Clinical Code Set
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A Clinical Code Set is a code set that is a set of alphanumerical strings created by a medical coding system to be used by healthcare information system to identify a health condition, medical procedure, medical treatment, or other clinical-related terms.
- AKA: Medical Code Set.
- Context:
- It can (often) be attributed by a clinical coder.
- It can range from being a Medical Diagnosis Code Set to being a Medical Procedure Code Set.
- It can range from being a Pharmaceutical Code Set to being a Topographical Code Set.
- Example(s):
- a Medical Diagnosis Code Set such as:
- a Medical procedure Code Set such as:
- a Pharmaceutical Code Set such as:
- a Topographical Code Set such as:
- LOINC Code Set,
- …
- Counter-Example(s):
- See: Medical Coding Dictionary, Clinical Terminology Standard, Healthcare Management System, Clinical Trial.
References
2022
- (Wikipedia, 2022) ⇒ https://en.wikipedia.org/wiki/Medical_classification Retrieved:2022-3-6.
- A medical classification is used to transform descriptions of medical diagnoses or procedures into standardized statistical code in a process known as clinical coding. Diagnosis classifications list diagnosis codes, which are used to track diseases and other health conditions, inclusive of chronic diseases such as diabetes mellitus and heart disease, and infectious diseases such as norovirus, the flu, and athlete's foot. Procedure classifications list procedure code, which are used to capture interventional data. These diagnosis and procedure codes are used by health care providers, government health programs, private health insurance companies, workers' compensation carriers, software developers, and others for a variety of applications in medicine, public health and medical informatics, including:
- statistical analysis of diseases and therapeutic actions
- reimbursement (e.g., to process claims in medical billing based on diagnosis-related groups)
- knowledge-based and decision support systems.
- direct surveillance of epidemic or pandemic outbreaks
- There are country specific standards and international classification systems.
- A medical classification is used to transform descriptions of medical diagnoses or procedures into standardized statistical code in a process known as clinical coding. Diagnosis classifications list diagnosis codes, which are used to track diseases and other health conditions, inclusive of chronic diseases such as diabetes mellitus and heart disease, and infectious diseases such as norovirus, the flu, and athlete's foot. Procedure classifications list procedure code, which are used to capture interventional data. These diagnosis and procedure codes are used by health care providers, government health programs, private health insurance companies, workers' compensation carriers, software developers, and others for a variety of applications in medicine, public health and medical informatics, including:
2010
- (Babre. 2010) ⇒ Deven Babre (2010). "Medical Coding in Clinical Trials". In: Perspectives in clinical research, 1(1), 29.
- QUOTE: Data generated in all clinical trial are recorded on the data collection instrument Case report Form/Electronic Case Report Form by investigators located at various sites in various countries. In multicentric clinical trials since different investigator or medically qualified experts are from different sites/centers recording the medical term(s) uniformly is a big challenge. Medical coders from clinical data management team process these terms and perform medical coding. Medical coding is performed to categorize the medical terms reported appropriately so that they can be analyzed/reviewed(...)
Two processes of coding – auto and manual are described below in brief:
- Auto Coding: The term recorded by the investigator on the data collection instrument gets coded automatically if it exactly matches with the appropriate term available in the medical dictionary.
- Manual Coding: Auto coding fails in respect of terms which do not match with the appropriate level of hierarchy in the medical dictionary. All these terms are required to be manually coded by the medical coder assigned to the project. The medical coder will find the appropriate match for the term from among the terms within the assigned dictionary and will manually assign the code(...)
The same process is depicted in a flow chart below
- QUOTE: Data generated in all clinical trial are recorded on the data collection instrument Case report Form/Electronic Case Report Form by investigators located at various sites in various countries. In multicentric clinical trials since different investigator or medically qualified experts are from different sites/centers recording the medical term(s) uniformly is a big challenge. Medical coders from clinical data management team process these terms and perform medical coding. Medical coding is performed to categorize the medical terms reported appropriately so that they can be analyzed/reviewed(...)
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