Health problems

ICPC can be used to record the provider’s assessment of the patient’s health problems. This can be done in terms of symptoms and complaints, or diagnoses, so can be derived from Component 1 or Component 7. The latter is based on the lists of diseases, injuries and related health problems in the International Classification of Diseases(ICD), but includes as separate rubrics only those that are common or important in primary care.

Many of the health problems which are managed in primary care cannot be designated in terms of disease or injury. They include symptoms and complaints, which are listed in Component 1. Sometimes there is no apparent health problem involved in an episode of care, as when it relates to need for immunisation or a pap smear or advice. These episodes can be labelled using rubrics such as A97 No Disease, or A98 Health Maintenance/Preventive Medicine. In Components 1 and 7 the corresponding ICD-10 codes are listed for each rubric. Sometimes these are an exact one-to-one match, but more often there are several ICD codes for an ICPC-2 rubric, and sometimes there are several ICPC-2 codes for a single ICD-10 rubric. A full conversion structure is given in Chapter 10.

In order to improve reliability of coding health problems using ICPC-2, many of the rubrics in Component 7 have inclusion criteria specified. These are explained in Chapter 6.

Rubrics in Components 1 and 7 often have additional information as a guide to their use: lists of synonyms and alternative descriptions as inclusion terms; lists of similar conditions which should be coded elsewhere as exclusion terms; and lists of less specific codes which might be considered if the particular patient’s condition does not meet the inclusion criteria. There are no such guidelines for rubrics in the process components 2 to 6.

General rules for coding health problems

  • the diagnosis reflects the FP’s assessment of the patient’s health problem;
  • it may be selected from the 1st component (a symptom diagnosis) or from the 7th component (a disease diagnosis); components 2-6 cannot be used for coding a diagnosis;
  • coding should occur at the highest level of the FP’s diagnostic certainty;
  • rubrics in component 1 and 7 often have criteria (inclusion and exclusion terms, criteria, and ‘consider’).Considering the criteria can be helpful in deciding for, or against, a code.

In ICPC, localization takes precedence over aetiology. When coding a condition that because of its nature could be coded in more than one chapter (e.g.trauma), the most appropriate chapter should be used. Chapter A (general) is mainly to be used in case of an unspecified site, or if the disease affects more than two body systems.

Users are encouraged to record during each encounter, the full spectrum of problems managed, including organic, psychological, and social health problems, in the form of episode(s) of care. Recording should be at the highest level of diagnostic refinement for which the user can be confident, and which meets the inclusion criteria for that rubric.

In any data system it is necessary to have clear and specific criteria for the way in which health problems or episodes of care are recorded. This applies particularly to the relationship between the underlying condition and manifestations when both may be available as rubrics in the classification, and is best illustrated by an example. A patient with ischaemic heart disease may also have atrial fibrillation and resulting anxiety. It should be policy to include as separate episodes of care manifestations which require different management, and in the above example the atrial fibrillation and anxiety would be recorded as additional episodes of care.

Some systems require that problems be coded only from components 1 and 7; others also accept codes from other components, so that if, for example, the patient attends for a tetanus immunization without a current injury, the problem could be coded as N44.

In ICPC localization within body system takes precedence over aetiology, so that when coding a condition which because of its aetiology can be found in several chapters (for example, trauma) the appropriate chapter should be used. Chapter A (general) should be considered only if the site is not specified or if the disease affects more than two body systems. All chapters provide specific rubrics based on the body system or organ involved in the disease and the aetiology. Conditions accompanying and affecting pregnancy or the puerperium are usually coded to Chapter W, but a condition is not coded to Chapter W merely because the patient is pregnant; it should be coded to the appropriate rubric in the chapter representing the body system involved. All social problems, whether identified as a reason for encounter or as a problem, are listed in the first component of Chapter Z.

Specific rules for coding health problems using inclusion criteria (see also Chapter 6)

  1. Coding of diagnoses should occur at the highest level of specificity possible for that patient encounter.
  2. Inclusion criteria contain the minimum number of criteria necessary to permit coding with that rubric.
  3. Consult the criteria after the diagnosis has been formulated. They are NOT guidelines for diagnosis, NOR are they intended to be used as a guide to therapeutic decisions.
  4. If the criteria cannot be fulfilled, consult other less specific rubrics suggested by the term “consider”.
  5. For those rubrics without inclusion criteria, consult the list of inclusion terms in the rubric, and take into account any exclusion terms.

Process of care, interventions

  • For coding interventions (process), components 2, 3, 5 and 6 (except rubrics -63, -64, -65, and -69) can be used;
  • ICPC’s potential to code interventions (process) is limited; rubrics are broad and general;
  • 4th and 5th digits might be added for more specificity, according to national needs.

-31 is a partial examination of a specific organ system or function: e.g., K31, measuring blood pressure. If more than 2 body systems are included, the code should be A31;

-30 refers to a complete examination according to the consensus of local professionals on the standard of care. It may be a complete examination of a body system (e.g., for the eye, F30), or a complete general examination (A30).

ICPC can be used to classify the interventions used in the process of medical care with Components 2, 3, 5, and part of Component 6; however, Component 4 and some rubrics of Component 6, namely, -63, -64, -65, and -69, cannot be used in this way.

These process rubrics are broad and general, rather than specific. For instance, a blood test (-34), even if relating to only one body system (e.g. cardiovascular, K34), may encompass a great variety of different tests such as enzymes, lipids or electrolytes.

The process codes in Components 2, 3, and 5 follow the major headings to be found in the far more detailed IC-Process-PC, which was developed by the WONCA Classification Committee25. ICPC and IC-Process-PC are, therefore, compatible one with the other. The details found in IC-Process-PC may be applied to the three-digit ICPC codes by expanding to four or five digits.

In Components 2, 3, 5, and the part of Component 6 which can be used to classify the process of care, the rubric codes are standard throughout the chapters at the two-digit level. The

alpha code of the correct chapter has to be added by the provider who is doing the coding. A limited number of rubrics in the first and seventh components of Chapters W, X and Y also contain procedures such as delivery, abortion, family planning.

The most important principle in coding process is to code all those interventions which take place during that particular encounter and which have a logical relation to the episode of care. A fourth or fifth digit may be necessary for increased specificity, as in the following examples:

Example 1

-54 Repair/fixation/suture/cast/prosthetic device

L54.1 Application of casts

L54.2 Removal of casts

Example 2

-40 Diagnostic endoscopy

-D40 Diagnostic endoscopy of the digestive system

-D40.1 Gastroscopy

More than one process code may be used for each encounter, but it is extremely important to be consistent. For instance, measuring the blood pressure, which is routine for hypertension, can be coded as K31 on every occasion. Routine examinations, complete or partial, both for body systems or for the general chapter must also be coded with consistency. Below are examples of definitions for complete and partial examinations which have been used in one setting. However, it is essential that each country develops a definition of what constitutes a “complete examination – general” and a “complete examination – body system” for that culture and that these definitions are used consistently. This will ensure that what is contained in each “partial examination – general” or “partial examination – body system”, in that country will also have consistency.

Complete examination

The term “complete examination” refers to an examination which contains those elements of professional assessment which by consensus of a group of local professionals reflects the usual standard of care. This examination will be complete with regard to either the body system (e.g. eye, Chapter F) or as a complete general examination (Chapter A).

Partial examination

The term “partial examination” in any chapter refers to a partial examination directed to the appropriate specific organ system or function. When more than two systems are involved in a limited or incomplete examination it is designated general (Chapter A). Most encounters will include a partial examination to evaluate acute and simple illnesses or return visits for chronic illnesses. The following are examples:

Complete examination – general, general check-up = A30 Complete neurological examination = N30 Partial examination-general, limited check on several body systems such as respiratory and cardiovascular = A31 Partial examination – body system, measuring blood pressure = K31

  • The following procedures are regarded by the WONCA Classification Committee as included in routine examinations to be coded in rubrics -30 and -31 rather than coded separately:
  • inspection, palpation, percussion, auscultation
  • visual acuity and fundoscopy
  • otoscopy
  • vibration sense (tuning fork examination)
  • vestibular function (excluding calormetric tests)
  • digital rectal and vaginal examination
  • vaginal speculum examination
  • blood pressure recording
  • indirect laryngoscopy
  • height/weight

All other examinations are to be included in other rubrics.

Component 2 – Diagnostic and preventive procedures

Diagnostic and preventive procedures cover a wide range of health care activities including immunisations, screening, risk appraisal, education, and counseling.

Component 3 – Medications, treatment, therapeutic procedures

This component is designed to classify those procedures done on site by the primary care provider. It is not intended that it be used to document procedures done by providers to whom the patient has been referred, for which a much more extensive list of procedures would be required. Immunisations are coded in Component 2.

Component 4 – Results

Component 4 does not relate to process or interventions.

Component 5 – Administrative

This component is designed to classify those instances where the provision of a written document or form by the provider for the patient or other agency is warranted by existing regulations, laws, or customs. Writing a referral letter is only considered to be an administrative service when it is the sole activity performed during the encounter, otherwise it is included in Component 6.

Component 6 – Referrals

Referrals to other primary care providers, physicians, hospitals, clinics or agencies for therapeutic or counselling purposes, are to be coded in this component. Referrals for an X-ray or a laboratory investigation should be coded in Component 2.

For more specificity, a fourth digit can be added, for example:

-66 Referral to other provider/nurse/therapist/social worker. -66.1 Nurse -66.2 Physiotherapist -66.3 Social worker

-67 Specialist -67.1 Internist -67.2 Cardiologist -67.3 Surgeon