GGastrointestinal EEndoscopic TTerminology CCoding

GET-CGET-C Extension of the ICD-10

M. GroenenW. Hirs, H. Becker, E. Kuipers,

G. van Berge Henegouwen, P. Fockens, R. Ouwendijk

Cancer in Europe 2000n= 2.051.439

0

100000

200000

300000

400000

500000

600000

cancers incidence 2000 Europe

Gi cancer

Lung

Breast

Prostate

Kidney/Bladder

Gynae

ENT

Brain

other

United European Gastroenterology Federation, 2003

No information of endoscopic diagnosis in Europe

COUNTRIES Austria Belgium Denmark Finland France Germany Greece Ireland

Practice in GE                                

Endoscopies Number Number Number Number Number Number Number Number

Colonoscopy     153534           680996              

Total number of procedures per year     143450           831286              

Number of diagnostic procedures     119344           unknown              

Number of therapeutic procedures     24106           unknown              

United European Gastroenterology Federation, 2003

Need for databases

• Surveillance– Polyps– Ulcers and Barrett oesophagus– Inflammatory Bowel Diseases

• Epidemiology

• Quality control

• Research

Endoscopic data that need a specific code

• Indication

• Endoscopic diagnosis

• Therapeutical interventions

• Advice

• Therapy

• Complications

D12 Benign neoplasm of colon, rectum, anus and anal canal ICD-10

D12.0 Benign neoplasm of cecumD12.1 Benign neoplasm of appendixD12.2 Benign neoplasm of ascending colonD12.3 Benign neoplasm of transverse colonD12.4 Benign neoplasm of descending colonD12.5 Benign neoplasm of sigmoid colonD12.6 Benign neoplasm of colon, unspecifiedD12.7 Benign neoplasm of rectosigmoid junctionD12.8 Benign neoplasm of rectumD12.9 Benign neoplasm of anus and anal canal

Important for polyps (1)

• Appearance of the polyp– XXX.X1 Pedunculated polyp– XXX.X2 Sessile polyp– XXX.X3 Villous adenoma– XXX.X4 Flat adenoma– XXX.X5 Hyperplastic polyp– XXX.X6 Incipient polyp

• Therapy, prognosis and follow up

Important for polyps (2)

• Number of polyps– XXX.XX1 One polyp– XXX.XX2 Two polyps– XXX.XX3 More polyps

• < 2 polyps Surveillance endoscopy 6 years• > 2 polyps Surveillance endoscopy 3 years

Benign neoplasm of descending colon

D12.4 Benign neoplasm of desc. Colon

D12.41 Pedunculated polyp in desc. colon D12.411 One ped. polyp in desc. colon D12.412 Two ped. polyps in desc. colon D12.413 Several ped. polyps in desc. colon

D12.42 Sessile polyp in descending colon D12.421 One sessile polyp in desc. colon D12.422 Two sessile polyps in desc. colon D12.423 Several sessile polyps in desc. colon

D12.43 Villous adenoma in desc.colon D12.431 One villous adenoma in desc. colon D12.432 Two villous adenomas in desc. colon D12.433 Several villous aden. in desc. colon

D12.44 Flat adenoma in descending colon D12.441 One flat adenoma in desc. colon D12.442 Two flat adenomas in desc. colon D12.443 Several flat adenomas in desc. Colon

D12.45 Hyperplastic polyp in desc.colon D12.451 One hyperplastic polyp in desc. colon D12.452 Two hyperplastic polyps in desc. colon D12.453 Several hyperpl. polyps in desc. Colon

D12.46 Incipient polyp in descending colon D12.461 One incipient polyp in descending colon D12.462 Two incipient polyps in desc. colon D12.463 Several incipient polyps in desc. colon

K25 Gastric ulcer ICD-10

K25.0 Acute gastric ulcer with hemorrhageK25.1 Acute gastric ulcer with perforationK25.2 Acute gastric ulcer with both hemorrhage and

perforationK25.3 Acute gastric ulcer without hemorrhage or perforationK25.4 Chronic or unspecified gastric ulcer with hemorrhageK25.5 Chronic or unspecified gastric ulcer with perforationK25.6 Chronic or unspecified gastric ulcer with both

hemorrhage and perforationK25.7 Chronic gastric ulcer without hemorrhage or

perforationK25.9 Gastric ulcer, unspecified as acute or chronic, without

hemorrhage or perforation

Important for ulcers (1)

• Forrest Classification• Ia Acute spurting bleeding• Ib Non-spurting active bleeding• IIa Vissible vessel• IIb Overlying clot• IIc Haematin covered basis• III Clean ulcer

– Prognosis– Treatment– Follow up

Extension of ICD-10 to GET-C

Important for ulcers (2)

• Number of ulcers at one location– XXX.XX1 One ulcer– XXX.XX2 Two ulcers– XXX.XX3 Several ulcers

Important for ulcers (3)

• Location of ulcers in stomach– XXX.XXX1 Cardia of stomach– XXX.XXX2 Fundus of stomach– XXX.XXX3 Corpus of stomach– XXX.XXX4 Angulus of stomach– XXX.XXX5 Antrum of stomach– XXX.XXX6 Pyloric region– XXX.XXX8 Whole stomach

New Gastrointestinal Endoscopic Terms

• New chapter with character μ

• Adaptations and extensions performed

by gastroenterologists

• More new techniques expected in near

future

GGastrointestinal EEndoscopic TTerminology CCoding (GET-C)(GET-C)

• Developed by TRANS.IT working group

• Accepted by Dutch Society of Gastroenterologists

• Revised by Dutch translation board of ICD-10

• Submitted for publication international journal

• Important for Epidemiology and Mortality statistics