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===Using more Attributes of Observation===
 
===Using more Attributes of Observation===
 +
 +
In diesem Abschnitt werden Attribute der Klasse Observation beschrieben, die zwar nicht
 +
direkt zur Beschreibung einer Diagnose verwendet werden, aber eventuell doch benutzt
 +
werden müssen.
 +
4.12.1. Das Attribut – id
 +
id Diagnose-Identifikator
 +
SET <II>[0..1]
 +
Über das Attribut id kann die Diagnose eine eindeutige Identifikation innerhalb eines
 +
Systems erhalten. Für die Verarbeitung von Diagnosedaten über ein rechnergestütztes
 +
System ist die Vergabe von Ids empfehlenswert, um gezielt auf den Datensatz der
 +
Diagnose zugreifen zu können. In der XML-Repräsentation wird die Diagnose-ID im
 +
Attribut @extension und die OID des Systems im Attribut @root angegeben.
 +
Sollen für Diagnosen später Änderungen oder Löschungen kommuniziert werden, ist eine
 +
eindeutige Referenzierung über diese Identifikation unerlässlich.
 +
4.12.2. Das Attribut – classCode
 +
@classCode classCode <= OBS
 +
Das Attribut spezifiziert den Haupttyp des Akts, der über eine Instanz repräsentiert wird.
 +
Über eine Klasse Observation wird immer eine Observation (Beobachtung) dargestellt.
 +
Somit hat das Attribut @classCode den festen Wert OBS. In der XML-Struktur wird das
 +
Attribut als XML-Attribut des Elements Observation dargestellt.
 +
Die Angabe des Attributs in der XML-Strukur ist optional. Wird es nicht angegeben, geht
 +
das empfangende System von dem festen Wert aus und verwendet diesen zur weiteren
 +
Verarbeitung.
 +
4.12.3. Das Attribut – moodCode
 +
@moodCode Mood-Code <= EVN
 +
Das Attribut @moodCode beschreibt, wie der Inhalt einer Act-Klasse zu interpretieren ist.
 +
Für die Klasse Observation, die eine Diagnose beschreibt, hat das Attribut den festen
 +
Wert EVN. Damit wird ausgedrückt, dass es sich um eine Dokumentation eines
 +
vorangegangen Dienstes handelt, also um die Dokumentation des Ergebnisses einer
 +
Beobachtung.
 +
Implementierungsleitfaden v1.1
 +
Diagnoseleitfaden für HL7-Version 3 CDA Rel.2 Seite 25
 +
4.12.4. Das Attribut – negationInd
 +
@negationInd Negation-Indikator
 +
BL [0..1]
 +
Das Attribut @negationInd ist vom Datentyp BL und hat damit die Ausprägungen “true”
 +
oder “false”. Wird das Attribut mit „true“ angegeben, so wird ausgesagt, dass die über
 +
die Observation-Klasse beschriebene Beobachtung negiert wird. In Bezug auf die
 +
Diagnosendarstellung bedeutet das, dass die beschriebene Diagnose nicht zutrifft.
 +
Die Angabe des Attributs ist optional. Wird es nicht angegeben, geht das empfangende
 +
System von dem Default-Wert aus und verwendet diesen zur weiteren Verarbeitung. Der
 +
Default–Wert ist „false“.
 +
4.12.5. Das Attribut – statusCode
 +
statusCode Statuscode <= completed
 +
Über dieses Attribut wird Status in dem der beschriebene Act sich befindet angegeben.
 +
Ein Act kann z.B. den Status „new“, „active“ oder „cancelled“ besitzen. Die Beobachtung
 +
einer Diagnose wird mit der Dokumentation als abgeschlossene Handlung betrachtet.
 +
Somit wird für das Attribut statusCode der feste Wert „completed“ vorgegeben.
 +
4.12.6. Beispiel-Darstellung
 +
Für die oben erläuterten Attribute ist nachfolgend ein Beispiel aufgeführt.
 +
<observation classCode="OBS" moodCode="EVN" negationInd="true">
 +
…
 +
<statusCode code="completed"/>
 +
…
 +
</observation>
  
 
==Representation of Diagnosis in specific Codesystems==
 
==Representation of Diagnosis in specific Codesystems==

Version vom 10. November 2011, 10:53 Uhr

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Information icon.svg Representation of Diagnosis based on the Clinical Document Architecture Rel.2 for Healthcare in Germany Version 1.1


Inhaltsverzeichnis

Introduction

Introduction

Scope

Diagnosis Types

Common Diagnosis Descriptions

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 shal 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 Confidence

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

the diagnosis confidence 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 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>

XML attribut @code in name shall specify the name of the diagnosis confidence qualifier, based on the table given below. 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) 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 Confidence/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 8superior) 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

In diesem Abschnitt werden Attribute der Klasse Observation beschrieben, die zwar nicht direkt zur Beschreibung einer Diagnose verwendet werden, aber eventuell doch benutzt werden müssen. 4.12.1. Das Attribut – id id Diagnose-Identifikator SET <II>[0..1] Über das Attribut id kann die Diagnose eine eindeutige Identifikation innerhalb eines Systems erhalten. Für die Verarbeitung von Diagnosedaten über ein rechnergestütztes System ist die Vergabe von Ids empfehlenswert, um gezielt auf den Datensatz der Diagnose zugreifen zu können. In der XML-Repräsentation wird die Diagnose-ID im Attribut @extension und die OID des Systems im Attribut @root angegeben. Sollen für Diagnosen später Änderungen oder Löschungen kommuniziert werden, ist eine eindeutige Referenzierung über diese Identifikation unerlässlich. 4.12.2. Das Attribut – classCode @classCode classCode <= OBS Das Attribut spezifiziert den Haupttyp des Akts, der über eine Instanz repräsentiert wird. Über eine Klasse Observation wird immer eine Observation (Beobachtung) dargestellt. Somit hat das Attribut @classCode den festen Wert OBS. In der XML-Struktur wird das Attribut als XML-Attribut des Elements Observation dargestellt. Die Angabe des Attributs in der XML-Strukur ist optional. Wird es nicht angegeben, geht das empfangende System von dem festen Wert aus und verwendet diesen zur weiteren Verarbeitung. 4.12.3. Das Attribut – moodCode @moodCode Mood-Code <= EVN Das Attribut @moodCode beschreibt, wie der Inhalt einer Act-Klasse zu interpretieren ist. Für die Klasse Observation, die eine Diagnose beschreibt, hat das Attribut den festen Wert EVN. Damit wird ausgedrückt, dass es sich um eine Dokumentation eines vorangegangen Dienstes handelt, also um die Dokumentation des Ergebnisses einer Beobachtung. Implementierungsleitfaden v1.1 Diagnoseleitfaden für HL7-Version 3 CDA Rel.2 Seite 25 4.12.4. Das Attribut – negationInd @negationInd Negation-Indikator BL [0..1] Das Attribut @negationInd ist vom Datentyp BL und hat damit die Ausprägungen “true” oder “false”. Wird das Attribut mit „true“ angegeben, so wird ausgesagt, dass die über die Observation-Klasse beschriebene Beobachtung negiert wird. In Bezug auf die Diagnosendarstellung bedeutet das, dass die beschriebene Diagnose nicht zutrifft. Die Angabe des Attributs ist optional. Wird es nicht angegeben, geht das empfangende System von dem Default-Wert aus und verwendet diesen zur weiteren Verarbeitung. Der Default–Wert ist „false“. 4.12.5. Das Attribut – statusCode statusCode Statuscode <= completed Über dieses Attribut wird Status in dem der beschriebene Act sich befindet angegeben. Ein Act kann z.B. den Status „new“, „active“ oder „cancelled“ besitzen. Die Beobachtung einer Diagnose wird mit der Dokumentation als abgeschlossene Handlung betrachtet. Somit wird für das Attribut statusCode der feste Wert „completed“ vorgegeben. 4.12.6. Beispiel-Darstellung Für die oben erläuterten Attribute ist nachfolgend ein Beispiel aufgeführt. <observation classCode="OBS" moodCode="EVN" negationInd="true"> … <statusCode code="completed"/> … </observation>

Representation of Diagnosis in specific Codesystems

ICD-10-GM-coded Diagnoses

Terms of ICD-10 Codes

Secondary Codes
Side Localisation
Confidence of Diagnoses

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 confidence. 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:

Datei:Figure2.jpg 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 Confidence

value.qualifier Diagnosis Confidence 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. 

<!-- 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 confidence, 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 confidence 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

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 then 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, thisexclusion ("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-Faktor (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 Classifikation 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 cliniclal (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 progonossi 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

Representation for specific Use Cases

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 1.2.276.0.76.5.413
Validity R­Classification 1.2.276.0.76.5.414
Existence of Residual Tumor 1.2.276.0.76.5.415
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 1.2.276.0.76.5.413)

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 1.2.276.0.76.5.414) 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

Information icon.svg 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).

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 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

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 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

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)


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)

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)

Appendix A: Other

Appendix B: Indices

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