva
 
|-
 
|-
|T3
 
 
|
 
|
 +
|Moderately differentiated (moderate anaplasia) (Gleason 5–6)
 
|
 
|
|X
+
|Prostata
|X
 
|X
 
 
|-
 
|-
|T3a
 
 
|
 
|
 +
|Malignant melanoma arising from primary acquired melanosis
 
|
 
|
|X
+
|Malignant Melanoma of Conjunctiva
|X
+
|-
|X
+
|3
 +
|poorly differentiated
 +
|Schlecht differenziert
 +
|all but Prostata, Penis, Kidney, Renal Pelvis and Ureter, Urinary Bladder, Urethra, Malignant Melanoma of Conjunctiva
 
|-
 
|-
|T3b
 
 
|
 
|
 +
|Malignant melanoma arising de novo
 
|
 
|
|X
+
|Malignant Melanoma of Conjunctiva
|X
 
|X
 
 
|-
 
|-
|T3c
+
|3­4
 +
|Poorly differentiated/ undifferentiated (marked anaplasia) (Gleason 7– 10)
 
|
 
|
|
+
|Prostata
|X
 
|X
 
|X
 
 
|-
 
|-
|T3d
 
 
|
 
|
 +
|Poorly differentiated/ undifferentiated
 
|
 
|
|
+
|Penis, Kidney, Renal Pelvis and Ureter, Urinary Bladder, Urethra
|X
+
|-
|X
+
|4
 +
|undifferentiated
 +
|Undifferenziert
 +
|all but Prostata, Penis, Kidney, Renal Pelvis and Ureter, Urinary Bladder, Urethra, Malignant Melanoma of Conjunctiva
 
|-
 
|-
|T4
+
|9
 
|
 
|
 
|
 
|
|X
+
|Grading not performed, not given or not applicable
|X
 
|X
 
 
|-
 
|-
|T4a
+
|L
 +
|low malignity  (G1­G2)
 +
|Niedriggradig maligne (G1­G2)
 
|
 
|
 +
|-
 +
|M
 +
|intermediate malignity (G2­G3)
 +
|Mittelgradig maligne (G2­G3)
 
|
 
|
|X
 
|X
 
|X
 
 
|-
 
|-
|T4b
+
|H
 +
|high malignity (G3­G4)
 +
|Hochgradig maligne (G3G4)
 
|
 
|
|
 
|X
 
|X
 
|X
 
 
|-
 
|-
|T4c
+
|B
|
+
|Borderline
 +
|Grenzfall
 
|
 
|
|X
 
|X
 
|X
 
 
|-
 
|-
|T4d
 
|
 
|
 
 
|X  
 
|X  
|X
+
|grade of differentiation cannot be assessed  
|X
+
|Differenzierungs­grad nicht be­stimmbar
|-
 
|T4e
 
|
 
|
 
|
 
|
 
|X
 
|-
 
|TX
 
|Primary tumor cannot be assessed  
 
|Stage of primary tumor cannot be determined
 
|
 
|
 
|
 
 
|}
 
|}
Table 20: (T) Tumor Codes Value Set (OID 1.2.276.0.76.11.1)
 
17 TNM 5.,6.,7. Edition
 
  
=== Nodes ===
+
{|
Any code for involvement of lymph nodes shall only be used together with tumor diagnosis.
 
{| class=wikitable
 
!
 
!
 
!
 
!
 
!UICC
 
!UICC
 
!UICC
 
 
|-
 
|-
 +
!This Grading may either be a qualifier in a containing ICDO or be documented as a component in a stand-alone code.
 +
|}
 +
Table 16:Grade of Differentiation/Gradings (OID 1.2.276.0.76.5.336)
 +
14 DIMDI www.dimdi.de ICD-O-3
 +
 +
 +
=== Cell Type ===
 +
This qualifier identifies the immune phenotype related to a lymphoma.
 +
{| class="hl7table"
 
!Code  
 
!Code  
!Description
 
 
!Meaning  
 
!Meaning  
!Entity
+
!Explanation  
!5.
 
!6.
 
!7.
 
 
|-
 
|-
|N0
+
|T
|No regional lymph node metastasis
+
|T­ cell type
|no lymph node affected
+
|affects T ­lymphocytes
|all
 
|X
 
|X
 
|X
 
 
|-
 
|-
|N1  
+
|B
 +
|B­ cell type
 +
|affects B lymphocytes
 +
|-
 +
|N  
 +
|Null cell type
 +
|[[NHL]]  Th0, null cell type lymphoma (and T-cell)
 +
|-
 +
|K
 +
|Natural­ Killer cell type  
 +
|affects NK­ cells: rare lymphoma, mostly in nose or of nasal type
 +
|-
 +
|X
 +
|
 +
|not determineable (undifferentiated lymphoma)
 +
|-
 +
|9
 +
|
 +
|affected cell type determination not performed, not specified or not applicable
 +
|-
 +
|U
 +
|
 +
|unknown, nullFlavor=UNK
 +
|}
 +
Table 17: Lymphoma-Affected Cell Type (OID 1.2.276.0.76.5.???)
 +
 
 +
=== Validity of R Classification ===
 +
This qualifier documents the focus of the Residual¬ Classification15.
 +
{| class="hl7table"
 +
!Code
 +
!Meaning
 +
!Explanation  
 +
|-
 +
|L
 +
|locoregionary tumor
 +
|nearby tumor(s)
 +
|-
 +
|M
 +
|distant metastasis
 +
|distant secondary tumors
 +
|-
 +
|G
 +
|overall phenomenon
 +
|
 +
|}
 +
Table 18: Validity of R-Classifikation (OID 1.2.276.0.76.5.???)
 +
15 Altmann based on TNM V7, Giessen, 2010
 +
 
 +
=== Existence of Residual Tumor ===
 +
This qualifier indicates, where a Residual Tumor exists ref. 16.
 +
 
 +
{| class="hl7table"
 +
!Code
 +
!Meaning
 +
!Explanation
 +
|-
 +
|L
 +
|locoregionary tumor
 +
|nearby tumor(s)
 +
|-
 +
|F
 +
|distant metastasis
 +
|distant secondary tumors
 +
|-
 +
|B
 +
|both
 +
|
 +
|-
 +
|U
 +
|unknown
 +
|nullFlavor=UNK
 +
|}
 +
Existence of residual Tumor
 +
 
 +
16 Dudeck J. Basisdokumentation für Tumorerkrankte. Giessen. 1999.
 +
 
 +
== Codes for TNM-Classification ==
 +
{{NoteBox|The TNM classification according to UICC is being a codesystem as a whole. Therefore all tables share the same OID for documentation purposes.
 +
 
 +
An easy way to handle this is the definition of value sets, each with the respective permitted values.
 +
Each code may only be used in some documentation if the respective UICC edition is checkmarked in our table– which states that the respective code is a part of that edition.}}
 +
 
 +
=== Tumors ===
 +
This section lists known T-Categories ref. 17 (without representing possible extensions). Descriptions vary with the related entity. Codes shall be used along with tumor diagnosis, as one code may have different meanings. (e.g. T1 may refer to 23 cm or 24 cm).
 +
 
 +
{| class="hl7table"
 +
!Code
 +
!Description
 +
!Explanation
 +
!5.
 +
!6.
 +
!7.
 +
|-
 +
|Ta
 +
|
 +
|
 +
|X
 +
|X
 +
|X
 +
|-
 +
|Tis
 +
|Carcinoma in situ
 +
|non invasive
 +
|X
 +
|X
 +
|X
 +
|-
 +
|T0
 +
|No evidence of primary tumour
 +
|
 +
|
 +
|X
 +
|X
 +
|-
 +
|T1
 +
|
 +
|
 +
|X
 +
|X
 +
|X
 +
|-
 +
|T1mic
 +
|
 +
|micro invasion
 +
|X
 +
|X
 +
|X
 +
|-
 +
|T1a
 +
|
 +
|
 +
|X
 +
|X
 +
|X
 +
|-
 +
|T1a1
 +
|
 +
|
 +
|X
 +
|X
 +
|X
 +
|-
 +
|T1a2
 +
|
 +
|
 +
|X
 +
|X
 +
|X
 +
|-
 +
|T1b
 +
|
 +
|
 +
|X
 +
|X
 +
|X
 +
|-
 +
|T1b1
 +
|
 +
|
 +
|X
 +
|X
 +
|X
 +
|-
 +
|T1b2
 +
|
 +
|
 +
|X
 +
|X
 +
|X
 +
|-
 +
|T1c
 +
|
 +
|
 +
|X
 +
|X
 +
|X
 +
|-
 +
|T1d
 +
|
 +
|
 +
|
 +
|
 +
|X
 +
|-
 +
|T2
 +
|
 +
|
 +
|X
 +
|X
 +
|X
 +
|-
 +
|T2a
 +
|
 +
|
 +
|X
 +
|X
 +
|X
 +
|-
 +
|T2a1
 +
|
 +
|
 +
|
 +
|
 +
|X
 +
|-
 +
|T2a2
 +
|
 +
|
 +
|
 +
|
 +
|X
 +
|-
 +
|T2b
 +
|
 +
|
 +
|X
 +
|X
 +
|X
 +
|-
 +
|T2c
 +
|
 +
|
 +
|X
 +
|X
 +
|X
 +
|-
 +
|T2d
 +
|
 +
|
 +
|
 +
|
 +
|X
 +
|-
 +
|T3
 +
|
 +
|
 +
|X
 +
|X
 +
|X
 +
|-
 +
|T3a
 +
|
 +
|
 +
|X
 +
|X
 +
|X
 +
|-
 +
|T3b
 +
|
 +
|
 +
|X
 +
|X
 +
|X
 +
|-
 +
|T3c
 +
|
 +
|
 +
|X
 +
|X
 +
|X
 +
|-
 +
|T3d
 +
|
 +
|
 +
|
 +
|X
 +
|X
 +
|-
 +
|T4
 +
|
 +
|
 +
|X
 +
|X
 +
|X
 +
|-
 +
|T4a
 +
|
 +
|
 +
|X
 +
|X
 +
|X
 +
|-
 +
|T4b
 +
|
 +
|
 +
|X
 +
|X
 +
|X
 +
|-
 +
|T4c
 +
|
 +
|
 +
|X
 +
|X
 +
|X
 +
|-
 +
|T4d
 +
|
 +
|
 +
|X
 +
|X
 +
|X
 +
|-
 +
|T4e
 +
|
 +
|
 +
|
 +
|
 +
|X
 +
|-
 +
|TX
 +
|Primary tumor cannot be assessed
 +
|Stage of primary tumor cannot be determined
 +
|
 +
|
 +
|
 +
|}
 +
Table 20: (T) Tumor Codes Value Set (OID 1.2.276.0.76.11.1)
 +
17 TNM 5.,6.,7. Edition
 +
 
 +
=== Nodes ===
 +
Any code for involvement of lymph nodes shall only be used together with tumor diagnosis.
 +
 
 +
{| class="hl7table"
 +
!
 +
!
 +
!
 +
!
 +
!UICC
 +
!UICC
 +
!UICC
 +
|-
 +
!Code
 +
!Description
 +
!Meaning
 +
!Entity
 +
!5.
 +
!6.
 +
!7.
 +
|-
 +
|N0
 +
|No regional lymph node metastasis
 +
|no lymph node affected
 +
|all
 +
|X
 +
|X
 +
|X
 +
|-
 +
|N1  
 +
|
 +
|
 +
|
 +
|X
 +
|X
 +
|X
 +
|-
 +
|N1mi
 +
|Bilateral regional lymph node metastasis
 +
|
 +
|vulva
 +
|
 +
|X
 +
|X
 +
|-
 +
|N1a
 +
|
 +
|
 +
|all
 +
|X
 +
|X
 +
|X
 +
|-
 +
|N1b
 +
|
 +
|
 +
|
 +
|X
 +
|X
 +
|X
 +
|-
 +
|N1b1
 +
|
 +
|
 +
|
 +
|X
 +
|
 +
|
 +
|-
 +
|N1b2
 +
|
 +
|
 +
|
 +
|X
 +
|
 +
|
 +
|-
 +
|N1b3
 +
|
 +
|
 +
|
 +
|X
 +
|
 +
|
 +
|-
 +
|N1b4
 +
|
 +
|
 +
|
 +
|X
 +
|
 +
|
 +
|-
 +
|N1c
 +
|
 +
|
 +
|
 +
|
 +
|X
 +
|X
 +
|-
 +
|N2
 
|
 
|
 
|
 
|
Zeile 2.168: Zeile 2.821:
 
|X  
 
|X  
 
|X  
 
|X  
 +
|}
 +
Table 21: (N) Lymph Node Codes Value Set (OID 1.2.276.0.76.11.2)
 +
 +
=== Metastasis ===
 +
Code describing distant metastases shall only be used together with tumor diagnosis.
 +
 +
{| class="hl7table"
 +
!Code
 +
!Description
 +
!German
 +
!Entity
 +
!5.
 +
!6.
 +
!7.
 
|-
 
|-
|N1mi
+
!
|Bilateral regional lymph node metastasis
+
!
|
+
!
|vulva
+
!
|
+
!UICC
|X
+
!UICC
|X
+
!UICC
 
|-
 
|-
|N1a
+
|M0
|
+
|No distant metastasis
|
+
|Fernmetastasen nicht vorhanden
|all
+
|all  
 
|X  
 
|X  
 
|X  
 
|X  
 
|X  
 
|X  
 
|-
 
|-
|N1b
+
|M1
|
+
|Distant metastasis
 +
|Fernmetastasen vorhanden
 +
|all
 +
|X
 +
|X
 +
|X
 +
|-
 +
|M1a
 
|
 
|
 
|
 
|
 +
|only oesophagus / prostate
 
|X  
 
|X  
 
|X  
 
|X  
 
|X  
 
|X  
 
|-
 
|-
|N1b1
+
|M1b
|
 
 
|
 
|
 
|
 
|
 +
|only  oesophagus / prostate
 +
|X
 +
|X
 
|X  
 
|X  
|
 
|
 
 
|-
 
|-
|N1b2
+
|M1c
 
|
 
|
 
|
 
|
 
|
 
|
 
|X  
 
|X  
 +
|X
 +
|X
 +
|-
 +
|M1d
 
|
 
|
 
|
 
|
|-
 
|N1b3
 
 
|
 
|
 
|
 
|
 
|
 
|
 
|X  
 
|X  
 +
|-
 +
|M1e
 
|
 
|
 
|
 
|
|-
 
|N1b4
 
 
|
 
|
 
|
 
|
 
|
 
|
 
|X  
 
|X  
|
 
|
 
 
|-
 
|-
|N1c
+
|MX
|
+
|Distant metastasis cannot be assessed
|
 
|
 
|
 
|X
 
|X
 
|-
 
|N2
 
|
 
|
 
 
|
 
|
 +
|all
 
|X  
 
|X  
 
|X  
 
|X  
 
|X  
 
|X  
 
|}
 
|}
Table 21: (N) Lymph Node Codes Value Set (OID 1.2.276.0.76.11.2)
+
Table 22: (M) Metastasis Code Value Set (OID 1.2.276.0.76.11.3)  
 +
 
 +
=== Residual Tumor ===
  
=== Metastasis ===
+
{| class="hl7table"
Code describing distant metastases shall only be used together with tumor diagnosis.
 
{| class=wikitable
 
 
!Code  
 
!Code  
 
!Description  
 
!Description  
 
!German  
 
!German  
!Entity
 
!5.
 
!6.
 
!7.
 
 
|-
 
|-
!
+
|R0
!
+
|No residual tumour
!
+
|kein Residualtumor
!
 
!UICC
 
!UICC
 
!UICC
 
 
|-
 
|-
|M0
+
|R1
|No distant metastasis
+
|Microscopic residual tumour
|Fernmetastasen nicht vorhanden
+
|nur mikroskopisch  Residualtumor nachweisbar
|all
 
|X
 
|X
 
|X
 
 
|-
 
|-
|M1
+
|R2
|Distant metastasis
+
|Macroscopic residual tumour and
|Fernmetastasen vorhanden
+
|makroskopischer Residualtumor und
|all
 
|X
 
|X
 
|X
 
 
|-
 
|-
|M1a
+
|R2a
|
+
| microscopically not confirmed
|
+
|­mikroskopisch nicht bestätigt
|only oesophagus / prostate
 
|X
 
|X
 
|X
 
 
|-
 
|-
|M1b
+
|R2b
|
+
| microscopically confirmed
|
+
|­mikroskopisch bestätigt
|only  oesophagus / prostate
+
|-
|X
+
|RX
|X
+
|Presence of residual tumour cannot be assessed
|X
+
|Unbekannt
 +
|}
 +
Table 23: Residualtumor Codes Value Set (OID 1.2.276.0.76.11.4)
 +
 
 +
=== Stage grading as of UICC ===
 +
 
 +
{| class="hl7table"
 +
!Code
 +
!Description
 +
!Meaning
 +
!5.
 +
!6.
 +
!7.
 
|-
 
|-
|M1c
 
 
|
 
|
 
|
 
|
 
|
 
|
 +
! colspan=3 | UICC
 +
|-
 +
|okk
 +
|
 +
|TX, N0, M0
 
|X  
 
|X  
 
|X  
 
|X  
 
|X  
 
|X  
 
|-
 
|-
|M1d
+
|0
|
+
|Carcinoma in situ
|
+
|Tis, N0, M0
|
+
|X
 +
|X
 +
|X
 +
|-
 +
|0a
 
|
 
|
 
|
 
|
 +
|X
 +
|X
 
|X  
 
|X  
 
|-
 
|-
|M1e
+
|0is
 
|
 
|
 
|
 
|
 +
|X
 +
|X
 +
|X
 +
|-
 +
|I
 
|
 
|
 
|
 
|
 
|
 
|
 +
|X
 
|X  
 
|X  
 
|-
 
|-
|MX
+
|IA
|Distant metastasis cannot be assessed
 
 
|
 
|
|all
+
|T1, N0, M0
 
|X  
 
|X  
 
|X  
 
|X  
 
|X  
 
|X  
|}
 
Table 22: (M) Metastasis Code Value Set (OID 1.2.276.0.76.11.3)
 
 
=== Residual Tumor ===
 
 
{| class=wikitable
 
!Code
 
!Description
 
!German
 
 
|-
 
|-
|R0
+
|IA1
|No residual tumour
+
|
|kein Residualtumor
+
|
 +
|X
 +
|X
 +
|X
 
|-
 
|-
|R1
+
|IA2
|Microscopic residual tumour
+
|
|nur mikroskopisch  Residualtumor nachweisbar
+
|
|-
+
|X
|R2
+
|X
|Macroscopic residual tumour and
+
|X
|makroskopischer Residualtumor und
 
|-
 
|R2a
 
| microscopically not confimed
 
|­mikroskopisch nicht bestätigt
 
|-
 
|R2b
 
| microscopically confimed
 
|­mikroskopisch bestätigt
 
|-
 
|RX
 
|Presence of residual tumour cannot be assessed
 
|Unbekannt
 
|}
 
Table 23: Residualtumor Codes Value Set (OID 1.2.276.0.76.11.4)
 
 
 
=== Stage grading as of UICC ===
 
 
 
{| class=wikitable
 
!Code
 
!Description
 
!Meaning
 
!5.
 
!6.
 
!7.
 
 
|-
 
|-
 +
|IB
 
|
 
|
|
+
|T2, N0, M0  
|
 
! colspan=3 | UICC
 
|-
 
|okk
 
|
 
|TX, N0, M0  
 
 
|X  
 
|X  
 
|X  
 
|X  
 
|X  
 
|X  
 
|-
 
|-
|0
+
|IB1
|Carcinoma in situ
+
|
|Tis, N0, M0
+
|
 
|X  
 
|X  
 
|X  
 
|X  
 
|X  
 
|X  
 
|-
 
|-
|0a
+
|IB2
 
|
 
|
 
|
 
|
Zeile 2.397: Zeile 3.035:
 
|X  
 
|X  
 
|-
 
|-
|0is
+
|IC
 
|
 
|
 
|
 
|
Zeile 2.404: Zeile 3.042:
 
|X  
 
|X  
 
|-
 
|-
|I
+
|II
|
 
 
|
 
|
 
|
 
|
 +
|X
 
|X  
 
|X  
 
|X  
 
|X  
 
|-
 
|-
|IA
+
|IIA
 
|
 
|
|T1, N0, M0  
+
|T1, N1, M0  
 
|X  
 
|X  
 
|X  
 
|X  
 
|X  
 
|X  
 
|-
 
|-
|IA1
+
|IIA1
 +
|
 +
|
 
|
 
|
 
|
 
|
|X
 
|X
 
 
|X  
 
|X  
 
|-
 
|-
|IA2
+
|IIA2
 +
|
 +
|
 
|
 
|
 
|
 
|
|X
 
|X
 
 
|X  
 
|X  
 
|-
 
|-
|IB
+
|IIB
 
|
 
|
|T2, N0, M0  
+
|T2, N1, M0  
 
|X  
 
|X  
 
|X  
 
|X  
 
|X  
 
|X  
 
|-
 
|-
|IB1
+
|IIC
|
 
 
|
 
|
 +
|T3, N0, M0
 
|X  
 
|X  
 
|X  
 
|X  
 
|X  
 
|X  
 
|-
 
|-
|IB2
+
|III
 
|
 
|
 
|
 
|
Zeile 2.453: Zeile 3.091:
 
|X  
 
|X  
 
|-
 
|-
|IC
+
|IIIA
|
 
 
|
 
|
 +
|T1, N2, M0
 
|X  
 
|X  
 
|X  
 
|X  
 
|X  
 
|X  
 
|-
 
|-
|II
+
|IIIA
 +
|
 +
|T2, N2, M0
 +
|
 
|
 
|
 
|
 
|
|X
 
|X
 
|X
 
 
|-
 
|-
|IIA
+
|IIIA
 
|
 
|
|T1, N1, M0  
+
|T3, N1,2, M0  
|X
 
|X
 
|X
 
|-
 
|IIA1
 
 
|
 
|
 
|
 
|
 
|
 
|
 +
|-
 +
|IIIB
 
|
 
|
 +
|T4, each N, M0
 +
|X
 +
|X
 
|X  
 
|X  
 
|-
 
|-
|IIA2
+
|IIIB
 
|
 
|
 +
|each T, N3, M0
 
|
 
|
 
|
 
|
 
|
 
|
|X
 
 
|-
 
|-
|IIB
+
|IIIC
 +
|
 
|
 
|
|T2, N1, M0
 
 
|X  
 
|X  
 
|X  
 
|X  
 
|X  
 
|X  
 
|-
 
|-
|IIC
+
|IS
 +
|
 
|
 
|
|T3, N0, M0
 
 
|X  
 
|X  
 
|X  
 
|X  
 
|X  
 
|X  
 
|-
 
|-
|III
+
|IV
|
 
 
|
 
|
 +
|each T, each N, M1
 
|X  
 
|X  
 
|X  
 
|X  
 
|X  
 
|X  
 
|-
 
|-
|IIIA
+
|IVA
 +
|
 
|
 
|
|T1, N2, M0
 
 
|X  
 
|X  
 
|X  
 
|X  
 
|X  
 
|X  
 
|-
 
|-
|IIIA
+
|IVB
|
 
|T2, N2, M0
 
|
 
 
|
 
|
 
|
 
|
 +
|X
 +
|X
 +
|X
 
|-
 
|-
|IIIA
+
|IVC
 
|
 
|
|T3, N1,2, M0
 
 
|
 
|
 +
|X
 +
|X
 +
|X
 +
|-
 +
|not defined
 
|
 
|
 
|
 
|
|-
 
|IIIB
 
|
 
|T4, each N, M0
 
 
|X  
 
|X  
 
|X  
 
|X  
 
|X  
 
|X  
 
|-
 
|-
|IIIB
+
|not recommended
 
|
 
|
|each T, N3, M0
 
|
 
|
 
|
 
|-
 
|IIIC
 
 
|
 
|
 
|
 
|
 
|X  
 
|X  
|X  
+
|X  
|X
+
|}
 +
Table 24: Stage Classification ref. 18 Value Set (OID 1.2.276.0.76.11.5)
 +
 
 +
18 In: Schmoll HJ, Höffken K, Possinger K eds. Kompendium Internistische Onkologie. „Collection of Internistic Oncology “. Springer. 4. Edition; 2006
 +
 
 +
=== Venous Invasion ===
 +
 
 +
{| class="hl7table"
 +
!Code
 +
!Description
 +
!German
 
|-
 
|-
|IS
+
|V0
|
+
|no venous invasion
|
+
|keine Veneninvasion
|X
 
|X
 
|X
 
 
|-
 
|-
|IV
+
|V1
|
+
|microscopic venous invasion
|each T, each N, M1
+
|mikroskopische Veneninvasion
|X
 
|X
 
|X
 
 
|-
 
|-
|IVA
+
|V2
|
+
|macroscopic venous invasion
|
+
|makroskopische Veneninvasion
|X
 
|X
 
|X
 
 
|-
 
|-
|IVB
+
|VX
|
+
|venous invasion cannot be assessed
|
+
|Veneninvasion nicht feststellbar
|X
+
|}
|X
+
Table 25: Venous Invasion Code Value Set (OID 1.2.276.0.76.11.6)
|X
+
 
 +
=== Lymphatic System Invasion ===
 +
 
 +
{| class="hl7table"
 +
!Code
 +
!Description
 +
!German
 
|-
 
|-
|IVC
+
|L0
|
+
|no lymphatic invasion
|
+
|keine Lymphsysteminvasion
|X
 
|X
 
|X
 
 
|-
 
|-
|not defined
+
|L1
|
+
|lymphatic invasion
|
+
|Lymphsysteminvasion
|X
 
|X
 
|X
 
 
|-
 
|-
|not recommended
+
|LX
|
+
|lmphatic invasion cannot be assessed
|
+
|Lymphsysteminvasion nicht fest­stellbar
|
 
|X
 
|X
 
 
|}
 
|}
Table 24: Stage Classification ref. 18 Value Set (OID 1.2.276.0.76.11.5)  
+
Table 26: Lymphatic Invasion Codes Value Set (OID 1.2.276.0.76.11.7)
  
18 In: Schmoll HJ, Höffken K, Possinger K eds. Kompendium Internistische Onkologie. „Collection of Internistic Oncology “. Springer. 4. Edition; 2006
+
=== Perineural Invasion ===
  
=== Venous Invasion ===
+
{| class="hl7table"
 
 
{| class=wikitable
 
 
!Code  
 
!Code  
 
!Description  
 
!Description  
 
!German  
 
!German  
 
|-
 
|-
|V0
+
|Pn0
|no venous invasion  
+
|no perineural invasion  
|keine Veneninvasion
+
|keine perineurale Invasion
 
|-
 
|-
|V1
+
|Pn1
|microscopic venous invasion  
+
|Perineural invasion  
|mikroskopische Veneninvasion
+
|perineurale Invasion
 
|-
 
|-
|V2
+
|PnX
|macroscopic venous invasion
+
|unknown
|makroskopische Veneninvasion
+
|Unbekannt
|-
 
|VX
 
|venous invasion cannot be assessed
 
|Veneninvasion nicht feststellbar
 
 
|}
 
|}
Table 25: Venous Invasion Code Value Set (OID 1.2.276.0.76.11.6)
+
Table 27: Perineural Invasion Code Value Set (OID 1.2.276.0.76.11.8)  
  
=== Lymphatic System Invasion ===
+
=== Qualifier ===
  
{| class=wikitable
+
{| class="hl7table"
 
!Code  
 
!Code  
 
!Description  
 
!Description  
 
!German  
 
!German  
 
|-
 
|-
|L0
+
|c
|no lymphatic invasion
+
|Assessment according to clinical criteria
|keine Lymphsysteminvasion
+
|Beurteilung nach klinischen Kriterien
 +
|-
 +
|p
 +
|according to the pathological results
 +
|nach dem pathologischen Befund
 
|-
 
|-
|L1
+
|r
|lymphatic invasion
+
|TNM result of recurrent tumor
|Lymphsysteminvasion
+
|TNM­Befund für Rezidivtumor
 
|-
 
|-
|LX
+
|y
|lmphatic invasion cannot be assessed
+
|Classification of initial multimodal therapy
|Lymphsysteminvasion nicht fest­stellbar
+
|Klassifikation nach initialer multi­modaler Therapie
 
|}
 
|}
Table 26: Lymphatic Invasion Codes Value Set (OID 1.2.276.0.76.11.7)
+
Table 28: TNM-Qualifier Value Set (OID 1.2.276.0.76.11.9)
  
=== Perineural Invasion ===
+
=== Certainty ===
  
{| class=wikitable
+
{| class="hl7table"
 
!Code  
 
!Code  
!Description  
+
!Description of Evidence
 
!German  
 
!German  
 
|-
 
|-
|Pn0
+
|C1
|no perineural invasion
+
|Evidence from standard diagnostic means (e.g., inspection, palpation, and standard radiography, intraluminal endoscopy for tumours of certain organs)
|keine perineurale Invasion
+
|Nachweis durch diagnostische Standardmethoden (Inspektion, Palpation, einfache Röntgenaufnahmen)
 +
|-
 +
|C2
 +
|Evidence obtained by special diagnostic means (e.g., radiographic imaging in special projections, tomography, computerized tomography [CT], ultrasonography, lymphography, angiography,scintigraphy,magnetic resonance imaging [MRI],endoscopy, biopsy, and cytology)
 +
|Nachweis durch spezielle klinische diagnostische Methoden einschließlich Computertomogramm, Magnet­Resonanz­Tomographie
 +
|-
 +
|C3
 +
|Evidence from surgical exploration, including biopsy and cytology
 +
|Nachweis durch Operation, einschließlich Biopsie und Zytologie
 
|-
 
|-
|Pn1
+
|C4
|Perineural invasion
+
|Evidence of the extent of disease following definitive surgery and pathological examination of the resected specimen
|perineurale Invasion
+
|Nachweis durch operative Behandlung mit pathologischer Untersuchung der entnommenen Gewebeteile
 
|-
 
|-
|PnX
+
|C5
|unknown
+
|Evidence from autopsy
|Unbekannt
+
|Nachweis durch Autopsie
 
|}
 
|}
Table 27: Perineural Invasion Code Value Set (OID 1.2.276.0.76.11.8)  
+
Table 29: Certainty Factor Codes (OID 1.2.276.0.76.5.341)
  
=== Qualifier ===
+
=== Localisation of Distant Tumours / Metastases ===
  
{| class=wikitable
+
{| class="hl7table"
 
!Code  
 
!Code  
 
!Description  
 
!Description  
 
!German  
 
!German  
 +
!Explanation
 
|-
 
|-
|c
+
|PUL
|Assessment according to clinical criteria
+
|Pulmonary
|Beurteilung nach klinischen Kriterien
+
|Pulmonal
 +
|Lungenmetastase
 
|-
 
|-
|p
+
|OSS
|according to the pathological results
+
|Osseous
|nach dem pathologischen Befund
+
|Ossär
 +
|Knochenmetastase
 
|-
 
|-
|r
+
|HEP
|TNM result of recurrent tumor
+
|Hepatic
|TNM­Befund für Rezidivtumor
+
|Hepatisch
 +
|Lebermetastase
 
|-
 
|-
|y
+
|BRA
|Classification of initial multimodal therapy
+
|Brain
|Klassifikation nach initialer multi­modaler Therapie
+
|Cerebral
|}
+
|Hirnmetastase
Table 28: TNM-Qualifier Value Set (OID 1.2.276.0.76.11.9)
 
 
 
=== Certainty ===
 
 
 
{| class=wikitable
 
!Code
 
!Description of Evidence
 
!German
 
 
|-
 
|-
|C1
+
|LYM
|Evidence from standard diagnostic means (e.g., inspection, palpation, and standard radiography, intraluminal endoscopy for tumours of certain organs)
+
|Lymph Nodes
|Nachweis durch diagnostische Standardmethoden (Inspektion, Palpation, einfache Röntgenaufnahmen)
+
|Lymphonodulär
 +
|Lymphknotenmetastase
 +
|-
 +
|OTH
 +
|Others
 +
|Andere
 +
|Andere Metastase
 
|-
 
|-
|C2
+
|MAR
|Evidence obtained by special diagnostic means (e.g., radiographic imaging in special projections, tomography, computerized tomography [CT], ultrasonography, lymphography, angiography,scintigraphy,magnetic resonance imaging [MRI],endoscopy, biopsy, and cytology)
+
|Bone Marrow
|Nachweis durch spezielle klinische diagnostische Methoden einschließlich Computertomogramm, Magnet­Resonanz­Tomographie
+
|Medullär
 +
|Knochenmarkmetastase
 
|-
 
|-
|C3
+
|PLE
|Evidence from surgical exploration, including biopsy and cytology
+
|Pleura
|Nachweis durch Operation, einschließlich Biopsie und Zytologie
+
|Pleural
 +
|RippenfellMetastase
 
|-
 
|-
|C4
+
|ADR
|Evidence of the extent of disease following definitive surgery and pathological examination of the resected specimen
+
|Adrenals
|Nachweis durch operative Behandlung mit pathologischer Untersuchung der entnommenen Gewebeteile
+
|Adrenal
 +
|Nebennierenmetastase
 
|-
 
|-
|C5
+
|SKI
|Evidence from autopsy
+
|Skin
|Nachweis durch Autopsie
+
|dermal
|}
+
|Hautmetastase
Table 29: Certainty Factor Codes (OID 1.2.276.0.76.5.341)
+
|}
 +
Table 30: Metastases Localisation Codes (OID 1.2.276.0.76.5.401)
 +
 
 +
== Codes for Gleason Score ==
  
=== Localisation of Distant Tumours / Metastases ===
+
The Gleason Grading system helps evaluating the prognosis of men with prostate cancer, as a part of a strategy of prostate cancer staging which predicts prognosis and guides therapy. The Gleason score is based on microscopic findings.
  
{| class=wikitable
+
{| class="hl7table"
 
!Code  
 
!Code  
 
!Description  
 
!Description  
 
!German  
 
!German  
!Explanation
 
 
|-
 
|-
|PUL
+
|1
|Pulmonary
+
|Round to oval equal individual glands, lying close to each other, sharply demarcated from the surrounding area
|Pulmonal
+
|Runde bis ovale gleich große Einzeldrüsen, dicht nebeneinander liegend, scharf gegen die Umgebung abgegrenzt
|Lungenmetastase
 
 
|-
 
|-
|OSS
+
|2
|Osseous
+
|Slightly less uniform single glands, separated by small amounts of stroma, less sharply defined tumor margin
|Ossär
+
|Etwas weniger uniforme Einzeldrüsen, getrennt durch geringe Mengen von Stroma, weniger scharf begrenzter Tumorrand
|Knochenmetastase
 
 
|-
 
|-
|HEP
+
|3
|Hepatic
+
|a) Irregularly large and irregularly shaped glands, usually with abundant stroma, sometimes also stored tightly irregular and indistinct tumor border
|Hepatisch
+
|Unregelmäßig große und unregelmäßig gestaltete Drüsen mit gewöhnlich reichlicherem Stroma, gelegentlich auch dicht gelagert, unregelmäßige und unscharfe Tumorgrenze
|Lebermetastase
 
 
|-
 
|-
|BRA
+
|
|Brain
+
|b) Papillary or cribriform structures, sometimes in large gang­like formations
|Cerebral
+
|Papilläre oder kribriforme Strukturen, z.T. in großen gangähnlichen Bildungen
|Hirnmetastase
 
 
|-
 
|-
|LYM
+
|4
|Lymph Nodes
+
|"a) Large irregular epithel formations by glandular fusion (""fused glands"") and branched glands with irregular infiltration into the surrounding area "
|Lymphonodulär
+
|Große unregelmäßige Epithelformationen durch Drüsenverschmelzung („fused glands“) sowie verzweigte Drüsen mit unregelmäßiger Infiltration in die Umgebung
|Lymphknotenmetastase
 
 
|-
 
|-
|OTH
+
|
|Others
+
|b) Adenocarcinoma with prominent clear cytoplasm similar to clear cell adenocarcinomas of the kidney
|Andere
+
|Adenokarzinom mit ausgeprägt klarem Zytoplasma ähnlich hellzelligen Adenokarzinomen der Niere
|Andere Metastase
 
 
|-
 
|-
|MAR
+
|5
|Bone Marrow
+
|a) Circumscribed round epithelial clusters with mostly solid and cribriform construction, usually with central necrosis
|Medullär
+
|Scharf begrenzte runde Epithelhaufen mit meist solidem und kribriformem Bau, gewöhnlich mit zentraler Nekrose
|Knochenmarkmetastase
 
 
|-
 
|-
|PLE
+
|
|Pleura
+
|(comedo carcinoma­like)
|Pleural
+
|(komedo­karzinomähnlich)
|RippenfellMetastase
 
 
|-
 
|-
|ADR
+
|
|Adrenals
+
|b) Irregularly shaped formations of an undifferentiated carcinoma, which only just discernible glandular formation or is identified vacuoles (signet ring­like) than adenocarcinoma
|Adrenal
+
|Unregelmäßig begrenzte Formationen eines undifferenzierten Karzinoms, das nur durch gerade noch erkennbare Drüsenbildung oder Vakuolen (siegelringähnlich) als Adenokarzinom zu identifizieren ist
|Nebennierenmetastase
 
|-
 
|SKI
 
|Skin
 
|dermal
 
|Hautmetastase
 
 
|}
 
|}
Table 30: Metastases Localisation Codes (OID 1.2.276.0.76.5.401)
+
Table 31: Loss of Differentiation according to Gleason Score ref. 19 (OID 1.2.276.0.76.5.402)
 +
 
 +
Documentation by the GleasonSum (Gleason¬Score) as the sum of the two most dominating findings: Uniformly structured tumors: two times the points of above table. Non-uniformly structured tumors: points for the dominating share of findings (so-called primary grading) + points for second-largest share (secondary grading), if  punch biopsy show more than two grades, the second component will be based on the most adverse component found.
  
== Codes for Gleason Score ==
+
19: Dt. Gesellschaft f. Urologie e.V.
  
The Gleason Grading system helps evaluating the prognosis of men with prostate cancer, as a part of a strategy of prostate cancer staging which predicts prognosis and guides therapy. The Gleason score is based on microscopic findings.
+
== Ann Arbor Codes ==
 +
The tumor staging system for lymphomas.
  
{| class=wikitable
+
Principal Stages
!Code
 
!Description
 
!German
 
|-
 
|1
 
|Round to oval equal individual glands, lying close to each other, sharply demarcated from the surrounding area
 
|Runde bis ovale gleich große Einzeldrüsen, dicht nebeneinander liegend, scharf gegen die Umgebung abgegrenzt
 
|-
 
|2
 
|Slightly less uniform single glands, separated by small amounts of stroma, less sharply defined tumor margin
 
|Etwas weniger uniforme Einzeldrüsen, getrennt durch geringe Mengen von Stroma, weniger scharf begrenzter Tumorrand
 
|-
 
|3
 
|a) Irregularly large and irregularly shaped glands, usually with abundant stroma, sometimes also stored tightly irregular and indistinct tumor border
 
|Unregelmäßig große und unregelmäßig gestaltete Drüsen mit gewöhnlich reichlicherem Stroma, gelegentlich auch dicht gelagert, unregelmäßige und unscharfe Tumorgrenze
 
|-
 
|
 
|b) Papillary or cribriform structures, sometimes in large gang­like formations
 
|Papilläre oder kribriforme Strukturen, z.T. in großen gangähnlichen Bildungen
 
|-
 
|4
 
|"a) Large irregular Epithelformationen by glandular fusion (""fused glands"") and branched glands with irregular infiltration into the surrounding area "
 
|Große unregelmäßige Epithelformationen durch Drüsenverschmelzung („fused glands“) sowie verzweigte Drüsen mit unregelmäßiger Infiltration in die Umgebung
 
|-
 
|
 
|b) Adenocarcinoma with prominent clear cytoplasm similar to clear cell adenocarcinomas of the kidney
 
|Adenokarzinom mit ausgeprägt klarem Zytoplasma ähnlich hellzelligen Adenokarzinomen der Niere
 
|-
 
|5
 
|a) Circumscribed round epithelial clusters with mostly solid and cribriform construction, usually with central necrosis
 
|Scharf begrenzte runde Epithelhaufen mit meist solidem und kribriformem Bau, gewöhnlich mit zentraler Nekrose
 
|-
 
|
 
|(comedo carcinoma­like)
 
|(komedo­karzinomähnlich)
 
|-
 
|
 
|b) Irregularly shaped formations of an undifferentiated carcinoma, which only just discernible glandular formation or is identified vacuoles (signet ring­like) than adenocarcinoma
 
|Unregelmäßig begrenzte Formationen eines undifferenzierten Karzinoms, das nur durch gerade noch erkennbare Drüsenbildung oder Vakuolen (siegelringähnlich) als Adenokarzinom zu identifizieren ist
 
|}
 
Table 31: Loss of Differentiation according to Gleason Score ref. 19 (OID 1.2.276.0.76.5.402)
 
 
 
Documentation by the GleasonSum (Gleason¬Score) as the sum of the two most dominating findings: Uniformly structured tumors: two times the points of above table. Non-uniformly structured tumors: points for the dominating share of findings (so-called primary grading) + points for second-largest share (secondary grading), if  punch biopsy show more than two grades, the second component will be based on the most adverse component found.
 
 
 
19: Dt. Gesellschaft f. Urologie e.V.
 
  
== Ann Arbor Codes ==
+
{| class="hl7table"
The tumor staging system for lymphomas.
 
 
 
Principal Stages
 
{| class=wikitable
 
 
!Code  
 
!Code  
 
!Description  
 
!Description  
Zeile 2.859: Zeile 3.442:
  
 
Modifiers for Constitutional Symptoms
 
Modifiers for Constitutional Symptoms
{| class=wikitable
+
{| class="hl7table"
 
!Code  
 
!Code  
 
!Description  
 
!Description  
Zeile 2.869: Zeile 3.452:
 
|presence of constitutional (B-type) symptoms is denoted by adding a ""B""  
 
|presence of constitutional (B-type) symptoms is denoted by adding a ""B""  
 
|}
 
|}
Table 34: Ann Arbor constitutional  symptoms (OID 1.2.276.0.76.5.416)
+
Table 34: Ann Arbor constitutional  symptoms (OID 1.2.276.0.76.5.416 {{Alert|Falsche OID: 1.2.276.0.76.5.416 ist atcgm2013))}}
 
 
  
 
Modifiers for Spread of Tumor
 
Modifiers for Spread of Tumor
{| class=wikitable
+
{| class="hl7table"
 
!Code  
 
!Code  
 
!Description  
 
!Description  
Zeile 2.886: Zeile 3.468:
 
|the largest deposit is >10 cm large (""bulky disease""), or the mediastinum is wider than 1/3 of the chest on a chest X-ray.
 
|the largest deposit is >10 cm large (""bulky disease""), or the mediastinum is wider than 1/3 of the chest on a chest X-ray.
 
|}
 
|}
Table 35: Ann Arbor Extensions for Spreading in Organs  Code Set (OID 1.2.276.0.76.5.417)
+
Table 35: Ann Arbor Extensions for Spreading in Organs  Code Set (OID 1.2.276.0.76.5.417) {{Alert|Falsche OID: 1.2.276.0.76.5.417 ist icd10gm2014}}
  
 
== Papanicolaou Coding ==
 
== Papanicolaou Coding ==
Zeile 2.892: Zeile 3.474:
 
Results of the so-called Pap-Test
 
Results of the so-called Pap-Test
  
{| class=wikitable
+
{| class="hl7table"
 
!Code  
 
!Code  
 
!Meaning  
 
!Meaning  
Zeile 2.931: Zeile 3.513:
  
 
Table 36: Grading according to Papanicolaou (OID 1.2.276.0.76.5.406)
 
Table 36: Grading according to Papanicolaou (OID 1.2.276.0.76.5.406)
 
=Appendix A: Other=
 
 
=Appendix B: Indices=
 

Aktuelle Version vom 11. November 2014, 11:52 Uhr


Inhaltsverzeichnis

Introduction

Introduction

Documentation of diagnoses is an essential part of many workflows in healthcare systems.

The ways of documenting a diagnosis may depend on the purpose such as medical, statistical, research-related, legal or administrative purposes.

This guideline focusses on the structured electronic documentation of diagnoses for the following applications:

Flag de.svg Germany

Fields of application for diagnosis documentation in Germany are e.g.

  • Capturing a diagnosis for the purpose of billing an ICD-10-GM code under Federal German Code SGB V
    • under law §301 for in-patients
    • under law §295 for out-patients /ambulatory care
    • under law §140 for integrated care plans ("IGV-MVZ")
  • Cause-of-death statistics based on ICD-10 WHO
  • Quality assurance as of law §137 SGB V and related hospital quality reports
  • Infectious disease reporting as required under Infektionsschutz-Gesetz
  • Epidemiology and cancer registers (using ICD-O), including further classification of tumor diseases (1)
  • Expertise by payor for the purpose of retirement plans and statutory insurances (using e.g. ICF)
  • Medical documentation in healthcare such as referral letters, admission letters, sick-leave-notes, prescriptions, in-patient EHRs
  • Clinical studies (MedDRA, WHO-Art)
  • Payor Risk Compensation as of "Risikostrukturausgleich" ruling
  • Product detail information for medication, such as indications, counter-indications amd sideeffects ("UAW")

Administrative documentation of diagnoses will be required for justifying the billing of therapy such as treatment/procedures.

Since Jan 1st 2000 the classification ICD-10 GM as mandatory for diagnosis encoding in both ambulatory and in-patient care, especially for lump sum billing as ruled under G-DRG (German Diagnosis Related Groups).

Primary care data and routine care data may not just be used for billing but also for further purposes. Only standardized guidelines support multiple use of such data.

Statistical processing of diagnostic data may e.g. be used for quality assurance and for research, with diagnoses typically being encoded using classifications, like ICD-10, but also ICD-O and ICF.

For future integrated applications which process structured electronic diagnoses to support medical decision-making processes, advanced terminologies may have to be used, like e.g. the alphabetical index into ICD and medication/substance directories.

Note 1 TNM- and the UICC-System proved to be insufficient for grading tumors of the central nervous systems because of their low metastasis and the weak relationship between tumor size and its aggressiveness. [Louis 2007]. Therefore we will apply the WHO-Grading (see 6.8)

Scope

Scope of this document is an elementary specification of how to represent diagnoses using HL7 V3 messages and documents.

Diagnoses exactly map from symptoms (diagnostic signs) to terms for diseases.

A a principle HL7 represents diagnoses as observations made by a doctor at a patient, which means that diagnostic data will be modelled using the HL7 Observation class, independent of the V3 model being used.

The goal is to have a model-independent specifiation of how to map relevant diagnostic data into the class Observation.

This document is based on using a structured diagnosis.

  • Chapter 3 explains attributes of diagnostic data
  • Chapter 4 explains the use of the Observation class
  • Chapter 5 focusses on the representation of encoded diagnoses, with section 5.1 mentioning specialties of ICD-10 encding especially in the context of German requirements
  • Chapter 6 specifies the representation of diagnoses in tumor documentation.
  • Chapter 7 includes examples representations of diagnosis from vrious fields of application.

Diagnosis Types

Clarification

In HL7 Version 3 the term classification of diagnoses means the type or kind of diagnosis, like e.g. "Admission Diagnosis" or "Referral Diagnosis". For clarity, we will use the term "type of diagnosis" in the following text.

Types of Diagnoses in Ambulatory Care

Flag de.svg Germany

The federal association (KBV) of regional statutory billing associations (KV) for out-patient/ambulatory care in Germany published the so-called KVDT data set as the mandatory format for billing. It combines billing data (ADT, not to be confused with the HL7 ADT data), the rehab billing data (KADT) and the statistical data (STDT) of a GPO reporting to its assigned (regional) KV. Part of the KVDT data set is a diagnosis specification with the following types of diagnosis

Billing Diagnosis - current diagnosis being the basis for billing Continued Diagnosis - diagnoses that are valid for more than three quarters (of a year).

Despite these billing diagnoses it is also allowed to send continued diagnoses (more than one quarter) which are related to the services billed. Using the record attribute 6001 ("ICD-10-code") for continued diagnoses is not permitted, instead the attribute 3673 ("continued diagnosis") shall store the ICD-10-code, combined with attribute 3674 ("reliability - continued diagnosis") and optionally the attributes 3675("side localization - continued diagnosis") or , attribute 3676 ("explanation - continued diagnosis") may be used. Either attributes 6001 or 3673 shall be used.

Types of Diagnoses for Inpatient Care

Flag de.svg Deutschland

The (Federal German Code SGB V) billing law § 301 SGB V states the diagnosis specifications which shall be sent by hospitals to payors. Based on that law, the data transfer guidance „Datenuebermittlung nach §301“ of the federal hospital association DKG has been published. This guidance defines different record types (e.g. admission record, discharge record) which also include diagnosis specifications, as given by the following table:

Record type Segment: Name Diagnosis
Admission Record EAD Admission Diagnosis
Indicator for Continuation DAU Continued Diagnosis - justiyfing sick leave
Indicator for Continuation FAB Diagnosis by specialized clinical department
Discharge Record DAU Continued Diagnosis - justiyfing sick leave
Discharge Record ETL Discharge Diagnosis
Discharge Record NDG Concurrent Diagnosis
Discharge Record FAB Diagnosis by specialized clinical department
Outpatient Procedure RZA Referral diagnosis
Outpatient Procedure BDG Treatment diagnosis

As a result this guidance distinguishes the following types of diagnoses under §301 SGB V:

  • Admission Diagnosis
  • Inpatient Admission Diagnosis
  • Special Department Diagnosis
  • Continued Diagnosis (with sick leave)
  • Discharge Diagnosis
  • Special Department Diagnosis Extension
  • Referral Diagnosis
  • Treatment Diagnosis

Main diagnoses and concurrent diagnoses (as defined by medical aspects) as well as primary and secondary diagnoses shall be represented via additional attributes.

Regarding further diagnosis types please see Annex A

Common Diagnosis Descriptions

Introduction

This chapter gives the attributes that are common parts of a structured diagnosis specification which are required for processing an electronic diagnosis information.

Plain-Text Description

This attribute describes the diagnosis through prosaic text, hate.g. may be entered via a text entry field by the medical professional. This plain text description should be a mandatory part of medical documentation.

Example: Allergic asthma

Note that plain-text descriptions will not necessarily match the associated text of diagnosis codes, like the ones from the systematic classification ICD-10.


Diagnosis Code

For the purposes of administrative and statistical processing, diagnoses are being encoded by encoding systems. E.g. ICD-10 is mandatory under billing according to (Federal German Code) SGB V §391 and §295.

Further systematic encoding systems are e.g. „Alpha-ID“, SNOMED CT and ID MACS.

Example: J45.0

Diagnosis Code – Catalog Text

The catalog text is the associated text for a given diagnosis code. It does not have to match the plain text and can be rendered by an automated system - based on a given diagnosis code.

Example: Predominantly allergic asthma

Diagnosis Type

The diagnosis type further specifies the type of a diagnosis and will be given in an encoded form. Examples may be "referral diagnosis", "admission diagnosis", "discharge diagnosis" etc.

Diagnosis Date

This attribute describes date and time when a medical professional made the given diagnosis.

Documentation Date

This attribute describes date and time when the diagnosis was documented.

Note that when there is no need to distinguish both dates, the diagnosis date shall be used.

Specification of the Clinically-Relevant Time of a Diagnosis

This attribute is a time interval specified by a start time and end time information giving the time in which the patient suffered from the specified disease.

Giving only a start date documents the time since when the patient had that diagnosis.

The start date may be different from the diagnosis date.

Date information in diagnoses may be with different precision.

Examples: Diabetes since 2006 or Fracture of Femur on March 12th, 2007

Diagnosis Reliability

This attribute describes the reliability of the specific diagnosis.

Flag de.svg Germany

For billing under ambulatory/out-patient care (under Federal German Code SGB V) defined attributes (suffices A, G, V or Z) are compulsory while such attributes are not allowed for in-patient billing (under Federal German Code SGB V).

Localization

The localization attribute specifies in which body site (topography) the disease was diagnosed.

Both plain text or encoded terms are allowed.

An example is the ICD-O site code for tumor documentation.

As a suffix the side may be used.

Explanations

This attribute allows medical professionals to document detailed explanations using a plain text.

Reasons for Exceptions

This plain-attribute may be required to justify a diagnosis e.g. in the context of billing.

Diagnosis Model in HL7 V3

Summary

Diagnoses represented in HL7 V3 shall useu the class Observation, which is modelled as shown in fig. 1.

Detailed descriptions of classes and data types in this model can be found in the related HL7 V3 documentation and Data Type Guidelines.

The following sections specifiy how diagnosis attributes shall be mapped into the Observation model.

Plain Text

value.originalText diagnosis as a plain text ST[0..1]

Plain text descriptions of the specific diagnosis shall be stored in the subelement originalText of element value. If it is not necessary to specify a text or should this text not be available, the @nullFlavour attribute shall be used. This element shall explain the reason why there is no plain text. A value of "NAV" states that no coded text is available (yet). More values are described in the HL7 documentation.

The attribute @language of subelement originalText may be used to specify the language of the prosaic diagnosis text.


<!-- structured representation of diagnosis -->
  <observation moodCode="EVN" classCode="OBS">
    ...
    <value xsi:type="CD" nullFlavor="NAV">
      <originalText>Rektumkarzinom mit Höhenlokalisation ab Anokutanlinie/Linea dentata
      </originalText>
    </value>
  </observation>

Diagnosis Code and Text

value Diagnosis Code CD[0..1]

Representing a diagnosis via a code and its associated text shall be done va the value element (in the model: an attribute of the Observation class).

The XML attribute @code shall store the diagnosis code and @displayname shall store the associated diagnosis text.

Such a structured representation of e.g. an ICD10 coded diagnosis looks like this:

The XML attribute @codeSystem shall store the OID for the specific ICD-10-GM version being used and the @codeSystemName attribute shall store the plain text name of the coding system and version.


  <!-- structured representation of diagnosis -->
  <observation moodCode="EVN" classCode="OBS">
  ...
    <!-- ICD-Code of a diagnosis -->
    <value xsi:type="CD" code="I01.0"
      displayName="Akute rheumatische Perikarditis"
      codeSystem="1.2.276.0.76.5.311" codeSystemName="icd10gm2006"/>
    ...
  </observation>

Diagnosis Type

code classification code CD CW[1..1]

The XML attribute shall specifiy the classification code using the attribute @codeSystem for storing the OID of that coding system (also see Annex <10>)

<!-- structured representation of diagnosis -->
  <observation moodCode="EVN" classCode="OBS">
     <code code="DX" codeSystem="1.2.276.0.76.5.342"/>
     ...
  </observation>

Diagnosis Date

author.time Diagnosis Date IVL<TS>[0..1]

The diagnsis date shall specify when the diagnosis was made as the time in the clinical process which is not necessarily the documentation date. The diagnosis date shall be represented using the author instance which shall be connected via Participation to the current Observation instance. Instances of author contain a model attribute time of type IVL<TS>. Detailed information regarding the person giving the diagnosis shall be modelled using an instance of assignedEntity.

<!-- structured representation of diagnosis -->
  <observation moodCode="EVN" classCode="OBS">
    ...
    <author>
      <!-- Diagnosedatum -->
      <time value="20100111"/>
      <assignedAuthor>
        ...
      </assignedAuthor>
    </author>
    ...
  </observation>

Documentation Date

dataEnterer.time documentation date TS [1..1]

The documentation is the date when the diagnosis has been entered by e.g. a clinician. The data value is mapped to an instance dataEnterer which is related via a Particpation to the Observation instance (see fig. 1 Observation Model).

The dataEnterer class has an model attribute time of type TS, such that in XML the data value will be mapped into an element time and an XML attribute @value.

In case there is no dataEnterer instance, the participation relation with its model attribute typeCode=ENT also manages a participationRole instance representing the data entering person that would otherwise be modelled through a instance of dataEnterer.

<!-- structured representation of diagnosis -->
  <observation classCode="OBS" moodCode="EVN" negationInd="true">
  ...
  <!-- documentation date -->
    <participant typeCode="ENT">
      <time value="20060606"/>
      <participantRole>
        ...
      </participantRole>
    </participant>
    ...
  </observation>

Diagnosis Time Interval

effectiveTime diagnosis time interval IVL<TS>[0..1]

The model attribute effectiveTime of class Observation specifies the time interval for which the specified is (or, has been) clinically relevant.

In XML, the sub-element low shall specify the begin data and sub-element high shall specifiy the end date. Dates for low or high may also be specified without the other.

<!-- structured representation of diagnosis -->
  <observation moodCode="EVN" classCode="OBS">
    ...
    <effectiveTime>
       <low value="20050127"/>
    </effectiveTime>
    ...
    </observation>

Diagnosis Reliability

value.qualifier diagnosis reliability CR [0..1]

the diagnosis reliability shall be represented in the model attribute value using a sub-element qualifier.

   <!-- structured representation of diagnosis -->
  <observation moodCode="EVN" classCode="OBS">
    ...
    <value xsi:type="CD" nullFlavor="NI">
      <originalText>......</originalText>
      <!--diagnosis reliability -->
      <qualifier>
        <name code="8" codeSystem="2.16.840.1.113883.3.7.1.0"/>
        <value code="G" codeSystem="2.16.840.1.113883.3.7.1.8"/>
      </qualifier>
    </value>
  </observation>

XML attribut @code in name shall specify the name of the diagnosis reliability qualifier, based on the table given below. XML attribut @codeSystem shall specify the OID of the system giving these qualifier names. The diagnosis reliability shall be specified using XML attribute @code in the XML element value.

Flag de.svg Germany

For out-patient care (§ 295 SGB V, Germany) diagnosis reliability attributes are mandatory, while for in-patient care (§ 301 SGB V) they are forbidden i.e. must not be specified. (Source: DIMDI)

Code as of §295 SGB V Implementation Meaning Explanation
G certain diagnosis validated
V uncertaintyCode=UN suspicious suspicion diagnosis
Z state after an earlier diagnosis is related
A negationInd=true excluded this diagnosis has been excluded (use negationInd in Level 3)

Table 2: Vocabulary Domain for Reliability Codesystem: Sciphox (OID: 2.16.840.1.113883.3.7.1.8)

In tumor documentation the validation of diagnosis is also documented by specifying the (superior) way of diagnosis. This information shall also be specified through the qualifier:

Code Implementation Meaning Explanation
k clinically
z zytologically
h histologically
a autoptically
d DCO Death certificate only.
nullFlavor = OTH Other
nullFlavor = NI unknown

Table 3: Vocabulary Domain for Diagnosis procedure in tumor documentation Codesystem: (OID: 1.2.276.0.76.5.418)

Localization

targetSiteCode Lokalisation CD CWE [0..1]

Localization of diagnoses shall be specified using the model attribute targetSiteCode. For localizations given as plain text the sub-element originalText of targetSiteCode shall be used. In case no localization code is available, the XML attribute @nullFlavor shall be specified.


<!-- structured representation of diagnosis -->
  <observation moodCode="EVN" classCode="OBS">
    ...
    <targetSiteCode nullFlavor="NI">
      <originalText>Oberhalb des rechten Knöchels</originalText>
    </targetSiteCode>
    ...
  </observation>

If a structured code is available, then model attribute targetSiteCode shall have a code sub-element with the code being specified in XML attribute @code and the coding system being specified using XML attribute @codeSystem.


Optionally the XML attribute @displayName may be used to specifiy a plain text for the code and @codeSystemName may be used for the name of the coding system.

<!-- structured representation of diagnosis -->
  <observation moodCode="EVN" classCode="OBS">
    ...
    <targetSiteCode code="299058009" codeSystem="2.16.840.1.113883.6.96"
    codeSystemName="SNOMED CT" displayName="kleiner Finger">
      <qualifier>
        <name code="78615007" codeSystem="2.16.840.1.113883.6.96"
              codeSystemName="SNOMED CT" displayName="mit Seitenlokalisation"/>
        <value code="24028007" codeSystem="2.16.840.1.113883.6.96"
               codeSystemName="SNOMED CT" displayName="rechts"/>
      </qualifier>
    </targetSiteCode>
    ...
  </observation>

Note: The localization codes suggested by the German health Ministry (BMG) shall only be used together with diagnoses encoded in ICD 10 (German).

Additional codes for the side localization may be used in out-patient care as well as in-patient care(see 4).

In tumor documentation further codes shall be use for the side localization:


Code Implementation Meaning Explanation Common Diagnoses Tumor Diagnoses
R Right side localization right X X
L Left side localization left X X
B both side diagnosed on both sides X X
M middle line middle line zone - 1 inch left or right from middle line X
nullFlavor = NA system disease in the sense of 'not applicable' X
nullFlavor = UNK unknown X X

Table 4: Vocabulary Domain for Localization Coding System: (OID: 1.2.276.0.76.5.412)

4 DIMDI 5 Literatur: Basisdokumentation für Tumorkranke 5. Auflage 1999; Dudeck et al


The side localization is used for diagnosis documentation for common and also for tumor documentation, but with differeent value sets, which are defined as follows:

Value Set Explanation OID
Common, based on ICD-10 2.16.840.1.113883.3.7.1.7
Tumor Documentation 1.2.276.0.76.11.10

Table 5: Value Sets for Localization

Explanations

text explanation of diagnosis ST [0..1]

Any explaining text shall be represented using the XML attribute text.

A structured representation will look like this:


<!-- structured representation of diagnosis -->
  <observation moodCode="EVN" classCode="OBS">
    <value xsi:type="CD" code="J45.0" codeSystem="1.2.276.0.76.5.311"
      displayName="Vorwiegend allergisches Asthma bronchiale">
      <originalText>Allergisches Asthma</originalText>
    </value>
    <text>Intermittierend, seit der Jugend</text>
  </observation>

Reasons for Exceptions

value Reasons for Exceptions ST [0..1]

Billling-related exceptions shall be encoded using the @value attribute of an extra Observation instance being related via an ActRelation-Ship instance to the original describing instance of Observation.

A structured representation will look like this:

<!-- structured representation of diagnosis -->
  <observation moodCode="EVN" classCode="OBS">
    ...
    <!-- reason for exception-->
      <entryRelationship typeCode="RSON">
        <observation moodCode="EVN" classCode="OBS">
          <code nullFlavor="UNK"/>
          <value xsi:type="ED">...........</value>
        </observation>
      </entryRelationship>
    ...
  </observation>

XML attribute @typeCode shall have the value RSON (= reason) specifying an exception for billing purposes.

Using more Attributes of Observation

This section describes more model attributes of Observation that may play a role in describing diagnoses.

Attribute 'id'

id diagnosis identificator SET <II>[0..1]

The model attribute id should be used to identify the instance of a diagnosis - which is recommended for computer-based processing of diagnoses in order to refer to the clinical specification of that diagnosis.

In XML representations the XML attribute @extension shall store the diagnosis identifier while the XML attribute @root should specify the OID of the diagnosis database.

In case changes or deletions have to be communicated for this diagnosis instance, this id will provide reference.

Attribute 'classCode'

@classCode classCode <= OBS

XML attribute shall be 'OBS' - specifiying Observation as the main type of the Act instance used for documenting the diagnosis.

In XML an attribute @classCode of the element Observation represents the model attribute 'classCode' of class Observation.

Attribute 'moodCode'

@moodCode Mood Code <= EVN

Attribute @moodCode specifies how to interpret the containing Act instance.

When using an Observation to specify a diagnosis, the @moodCode shall have the value EVN, indicating that the Observation documents an earlier action.

Attribute 'negationInd'

@negationInd Negation Indicator BL [0..1]

The optional attribute @negationInd is of data type BL with values 'true' or 'false'.

Specifying a 'true' value states that the specified diagnosis has been excluded.

@negationInd is optional, the default is 'false'. If not specified, the receiving system will interpret the diagnosis as specified.

Attribute 'statusCode'

statusCode Statuscode <= completed

This attribute can be use to represent the state of the containing Act, which can be in states like e.g. "new", "active" or "cancelled". As diagnoses are considered the documentation of an action already completed, the fixed value "completed" shall be used in XML attribute @code of sub-element statusCode.


An Example

A small example shows all of the above attributes:

  <observation classCode="OBS" moodCode="EVN" negationInd="true">
    <statusCode code="completed"/>
    </observation>

Representation of Diagnosis in specific Codesystems

ICD-10-GM-coded Diagnoses

The „International Statistical Classification of Diseases” (ICD) is a classification system for diseases and related health issues. It has a hierarchical structure. As the german localized version ICD-10-GM is a varient of the ICD-10 released by WHO.

Diseases are specified through alphanumeric codes. Each disease has a unique code and vice versa. The majority of codes are so-called primary diagnosis keys, i.e.they contain all information to encode a given diagnosis.

Flag de.svg Germany

ICD also provides the ability to specify secondary keys for additional information. Such secondary keys must only be used together with a primary diagnosis and are marked through asterisk (*) or exclamation (!) as additional codes .

Primary diagnosis codes either have no prefix or a cross (+).

Example.: E14.30+, H28.0* ICD-10 Code for “Diabetes mellitus with cataract“

Terms of ICD-10 Codes

ICD-10-GM will be used for encoding diagnoses in both in-patient and ambulatory care. In-patient diagnosis encoding additionally has to adhere to the German coding guidelines (§ 301, Deutsche Codierrichtlinien) and the extensions authorized by the Health Ministry (BMG).

For ambulatory care, the WHO-Table with BMG-extension is to be used.

Secondary Codes

ICD-10 GM distinguishes between primary codes and secundary codes.

Primary codes are codes without suffix or with a cross(+).

Secondary codes are those codes with an asterisk (*) or an exclam (!).

In oorder to explain their meaning we will translate some quotes of „Basiswissen Kodieren“ [Basic Encoding Knowledge by DIMDI,www.dimdi.de]

"The code for etiology (cause, origin) of a disease shall be marked with a cross (+) and its manifestation with an asterisk (*) - with the cross-code being the primary code and the asterisk-code never being used alone."

Another translated quote:

„ Asterisk codes shall only be those that are marked as explicitly permitted in ICD-10 for the asterisk-suffix."


„ Provided that the secondary code is permitted for asterisk, any other code describing the underlying disease may be used as primary code with the cross-suffix."

„... Some Codes are being marked with an exclam (!) indicating that therse are further descriptions or definitions of the severity. Such codes must not be used alone“ (without primary code).

As a result, each diagnosis must at least have a primary code and optionally secondary codes.

Each primary/secondary code is the alphanumeric string given by ICD-10 code followed by the suffix, either (†, *, !)

Side Localization

Regarding the encoding of side localizations, we translated a section from „ICD-10- Bekanntmachung des BMGS“ ("ICD-10 Communications of the German Health Ministry", 2004)

„..for the application of ICD-10-GM the following holds: When encoding the side localization, the following suffices may be used: – right: R – left: L – both sides: B ...“ [BMGS, 2004]

As a result, for each ICD-10 code, an independent side localization suffix can be appended. Note: primary code and secondary code can have different side localizations.

Example: C50.4 R Mamma Ca - right J91* L Pleural effusion in conditions classified elsewhere - left

For tumor documentation the extended table is valid.

Reliability of Diagnoses

„... When using ICD-10-GM according to § 295 SGB V (ambulatory sector) additionally the following holds: For encoding the diagnosis reliability one of the follwing suffices must be used: – for an excluded diagnosis: A – for a suspected diagnosis: V – for state (without symptoms) after the given diagnosis: Z – for a validated diagnosis: G“ [BMGS, 2004, translated by author]

As a result, ambulatory diagnoses used in the context of „Abrechnung ärztlicher Leistungen“ (billing of medical services, fixed term in the German statutory GP system acc. to german federal regulation §295 SGB V) the specification of diagnosis reliability is mandatory.

For in-patient care these suffices MUST NOT be used.

Mapping of ICD-10-coded Diagnoses into HL7 v3

Structured representations of ICD10-encoded diagnoses must support primary and secondary codes, code extensions, side localizations and reliability . The primary code represents the main disease. The secondary code extends the primary code and is either used to describe manifestations in organs ("asterisk") or the cause (etiology, e.g. which bacteria) of the main disease ("exclamation") In order to represent this dependency, an additional oberservation instance will be connected via the ActRelationship to that Observation instance containing the primary code.

So we have the following basic structure for ICD10-encoded diagnoses:

27px

Figure 2: Class Diagram of ICD-10 Diagnoses in HL7 v3

The attribute typeCode in the ActRelationship shall represent the code extension

The related Observation instance (connected via the ActRelationship) has MFST (Manifestation) as its typeCode in order to represent 'asterisk"-codes.

Exclamation-Code extensions are being represented as Observation instances connected via ActRelationships with typeCode CAUS (Cause).

The resulting XML structure of an ICD-10 encodeded diagnosis looks like this:

<!-- Structured Representation of Diagnosis-->
   <observation moodCode="EVN" classCode="OBS">
            <!-- Primary Code-->
      <value xsi:type="CD" code=" E14.30" codeSystem=" 1.2.276.0.76.5.311"/>
      <entryRelationship typeCode="MFST">
         <observation moodCode="EVN" classCode="OBS">
                     <!-- Secondary Code-->
            <value xsi:type="CD" code=" H28.0" codeSystem=" 1.2.276.0.76.5.311"/>
         </observation>
      </entryRelationship>
   </observation>

In this case the containing ActRelationship instance is of class entryRelationship- repesented by an element of that name.

Attribute @typeCode has MFST as a fixed value for representing an asterisk code.

value.@code ICD-Code ST [1..1] XML-Attribute @code shall store the specific ICD-10 Code.

value.@codeSystem OID of ICD-Codeset UID [1..1] XML-Attribute @codeSystem shall keep the OID of the ICD-10 Version being used. The appendix gives hints towards versions being used in practice.

value.@codeSystemName Name of ICD-10 Version ST [0..1] XML-Attribute @codeSystemName may store the Name of the used ICD-10 Version.

value.@displayName ICD-Code Text ST [0..1] XML-Attribute @displayName may store the verbose text of the ICD-Code.

OIDs and names of ICD-10 versions may be obtained from DIMDI (www.dimdi.de)

Representation of Side Localisation

value.qualifier Side Localisation CR [0..1]

The side localisation code shall be represented using the child element qualifier of the value element, as it refines the specification of that diagnosis code (as decided by HL7 DE TC meeting on 2005-09-01, minutes item 1.3.2).

An example representation looks like this:

<!-- Structured Representation of a Diagnosis -->
   <observation moodCode="EVN" classCode="OBS">
      <code code="DX" codeSystem=""/>
      <!-- Primary code-->
      <value xsi:type="CD" code="E14.30" codeSystem="1.2.276.0.76.5.311">
         <qualifier>
            <name code="7" codeSystem="2.16.840.1.113883.3.7.1.0"/>
            <value code="L" codeSystem="2.16.840.1.113883.3.7.1.7"/>
         </qualifier>
      </value>
      <entryRelationship typeCode="CAUS">
         <observation moodCode="EVN" classCode="OBS">
            <code/>
            <!-- Sekundary code-->
            <value xsi:type="CD" code="H28.0" codeSystem="1.2.276.0.76.5.311">
               <qualifier>
                  <name code="7" codeSystem="2.16.840.1.113883.3.7.1.0"/>
                  <value code="B" codeSystem="2.16.840.1.113883.3.7.1.7"/>
               </qualifier>
            </value>
         </observation>
      </entryRelationship>
   </observation>

Child element 'name' within element 'qualifier' defines the type of qualifier.

Therefore, in order to express a qualifier for side localisation, the fixed value „7“ from code system OID 2.16.840.1.113883.3.7.1.0 shall be used:

   <qualifier>
      <name code="7" codeSystem="2.16.840.1.113883.3.7.1.0"/>
      <value code="L" codeSystem="2.16.840.1.113883.3.7.1.7"/>
   </qualifier>
Representation of Diagnosis Reliability

value.qualifier Diagnosis Reliability CR [0..1]

The diagnosis reliability can be considered an extension to the ICD-10 code, shall be represented by the child element qualifier of the value element.

<!-- Structured Representation of a diagnosis-->
   <observation moodCode="EVN" classCode="OBS">
      <code code="" codeSystem=""/>
      <!-- Primary code-->
      <value xsi:type="CD" code="E14.30" codeSystem="1.2.276.0.76.5.311">
         <qualifier>
            <name code="8" codeSystem="2.16.840.1.113883.3.7.1.0"/>
            <value code="G" codeSystem="2.16.840.1.113883.3.7.1.8"/>
         </qualifier>
      </value>
      <entryRelationship typeCode="CAUS">
         <observation moodCode="EVN" classCode="OBS" negationInd="true">
            <code/>
            <!-- Secondary code-->
            <value xsi:type="CD" code="H28.0" codeSystem="1.2.276.0.76.5.311">
               <qualifier>
                  <name code="8" codeSystem="2.16.840.1.113883.3.7.1.0"/>
                  <value code="A" codeSystem="2.16.840.1.113883.3.7.1.8"/>
               </qualifier>
            </value>
         </observation>
      </entryRelationship>
   </observation>

Child element 'name' within element 'qualifier' defines the type of qualifier.

Therefore, in order to express a qualifier for diagnosis reliability, the fixed value '8' from code system OID 2.16.840.1.113883.3.7.1.0 shall be used:

Child element 'value' within 'qualifier shall store the respective reliability value.

Possible values are listed in Table 2.

   <observation classCode="OBS" moodCode="EVN">
      ...
      <value xsi:type="CD" code="A25.1" codeSystem="1.2.276.0.76.5.311" codeSystemName="icd10gm2006">
         <qualifier>
            <name code="8" codeSystem="2.16.840.1.113883.3.7.1.0"/>
            <value code="G" codeSystem="2.16.840.1.113883.3.7.1.8"/>
         </qualifier>
      </value>
   </observation>

When representing an EXCLUDED diagnosis the attribute @negationInd shall be specified as „true“.

Specifying a Diagnosis using a Thesaurus Index

One more way of specifying a diagnosis is by using an index referring to an entry in a medical thesaurus.


Example: Mapping an Alpha-ID-coded Diagnosis

Flag de.svg Germany

As an example, the diagnostic thesaurus „Alphabetische Verzeichnis zur ICD-10 GM“ (alphabetic directory of ICD-10 GM) is being used in Germany.

This directory allows to locate a verbose description of ICD-10 terms and to find the corresponding ICD-10 GM code.

The so-called Alpha-ID has been developed to process entries of that alphabetic directory.

It is an identification number for each textual entry in the "alphabetic directory".

In order to find this alpha-ID, a mapping file has been provided by DIMDI (www.dimdi.de).

The Alpha-ID is needed because in medical documentation, the descriptions of diagnoses need to be more differentiated than what ICD-10 codes actually can express.

Using the alpha-ID allows for a much finer granularity of diagnosis descriptions.[DIMDI,Alpha_Id].

As an example the ICD-10 Code “A01.0 Typhus caused by Salmonella typhi“ encodes multiple diagnoses such as „liver typhus“, „lung typhus“ and many more.

By using the Alpha-Id it is possible to specify the specific type of typhus, like e.g. „liver typhus“ as„I18721“ and „lung typhus“ as „I21312“.

  1;I22457;A01.0;;;Darmtyphus
  1;I75303;A01.0;;;Eberth-Krankheit
  1;I71406;A01.0;;;Enteritisches Fieber
  1;I22466;A01.0;;;Enterotyphus
  1;I22467;A01.0;;;Febris enterica
  1;I17704;A01.0;;;Gallenblasentyphus
  1;I71415;A01.0;;;Gastroenteritisches Fieber
  0;I78350;A01.0;;;Gastrointestinale Perforation bei Typhus
  1;I17794;A01.0;;;Gehirntyphus
  1;I21313;A01.0;;;Hauttyphus
  1;I22455;A01.0;;;Ileotyphus
  1;I94981;A01.0;;;Infektion durch Bacterium typhosum
  1;I73671;A01.0;;;Infektion durch Eberthella typhosa
  1;I22458;A01.0;;;Infektion durch Salmonella typhi
  1;I18721;A01.0;;;Lebertyphus
  1;I21312;A01.0;;;Lungentyphus
  1;I96251;A01.0;;;Lymphadenitis mesenterialis durch Salmonella typhi
  1;I66509;A01.0;;;Posttyphoider Abszess
  1;I22456;A01.0;;;Status typhoides
  1;I22463;A01.0;;;Typhoenteritis
  1;I71447;A01.0;;;Typhogastrisches Fieber
  1;I22462;A01.0;;;Typhoides Fieber
  1;I31416;A01.0;;;Typhomanie
  1;I22464;A01.0;;;Typhoperitonitis
  1;I22454;A01.0;;;Typhus
  1;I22461;A01.0;;;Typhus abdominalis
  1;I73926;A01.0;;;Typhusinfektion

Figure 3: Excerpt from mapping file „icd10gm2009_alphaid_edv_ascii20081006.txt“


Figure 4 shows an excerpt of the metafile which defines the fields of the mapping file for the Alpha-Id.

Each record consists of six fields, each being separated by a semicolon.

The fields in each record contain the following data:

  Field 1: Validity (0-not valid, 1-valid)
  Field 2: Stable Identification with prefix I or T ("Alpha-Identifikationsnummer")
  Field 3: Primary key (with cross)
  Field 4: Asterisk key (with asterisk)
  Field 5: Additional key (with exclamation)
  Field 6: Related text

Figure 4: Excerpt from Alpha-ID metafile „icd10gm_alphaid_edv_ascii_liesmich.txt“


A structured representation of a thesaurus uses the @value attribute of class Observation and an example instance lloks like this:

   <observation moodCode="EVN" classCode="OBS">
      <value xsi:type="CD" code="I2173" codeSystem="1.2.276.0.76.5.309" codeSystemName="alphaid2006"/>
   ...
   </observation>

value.@code Alpha-Id ST [1..1] XML-Attribute @code stores the index referring to an enty in the „Alphabetisches Verzeichnis“

value.@codeSystem OID ofAlpha-ID UID [1..1] XML-Attribute @codeSystem stores the OID of the Alpha-ID Version being used.

value.@displayName Alpha-Id Text ST [0..1] XML-Attribute @displayName may be used to display a text related to the current Alpha-Id

value.@codeSystemName Name of Alpha-ID Version ST [0..1] XML-Attribut @codeSystemName represents the Name of the coding system, in our case alphaid2006.

OID and name of ICD-10 Version can be obtained from DIMDI (www.dimdi.de)

Diagnosis Specification using Identifiers in a Nomenclature

One way of specififying a diagnosis is to use the code representing a diagnostic term in some medical nomenclature.

A well-known nomenclature in medicine is SNOMED-CT ("systematic nomenclature of medicine - clinical terms")

Compared to ICD-10 it has more concepts for diagnoses and mostly does not classify.

In general using a term of a nomenclature often preserves more information than using a term of a classification.

Classification is selecting a common representation for a set of concepts that are (under some aspect) considered similar.

As a result, classification reduces information, which is demonstrated by the following examples

I.e. as a part of clinical documentation of diagnosis the encoding using alpha-id or some identifier in a nomenclature would be preferred over using a classification like e.g. ICD-10.

The example shows concepts all being represented through the same ICD-10 code Q92.8 for 'Other specified trisomies and partial trisomies of autosomes'.

A simple comparison of codes from nomenclatures gives an example of missing clarity and precision of the ICD-10 classification.

Diagnosis ICD-10 Code Alpha-ID Snomed CT ID MACS
Imbalanced Insertion Q92.8 I87548 254262003 M002405-D62839-58
Trisomy 22 Q92.8 I81282 205655003 M001897-D55549-58
Trisomy 20 Q92.8 I81283 53346000 M002406-D55530-58
Partial Trisomy a.n.k. Q92.8 I81284 133849008 M001D1C-C78409-58

Table 6: Diagnoses in different coding systems


Precoordinated and Postcoordinated Concepts of a Nomenclature

For specifiying a diagnosis using a terminology there are two fundamental approaches:

The pre-coordinated approach selects a fixed term among a comprehensive list with representations for all possible concepts.

The list of all pre-coordinated terms limits the set of concepts which can be represented.

The post-coordinated approach constructs each term out of (more or less independently) encoded aspects of the concept to be represented.

The resulting term is the combination of the encoded aspects of the given concept.

ICD-10 is a good example of a pre-coordinated terminology, as it lists all the terms for the concepts it can represent.

The cross-asterisk extension to ICD-10 is an example of post-coordination.

More info can be found under the Terminfo project [Terminfo] of HL7 International.

Diagnosis by Thesaurus Index or Term within a Nomenclature

A term in a nomenclature is specified through the @value attribute of class Observation.

An example (SNOMED CT) of the structured representation looks like this:

   <observation moodCode="EVN" classCode="OBS">
   ...
   <value 
      xsi:type="CD" code="314888007" 
      codeSystem="2.16.840.1.113883.6.96"
      codeSystemName="SNOMED CT"
      displayName="Typ-II-Diabetes with diabetic cataract"/>
   ...
   </observation>
Attribute value.@code Index or Term in Nomenclature

CD CWE [1..1] The XML attribute @code keeps the index referring to an entry in a thesaurus or nomenclature.

Attribute value.@codeSystem OID of Nomenclature

UID [1..1] The XML attribute @codeSystem stores the OID of the thesaurus or nomenclature.

Attribute value.@displayName Text

ST [0..1] Through the XML attribute @displayName a plain text related to the index can be given.

Attribute value.@codeSystemName Name of Nomenclature

[0..1] The XML attribut @codeSystemName describes the name of the thesausrus or nomenclature.

Representation of Cancer Diagnosis

Introduction

In this chapter, diagnostic aspects of documentation of tumor diseases will be described. Different aspects of diagnostical descriptions of tumor diseases are described by ICD-O (Oncology) and by further classifications to document the expansion (tumor spread) or diseases stage, respectively, the latter one mostly being classified by the TNM-System.

Especially for hemato oncological diseases (Leukemias and Lymphomas), other systems (e.g. Ann-Arbor-Classification) are used. TNM-System discribes:

  • Expansion of primary tumor (extent or, spread in distant organs repectively)
  • Affection of lymph nodes in lymph flow area
  • Existence of distant metastases.

For non-TNM–-classifiable diseases or in addition to the TNM-System there are a number of further classification systems:

  • Ann Arbor
  • Rai
  • Binet
  • CML-Phasen
  • FAB
  • Durie and Salmon
  • Gleason-Score

Discriptions can be found here: http://www.med.uni-giessen.de/akkk/gtds/grafisch/doku/bd5f.htm http://www.tumorzentren.de/tl_files/dokumente/adt_basis.pdf

This list probably will be always incomplete because of the medical progress.

ICD-O

Third Edition of ICD-O [DIMDI, WHO] is the topical one. ICD-O consists of two axes, Topography- and Morphology-Axis. In ICD-O, tumor can be classified by

  • Site
  • Tissue Structure (Histology)
  • Biological behaviour (Dignity)
  • Tissue grading (mostly in two or four stages)

In this case, tissue structure and tissue grading is redundant. Precisely: The first four digits of morphology-code describe tissue-type. The fifth one describes biological behaviour (dignity-code):

  • /0 = benign
  • /1 = neoplasm with uncertain or unknown behaviour
  • /2 = Cancer in situ
  • /3 = malignant, primary tumor
  • /6 = malignant, metastasis (not used in tumor documentation)
  • /9 = malignant, uncertain wether primary tumor or a metastatic

The sixth digit describes grading, differentiation or phenotype (Histology/Pathology):

  • 1 = Grade I, well differentiated (Low grade)
  • 2 = Grade II, moderately differentiated (Intermediate grade)
  • 3 = Grade III, poorly differentiated (High grade)
  • 4 = Grade IV, undifferentiated (High grade)
  • 9 = Grade IX, grade cannot be assessed

For Leukemias and Lymphomas, the sixth digit signifies the immunophenotype

  • 5 = T-Cell
  • 6 = B-Cell, Pre-B-Cell, B-Ancestor-Cell
  • 7 = Null-Cell, Not-T-Cell-Not-B-Cell
  • 8 = NK-Cell, Natural Killer Cell
  • 9 = Determination of Cell Type was not accomplished, not specified or not applicable

TNM System describes

  • Expansion of primary tumor (extent repectivly spread in distant organs)
  • Affection of lymph nodes in lymph flow area
  • Exisistence of distant metastasis

For the topography axis, there exists an (hierarchical) enlargement, the ‘localisation key’ (Wagner, G. (HRSG.): Tumorlokalisationsschlüssel, 5. Auflage, Springer Verlag, Berlin, Heidelberg, New York, Tokyo 1993), which can supply at some positions clinical relevant differentiation. The morphology axis is composed of a four-digit code for tissue basic structure, a characteristic number for dignity and an additional grading item. The key itself does not contain all possible combinations of histology and dignity, but points out those ones, for whome exist special discriptions. Vice versa not all combinations of basic structure and dignity are possible (so there is no ‘benign leukemia’). Not either there is a grading system available for all kinds of tumor. For some ones, additional information (for Example ‘Cell-line’) is used at the corresponding position.

Tumor Localization

For Tumor-Coding first of all, the site is important. It will be classified by the Topography -Axis of ICD-O. Topographical -Codes of ICD-10 are based on chapter II (Neoplasm –C 00 – C 97) of ICD-10. However, some of the topographical Codes of ICD-10 (Codes) are not used, because their content is discribed by histology- and digit-Codes of ICD-O. (e.g. Differentiation in situ/ infiltrated, melanoma vs. scin cancer).

Tumor Histology and Dignity

Furthermore, in ICD-O, tumor morphology i.e. tissue structure (histology) and biological behavior (dignity) is discribed by special Codes. Tumor histology is coded by a four-digit number, which is assumed of the morphology-axis of Standardized Nomenclature of Patholoy (SNOP). Dignity-Code is attendant on morphology-Code, seperated by /. Examples:

  • 8060/0 squamous epithelium - papillomatose
  • 8070/2 squamous epithelium – cancer in situ undifferentiated
  • 8070/3 squamous epithelium – cancer undifferentiated
  • 8070/6 squamous epithelium – cancer metastasis undifferentiated

Tumor Grading

Grading is derived from the comparison of primary tissue with the neoplasm of this tissue. There are five grading-degrees (s.o.) and further three degrees for Malignant Lymphoma. Registration of tumor grading is also provided in TNM.

Qualifier of Tumor Formula

ICD-O –Codes can be specified by the following qualifier:

Here ICD-O provides additionally the following codes for Lymphoma, which specify the Cell line: B-Cell, T-Cell, Null-Cell Lymphoma. ICD-O uses the Codes 1 – 9. A detailled System is discribed in Chapter 9 under 9.5.2 and 9.53.

Example

GRAPHIC IS MISSING

DisplayName is only available in correlation to qualifiers. According to ICD-O-3 formation rule there are much more discriptions possible as ICD-Catalog proposes.


TNM Classification

The TNM classification describes the expansion (spread) of the tumor , i.e. stadium and prognosis of the disease.

As a special feature, the TNM classification uses the same notation for all tumors but supports different interpretations for different entities.

As an example, a T3 for mamma carcinoma has a different interpretation than the stomach carcinoma.

The current edition is 7th which is valid since January 2010, which is a reason why many TNM-6- codes may still be in use. Therefore all TNM-codes should have a version identifier, because non translatable differences are in the different editions.

A simple overview can be found in http://de.wikipedia.org/wiki/TNM.


The T category will be used for the expansion of the primary tumor, where the stages T0, Tis, T1-T4 und TX are being used, the "higher" the number, the more progress is being diagnosed and the more adverse the prognosis.

T0 stands for "no primary tumor found" (e.g. because being eradicated by therapy) Tis stands for a very early (non-infiltrating) stage tumor (Tumor in situ) and TX stands for a diagnosis which can not judge the stage because of missing data

For some tumors subcategories like e.g. T2a, T2b have been defined.


The N-category classifies the affection of lymphatic nodes - usingN0, N1-N3, NX, where N0 means "no lymphatic node affected".

For some tumors, this exclusion ("N0") requires the examination of a minimum amount of nodes.

The higher the N category the more severe is the lymphatic node affection.

If no sufficient data is available NX is being diagnosed.


The M category describes the existence of distant metastases, with the vallues of M0 (no metastases detectable), M1 (metastases detectable) and MX (insufficient data).


The TNM can be used according to clinical criteria (preoperative, cTNM) and according to the pathology findings (pTNM).

For many patients one single diagnoss will be made, either a cTNM or a pTNM, such that this type of finding must be distinguished.

This preoperative ("c" or no prefix) / pathology ("p") attribute can be captured independently for each of the T N M categories.

Therefore the typically used pTNM often meanes pTpNcM, because the spread of a timur can best be diagnosed through surgery while lymphatic spread only by pathology.

The prefix "r" describes remaining tumors (after non-disease intervals) and a prefix "y" if the classification was assessed after systemic or radiation treatment (ycTNM, ypTNM etc.).

For multiple Primary tumors the suffix "m" (or the number of tumors) will be put after the T-category value(T2(m), T2(5)).


Therefore a complete TNM formula looks like this:

There are voluntary components e.g. the certainty-Faktor (C-Factor)

Other components require pathology lab examination (L-, V- or Pn-Category)

  • y-Symbol (y or empty, disgnosis after systematic or xray treatment)
  • r-Symbol (r or empty, remainder)
  • p/c/a-Symbol for pT-category (clinical or pathological)
  • T-Category
  • (m) for multiple localizations or number of tumors
  • C-Factor for T-Category (certainty)
  • L-Category
  • V-Category
  • Pn-Category
  • p/c/a-Symbol for pN-Category (clinical or pathological)
  • N-Category
  • C-Factor for N-Category (certainty)
  • p/c/a-Symbol für pM-Category
  • M-Category
  • C-Factor for M-Category (certainty)
  • S-Kategorie (serological values, only for testicle tumors)
  • UICC-Stadium (Grading via UICC 0 and I-IV together with

letter A, B and C for further classification).

For some tumors further modifiers are being documented as a suffix (mostly in parenthenses) like e.g. (sn), (mol-),(mol+).

In addition, the TNM supplement introduces innovative or "under test" extensions, which raises doubts whether ta full control of TNM entries.

Typical T-Categories (without pre-/suffices) are being listed in chapter "Sites"

Typical N-Categories (without pre-/suffices) are being listed in chapter "Nodes".

Typical M-Categories (without pre-/suffices) are being listed in chapter "Metastases".

9 Reference: DKFZ

Qualifiers of the Tumor Formula

Despite values for T,N and M the TNM formula may also contain various qualifiers. The following table gives an overview which qualifiers can be used for which information and where they are being used. This is case-sensitive!

  • a Autoptical
  • c Clinical
  • C C-Factor (certainty)
  • G histopathological Grading
  • L Lymphatic vessel invasion
  • m multiple Tumors
  • M distant metastases
  • N Regional lymphatic node metastases
  • p pathological
  • Pn perineural Invasion
  • r Rezidiv tumor
  • R Residual tumor after treatment
  • sn Sentinel-Lymphatic nodes
  • Stage Anatomic Stage-Grouping
  • T Expansion (spreading) of Primary tumor
  • V Venous invasion
  • y Classification after initial multi-modal Therapy

Ann Arbor Classification

For lymphoma the TNM-classification does not make sense and therefore theso-called Ann-Arbor classification will be applied.

In this system, the stages I-IV are being distinguished, with an additional suffix letter

  • A meaning "no general symptoms"
  • B "with general symptoms"
  • E "extra-lymphatic organ affected"
  • S "spleen affected"

As with TNM, the Ann-Arbor classification distinguishes between clinical (cS) and pathological (pS) grading.

According to Durie & Salmon tere are gradings from I to III or the grades according to SWOG from 1-4 for the "Multiple Myeloma".

FIGO Stages

FIGO stages ignificantly overlap with the TNM classification, especially on the T-axis.

Therefore no details are being given here.

Gleason Score

The so-called Gleason-Score serves to classify the prostate carcinoma. The total numeric value is the sum of two indicators for • loss of differentiation (1-5) • growth pattern (1-5)

Resulting values range from 2 to 10 (also see Scores & Assessment DSTU).

Furthermore there is a more recent Gleason classification (according to Dhom, Müller and Helpap [Helpap 2002, Helpap2007]), which also requires to specify the procedure (esp. the two degrees) being used.

Papanikolaou

The so-called Pap-Test [Pap] is based on colored cell samples from the cervix and is used as an early indocator for cervical cancers.

WHO Grading

The so-called WHO Grading serves as an individual progonosis on the one hand and also is an indicator towards further treatment on the other hand.

Tumors of WHO Grade I and II in most cases can be treated by surgery alone, while tumors with WHO Grading III and IV normally need additional treatment by radiation or chemotherapie after surgery.

The grading looks like this:

Code Codename Meaning
I benign,slow growth of tumor, very good prognosis
II still benign, slow growth of tumor,tendency to recur
III malignant,actively producing abnormal cells,tends to recur
IV very malignant,fast growth,needs systemic therapy, bad prognosis

Table 9: WHO Grading (OID 1.2.276.0.76.5.394)

The fourth edition of the "World Health Organization (WHO) Classification of tumours of the central nervous system" (2007) lists all relevant tumor entities.

Also see "Brain Tumor Basics" (http://www.abta.org/sitefiles/sitepages/524309b806778d4f7b79044d97f324ea.pdf)

Conclusion

The following data of tumors can be represented by these respective classifications (through values and/or modifiers)


Concept Classification
Tumor localisation ICD-O
Morphology + dignity ICD-O
Tissue differentiation ICD-O ICD-O/TNM
type of stage codes (c,p,r,y) TNM/Ann-Arbor
T Code + C Factor, multiplicity TNM
M Code + C Factor, multiplicity TNM
N Code + C Factor, multiplicity TNM
Residual Tumor TNM
stage grouping TNM/Ann-Arbor/Durie&Salmon/SWOG

Cancer Diagnosis in HL7 V3

Representing Cancer Diagnoses in HL7

Tumor diagnoses shall be represented in HL7 V3 according to the following schema: A centralised instance of Observation shall specify the ICD-O code in the 'value' model-attribute with Dignity and (differentiation) grading in its 'qualifier' sub-element.

Further details shall be represented in more Observation-instances being connected via supporting ActRelationShip instances with typeCode:=SPRT .

The CertaintyFactor shall be in the 'qualifier' sub-element of the model-attribute 'value' but only for those Observation instances which represent a T-, N- or M-Classification.

Multiplicity shall be in one more Observation instance related (supporting ActRelationShip) to that Observation instance representing the T-Classifier.

Tree View of HL7-based Representation of Cancer Diagnosis

 +- ICD-O (Dignity, Grading)
 +- T-Category (c, p, r, y)
 | +- Multiplicity
 +- N-Category (c, p, sn)
 | +- Number of nodes examined and marked positive
 +- M-Category (c, p)
 +- Residual Tumor
 +- Grading
 +- Cell Type
 +- Lymphatic Invasion
 +- Venous Invasion
 +- Perineural Invasion
 +- Staging
 +- Ann-Arbor
 +- Gleason-Score
Code Codename Class / Path Representation (Observation or Qualifier)
DF Differenzierungsgrad Observation (ICD-O) qualifier.@name
DN Dignität Observation (ICD-O) qualifier.@name
T T support-Observation Observation/value.@code
M M support-Observation Observation/value.@code
N N support-Observation Observation/value.@code
MP Multiplicity support-Observation

(T)-support-Observation

Observation/value.@code
CF Certainty Factor support-Observation(T or N or M) qualifier.@name
RS Residual tumor support-Observation Observation/value.@code
GR Grading support-Observation Observation/value.@code
LI Lymphatic invasion support-Observation Observation/value.@code
VI Venous invasion support-Observation Observation/value.@code
SG Staging support-Observation Observation/value.@code
AA Ann-Arbor-Classification support-Observation Observation/value.@code

Table 10: Codes for Tumor Diagnoses (OID 1.2.276.0.76.5.334)

Example

<observation classCode="OBS" moodCode="EVN">
  ...
  <value xsi:type="CD" code="8070" codeSystem="2.16.840.1.113883.6.43.1"
    displayName="Plattenepithelkarzinom"
    codeSystemName="icd-o-3">
    <qualifier>
      <!-- Dignity -->
      <name code="335" codeSystem="2.16.840.1.113883.3.7.1.0"/>
      <value code="0" codeSystem="1.2.276.0.76.5.335"/>
    </qualifier>
    <qualifier>
      <!-- Differentiation/Grading -->
      <name code="336" codeSystem="2.16.840.1.113883.3.7.1.0"/>
      <value code="1" codeSystem="1.2.276.0.76.5.336"/>
    </qualifier>
  </value>
  <!-- Tumor formula -->
  <entryRelationship typeCode="SPRT">
    <observation moodCode="EVN" classCode="OBS">
      <!-- T-Code -->
      <value xsi:type="CD" code="T1" codeSystem="2.16.840.1.113883.15.8" codeSystemName=" tnm5"/>
        <qualifier>
          <name code="341" codeSystem="2.16.840.1.113883.3.7.1.0"/>
          <value code="C2" codeSystem="1.2.276.0.76.5.341"/>
        </qualifier>
      </value>
    </observation>
  </entryRelationship>
  <entryRelationship typeCode="SPRT">
    <observation moodCode="EVN" classCode="OBS">
    <!-- N-Code -->
      <value xsi:type="CD" code="N2" codeSystem="2.16.840.1.113883.15.8" codeSystemName="tnm5"/>
      </value>
    </observation>
  </entryRelationship>
  <entryRelationship typeCode="SPRT">
    <observation moodCode="EVN" classCode="OBS">
    <!-- M-Code -->
      <value xsi:type="CD" code="M0" displayName="Fernmetastasen nicht vorhanden"
        codeSystem="2.16.840.1.113883.15.8" codeSystemName="tnm5"/>
      </value>
    </observation>
  </entryRelationship>
</observation>

Representation for specific Use Cases

Introduction

The following sections present examples for structured diagnosis representations in selected applications.

GP/Ambulatory Billing Diagnosis (Germany)

This example shows a so-called "KVDT Record" according to §295 (German Federal Code SGB V) with a diagnosis to be represented through HL7 version 3.

Diagnosis fields in the current KVDT record:

FK Usage Field Name Field Type Conditions Explanations
6001 n ICD-Code m
Rule 486
Rule 488
Rule 489
Rule 490
Rule 492
see chapter 7
6003 1 Diagnosis Reliability m Rule 484 see chapter 7
6004 1 Side Localization k see chapter 7
6006 n Diagnosis Explanations k see chapter 7
6008 n Diagnosis Exception Case m Rule 491
3673 n Continued Diagnosis (ICD-Code) m
Rule 486
Rule 488
Rule 489
Rule 490
Rule 492
3674 1 Diagnosis Reliability/

Continued Diagnosis

m
3675 1 Side Localization

Continued Diagnosis

k
3676 n Diagnosis Explanation

Continued Diagnosis

k
3677 n Diagnosis Exception Case

Continued Diagnosis

m Regel 491

Table 11: GP/Ambulatory Billing Diagnoses (Germany) ref 10,11

Multiple ICD-10 codes may be specified - without a (mandatory) check of its medical validity but with at least one primary ICD-10 code being required.

With each code, a ide localization, a diagnosis reliability, diagnosis explanations and exception cases may be specified.

Control code 6001 indicates a (current) billing diagnosis, while control code 3673 indicates a continued diagnosis.

  • 10 FK: Field (control) code
  • 11 m = MANDATORY, k = OPTIONAL

Example in HL7-V3:

<!-- Diagnose (Abrechnungsdiagnose) 6001-->
<!-- :A17.0+;G01*;;Tuberkulöse Meningitis Gesichert Rechts-->
<!-- Diagnose 1***************************************************************--><observation classCode="OBS" moodCode="EVN">
  <!-- Code für Abbrechungsdiagnose 6001-->
  <code code="XXX_DX" codeSystem="2.16.840.1.113883.5.4"/>
  <!-- Diagnoseerläuterung 6006**********************************************-->
  <text/>
  <!-- Primärcode 6001*******************************************************-->
  <value xsi:type="CD" code="A17.0" codeSystem="1.2.276.0.76.5.311"
    codeSystemName="icd10gm2006">
    <!-- Diagnosesicherheit 6003-->
    <qualifier>
      <name code="DSH" codeSystem="111.111.1.1.1"/>
      <value code="G" codeSystem="1.2.276.0.76.3.1.1.5.1.21"/>
    </qualifier>
    <!-- Seitenlokalisation 6004-->
    <qualifier>
      <name code="SL" codeSystem="111.111.1.1.1"/>
      <value code="R" codeSystem="1.2.276.0.76.3.1.1.5.1.22"/>
    </qualifier>
  </value>
  <!-- Ausnahmetatbestand zu Primärcode**************************************-->
  <entryRelationship typeCode="RSON">
    <observation classCode="OBS" moodCode="EVN">
      <code nullFlavor="NI"/>
      <value xsi:type="ST"></value>
    </observation>
  </entryRelationship>
  <entryRelationship typeCode="MFST">
  <!-- Sekundärcode 6001*************************************************-->
    <observation classCode="OBS" moodCode="EVN">
      <code code="XXX_DX" codeSystem="2.16.840.1.113883.5.4"/>
      <!-- Diagnoseerläuterung 6006**************************************-->
      <text>Diagnoseerläuterung</text>
      <value xsi:type="CD" code="G01" codeSystem="1.2.276.0.76.5.311" codeSystemName="icd10gm2006">
        <!-- Diagnosesicherheit 6003-->
        <qualifier>
          <name code="DSH" codeSystem="2.16.840.1.113883.3.7.1.0"/>
          <value code="G" codeSystem="1.2.276.0.76.3.1.1.5.1.21"/>
        </qualifier>
        <!-- Seitenlokalisation 6004-->
        <qualifier>
          <name code="SL" codeSystem="2.16.840.1.113883.3.7.1.0"/>
          <value code="R" codeSystem="1.2.276.0.76.3.1.1.5.1.22"/>
        </qualifier>
      </value>
      <!-- Ausnahmebegründung zum Sekundärcode 6008***********************-->
      <entryRelationship typeCode="RSON">
        <observation classCode="OBS" moodCode="EVN">
          <code nullFlavor="NI"/>
          <value xsi:type="ST"></value>
        </observation>
      </entryRelationship>
    </observation>
  </entryRelationship>
</observation>

Diagnosis in the Referral Letter / Medical Documentation

The Implementation Guideline „Arztbrief“ (www.hl7.de) as well as related documents lists various examples of how to represent diagnoses via HL7 V3/CDA Release 2 (see [CDAr2Arztbrief]).

Terminology

Introduction

This chapter separates codes in use from normative specifications, in order to allow updates to such codes without having to rewrite the normative part. Therefore this chapter is just informative. Current codes have to be requested.

Due to pending third-party copy rights regarding some of the the following tables, the textual descriptions may not be given here such that the respective fields remain empty.

Overview of Value Sets

Value Sets OID Short Term German English
Tumors 1.2.276.0.76.11.1 uicctumor ValueSet für Tumore in der Tumordokumentation ValueSet for tumors in the cancer documentation
Nodes 1.2.276.0.76.11.2 uiccodes ValueSet für Knoten in der Tumordokumentation ValueSet for nodes in the cancer documentation
Metastases 1.2.276.0.76.11.3 uiccmetastasen ValueSet für Metastasen in der Tumordokumentation ValueSet for metastases in the cancer documentation
ResidualTumor 1.2.276.0.76.11.4 uiccresidualtumor ValueSet für Residualtumor in der Tumordokumentation ValueSet for residual tumor in the cancer documentation
Stage Classification 1.2.276.0.76.11.5 uiccstages ValueSet für die Stadiengruppier ung in der Tumordokumentation ValueSet for stages in the cancer documentation
Venous Invasion 1.2.276.0.76.11.6 uiccveneninvasion ValueSet für die Veneninvasion in der Tumordokumentation ValueSet for venous invasion in the cancer documentation
Lymphatic Invasion 1.2.276.0.76.11.7 uicclymphsysteminvasion ValueSet für die Lymphsysteminvasion in der Tumordokumentation ValueSet for the lymphatic system invasion in the cancer documentation
Perineural Invasion 1.2.276.0.76.11.8 uiccneuralscheideninvasion ValueSet für die Neuralscheideninvasion in der Tumordokumentation ValueSet for the perineural invasion in the cancer documentation
TNM Qualifier 1.2.276.0.76.11.9 uicctnmqualifier ValueSet für die TNM-Qualifier in der Tumordokumentation ValueSet for tnm qualifier in the cancer documentation
TNM Localisation for Tumor Documentation 1.2.276.0.76.11.10 uicclocalisation ValueSet für die TNM-Seitenlokalisation in der Tumordokumentation ValueSet for tnm localisation in the cancer documentation

Table 12: Value Sets

UICC 5. Edition (OID 2.16.840.1.113883.15.8) UICC 6. Edition (OID 2.16.840.1.113883.15.7) UICC 7. Edition (OID 2.16.840.1.113883.15.6)


Overview of Coding Schemata

Vocabulary Domain/Coding System OID Short Term
ICD10GM
ICD­10 GM Version 2012 1.2.276.0.76.5.409 icd10gm2012
ICD­10 GM Version 2011 1.2.276.0.76.5.388 icd10gm2011
ICD­10 GM Version 2010 1.2.276.0.76.5.384 icd10gm2010
ICD­10 GM Version 2009 1.2.276.0.76.5.356 icd10gm2009
ICD­10 GM Version 2008 1.2.276.0.76.5.330 icd10gm2008
ICD­10 GM Version 2007 1.2.276.0.76.5.318 icd10gm2007
ICD­10 GM Version 2006 1.2.276.0.76.5.311 icd10gm2006
ICD­O
ICD­O­3 2.16.840.1.113883.6.43.1 icd­o­3
ICD­O­DA­1978 n.a.
ICD­O­DA­2002 n.a.
TNM
C­Faktor 1.2.276.0.76.5.341 c­faktor­tumor
TNM 5. Edition 2.16.840.1.113883.15.8 tnm5
TNM 6. Edition 2.16.840.1.113883.15.7 tnm6
TNM 7. Edition 2.16.840.1.113883.15.6 tnm7
Dignity 1.2.276.0.76.5.335 dignitaet­tumor
Cell­ Type 1.2.276.0.76.5.???
Validity R­Classification 1.2.276.0.76.5.???
Existence of Residual Tumor 1.2.276.0.76.5.???
Tumor Diagnoses 1.2.276.0.76.5.334 tumordiagnosen
Grading 1.2.276.0.76.5.336 grading_tumor
­Localisation of Metastases 1.2.276.0.76.5.401
Scores
Gleason­Score
Gleason­Score: Loss of Differentiation 1.2.276.0.76.5.402
Gleason­Score: Growth Pattern 1.2.276.0.76.5.403
Gleason­Score: Grading 1.2.276.0.76.5.404
Ann­Arbor 1.2.276.0.76.5.405
Papanikolaou: Grading 1.2.276.0.76.5.406
Alpha­ID
Alpha­ID 2012 1.2.276.0.76.5.408 alphaid2012
Alpha­ID 2011 1.2.276.0.76.5.387 alphaid2011
Alpha­ID 2010 1.2.276.0.76.5.383 alphaid2010
Alpha­ID 2009 1.2.276.0.76.5.355 alphaid2009
Alpha­ID 2008 1.2.276.0.76.5.329 alphaid2008
Alpha­ID 2007 1.2.276.0.76.5.316 alphaid2007
Alpha­ID 2006 1.2.276.0.76.5.309 alphaid2006
MeSH
MeSH 2.16.840.1.113883.6.177.5 MSHGER
Snomed CT
SNOMED CT 2.16.840.1.113883.6.96 SNOMED CT
ID Macs
ID Macs 1.2.276.0.76.5.305 id_macs
Typing Diagnosis 1.2.276.0.76.5.342

Table 13: Coding Schemata

Diagnosis Types In Germany

The following codes are being used for typing of diagnoses. This table is a pragmatic collection of the current state-of-the-art in german systems. An international classification is not available at this time.

Code Meaning
DX Diagnosis, not specified any further
RFFDX Referral Diagnosis
ENTDX Entry Diagnosis
TRFDX Transfer Diagnosis
ADMDX Admittance Diagnosis
CDDX Clinical Department’s Diagnosis
CDXDX Clinical Department’s extra Diagnosis
CDTDX Clinical Department’s Treatment Diagnosis
CDDISDX Clinical Department’s Discharge Diagnosis
CDADMDX Clinical Department’s Admittance Diagnosis
SUCCDX Successive Diagnosis (with continuing sick leave)
DISDX Discharge Diagnosis
TDX Transfer Diagnosis
PERMDX Permanent Diagnosis
APERMDX Anamnestic Permanent Diagnosis
BPERMDX Treatment-related Permanent Diagnosis
EMERDX Emergency-related Diagnosis
REIMDX Reimbursement Diagnosis
POSTOPDX Post-operative Diagnosis
PREOPDX Pre-operative Diagnosis
ADR UAW ­Observed Unwanted Side Effects
ADRPD UAW Main Disease
ADRCCD UAW Side Disease  
IFSGDX If–G ­Diagnoses
IFSGSUSPDX If–G ­Suspicious Diagnoses
IFSGDD If–G ­Differential Diagnoses
COD Cause of Death (fatal disease)
CCCOND Accompanying Diseases
EXTCS External Cause
NEO Neoblasts
UAE Unwanted Medication Event
UAW Unwanted Medication Effect12
CAREDX Care Diagnosis
SYMDX Symptom
OTHDX Miscellaneous Diagnosis

Table 14: Diagnosis Types (OID 1.2.276.0.76.5.342)

ICD-O Codes

Dignity

Dignity refers to a tumor property related to their biological behavior in the body. 13

Meaning Code
0 benign
1 Neoplasm with uncertain or unknown behaviour
2 Carcinoma in situ
3 malign, Primary Tumor
6 malign, Metastasis
9 malign, not differentiated between Primary Tumor or Metastasis

Table 15: Dignity Codes (OID 1.2.276.0.76.5.335)

12 In this case, a cause has to be documented along with the diagnosis – but that is not covered in this implementation guide. It also has to be clarified whether such diagnosis is equal to “suspicious for”. 13 DIMDI www.dimdi.de ICD10GM, ICDO3


Grade of Differentiation/Grading

The following table lists possible gradings. The entity column lists to what tumor entities these grades apply. ref.14

Code Description German Entity
0 Primary acquired melanosis Malignant Melanoma of Conjunctiva
1 well differentiated Gut differenziert all but Prostata, Malignant Melanoma of Conjunctiva
Well differentiated (slight anaplasia) (Gleason 2­4) Prostata
Malignant melanoma arising from a naevus Malignant Melanoma of Conjunctiva
2 moderately differentiated Mäßig differenziert all but Prostata, Malignant Melanoma of Conjunctiva
Moderately differentiated (moderate anaplasia) (Gleason 5–6) Prostata
Malignant melanoma arising from primary acquired melanosis Malignant Melanoma of Conjunctiva
3 poorly differentiated Schlecht differenziert all but Prostata, Penis, Kidney, Renal Pelvis and Ureter, Urinary Bladder, Urethra, Malignant Melanoma of Conjunctiva
Malignant melanoma arising de novo Malignant Melanoma of Conjunctiva
3­4 Poorly differentiated/ undifferentiated (marked anaplasia) (Gleason 7– 10) Prostata
Poorly differentiated/ undifferentiated Penis, Kidney, Renal Pelvis and Ureter, Urinary Bladder, Urethra
4 undifferentiated Undifferenziert all but Prostata, Penis, Kidney, Renal Pelvis and Ureter, Urinary Bladder, Urethra, Malignant Melanoma of Conjunctiva
9 Grading not performed, not given or not applicable
L low malignity (G1­G2) Niedriggradig maligne (G1­G2)
M intermediate malignity (G2­G3) Mittelgradig maligne (G2­G3)
H high malignity (G3­G4) Hochgradig maligne (G3G4)
B Borderline Grenzfall
X grade of differentiation cannot be assessed Differenzierungs­grad nicht be­stimmbar
This Grading may either be a qualifier in a containing ICDO or be documented as a component in a stand-alone code.

Table 16:Grade of Differentiation/Gradings (OID 1.2.276.0.76.5.336) 14 DIMDI www.dimdi.de ICD-O-3


Cell Type

This qualifier identifies the immune phenotype related to a lymphoma.

Code Meaning Explanation  
T T­ cell type affects T ­lymphocytes
B B­ cell type affects B lymphocytes
N   Null cell type NHL  Th0, null cell type lymphoma (and T-cell)
K Natural­ Killer cell type   affects NK­ cells: rare lymphoma, mostly in nose or of nasal type
X not determineable (undifferentiated lymphoma)
9 affected cell type determination not performed, not specified or not applicable
U unknown, nullFlavor=UNK

Table 17: Lymphoma-Affected Cell Type (OID 1.2.276.0.76.5.???)

Validity of R Classification

This qualifier documents the focus of the Residual¬ Classification15.

Code Meaning Explanation  
L locoregionary tumor nearby tumor(s)
M distant metastasis distant secondary tumors
G overall phenomenon

Table 18: Validity of R-Classifikation (OID 1.2.276.0.76.5.???) 15 Altmann based on TNM V7, Giessen, 2010

Existence of Residual Tumor

This qualifier indicates, where a Residual Tumor exists ref. 16.

Code Meaning Explanation
L locoregionary tumor nearby tumor(s)
F distant metastasis distant secondary tumors
B both
U unknown nullFlavor=UNK

Existence of residual Tumor

16 Dudeck J. Basisdokumentation für Tumorerkrankte. Giessen. 1999.

Codes for TNM-Classification

Tumors

This section lists known T-Categories ref. 17 (without representing possible extensions). Descriptions vary with the related entity. Codes shall be used along with tumor diagnosis, as one code may have different meanings. (e.g. T1 may refer to 23 cm or 24 cm).

Code Description Explanation 5. 6. 7.
Ta X X X
Tis Carcinoma in situ non invasive X X X
T0 No evidence of primary tumour X X
T1 X X X
T1mic micro invasion X X X
T1a X X X
T1a1 X X X
T1a2 X X X
T1b X X X
T1b1 X X X
T1b2 X X X
T1c X X X
T1d X
T2 X X X
T2a X X X
T2a1 X
T2a2 X
T2b X X X
T2c X X X
T2d X
T3 X X X
T3a X X X
T3b X X X
T3c X X X
T3d X X
T4 X X X
T4a X X X
T4b X X X
T4c X X X
T4d X X X
T4e X
TX Primary tumor cannot be assessed Stage of primary tumor cannot be determined

Table 20: (T) Tumor Codes Value Set (OID 1.2.276.0.76.11.1) 17 TNM 5.,6.,7. Edition

Nodes

Any code for involvement of lymph nodes shall only be used together with tumor diagnosis.

UICC UICC UICC
Code Description Meaning Entity 5. 6. 7.
N0 No regional lymph node metastasis no lymph node affected all X X X
N1 X X X
N1mi Bilateral regional lymph node metastasis vulva X X
N1a all X X X
N1b X X X
N1b1 X
N1b2 X
N1b3 X
N1b4 X
N1c X X
N2 X X X

Table 21: (N) Lymph Node Codes Value Set (OID 1.2.276.0.76.11.2)

Metastasis

Code describing distant metastases shall only be used together with tumor diagnosis.

Code Description German Entity 5. 6. 7.
UICC UICC UICC
M0 No distant metastasis Fernmetastasen nicht vorhanden all X X X
M1 Distant metastasis Fernmetastasen vorhanden all X X X
M1a only oesophagus / prostate X X X
M1b only oesophagus / prostate X X X
M1c X X X
M1d X
M1e X
MX Distant metastasis cannot be assessed all X X X

Table 22: (M) Metastasis Code Value Set (OID 1.2.276.0.76.11.3)

Residual Tumor

Code Description German
R0 No residual tumour kein Residualtumor
R1 Microscopic residual tumour nur mikroskopisch Residualtumor nachweisbar
R2 Macroscopic residual tumour and makroskopischer Residualtumor und
R2a microscopically not confirmed ­mikroskopisch nicht bestätigt
R2b microscopically confirmed ­mikroskopisch bestätigt
RX Presence of residual tumour cannot be assessed Unbekannt

Table 23: Residualtumor Codes Value Set (OID 1.2.276.0.76.11.4)

Stage grading as of UICC

Code Description Meaning 5. 6. 7.
UICC
okk TX, N0, M0 X X X
0 Carcinoma in situ Tis, N0, M0 X X X
0a X X X
0is X X X
I X X
IA T1, N0, M0 X X X
IA1 X X X
IA2 X X X
IB T2, N0, M0 X X X
IB1 X X X
IB2 X X X
IC X X X
II X X X
IIA T1, N1, M0 X X X
IIA1 X
IIA2 X
IIB T2, N1, M0 X X X
IIC T3, N0, M0 X X X
III X X X
IIIA T1, N2, M0 X X X
IIIA T2, N2, M0
IIIA T3, N1,2, M0
IIIB T4, each N, M0 X X X
IIIB each T, N3, M0
IIIC X X X
IS X X X
IV each T, each N, M1 X X X
IVA X X X
IVB X X X
IVC X X X
not defined X X X
not recommended X X

Table 24: Stage Classification ref. 18 Value Set (OID 1.2.276.0.76.11.5)

18 In: Schmoll HJ, Höffken K, Possinger K eds. Kompendium Internistische Onkologie. „Collection of Internistic Oncology “. Springer. 4. Edition; 2006

Venous Invasion

Code Description German
V0 no venous invasion keine Veneninvasion
V1 microscopic venous invasion mikroskopische Veneninvasion
V2 macroscopic venous invasion makroskopische Veneninvasion
VX venous invasion cannot be assessed Veneninvasion nicht feststellbar

Table 25: Venous Invasion Code Value Set (OID 1.2.276.0.76.11.6)

Lymphatic System Invasion

Code Description German
L0 no lymphatic invasion keine Lymphsysteminvasion
L1 lymphatic invasion Lymphsysteminvasion
LX lmphatic invasion cannot be assessed Lymphsysteminvasion nicht fest­stellbar

Table 26: Lymphatic Invasion Codes Value Set (OID 1.2.276.0.76.11.7)

Perineural Invasion

Code Description German
Pn0 no perineural invasion keine perineurale Invasion
Pn1 Perineural invasion perineurale Invasion
PnX unknown Unbekannt

Table 27: Perineural Invasion Code Value Set (OID 1.2.276.0.76.11.8)

Qualifier

Code Description German
c Assessment according to clinical criteria Beurteilung nach klinischen Kriterien
p according to the pathological results nach dem pathologischen Befund
r TNM result of recurrent tumor TNM­Befund für Rezidivtumor
y Classification of initial multimodal therapy Klassifikation nach initialer multi­modaler Therapie

Table 28: TNM-Qualifier Value Set (OID 1.2.276.0.76.11.9)

Certainty

Code Description of Evidence German
C1 Evidence from standard diagnostic means (e.g., inspection, palpation, and standard radiography, intraluminal endoscopy for tumours of certain organs) Nachweis durch diagnostische Standardmethoden (Inspektion, Palpation, einfache Röntgenaufnahmen)
C2 Evidence obtained by special diagnostic means (e.g., radiographic imaging in special projections, tomography, computerized tomography [CT], ultrasonography, lymphography, angiography,scintigraphy,magnetic resonance imaging [MRI],endoscopy, biopsy, and cytology) Nachweis durch spezielle klinische diagnostische Methoden einschließlich Computertomogramm, Magnet­Resonanz­Tomographie
C3 Evidence from surgical exploration, including biopsy and cytology Nachweis durch Operation, einschließlich Biopsie und Zytologie
C4 Evidence of the extent of disease following definitive surgery and pathological examination of the resected specimen Nachweis durch operative Behandlung mit pathologischer Untersuchung der entnommenen Gewebeteile
C5 Evidence from autopsy Nachweis durch Autopsie

Table 29: Certainty Factor Codes (OID 1.2.276.0.76.5.341)

Localisation of Distant Tumours / Metastases

Code Description German Explanation
PUL Pulmonary Pulmonal Lungenmetastase
OSS Osseous Ossär Knochenmetastase
HEP Hepatic Hepatisch Lebermetastase
BRA Brain Cerebral Hirnmetastase
LYM Lymph Nodes Lymphonodulär Lymphknotenmetastase
OTH Others Andere Andere Metastase
MAR Bone Marrow Medullär Knochenmarkmetastase
PLE Pleura Pleural RippenfellMetastase
ADR Adrenals Adrenal Nebennierenmetastase
SKI Skin dermal Hautmetastase

Table 30: Metastases Localisation Codes (OID 1.2.276.0.76.5.401)

Codes for Gleason Score

The Gleason Grading system helps evaluating the prognosis of men with prostate cancer, as a part of a strategy of prostate cancer staging which predicts prognosis and guides therapy. The Gleason score is based on microscopic findings.

Code Description German
1 Round to oval equal individual glands, lying close to each other, sharply demarcated from the surrounding area Runde bis ovale gleich große Einzeldrüsen, dicht nebeneinander liegend, scharf gegen die Umgebung abgegrenzt
2 Slightly less uniform single glands, separated by small amounts of stroma, less sharply defined tumor margin Etwas weniger uniforme Einzeldrüsen, getrennt durch geringe Mengen von Stroma, weniger scharf begrenzter Tumorrand
3 a) Irregularly large and irregularly shaped glands, usually with abundant stroma, sometimes also stored tightly irregular and indistinct tumor border Unregelmäßig große und unregelmäßig gestaltete Drüsen mit gewöhnlich reichlicherem Stroma, gelegentlich auch dicht gelagert, unregelmäßige und unscharfe Tumorgrenze
b) Papillary or cribriform structures, sometimes in large gang­like formations Papilläre oder kribriforme Strukturen, z.T. in großen gangähnlichen Bildungen
4 "a) Large irregular epithel formations by glandular fusion (""fused glands"") and branched glands with irregular infiltration into the surrounding area " Große unregelmäßige Epithelformationen durch Drüsenverschmelzung („fused glands“) sowie verzweigte Drüsen mit unregelmäßiger Infiltration in die Umgebung
b) Adenocarcinoma with prominent clear cytoplasm similar to clear cell adenocarcinomas of the kidney Adenokarzinom mit ausgeprägt klarem Zytoplasma ähnlich hellzelligen Adenokarzinomen der Niere
5 a) Circumscribed round epithelial clusters with mostly solid and cribriform construction, usually with central necrosis Scharf begrenzte runde Epithelhaufen mit meist solidem und kribriformem Bau, gewöhnlich mit zentraler Nekrose
(comedo carcinoma­like) (komedo­karzinomähnlich)
b) Irregularly shaped formations of an undifferentiated carcinoma, which only just discernible glandular formation or is identified vacuoles (signet ring­like) than adenocarcinoma Unregelmäßig begrenzte Formationen eines undifferenzierten Karzinoms, das nur durch gerade noch erkennbare Drüsenbildung oder Vakuolen (siegelringähnlich) als Adenokarzinom zu identifizieren ist

Table 31: Loss of Differentiation according to Gleason Score ref. 19 (OID 1.2.276.0.76.5.402)

Documentation by the GleasonSum (Gleason¬Score) as the sum of the two most dominating findings: Uniformly structured tumors: two times the points of above table. Non-uniformly structured tumors: points for the dominating share of findings (so-called primary grading) + points for second-largest share (secondary grading), if punch biopsy show more than two grades, the second component will be based on the most adverse component found.

19: Dt. Gesellschaft f. Urologie e.V.

Ann Arbor Codes

The tumor staging system for lymphomas.

Principal Stages

Code Description
I cancer is located in a single region, usually one lymph node and the surrounding area
II cancer is located in two separate regions, an affected lymph node or organ and a second affected area, and that both affected areas are confined to one side of the diaphragm
III cancer has spread to both sides of the diaphragm, including one organ or area near the lymph nodes or the spleen
IV diffuse or disseminated involvement of one or more extralymphatic organs

Table 33: Ann Arbor (OID 1.2.276.0.76.5.405)

Modifiers for Constitutional Symptoms

Code Description
A absence of constitutional symptoms is denoted by adding an ""A""
B presence of constitutional (B-type) symptoms is denoted by adding a ""B""

Table 34: Ann Arbor constitutional symptoms (OID 1.2.276.0.76.5.416 Attention icon.svg Falsche OID: 1.2.276.0.76.5.416 ist atcgm2013))

Modifiers for Spread of Tumor

Code Description
E disease is ""extranodal"" (not in the lymph nodes) or has spread from lymph nodes to adjacent tissue.
S the disease has spread to the spleen.
X the largest deposit is >10 cm large (""bulky disease""), or the mediastinum is wider than 1/3 of the chest on a chest X-ray.

Table 35: Ann Arbor Extensions for Spreading in Organs Code Set (OID 1.2.276.0.76.5.417) Attention icon.svg Falsche OID: 1.2.276.0.76.5.417 ist icd10gm2014

Papanicolaou Coding

Results of the so-called Pap-Test

Code Meaning
Pap0 non representative sample
PapI normal cell findings
PapII atypical, benign disorder, infection, metaplasia, atrrophy, bacteria, viruses,
PapIIw insufficient samples
PapIII cell proliferation and atypic cells
PapIIID dysplastic , mostly with HPV infection
PapIIIG moderate/severe dyskaryosis and/or dysplasia
PapIV biopsy sample and histological clarification required
PapIVa carcinoma in situ
PapIVb single certain tumour cells, carcinoma very certain
PapV many certain tumour cells, carcinoma certain, cellular changes suggestive of invasive squamous carcinoma, and cellular changes indicative of adenocarcinoma of the uterine cervix and other invasive cancer.

Table 36: Grading according to Papanicolaou (OID 1.2.276.0.76.5.406)