Medical classification, or medical coding, is the process of transforming descriptions of medical diagnoses and procedures into universal medical code numbers. The diagnoses and procedures are usually taken from a variety of sources within the health care record, such as the transcription of the physician's notes, laboratory results, radiologic results, and other sources.
Diagnosis codes are used to track diseases and other health conditions, whether they are chronic diseases such as diabetes mellitus and heart disease, to contagious diseases such as norovirus, the flu, and athlete's foot. These diagnosis and procedure codes are used by government health programs, private health insurance companies, workers' compensation carriers and others.
Medical classification systems are used for a variety of applications in medicine, public health and medical informatics, including:
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There are many different medical classifications, but they fall into two main groupings: Statistical classifications and Nomenclatures.
A statistical classification brings together similar clinical concepts and groups them into categories. The number of categories is limited so that the classification does not become too big. An example of this is the International Statistical Classification of Diseases and Related Health Problems (known as ICD). It groups diseases of the circulatory system into one "chapter" (known as Chapter IX, covering codes I00–I99). Within this chaper, there is for instance, code I47.1. The code title (rubric) is Supraventricular tachycardia. However, there are several other clinical concepts that are also classified here. Amongst them are paroxysmal atrial tachycardia, paroxysmal junctional tachycardia, auricular tachycardia and nodal tachycardia.
Another feature of statistical classifications is the provision of residual categories for "other" and "unspecified" conditions that do not have a specific category in the particular classification.
In a nomenclature there is a separate listing and code for every clinical concept. So, in the previous example, each of the tachycardia listed would have its own code. This makes nomenclatures unwieldy for compiling health statistics.
Types of coding systems specific to health care include:
The World Health Organization (WHO) maintains several internationally endorsed classifications designed to facilitate the comparison of health related data within and across populations and over time as well as the compilation of nationally consistent data.[1] This "Family of International Classifications" (FIC) include three main (or reference) classifications on basic parameters of health prepared by the organization and approved by the World Health Assembly for international use, as well as a number of derived and related classifications providing additional details. Some of these international standards have been revised and adapted by countries for national use.
Derived classifications are based on the WHO reference classifications (i.e. ICD and ICF).[1] They include:
Related classifications in the WHO-FIC are those that partially refer to the reference classifications, e.g. only at specific levels.[1] They include:
The categories in a diagnosis classification classify diseases, disorders, symptoms and medical signs. In addition to the ICD and its national variants, they include:
The categories in a procedure classification classify specific health interventions undertaken by health professionals. In addition to the ICHI and ICPC, they include:
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