Use of ICPC recording RFE
Procedures for coding information using ICPC vary somewhat according to the type of information being recorded, for example reason for encounter, health problem, or intervention. In order to promote consistent recording and therefore better comparability of data between centres, the following standards are suggested.
Reason for encounter
The primary care provider should identify and clarify the reason for the encounter (RFE) as stated by the patient without making any judgments as to the correctness or accuracy of the reason. This use of the classification is guided by three principles:
- The reason for encounter should be understood and agreed upon between the patient and the provider and should be recognized by the patient as an acceptable description.
- The ICPC rubric chosen should be as close as possible to the original statement of the reason given by the patient and must represent a minimal or no transformation by the provider. However clarification of the patient’s reasons for encounter within the framework of ICPC is necessary so that the most appropriate rubric in the classification can be applied.
- The inclusion criteria listed for rubrics for use in recording health problems/diagnoses are NOT to be used, since the reason for encounter is to be documented from the patient’s point of view, based entirely on the patient’s statement of the reason.
The way in which a patient expresses his/her reason(s) for encounter determines which chapter and which component to use (Figure 1 and Table 2). The entire classification is applicable as patients can describe their reasons for seeking health care in the form of symptoms or complaints, as requests for services, or as health problems.
Most importantly: it is the PATIENT’S statement, clarified by the FP. For coding RFE(s), all ICPC codes may be used. An RFE may be a:
- Symptom/complaint (headache, tiredness, feeling depressed, fear of cancer): 1st component of each chapter;
- Disease (diabetes, mumps): 7th component of each chapter (except chapter Z);
- Request for an intervention (BP, prescription, test results, administrative procedure): 2nd-6th components of each chapter.
- The RFE should be agreed upon by patient and FP, and the code should be as close as possible to the original statement by the patient (or his/ her representative, e.g. parent);
- All RFEs should be coded, regardless of the stage of the encounter at which it is presented;
- Inclusion criteria are NOT TO BE USED when coding RFEs.
Choosing the chapter code
First, choose the chapter:
is the RFE linked to a digestive problem? à D
…to a social problem? à Z
…to a skin problem? à S
To code the RFE it is necessary to first select the appropriate organ system or chapter, assign the correct alpha code, and then the two-digit numeric code in the relevant component such as a symptom or complaint, a diagnosis, or an intervention. The alphabetical index should be used when there is uncertainty about the chapter or component in which a specific reason for encounter should be placed. Chapter A is used for reasons for encounter which relate to unspecified or multiple body systems. When ICPC is used for recording RFE four rules apply to the use of the chapters, and three rules to the use of components. Those rules are listed below with examples of the application of those rules.
The reason for the encounter should be coded as specifically as possible and may require some clarification by the provider.
Chest pain can be coded as A11 (chest pain not otherwise specified [NOS]), or as K01 (pain attributed to heart), or as R01 (pain respiratory), or as L04 (chest symptoms/complaints). The decision as to the correct selection is not based on the opinion of the provider as to the type of chest pain but, rather, to the manner in which the patient expresses his/her reason for encounter when clarification is sought by the provider.
- “Its all over my chest….” A11
- “My chest hurts when I cough” R01
- “I have chest pain…I think its my heart” K01
- “I have chest pain after falling down stairs” L04
When the patient is unable to describe his/her complaint, the reason given by the accompanying person is acceptable as that stated by the patient. (e.g. a mother bringing in a child or relatives accompanying an unconscious patient)
Any problem whatsoever presented verbally by the patient should be recorded as a reason for encounter. Multiple coding is required if the patient gives more than one reason. Code every reason presented at whatever stage in the encounter it occurs.
“I need my blood pressure tablets. Also my breasts are tender and sore” – K50, X18. If later the patients asks “What is this lump on my skin?” that is also coded as a reason for encounter- S04
Choosing the component code
Component 2: Diagnostic, screening and preventive procedures
to be used for RFEs that are a request for such an intervention: e.g., -35: ‘I want a urine test’;
often, the FP will have to clarify the reason for the request in order to able to select the alpha for the chapter. If a patient wants a urine test because of diabetes, the code is T35; if s/he thinks to have a cystitis, the code is U35.
The reasons included in this concept are those in which the patient seeks some sort of procedure, such as “I’m here to have a blood test” (-34). The patient may request a particular procedure in connection with an expressed problem or as a single demand, such as
- “I want the doctor to examine my heart” (K31), or
- “I think I need to have my urine tested” (-35), or
- “I’ve come for the result of my X-ray” (-60), or
- “I need a vaccination” (-44).
Clarification by the provider is necessary to find out why the patient thinks he or she needs a urine test in order to select the appropriate alpha code. If it is because of a possible bladder infection the code is U35; if because of diabetes T35. If the result of an X-ray which is being requested refers to a barium meal – D60. A request for vaccination against Rubella – A44.
Component 3: Treatment, procedures and medication
to be used for RFEs that are a request for such an intervention: e.g., -50: ‘I want medication’;
often, the FP will have to clarify the reason for the request in order to be able to select the alpha for the chapter. If a patient wants (repeat) medication because of hypertension, the code is K50; for sinusitis, the code is R50.
These reasons are expressed when the patient requests a treatment or when the patient refers to the physician’s instructions to return for specific treatment, procedure, or medication as the reason for encounter. Further clarification by the provider is often necessary in order to identify the most appropriate code.
- “I need my medication” (-50). If the patient expresses the reason why he is taking the medication or the provider knows the reason, select the appropriate alpha code eg. for a sinus infection the code would be R50.
- “I’m here to have my cast removed” (-54). If it is evident that, for instance, the patient had a fracture of the left arm the correct alpha code to select would be L.
- “I was told to come for removal of the stitches today” (-54). Although at first one might assume that all suture removal would be in the Skin Chapter, the patient might have stitches from eyelid surgery (F54) or from a phimosis operation (Y54).
Component 1: Symptoms and complaints
The most common reasons patients give for seeking health care are presented in the form of symptoms and complaints14,16,23,24,. Therefore, it is expected that Component 1 (symptoms and complaints) will be used extensively. These symptoms are specific for each chapter; nausea is found in the Digestive Chapter (D09), while sneezing (R07) is located in the Respiratory Chapter. While most of the entries in this component are symptoms specific to the chapter in which they are found, some standardization has been introduced for ease of coding.
Throughout most of the chapters, with the exception of psychological and social, the first rubric(s) relate to the symptom pain. Examples of these are earache (H01) and headache (N01). There are also four standard Component 1 rubrics in each chapter. They are:
- 26 Fear of cancer
- 27 Fear of having a disease or condition
- 28 Limited function/disability
- 29 Other symptoms/complaints
Codes 26 and 27, and sometimes also a few others, are used when the patient expresses concern about or fear of cancer or some other condition or disease.
- “I’m afraid I have TB” -A27
- “I’m worried that I have cancer of the breast” -X26
- “I’m scared of venereal disease” -Y25
Even though the provider thinks that such an expressed fear is unwarranted or illogical, it constitutes the patient’s reason for encounter.
Rubric -28 should be used when the patient’s reason for encounter is expressed in terms of a disability which affects activities of daily life and social functions.
- “I cannot climb stairs because of the cast they have put on my leg for my fractured ankle” – L28 (Component 1) and L76 (Component 7).
- “I can’t work in the office because I can’t sit for any length of time because of my hemorrhoids” – K28 (Component 1) and K96 (Component 7).
In each chapter the component code 29 is the residual or “rag-bag” rubric for symptoms/complaints. This contains uncommon and unusual symptoms and complaints which do not have a separate rubric, and is also appropriate for symptoms/complaints which are not clearly stated. The index should be checked for synonymous terms in other rubrics before using this rubric.
Component 4: Test results
to be used if a patient specifically requests the results of a test, e.g., ‘what came out of the
X-ray of my stomach?’ (D60);
if a patient seeks further information on the underlying problem, consider using the additional code -45 (health education, advice).
This component should be used when the patient is specifically requesting the results of tests previously carried out. The fact that the results of the test may be negative does not affect the use of this component. Often the patient will request the test result and its consequences and seek more information on the underlying problem. In that case, also consider using the additional code -45 (health education, advice).
- “I need the results of my blood test”. If the test was for anaemia code B60, if for lipids T60, if the patient cannot specify A60.
- “I want to know what they found on the X-rays of my stomach that were taken last week” (D60).
- “I am supposed to pick up the result of my urine test and take it to the urologist. I also want to know what he will do and which examinations and treatment I can expect” (U60, U45).
Component 5: Administrative
Administrative reasons for encounter with the health care system include such things as examinations required by a third party (someone other than the patient), insurance forms which require completion, and discussions regarding the transfer of records.
- “I need this medical insurance form completed” (A62).
- “My fracture is healed and I need a certificate to go back to work” (L62).
Component 6: Referrals and other reasons for encounter
If the patient’s reason for encounter is to be referred to another provider -66, -67, and -68 can be used for this purpose. If the patient states his/her reason for the encounter is “being told by you to come back”, or “being sent by someone else”, use -64 or -65.
When a provider initiates a new episode or takes the initiative for the follow-up of an already existing episode of a health problem such as hypertension, obesity, alcoholism, or a smoking habit, it will be appropriate to code the reason for encounter as -64.
A patient presenting with a blocked ear due to earwax, which is removed, has his blood pressure measured and found to be high, and also receives advice about smoking. The patient’s reasons for encounter and the related problems and treatment would be recorded as follows:
- H13 (blocked feeling in ear), H81 (earwax), H51 (removal of earwax).
- K64 (provider initiated), K85 (raised blood pressure), K31 (checking of blood pressure).
- P64 (provider-initiated), P17 (tobacco abuse), P45 (advice to stop smoking).
Component 7: Diagnosis/disease
Use a code from this component if a patient states the RFE as e.g., ‘I am here because of my asthma’ (R96), ‘my hypertension’ (K86), or ‘my diabetes’ (T90).
Note: do this regardless of whether or not the diagnosis is correct; e.g., when the patient states ‘I came for my migraine’, use the code for migraine (N89), even if you know it is, in fact, tension headache.
- First, choose the chapter:
is it a digestive problem? à D
is it a social problem? à Z
is it a skin problem? à S
- Next: choose a component.
- Component 1: Symptoms and Complaints
a symptom/complaint diagnosis sometimes reflects the highest specificity for the time being (e.g. in a patient first presenting with headache, abdominal complaints, feeling tired); the diagnosis may or may not, over time, be modified into a 7th component diagnosis.
- Component 7: Diseases
generally, rubrics in component 7 are ordered as follows:
- infectious diseases
- congenital anomalies
- other specific diseases
- Chapter Z (social problems) has, for obvious reasons, no 7th component
note the following important codes:
- A97: in case a patient presents with a question or symptom leading to the diagnosis ‘no disease’;
- A98: prevention.
These codes are essential, since they preclude patients’ inclusion in a rubric indicating a problem/disease. In the EFP data base, A97 and A98 have been combined into code A97 (no disease/prevention).
- Component 1: Symptoms and Complaints
Only when the patient expresses the reason for encounter as a specific diagnosis or disease should it be coded in Component 7. The reason for encounter of a patient who is known to be a diabetic but comes in complaining of weakness should not be coded to diabetes but to the problem expressed: weakness (A04). However, if the patient states that he has come about his diabetes the diagnosis “diabetes” should be coded as his reason for encounter (T90).
If the patient names a reason for encounter in the form of a diagnosis which the provider knows is not correct, the “wrong” RFE of the patient is coded rather than the “correct” one of the physician; for example a patient presenting with a reason for encounter of “migraine”, when the provider knows it is tension headache, or a patient who is known to have nasal polyps presenting with “hayfever”.
- “I am here because of my hypertension” (K86) “I come every month for the arthritis of my hip” (L89)
Rules for components
The following rules for the use of each component will reinforce the description of the components.
Whenever a code is shown preceded by a dash (-), select the chapter code (alpha). Use A when no specific chapter can be selected, or when multiple chapters are involved. All codes must begin with an alpha code to be complete.
- Biopsy will be coded -52, for digestive system D52, for skin S52.
- Medication prescribed will be coded as -50. A patient requesting medication for asthma R50.
Rubrics from more than one component, or more than one rubric from the same component, can be used for the same encounter if more than one reason is presented by the patient.
- “I’ve had abdominal pain since last night and I vomited several times” D01, D10.
- “I have some abdominal pain and I think that I may have appendicitis” D06, D88.