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Understanding Code Values and Their Applications in Healthcare Coding Systems

This document outlines Real World Concept Types as they relate to coded data in healthcare. It defines key elements such as Code Value, Code Phrase, and Code Translation, providing examples for clarity. The structure for handling coded information is emphasized, detailing the significance of value and replacement within Code Values, as well as the use of ordered lists in Code Phrases. Additionally, it addresses common questions about coded fields, local coding schemes, and conformance requirements, essential for accurate data representation in healthcare.

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Understanding Code Values and Their Applications in Healthcare Coding Systems

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  1. V3DTs: Real World Concepts January 25, 1999 Orlando, FL

  2. Real World Concept Types • Code Value • Code Phrase • Code Translation • Concept Descriptor

  3. Code Value (definition) • value (Character String, conditional) • code system (code, required) • code system version (Character String, optional) • print name (Character String, optional) • replacement (Character String, conditional) • Condition: An instance of a code value will contain either a value or a replacement, but not both.

  4. Code Value (example 1) Patient Blood Type == Code Value { value “F-D1111”, code-system “SMI” -- from a table code-system-version “3.4” print-name “Blood group A” }

  5. Code Value (example 2a) Patient Sex == Code Value { value “M”, code-system “HL70001” code-system-version “3.0” print-name “Male” }

  6. Code Value (example 2b) Tetanus Special Circumstances == Code Value { value “3”, code-system “DEEDS4.31” -- subpart needed? code-system-version “1.0” print-name “only the year is known” }

  7. Code Value (example 3) Patient Sex == Code Value { code-system “HL70001” code-system-version “3.0” replacement “Male Pseudo-hermaphrodite” } • Desired value is not a member of the coding system

  8. Code Value (incorrect 4) Patient Sex == Code Value { value “MPH” code-system “HL70001” code-system-version “3.0” replacement “Male Pseudo-hermaphrodite” } • Value and Replacement should not be present at the same time.

  9. Code Value (example 5) Patient Blood Type == Code Value { value “F-D1111”, code-system “SMI” -- from a table } • Code System Version and Print Name are not required.

  10. Code Phrase (definition) • ORDERED LIST OF Code Value

  11. Code Phrase (example 1) Body Location == Code Phrase { { value “R” code-system “99Lab” -- A Local coding system print-name “right” } { value “ARM” code-system “99Lab” print-name “arm” } } • Note that the “roles” (side, body part) of these items are not specified. Roles can be specified by making separate coded fields in a message.

  12. Code Phrase (example 2) Body Location == Code Phrase { {value “R” code-system “99Lab” -- A Local coding system print-name “right” } {code-system “99Lab” replacement “anterior axillary fold” } } • A Code Phrase can consist of a true code and a replacement code as part of the same ordered list.

  13. Code Translation (definition) • term (Code Phrase, required) • origin (reference to Code Translation, required) • producer (TII, optional) • quality (floating point number, optional) • label (Character String, optional) (Examples are shown with Concept Descriptor)

  14. Concept Descriptor (definition) • SET OF Code Translation (required) • Original Text (Free Text, optional)

  15. Go To Word Document

  16. Questions/Issues • How do we indicate CNE, CWE? • Which type(s) are assigned to a RIM attribute? Can one coded type be substituted for another coded type? • Can “no information” type be substituted for the types within types, or only for the whole field? • Conformance requirements for coded fields • Allow local coding schemes? • Strategy for negation (“Not”)

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