ICPC Tutorial

INTERNATIONAL
CLASSIFICATION
OF PRIMARY CARE
(ICPC)
ICPC-1: 1987, ICPC-2: 1998,
ICPC-2-E: 2000, ICPC-2-R: 2005

NOTE
This ICPC Tutorial has been developed by
Henk Lamberts and Inge Okkes.
We have used some slides/ideas from
presentations by Dr. Bob Bernstein
(University of Ottawa, Canada), and
Dr.Jean Karl Soler (Attard, Malta).
It is recommended to view the Tutorial in
the presentation mode.

A classification is the
ordering principle of a
defined domain

ICPC
orders the domain
of primary care
(family medicine)…

.. and allows the coding of
encounters in an episode of
care structure

An encounter - the professional
interchange between patient
and FP - is, in ICPC,
characterized by three
elements…

1. patient’s reason(s) for encounter
(RFE): why has s/he come?
2. FP’s diagnosis/es: what’s the
patient’s problem?
3. process: what is done?

An episode of care is a
health problem from its first
presentation to a health care
provider until (and including)
the last encounter for it

At an encounter,
more than 1 episode of care
may be dealt with, e.g.
diabetes and hypertension…

..in such a case, diabetes and
hypertension are the two
sub-encounters in that
encounter

An episode of care can be dealt
with in a single encounter, or
extend over a long period of
time, with any number of
encounters

EPISODE OF CARE
diagnosis,
episode
title
diagnosis,
episode
title
diagnosis,
episode
title
reason for
encounter,
demand
for care
perceived
need
for care
reason for
encounter,
demand
for care
reason for
encounter,
demand
for care
process
process
process
perceived
health
problem
Start of a new episode
of care: first encounter

EPISODE OF CARE
diagnosis,
episode
title
diagnosis,
episode
title
diagnosis,
episode
title
reason for
encounter,
demand
for care
perceived
need
for care
reason for
encounter,
demand
for care
reason for
encounter,
demand
for care
process
process
process
perceived
health
problem
Follow up of an old
episode of care,
second encounter
Follow up of an old
episode of care,
third encounter

Episode of care, example
Process
Hb
Process
colonoscopy
Process
referral,
advice
RFE
‘I’m feeling
tired’
Diagnosis
tiredness
RFE
‘what’s the
test result?’
Diagnosis
iron deficiency
anemia
Diagnosis
Ca colon
RFE
‘what’s the
test result?’
1st
encounter
2nd
encounter
3rd
encounter

ICPC structure
 bi-axial
 one axis: 17 chapters with an alpha
code based on body systems/problem
areas
 second axis: 7 identical components,
with rubrics bearing a two-digit numeric
code

ICPC CHAPTERS
A General and unspecified
B Blood/bloodforming organs, lymphatics (spleen, bone marrow)
D Digestive
F Eye (Focal)
H Ear (Hearing)
K Circulatory
L Musculoskeletal (Locomotion)
N Neurological
P Psychological
R Respiratory
S Skin
T Endocrine, metabolic and nutritional (Thyroid)
U Urological
W Pregnancy, child bearing, family planning (Women)
X Female genital (X-chromosome)
Y Male genital (Y-chromosome)
Z Social problems

ICPC COMPONENTS
(standard, if possible, for all chapters)
1. Symptoms and complaints 1-29
2. Diagnostic and preventive procedures 30-49
3. Treatment procedures, medication 50-59
4. Test results 60-61
5. Administrative 62
6. Referral and other reasons for encounter 63-69
7. Diseases: 70-99
- infectious diseases
- neoplasms
- injuries
- congenital anomalies
- other specific diseases

Chapters and components
together form a ‘chessboard’..

An ICPC code always has an alpha for the chapter, and
two digits for the rubric in the component, e.g.:
Heartburn
Chapter D(igestive), symptom/complaint component 1:
D03
Pneumonia
Chapter R(espiratory), disease  component 7: R81

ICPC provides separate
codes for RFEs, diagnoses,
and interventions that are
frequent in primary care
(≥1/1000 ppy)…

…which is, for diagnoses, only a
small proportion of all
known diseases…

In ICPC, entities without a separate
code are included in rag-bag rubrics
at the end of each (sub)section, where
the diseases included in that rag-bag
are listed..
e.g. S99: other skin disease....

ICPC orders the domain of
primary care…
….but has insufficient granularity to
document all individual patients’ diagnoses

n≈100
n≈600
n≈300
n≈13.000
SYMPTOMS DIAGNOSES
>1/1000 PPY
<1/1000 PPY

For hierarchical expansion of
ICPC, ICD-10 is recommended;
the ICPC2-ICD10 Thesaurus on
this CD-ROM allows…

easy, semi-automatic double coding
by the simultaneous use of:
 ICPC-2 as an ordering principle (based
on the high prevalence of common
diagnoses in family practice),
 and of ICD-10 as a nomenclature
(based on the wide range of ‘known’
diagnoses)

2.
THE CONTENT OF ICPC IN
MORE DETAIL

CODING WITH ICPC
 is easy because of its substantial
mnemonic quality: the chapter’s alpha
refers to the body system (S: Skin), and
components and order of rubrics are, as
far as possible, the same in all chapters;
 first select the chapter: what body system
or problem area?
 next the component (symptom? disease?
intervention?)
 next the rubric

EPISODE OF CARE:
A CORE CONCEPT IN ICPC
• a health problem from its first presentation
to a health care provider until the
completion of the last encounter for it
• the unit of assessment of ICPC coded
data: an individual patient’s problem
followed over time

EPISODE OF CARE: ELEMENTS
 the patient’s Reason(s) for Encounter (RFEs):
 should be recognizable by the patient as an
acceptable description of his/her demand
for care
 the FP’s diagnosis:
 gives the name to the episode of care
 qualified as new or old, and certain or
uncertain
 process: the interventions that occur

REASON FOR ENCOUNTER
(RFE)
......is a true primary care concept, since
primary care is RFE driven rather than
diagnosis driven..

CODING THE RFE (1)
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.

CODING THE RFE (2)
• 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.

CODING THE RFE (3)
First, choose the chapter:
is the RFE linked to a digestive problem?  D
...to a social problem?  Z
...to a skin problem?  S

CODING THE RFE (4)
Next: choose a
component..

CODING THE RFE (5)
Component 1: Symptoms and Complaints
 is the most frequently used component in coding
RFEs;
 generally, -01 refers to pain (e.g., H01, ear pain);
 specific by chapter (nausea D09, red eye F02);
 four standard codes in 1st component of each
chapter:
 -26 fear of cancer;
 -27 fear of another disease;
 -28 limited function/disability;
 -29 other symptoms/complaints (rag-bag rubric).

CODING THE RFE (6)
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.

CODING THE RFE (7)
Component 3: Treatment procedures,
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.

CODING THE RFE (8)
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).

CODING THE RFE (9)
Component 5: Administrative
 for examinations and administrative procedures
required by a third party, insurance forms,
discussions regarding the transfer of records,
certificates, etc.

CODING THE RFE (10)
Component 6: Referrals and other RFEs
 for a request for referral to another primary care
provider (-66) or specialist/hospital (-67);
 if a patient states as RFE that someone else
sent him/her (-65);
 use -64 for the FP’s initiative to start or follow up
an episode of care (see for more on this:
Glossary, initiative of the FP).

CODING THE RFE (11)
Component 7: Diseases
 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.

CODING THE DIAGNOSIS (1)
 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.

The inclusion criteria in ICPC contain the
minimum requirements for that diagnosis. Criteria
are NOT meant as a diagnostic tool, but rather as
a tool to assign the correct code. The next three
slides show examples of criteria in ICPC...

First, choose the chapter:
is it a digestive problem?  D
is it a social problem?  Z
is it a skin problem?  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.

 generally, rubrics in component 7 are ordered as
follows:
 infectious diseases
 neoplasms
 injuries
 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).

CODING PROCESS (1)
 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.

CODING PROCESS (2)
again, first choose the chapter
(usually the same as for the
diagnosis), and next the
component...

CODING PROCESS (3)
 Component 2 for diagnostic, preventive and
screening procedures (including immunizations,
education, counseling);
 Component 3 for medication and treatment
procedures;
 Component 5 for administrative procedures;
 Component 6 for referrals:
 -66 other provider/therapist/social worker (may be extended:
-66.1 nurse, -66.2 psychotherapist, -66.3 social worker, etc.)
 -67 specialist (may be extended: -67.1 internist, -67.2 cardiologist,
-67.3 surgeon, etc);
 -68 other referrals.

CODING PROCESS (4)
 -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).

CODING PROCESS (5)
 the following examinations are to be coded as -31
or (included in) -30:
 inspection, palpation, percussion, auscultation;
 visual acuity and fundoscopy
 otoscopy
 vibration sense (tuning fork examination)
 vestibular function (excluding calorimetric 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

CODING EXERCISE 1: RFE
Chapter Code
Feeling sad ? ?
Diarrhoea ? ?
Fear of colon cancer ? ?
`How is your migraine?’ ? ?
Request X-ray ankle ? ?

RFE: FEELING SAD
Chapter Code
Feeling sad P - psych P03
Diarrhoea
Fear of colon cancer
`how is your migraine?’
Request X-ray ankle

RFE: DIARRHOEA
Chapter Code
Diarrhoea D - digestive D11
Fear of colon cancer
Request X-ray ankle

RFE: FEAR OF COLON CANCER
Chapter Code
Fear of colon cancer D - digestive D26
Request X-ray ankle

RFE: FP’S INITIATIVE (CHAPTER N)
Chapter Code
`how is your migraine?’ N - neurol N64
Request X-ray ankle

RFE: REQUEST X-RAY ANKLE
Chapter Code
`how is your migraine?’ N - neurol N64
Request X-ray ankle L - musc L41

CODING EXERCISE 2: DIAGNOSIS
Chapter Code
measles ? ?
lump breast (female) ? ?
ca breast (female) ? ?
marital problems ? ?

DIAGNOSIS: MEASLES
Chapter Code
measles A - general A71
lump breast (female)
ca breast (female)
marital problems

DIAGNOSIS: LUMP IN BREAST (FEMALE)
Chapter Code
lump breast (female) X - female X19
ca breast (female)
marital problems

DIAGNOSIS: BREAST CANCER
(FEMALE)
Chapter Code
ca breast (female) X - female X76
marital problems

DIAGNOSIS: MARITAL PROBLEMS
Chapter Code
ca breast (female) X - female X76
marital problems Z - social Z12

CODING EXERCISE 3: PROCESS
Chapter Code
prescription psoriasis ? ?
removal ear wax ? ?
discussion marital problems ? ?
referral to nurse ? ?

PROCESS: PRESCRIPTION PSORIASIS
Chapter Code
prescription psoriasis S - skin S50
removal ear wax
discussion marital problems
referral to nurse

PROCESS: REMOVAL EAR WAX
Chapter Code
removal ear wax H - hearing H51
discussion marital problems
referral to nurse

PROCESS: DISCUSSION OF MARITAL PROBLEMS
Chapter Code
discussion marital problems Z - social Z45
referral to nurse

REFERRAL TO NURSE AS PROCESS
Chapter Code
discussion marital problems Z - social Z45
referral to nurse -66.1

CODING EXERCISE 4: EPISODE OF CARE
Process
Hb
Process
colonoscopy
Process
referral,
advice
RFE
‘I’m feeling
tired’
Diagnosis
tiredness
RFE
‘what’s the
test result?’
Diagnosis
iron deficiency
anemia
Diagnosis
Ca colon
RFE
‘what’s the
test result?’
1st
encounter
2nd
encounter
3rd
encounter

RFE: TIREDNESS
Process
Hb
Process
colonoscopy
Process
referral,
advice
RFE
‘I’m feeling
tired’ A04
Diagnosis
tiredness
RFE
‘what’s the
test result?’
Diagnosis
iron deficiency
anemia
Diagnosis
Ca colon
RFE
‘what’s the
test result?’
1st
encounter
2nd
encounter
3rd
encounter

(SYMPTOM)DIAGNOSIS: TIREDNESS
Process
Hb
Process
colonoscopy
Process
referral,
advice
RFE
‘I’m feeling
tired’ A04
Diagnosis
tiredness
A04
RFE
‘what’s the
test result?’
Diagnosis
iron deficiency
anemia
Diagnosis
Ca colon
RFE
‘what’s the
test result?’
1st
encounter
2nd
encounter
3rd
encounter

PROCESS: Hb TEST
Process
Hb A34
Process
colonoscopy
Process
referral,
advice
RFE
‘I’m feeling
tired’ A04
Diagnosis
tiredness
A04
RFE
‘what’s the
test result?’
Diagnosis
iron deficiency
anemia
Diagnosis
Ca colon
RFE
‘what’s the
test result?’
1st
encounter
2nd
encounter
3rd
encounter

RFE: REQUEST TEST RESULT
Process
Hb A34
Process
colonoscopy
Process
referral,
advice
RFE
‘I’m feeling
tired’ A04
Diagnosis
tiredness
A04
RFE
‘what’s the
test result?’ A60
Diagnosis
iron deficiency
anemia
Diagnosis
Ca colon
RFE
‘what’s the
test result?’
1st
encounter
2nd
encounter
3rd
encounter

NEW DIAGNOSIS: IRON DEFICIENCY ANEMIA
Process
Hb A34
Process
colonoscopy
Process
referral,
advice
RFE
‘I’m feeling
tired’ A04
Diagnosis
tiredness
A04
RFE
‘what’s the
test result?’ A60
Diagnosis
iron deficiency
anemia B80
Diagnosis
Ca colon
RFE
‘what’s the
test result?’
1st
encounter
2nd
encounter
3rd
encounter

PROCESS: COLONOSCOPY
Process
Hb A34
Process
colonoscopy
D40
Process
referral,
advice
RFE
‘I’m feeling
tired’ A04
Diagnosis
tiredness
A04
RFE
‘what’s the
test result?’ A60
Diagnosis
iron deficiency
anemia B82
Diagnosis
Ca colon
RFE
‘what’s the
test result?’
1st
encounter
2nd
encounter
3rd
encounter

RFE: REQUEST TEST RESULT
Process
Hb A34
Process
colonoscopy
D40
Process
referral,
advice
RFE
‘I’m feeling
tired’ A04
Diagnosis
tiredness
A04
RFE
‘what’s the
test result?’ A60
Diagnosis
iron deficiency
anemia B80
Diagnosis
Ca colon
RFE
‘what’s the
test result?’ D60
1st
encounter
2nd
encounter
3rd
encounter

NEW DIAGNOSIS: COLON CANCER
Process
Hb A34
Process
colonoscopy
D40
Process
referral,
advice
RFE
‘I’m feeling
tired’ A04
Diagnosis
tiredness
A04
RFE
‘what’s the
test result?’ A60
Diagnosis
iron deficiency
anemia B80
Diagnosis
Ca colon D75
RFE
‘what’s the
test result?’ D60
1st
encounter
2nd
encounter
3rd
encounter

PROCESS: REFERRAL AND ADVICE
Process
Hb A34
Process
colonoscopy
D40
Process
referral D67
advice D45
RFE
‘I’m feeling
tired’ A04
Diagnosis
tiredness
A04
RFE
‘what’s the
test result?’ A60
Diagnosis
iron deficiency
anemia B80
Diagnosis
Ca colon D75
RFE
‘what’s the
test result?’ D60
1st
encounter
2nd
encounter
3rd
encounter

3.
THE USE OF ICPC IN THE
TRANSITION PROJECT

DATA ENTRY IN THE TRANSITION PROJECT
Note: documentation and coding is in conformity with the ‘new encounter structure’ as
shown in figure 3 (p15), and described on pp 17-18 of ICPC-2-R
RFE:
Symptom/
Complaintor
Diagnosis
RFE:
Request for
intervention
Clinical
Findings
Diagnosis
+ Certainty
and
Episode
Status
Process
Intermediate
Intervention(s)
Process
Resulting
Inter-vention(s)
Repeated for each sub-
encounter at an encounter
Repeated at each encounter for
an episode of care

SOME SCREENS FROM
THE WINDOWS VERSION OF
TRANSHIS, THE EPR IN USE
IN THE TRANSITION PROJECT..

SELECTING A PATIENT..
(Mr. K.R.F.Bakerpraat, born 19-05-1926; real patient, name/address changed,
date of birth changed (without changing age)

..THE PATIENT’S PROBLEM LIST
(8 episodes of care that are considered important; see Glossary: problem list)

THE PATIENT’S EPISODE LIST
(the patient’s full episode list contains 21 episodes of care)

THE PATIENT’S MEDICATION LIST
(this patient has had 111 prescriptions for 12 drugs)

THE PATIENT’S TEST RESULTS
(this patient has had 42 measurements in 11 test types)

SUMMARY OF THIS PATIENT’S
UTILIZATION OF FP CARE SINCE 1989

THE FP NOW BROWSES ALL SUB-ENCOUNTERS FOR
THE EPISODE OF CARE K86, UNCOMPLICATED
HYPERTENSION, AND SELECTS THE ENCOUNTER
DATED NOV 24, 2003

..AND CHECKS ALL MEDICATION PRESCIBED IN THAT
EPISODE OF CARE..

..END OF THE ICPC TUTORIAL..
also check the Glossary for any
questions you might have...

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