ICD und OPS

Abstract

This survey describes some general problems of medical classifications and their historical development at international and national levels. The emphasis is on the "International Statistical Classification of Diseases and Related Health Problems (ICD)" of the World Health Organization (WHO). Evolving from an "International List of Causes of Death", initiated more than 100 years ago, particularly since 1948 the ICD has increasingly developed into an internationally essential classification also for all problems of morbidity. In Germany, the implementation for the mandatory coding of diagnoses of inpatients began with ICD-8 in 1968. With the 10th revision (ICD-10) the coding of diagnoses of all inpatient and outpatient cases became mandatory in the year 2000. Since 2004 this specific German version is called ICD-10-GM and revised yearly. No internationally valid classification is available for operations and other medical procedures. "The International Classification of Procedures in Medicine (ICPM)", published by the WHO in 1978, has not been revised since, but served as a model for several national classifications. Also the German "Operationen- und Prozedurenschlüssel (OPS)" (Code of Operations and Procedures), initially published in 1994, derives from the ICPM. Since 2004 both the ICD-10-GM und the OPS are revised yearly. This paper shows historical development, contents and areas of application for ICD-10-GM and OPS. In the case of inpatient treatment, the classifications are mainly used for reimbursement based on the German G-DRG System, in the case of outpatient treatment for the legally required coding of diagnoses and other reasons for medical treatment and of selected surgical procedures for reimbursement purposes.

The influence of a specific ophthalmological electronic health record on ICD-10 coding

“…Every case carries a unique case number, and all visits during that quarter of the year are documented by using this case number. Diagnoses are documented by using the ICD-10 GM system [ 8 ].…”

Early Psychosis in People from Chinese Backgrounds Around the World

“…In the following review sections, we will use the term "early psychosis" when referring to these patients. All subjects were diagnosed using either the Diagnostic and Statistical Manual of Mental Disorders or the International Classification of Diseases and Health Related Problems, 10th version [9,14]. Those with organic or drug-induced psychosis were excluded.…”

“…People from Chinese background constitute the largest population in the world, with 1.3 billion in China and the rest residing in different parts of the world [9]. The Chinese population is the fastest growing immigrant population in the North American continent [10].…”

Oncology on FHIR: A Data Model for Distributed Cancer Research

“…For each primary diagnosis, the therapies performed (surgery, radiation, systemic therapies) are defined using the following profiles. The therapy outcome (Rclassification) is incorporated into the model via further Observations:  Surgery (Procedure): includes surgical data such as OPS [26] and body site  Radiotherapy (Procedure): covers the radiotherapy data  Systemic therapy (MedicationStatement): includes chemotherapy and all types of therapy not covered by surgical data or radiotherapy  Residual status (Observations): overall and local assessment of the residual tumour (R-classification)  Overall assessment of tumour status (Observation): overall assessment of the disease, such as partial remission, complete remission and progressive disease…”