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Clinical data representations have been widely used to document diagnoses and procedures. There are over 150 known code systems.

Current Procedural Terminology (CPT) codes: These codes are maintained by the American Medical Association (AMA) and are widely used in the United States for reimbursement and utilization review purposes. The codes are derived from medical specialty nomenclatures and are updated annually. (Chute, 1995)

Diagnostic and Statistical Manual of Mental Disorders (DSM), now in its fourth edition (DSM-IV): This code structure is maintained by the American Psychiatric Association (APA). It sets forth a standard set of codes and descriptions for use in diagnoses, prescriptions, research, education, and administration. (Chute, 1995)

Diagnostic Related Groups (DRGs): These codes are maintained by HCFA. They are derivatives of ICD-9-CM codes and are used to facilitate reimbursement and case-mix analysis. They lack the clinical specificity to be of value in direct patient care or clinical research. (Chute, 1995)

International Classification of Diseases (ICD) codes, now in the tenth edition (ICD-10): These codes are maintained by the World Health Organization (WHO) and are accepted worldwide.

In the United States, HCFA and the National Center for Health Statistics (NCHS) have supported the development of a clinical modification of the ICD codes (ICD-9-CM)

WHO has been developing ICD-10 and HCFA has formed a voluntary technical panel to assist with the development of the ICD-10 Procedure Coding System (ICD-10-PCS). However, HCFA projects that ICD-10 will not be available for use within the United States for a few years. Payors require the use of ICD-9-CM codes for reimbursement purposes, but they have limited value for clinical and research purposes due to their lack of clinical specificity. WHO's ICD10 codes

ICD-O International Classification of Diseases for Oncology. ICD-O is a dual classification with coding systems for both topography and morphology of tumors. The topography code describes the site of origin of the neoplasms and uses the same 3-character and 4-character categories as ICD-10 for malignant neoplasms (C00-C80); this allows greater specificity for coding sites of non-malignant neoplasms than is possible in ICD-10. The morphology code describes the cell type of the tumor and its biologic activity, in other words, the characteristics of the tumor itself

Healthcare Common Procedure Coding System (HCPCS)

Laboratory Observation Identifier Names and Codes (LOINC): The purpose of the LOINC® database is to facilitate the exchange and pooling of results, such as blood hemoglobin, serum potassium, or vital signs, for clinical care, outcomes management, and research. Currently, most laboratories and other diagnostic services use HL7 to send their results electronically from their reporting systems to their care systems. However, most laboratories and other diagnostic care services identify tests in these messages by means of their internal and idiosyncratic code values. Thus, the care system cannot fully "understand" and properly file the results they receive unless they either adopt the producer's laboratory codes (which is impossible if they receive results from multiple sources), or invest in the work to map each result producer's code system to their internal code system. LOINC codes are universal identifiers for laboratory and other clinical observations that solve this problem

The Systematized Nomenclature of Human and Veterinary Medicine (SNOMED) International: This code structure is maintained by the College of American Pathologists (CAP) and is widely accepted for describing pathological test results. It has a multi-axial (eleven fields) coding structure that gives it greater clinical specificity than the ICD and CPT codes, and it has considerable value for clinical purposes. The CAP has begun to coordinate SNOMED development with the message standards organizations HL7 and ACR-NEMA. SNOMED is currently owned by the Internationla Health Terminology Standards Development Organization (IHTSDO)

MedDRA. the Medical Dictionary for Regulatory Activities - is a medical terminology used to classify adverse event information associated with the use of biopharmaceuticals and other medical products (e.g., medical devices and vaccines). Coding these data to a standard set of MedDRA terms allows health authorities and the biopharmaceutical industry to more readily exchange and analyze data related to the safe use of medical products

MeSH. Medical Subject Heading is a major undertaking of the National Library of Medical to indexing the medical literature.

National Cancer Institute(NCI) Terminology resources, NCI Thesaurus, Enterprise Vocabulary Services, and Dictionaries.

The National Drug Code (NDC): This code is maintained by the Food and Drug Administration (FDA) and is required for reimbursement by Medicare, Medicaid, and insurance companies. It is sometimes included within the UPC format.

Unified Medical Language System (UMLS): This system is maintained by the National Library of Medicine (NLM). It contains a metathesaurus that links biomedical terminology, semantics, and formats of the major clinical coding and reference systems. It links medical terms (e.g., ICD, CPT, SNOMED, DSM, CO-STAR, and D-XPLAIN) to the NLM's medical index subject headings (MeSH codes) and to each other. The UMLS also contains a specialist lexicon, a semantic network, and an information sources map. Together, these elements should eventually represent all of the codes, vocabularies, terms, and concepts that will become the foundation for an emerging medical informatics infrastructure.

Unified Medical Language System of the National Library of Medicine.  Unified Medical Language System of the National Library of Medicine

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