Leitfaden Basis DE (R4)

ICD-10 Codierung

Folgende Extensions werden im Kontext der Abbildung einer Kodierung nach ICD-10 GM definiert:

Name: Extension-seitenlokalisation (Simplifier Projekt Link)

Beschreibung:

Dokumentation der Lateralität bei OPS und ICD-10 Codes

Canonical: http://fhir.de/StructureDefinition/seitenlokalisation

Kontext:

CodeableConcept.coding

Coding

Extension		0..*	Extension	There are no (further) constraints on this element Element Id Extension Short description Optional Extensions Element Definition Optional Extension Element - found in all resources. Data Type Extension 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()` Mappings rim:n/a rim:N/A
url		1..1	System.StringFixed Value	Element Id Extension.url Short description identifies the meaning of the extension Definition Source of the definition for the extension code - a logical name or a URL. Comments The definition may point directly to a computable or human-readable definition of the extensibility codes, or it may be a logical URI as declared in some other specification. The definition SHALL be a URI for the Structure Definition defining the extension. Data Type System.String Fixed Value http://fhir.de/StructureDefinition/seitenlokalisation Mappings rim:N/A
value[x]		1..1	Binding	Element Id Extension.value[x] Short description Value of extension Definition Value of extension - must be one of a constrained set of the data types (see Extensibility for a list). Comments A stream of bytes, base64 encoded Binding https://fhir.kbv.de/ValueSet/KBV_VS_SFHIR_ICD_SEITENLOKALISATION (required) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a rim:N/A
system	Σ	1..1	uri	There are no (further) constraints on this element Element Id Extension.value[x].system Short description Identity of the terminology system Definition The identification of the code system that defines the meaning of the symbol in the code. Requirements Need to be unambiguous about the source of the definition of the symbol. Comments 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. Data Type uri Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a v2:CE.3 rim:./codeSystem orim:*fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem
version	Σ	0..1	string	There are no (further) constraints on this element Element Id Extension.value[x].version Short description Version of the system - if relevant Definition The version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured, and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Comments 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. Data Type string Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a v2:CE.7 rim:./codeSystemVersion orim:*fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion
code	Σ	1..1	code	There are no (further) constraints on this element Element Id Extension.value[x].code Short description Symbol in syntax defined by the system 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). Requirements Need to refer to a particular code in the system. Comments Note that FHIR strings SHALL NOT exceed 1MB in size Data Type code Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a v2:CE.1 rim:./code orim:*fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code
display	Σ	0..1	string	There are no (further) constraints on this element Element Id Extension.value[x].display Short description Representation defined by the system Definition A representation of the meaning of the code in the system, following the rules of the system. Requirements Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Comments Note that FHIR strings SHALL NOT exceed 1MB in size Data Type string Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a v2:CE.2 - but note this is not well followed rim:CV.displayName orim:*fhir:Coding.display rdfs:subPropertyOf dt:CDCoding.displayName
userSelected	Σ	0..1	boolean	There are no (further) constraints on this element Element Id Extension.value[x].userSelected Short 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). Requirements 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. Comments 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. Data Type boolean Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings 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 ]
valueCoding			Coding	Data Type Coding

Hinweise: Es ist zu beachten, dass laut ICD-10 GM die Angabe der Seitenlokalisation ein Bestand des Codes ist. Somit sollte die Kodierung i.d.R. auf Condition.code.coding erfolgen. Condition.bodySite sollte nicht verwendet werden.

Hinweis	Under Construction!
	Das vorliegende Profil enthält Verweise auf CodeSysteme / NamingSystems der Kassenärztliche Bundesvereinigung (KBV). Diese Ressourcen werden nicht als Teil der Deutschen Basisprofile veröffentlicht und sind separat zu Validierungszwecke o.Ä. in die entsprechenden Projekte einzubinden. Siehe fhir.kbv.de.

Beispiel:

<extension url="http://fhir.de/StructureDefinition/seitenlokalisation" >
    <valueCoding>
        <system value="https://fhir.kbv.de/CodeSystem/KBV_CS_SFHIR_ICD_SEITENLOKALISATION" />
        <value value="B" />
        <display value="beiderseits" />
    </valueCoding>
</extension>

Name: Extenstion-ICD10GMAusrufezeichen (Simplifier Projekt Link)

Beschreibung:

Der Ausrufezeichen-Code bei postkoordinierten ICD-10-GM-Codes (Ausrufezeichen-Notation) An dieser Stelle ohne '!'-Symbol

Canonical: http://fhir.de/StructureDefinition/icd-10-gm-ausrufezeichen

Kontext:

CodeableConcept.coding

Coding.code

Extension	0..*	Extension	There are no (further) constraints on this element Element Id Extension Short description Optional Extensions Element Definition Optional Extension Element - found in all resources. Data Type Extension 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()` Mappings rim:n/a rim:N/A
url	1..1	System.StringFixed Value	Element Id Extension.url Short description identifies the meaning of the extension Definition Source of the definition for the extension code - a logical name or a URL. Comments The definition may point directly to a computable or human-readable definition of the extensibility codes, or it may be a logical URI as declared in some other specification. The definition SHALL be a URI for the Structure Definition defining the extension. Data Type System.String Fixed Value http://fhir.de/StructureDefinition/icd-10-gm-ausrufezeichen Mappings rim:N/A
value[x]	1..1		Element Id Extension.value[x] Short description A reference to a code defined by a terminology system Definition A reference to a code defined by a terminology system. Comments 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. Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a 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
valueCoding		Coding-Profil für ICD-10-GM	Data Type Coding-Profil für ICD-10-GM

Hinweise: Siehe Kodierungshinweise für ICD-10 GM - Datentypen - Coding - ICD-10-GM

Beispiel:

<extension url="http://fhir.de/StructureDefinition/icd-10-gm-ausrufezeichen">
    <valueCoding>
        <system value="http://fhir.de/CodeSystem/dimdi/icd-10-gm" />
        <version value="2019" />
        <code value="U69.32" />
    </valueCoding>
</extension>

Name: Extension-ICD10GMDiagnosesicherheit (Simplifier Projekt Link)

Beschreibung:

Canonical: http://fhir.de/StructureDefinition/icd-10-gm-diagnosesicherheit

Kontext:

CodeableConcept.coding

Extension	0..*	Extension	There are no (further) constraints on this element Element Id Extension Short description Optional Extensions Element Definition Optional Extension Element - found in all resources. Data Type Extension 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()` Mappings rim:n/a rim:N/A
url	1..1	System.StringFixed Value	Element Id Extension.url Short description identifies the meaning of the extension Definition Source of the definition for the extension code - a logical name or a URL. Comments The definition may point directly to a computable or human-readable definition of the extensibility codes, or it may be a logical URI as declared in some other specification. The definition SHALL be a URI for the Structure Definition defining the extension. Data Type System.String Fixed Value http://fhir.de/StructureDefinition/icd-10-gm-diagnosesicherheit Mappings rim:N/A
value[x]	1..1	Binding	Element Id Extension.value[x] Short description Value of extension Definition Value of extension - must be one of a constrained set of the data types (see Extensibility for a list). Comments A stream of bytes, base64 encoded Binding https://fhir.kbv.de/ValueSet/KBV_VS_SFHIR_ICD_DIAGNOSESICHERHEIT (required) Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` icd-4:Wenn die Diagnosesicherheit "A (Ausschluss)" verwendet wird, dann muss clinicalStatus leer bleiben und verificationStaus auf "refuted" gesetzt werden. `code!='A' or (%resource.verificationStatus.coding.where(code='refuted').exists() and %resource.clinicalStatus.empty())` icd-5:Wenn die Diagnosesicherheit "G (Gesichert)" verwendet wird, dann muss clinicalStatus auf "active" und verificationStatus auf "confirmed" gesetzt werden. `code!='G' or (%resource.clinicalStatus.coding.where(code='active').exists() and %resource.verificationStatus.coding.where(code='confirmed').exists())` icd-6:Wenn die Diagnosesicherheit "V (Verdacht auf)" verwendet wird, dann muss clinicalStatus auf "active" und verificationStatus auf "provisional" oder "differential" gesetzt werden. `code!='V' or (%resource.clinicalStatus.coding.where(code='active').exists() and (%resource.verificationStatus.coding.where(code='provisional').exists() or %resource.verificationStatus.coding.where(code='differential').exists()))` icd-7:Wenn die Diagnosesicherheit "Z (Zustand nach)" verwendet wird, dann muss clinicalStatus auf "resolved" und verificationStatus auf "confirmed" gesetzt werden. `code!='Z' or (%resource.clinicalStatus.coding.where(code='resolved').exists() and %resource.verificationStatus.coding.where(code='confirmed').exists())` Mappings rim:n/a rim:N/A
valueCoding		Coding	Data Type Coding

Constraints:

icd-4	warning	Wenn die Diagnosesicherheit "A (Ausschluss)" verwendet wird, dann muss clinicalStatus leer bleiben und verificationStaus auf "refuted" gesetzt werden.	code!='A' or (%resource.verificationStatus.coding.where(code='refuted').exists() and %resource.clinicalStatus.empty())
icd-5	warning	Wenn die Diagnosesicherheit "G (Gesichert)" verwendet wird, dann muss clinicalStatus auf "active" und verificationStatus auf "confirmed" gesetzt werden.	code!='G' or (%resource.clinicalStatus.coding.where(code='active').exists() and %resource.verificationStatus.coding.where(code='confirmed').exists())
icd-6	warning	Wenn die Diagnosesicherheit "V (Verdacht auf)" verwendet wird, dann muss clinicalStatus auf "active" und verificationStatus auf "provisional" oder "differential" gesetzt werden.	code!='V' or (%resource.clinicalStatus.coding.where(code='active').exists() and (%resource.verificationStatus.coding.where(code='provisional').exists() or %resource.verificationStatus.coding.where(code='differential').exists()))
icd-7	warning	Wenn die Diagnosesicherheit "Z (Zustand nach)" verwendet wird, dann muss clinicalStatus auf "resolved" und verificationStatus auf "confirmed" gesetzt werden.	code!='Z' or (%resource.clinicalStatus.coding.where(code='resolved').exists() and %resource.verificationStatus.coding.where(code='confirmed').exists())

Hinweise: Siehe Kodierungshinweise für ICD-10 GM - Datentypen - Coding - ICD-10-GM

Beispiel:

<extension url="http://fhir.de/StructureDefinition/icd-10-gm-diagnosesicherheit">
    <valueCoding>
        <system value="https://fhir.kbv.de/CodeSystem/KBV_CS_SFHIR_ICD_DIAGNOSESICHERHEIT" />
        <code value="G" />
        <display value="gesicherte Diagnose" />
    </valueCoding>
</extension>

Name: Extension-ICD10GMPrimaercode (Simplifier Projekt Link)

Beschreibung:

Der Primärcode (einschließlich: Kreuz-Code), insbesondere bei postkoordinierten ICD-10-GM-Codes (Kreuz-Stern-Notation, Ausrufezeichen-Notation). An dieser Stelle ohne '+'-Symbol

Canonical: http://fhir.de/StructureDefinition/icd-10-gm-primaercode

Kontext:

CodeableConcept.coding

Coding

Extension	0..*	Extension	There are no (further) constraints on this element Element Id Extension Short description Optional Extensions Element Definition Optional Extension Element - found in all resources. Data Type Extension 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()` Mappings rim:n/a rim:N/A
url	1..1	System.StringFixed Value	Element Id Extension.url Short description identifies the meaning of the extension Definition Source of the definition for the extension code - a logical name or a URL. Comments The definition may point directly to a computable or human-readable definition of the extensibility codes, or it may be a logical URI as declared in some other specification. The definition SHALL be a URI for the Structure Definition defining the extension. Data Type System.String Fixed Value http://fhir.de/StructureDefinition/icd-10-gm-primaercode Mappings rim:N/A
value[x]	1..1		Element Id Extension.value[x] Short description A reference to a code defined by a terminology system Definition A reference to a code defined by a terminology system. Comments 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. Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a 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
valueCoding		Coding-Profil für ICD-10-GM	Data Type Coding-Profil für ICD-10-GM

Hinweise: Siehe Kodierungshinweise für ICD-10 GM - Datentypen - Coding - ICD-10-GM

Beispiel:

<extension url="http://fhir.de/StructureDefinition/icd-10-gm-primaercode">
    <valueCoding>
        <system value="http://fhir.de/CodeSystem/dimdi/icd-10-gm" />
        <version value="2019" />
        <code value="F16.1" />
        <display value="Psychische und Verhaltensstörungen durch Halluzinogene : Schädlicher Gebrauch" />
    </valueCoding>
</extension>

Name: Extension-ICD10GMManifestationscode (Simplifier Projekt Link)

Beschreibung:

Der 'Manifestations'-Code aus der Kreuz-Stern-Notation. An dieser Stelle ohne '*'-Symbol

Canonical: http://fhir.de/StructureDefinition/icd-10-gm-manifestationscode

Kontext:

CodeableConcept.coding

Coding

Extension	0..*	Extension	There are no (further) constraints on this element Element Id Extension Short description Optional Extensions Element Definition Optional Extension Element - found in all resources. Data Type Extension 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()` Mappings rim:n/a rim:N/A
url	1..1	System.StringFixed Value	Element Id Extension.url Short description identifies the meaning of the extension Definition Source of the definition for the extension code - a logical name or a URL. Comments The definition may point directly to a computable or human-readable definition of the extensibility codes, or it may be a logical URI as declared in some other specification. The definition SHALL be a URI for the Structure Definition defining the extension. Data Type System.String Fixed Value http://fhir.de/StructureDefinition/icd-10-gm-manifestationscode Mappings rim:N/A
value[x]	1..1		Element Id Extension.value[x] Short description A reference to a code defined by a terminology system Definition A reference to a code defined by a terminology system. Comments 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. Constraints ele-1:All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim:n/a 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
valueCoding		Coding-Profil für ICD-10-GM	Data Type Coding-Profil für ICD-10-GM

Hinweise: Siehe Kodierungshinweise für ICD-10 GM - Datentypen - Coding - ICD-10-GM

Beispiel:

<extension url="http://fhir.de/StructureDefinition/icd-10-gm-manifestationscode">
    <valueCoding>
        <system value="http://fhir.de/CodeSystem/dimdi/icd-10-gm" />
        <version value="2019" />
        <code value="F71" />
        <display value="Mittelgradige Intelligenzminderung" />
    </valueCoding>
</extension>