ICD-10-GM (Profil)

Profil für die Validierung von Conditions mit ICD-kodierten Diagnosen:

identifierΣ0..*Identifier
clinicalStatusΣ ?!0..1CodeableConceptBinding
verificationStatusΣ ?!0..1CodeableConceptBinding
category0..*CodeableConceptBinding
severity0..1CodeableConceptBinding
Primaercode0..1Extension(Coding-Profil für ICD-10-GM)
Manifestationscode0..*Extension(Coding-Profil für ICD-10-GM)
Ausrufezeichen0..*Extension(Coding-Profil für ICD-10-GM)
Diagnosesicherheit0..1Extension(Coding)
Seitenlokalisation0..1Extension(Coding)
systemΣ1..1uriFixed Value
versionΣ1..1string
codeΣ1..1code
displayΣ0..1string
userSelectedΣ0..1boolean
textΣ0..1string
bodySiteΣ0..*CodeableConcept
subjectΣ1..1Reference(Patient| Group)
encounterΣ0..1Reference(Encounter)
onsetDateTimedateTime
onsetAgeAge
onsetPeriodPeriod
onsetRangeRange
onsetStringstring
abatementDateTimedateTime
abatementAgeAge
abatementPeriodPeriod
abatementRangeRange
abatementStringstring
recordedDateΣ0..1dateTime
recorderΣ0..1Reference(Practitioner| PractitionerRole| Patient| RelatedPerson)
asserterΣ0..1Reference(Practitioner| PractitionerRole| Patient| RelatedPerson)
summary0..1CodeableConcept
assessment0..*Reference(ClinicalImpression| DiagnosticReport| Observation)
type0..1CodeableConcept
codeΣ0..*CodeableConcept
detailΣ0..*Reference(Resource)
note0..*Annotation

Condition.code

Bei der Kodierung nach ICD-10(-GM) muss das Element Condition.code mit mindestens einem Coding gefüllt sein, das den Anforderungen der ICD-Kodierung genügt.

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Die Angabe der ICD-Version (z.B."2019"), aus der ein Code stammt, ist verpflichtend.

Beispiel: Diagnosesicherheit: "Zustand nach"

<Condition xmlns="http://hl7.org/fhir">
    <meta>
        <profile value="http://fhir.de/StructureDefinition/condition-de-icd10" />
    </meta>
    <clinicalStatus>
        <coding>
            <system value="http://terminology.hl7.org/CodeSystem/condition-clinical" />
            <code value="resolved" />
        </coding>
    </clinicalStatus>
    <verificationStatus>
        <coding>
            <system value="http://terminology.hl7.org/CodeSystem/condition-ver-status" />
            <code value="confirmed" />
        </coding>
    </verificationStatus>
    <code>
        <coding>
            <extension url="http://fhir.de/StructureDefinition/icd-10-gm-diagnosesicherheit">
                <valueCoding>
                    <system value="http://fhir.de/CodeSystem/kbv/s-icd-diagnosesicherheit" />
                    <code value="Z" />
                </valueCoding>
            </extension>
            <system value="http://fhir.de/CodeSystem/dimdi/icd-10-gm" />
            <version value="2019" />
            <code value="F16.1" />
            <display value="Psychische Verhaltensst&#246;rung durch Halluzinogene (Akute Intoxikation)" />
        </coding>
    </code>
    <subject>
        <reference value="Patient/example" />
    </subject>
</Condition>

{
    "resourceType": "Condition",
    "meta": {
        "profile":  [
            "http://fhir.de/StructureDefinition/condition-de-icd10"
        ]
    },
    "clinicalStatus": {
        "coding":  [
            {
                "system": "http://terminology.hl7.org/CodeSystem/condition-clinical",
                "code": "resolved"
            }
        ]
    },
    "verificationStatus": {
        "coding":  [
            {
                "system": "http://terminology.hl7.org/CodeSystem/condition-ver-status",
                "code": "confirmed"
            }
        ]
    },
    "code": {
        "coding":  [
            {
                "extension":  [
                    {
                        "url": "http://fhir.de/StructureDefinition/icd-10-gm-diagnosesicherheit",
                        "valueCoding": {
                            "system": "http://fhir.de/CodeSystem/kbv/s-icd-diagnosesicherheit",
                            "code": "Z"
                        }
                    }
                ],
                "system": "http://fhir.de/CodeSystem/dimdi/icd-10-gm",
                "version": "2019",
                "code": "F16.1",
                "display": "Psychische Verhaltensstörung durch Halluzinogene (Akute Intoxikation)"
            }
        ]
    },
    "subject": {
        "reference": "Patient/example"
    }
}

Beispiel: einfacher ICD-Code

<Condition xmlns="http://hl7.org/fhir">
    <meta>
        <profile value="http://fhir.de/StructureDefinition/condition-de-icd10" />
    </meta>
    <code>
        <coding>
            <system value="http://fhir.de/CodeSystem/dimdi/icd-10-gm" />
            <version value="2019" />
            <code value="F71" />
            <display value="Mittelgradige Intelligenzminderung" />
        </coding>
    </code>
    <subject>
        <reference value="Patient/example" />
    </subject>
</Condition>

{
    "resourceType": "Condition",
    "meta": {
        "profile":  [
            "http://fhir.de/StructureDefinition/condition-de-icd10"
        ]
    },
    "code": {
        "coding":  [
            {
                "system": "http://fhir.de/CodeSystem/dimdi/icd-10-gm",
                "version": "2019",
                "code": "F71",
                "display": "Mittelgradige Intelligenzminderung"
            }
        ]
    },
    "subject": {
        "reference": "Patient/example"
    }
}

Beispiel: ICD-Code mit Ausrufezeichen-Notation

<Condition xmlns="http://hl7.org/fhir">
    <meta>
        <profile value="http://fhir.de/StructureDefinition/condition-de-icd10" />
    </meta>
    <code>
        <coding>
            <extension url="http://fhir.de/StructureDefinition/icd-10-gm-haupt-kreuz">
                <valueCoding>
                    <system value="http://fhir.de/CodeSystem/dimdi/icd-10-gm" />
                    <version value="2019" />
                    <code value="F16.1" />
                </valueCoding>
            </extension>
            <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>
            <system value="http://fhir.de/CodeSystem/dimdi/icd-10-gm" />
            <version value="2019" />
            <code value="F16.1 U69.32!" />
            <display value="Psychische Verhaltensst&#246;rung duch Halluzinogene (Akute Intoxikation) bei intraven&#246;sem Konsum" />
        </coding>
    </code>
    <subject>
        <reference value="Patient/example" />
    </subject>
</Condition>

{
    "resourceType": "Condition",
    "meta": {
        "profile":  [
            "http://fhir.de/StructureDefinition/condition-de-icd10"
        ]
    },
    "code": {
        "coding":  [
            {
                "extension":  [
                    {
                        "url": "http://fhir.de/StructureDefinition/icd-10-gm-haupt-kreuz",
                        "valueCoding": {
                            "system": "http://fhir.de/CodeSystem/dimdi/icd-10-gm",
                            "version": "2019",
                            "code": "F16.1"
                        }
                    },
                    {
                        "url": "http://fhir.de/StructureDefinition/icd-10-gm-ausrufezeichen",
                        "valueCoding": {
                            "system": "http://fhir.de/CodeSystem/dimdi/icd-10-gm",
                            "version": "2019",
                            "code": "U69.32"
                        }
                    }
                ],
                "system": "http://fhir.de/CodeSystem/dimdi/icd-10-gm",
                "version": "2019",
                "code": "F16.1 U69.32!",
                "display": "Psychische Verhaltensstörung duch Halluzinogene (Akute Intoxikation) bei intravenösem Konsum"
            }
        ]
    },
    "subject": {
        "reference": "Patient/example"
    }
}

Beispiel: ICD-Code mit Kreuz-Stern-Notation

<Condition xmlns="http://hl7.org/fhir">
    <meta>
        <profile value="http://fhir.de/StructureDefinition/condition-de-icd10" />
    </meta>
    <code>
        <coding>
            <extension url="http://fhir.de/StructureDefinition/icd-10-gm-haupt-kreuz">
                <valueCoding>
                    <system value="http://fhir.de/CodeSystem/dimdi/icd-10-gm" />
                    <version value="2019" />
                    <code value="E10.30" />
                </valueCoding>
            </extension>
            <extension url="http://fhir.de/StructureDefinition/icd-10-gm-stern">
                <valueCoding>
                    <system value="http://fhir.de/CodeSystem/dimdi/icd-10-gm" />
                    <version value="2019" />
                    <code value="H36.0" />
                </valueCoding>
            </extension>
            <system value="http://fhir.de/CodeSystem/dimdi/icd-10-gm" />
            <version value="2019" />
            <code value="E10.30† H36.0*" />
            <display value="Diabetische Retinopathie" />
        </coding>
    </code>
    <subject>
        <reference value="Patient/example" />
    </subject>
</Condition>

{
    "resourceType": "Condition",
    "meta": {
        "profile":  [
            "http://fhir.de/StructureDefinition/condition-de-icd10"
        ]
    },
    "code": {
        "coding":  [
            {
                "extension":  [
                    {
                        "url": "http://fhir.de/StructureDefinition/icd-10-gm-haupt-kreuz",
                        "valueCoding": {
                            "system": "http://fhir.de/CodeSystem/dimdi/icd-10-gm",
                            "version": "2019",
                            "code": "E10.30"
                        }
                    },
                    {
                        "url": "http://fhir.de/StructureDefinition/icd-10-gm-stern",
                        "valueCoding": {
                            "system": "http://fhir.de/CodeSystem/dimdi/icd-10-gm",
                            "version": "2019",
                            "code": "H36.0"
                        }
                    }
                ],
                "system": "http://fhir.de/CodeSystem/dimdi/icd-10-gm",
                "version": "2019",
                "code": "E10.30† H36.0*",
                "display": "Diabetische Retinopathie"
            }
        ]
    },
    "subject": {
        "reference": "Patient/example"
    }
}