ICD-10 GM
Bei der Kodierung per ICD-10-GM muss das Element Condition.code mit mindestens einem Coding gefüllt sein, das den Anforderungen der ICD-Kodierung genügt. Hierzu sollte beim Einbinden des Coding-Profils in das entsprechende Use-Case-Profil ein Binding auf das ICD-10-GM ValueSet hinzugefügt werden. Siehe Terminologie - ValueSets.
Die Angabe der ICD-Version (z.B."2019"), aus der ein Code stammt, ist verpflichtend, das ICD-GM nicht versions-stabil ist, d.h. Codes können zwischen den unterschiedlichen Jahresangaben in der Bedeutung wechseln.
Name: CodingICD10GM (Simplifier Projekt Link)
Canonical: http://fhir.de/StructureDefinition/CodingICD10GM
| Coding | | | Coding | There are no (further) constraints on this element Element IdShort description A reference to a code defined by a terminology system Definition A reference to a code defined by a terminology system.
Codes may be defined very casually in enumerations or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information.
Coding Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim:n/a
- v2:CE/CNE/CWE subset one of the sets of component 1-3 or 4-6
- rim:CV
- orim:fhir:Coding rdfs:subClassOf dt:CDCoding
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| extension | | 0..* | Extension | Element IdShort description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Extension Sliced: Unordered, Open, by url(Value) Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ext-1:Must have either extensions or value[x], not both
extension.exists() != value.exists()
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| Mehrfachcodierungs-Kennzeichen | | 0..1 | Extension(Coding) | Element IdCoding.extension:Mehrfachcodierungs-Kennzeichen Optional Extensions Element Alternate names extensions, user content Definition Optional Extension Element - found in all resources.
There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Extension(Coding) Extension URL http://fhir.de/StructureDefinition/icd-10-gm-mehrfachcodierungs-kennzeichen Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ext-1:Must have either extensions or value[x], not both
extension.exists() != value.exists()
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| Seitenlokalisation | | 0..1 | Extension(Coding) | Element IdCoding.extension:Seitenlokalisation Optional Extensions Element Alternate names extensions, user content Definition Optional Extension Element - found in all resources.
There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Extension(Coding) Extension URL http://fhir.de/StructureDefinition/seitenlokalisation Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ext-1:Must have either extensions or value[x], not both
extension.exists() != value.exists()
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| Diagnosesicherheit | | 0..1 | Extension(Coding) | Element IdCoding.extension:Diagnosesicherheit Optional Extensions Element Alternate names extensions, user content Definition Optional Extension Element - found in all resources.
There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Extension(Coding) Extension URL http://fhir.de/StructureDefinition/icd-10-gm-diagnosesicherheit Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - ext-1:Must have either extensions or value[x], not both
extension.exists() != value.exists()
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| system | Σ | 1..1 | uriFixed Value | Element IdShort description Canonische CodeSystem URL für ICD-10-GM Definition The identification of the code system that defines the meaning of the symbol in the code.
Need to be unambiguous about the source of the definition of the symbol.
The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.
uri Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
http://fhir.de/CodeSystem/bfarm/icd-10-gm Mappings- rim:n/a
- v2:C*E.3
- rim:./codeSystem
- orim:fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem
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| version | Σ | 1..1 | string | Element IdShort description Die Jahresversion von ICD-10-GM. Angegeben wird immer die vierstellige Jahreszahl (z.B. "2017") Definition Bie Verwendung von ICD-10-GM ist die Angabe der Version zwingend erforderlich.
Hierdurch wird der Tatsache Rechnung getragen, dass jede der jährlich neu erscheinenden Fassung von ICD-10-GM ein neues Codesystem darstellt.
Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
string Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim:n/a
- v2:C*E.7
- rim:./codeSystemVersion
- orim:fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion
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| code | Σ | 1..1 | code | Element IdShort description Der ICD-10-Code Definition A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).
Need to refer to a particular code in the system.
Note that FHIR strings SHALL NOT exceed 1MB in size
code Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count()) - icd-regex:In code sind nur gültige ICD-10-Codes ohne Zusätze erlaubt
matches('^[A-Z][0-9][A-Z0-9](\\.?[A-Z0-9]{0,4})?$')
Mappings- rim:n/a
- v2:C*E.1
- rim:./code
- orim:fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code
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| display | Σ | 0..1 | string | There are no (further) constraints on this element Element IdShort description Representation defined by the system Definition A representation of the meaning of the code in the system, following the rules of the system.
Need to be able to carry a human-readable meaning of the code for readers that do not know the system.
Note that FHIR strings SHALL NOT exceed 1MB in size
string Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim:n/a
- v2:C*E.2 - but note this is not well followed
- rim:CV.displayName
- orim:fhir:Coding.display rdfs:subPropertyOf dt:CDCoding.displayName
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| userSelected | Σ | 0..1 | boolean | There are no (further) constraints on this element Element IdShort description If this coding was chosen directly by the user Definition Indicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays).
This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing.
Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
boolean Constraints- ele-1:All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
- rim:n/a
- v2:Sometimes implied by being first
- rim:CD.codingRationale
- orim:fhir:Coding.userSelected fhir:mapsTo dt:CDCoding.codingRationale. fhir:Coding.userSelected fhir:hasMap fhir:Coding.userSelected.map. fhir:Coding.userSelected.map a fhir:Map; fhir:target dt:CDCoding.codingRationale. fhir:Coding.userSelected\#true a [ fhir:source "true"; fhir:target dt:CDCoding.codingRationale\#O ]
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