3431 Gastrointestinal endoscopic terminology coding; GET-C. An extended coding system based on the internal classification of diseases-10th edition.

Abstract

Endoscopic report systems are becoming more and more available in the current endoscopic practice. The way reports are composed and data is stored differ considerable between the systems. They all use different kinds of databases and it is only possible to evaluate the endoscopic data of their own system. One problem is that there is no specific code system for endoscopic terminology and findings that is widely used. To be able to compare different ways of report writing we developed a comprehensive code-system suitable to code every used term during gastrointestinal endoscopy. This new extended code system was based on a code-system, already in use throughout the world. The International Classification of Diseases 10^thedition (ICD-10) is a comprehensive and widely used codesystem, published by the World Health Organization (WHO) and translated into many different languages. The ICD-10 was originally composed for mortality statistics. However on conditions defined by the WHO this ICD- 10 can be extended for local purposes. Terms that are used during gastrointestinal endoscopy were based on Minimal Standard Terminology (MST). However MST only includes terms that are commonly used. So this list was expanded to be able to describe every possible gastrointestinal endoscopic term. By extending the ICD-10 a complete coding system for endoscopic terminology was created on conditions of the WHO. It is possible to code every indication. In this way, it is also possible to code severity and classification of certain endoscopic findings into generally used grading scores. Abnormalities that can only be endoscopically diagnosed and precise locations were added. The medication given during the examination, the proceeding of the examination, any therapeutic interventions but also complications can be given a specific code. A project was started to evaluate endoscopic examinations in the Netherlands. In this TRANS.IT project, different ways of report writing are used in Endobase III® and a central database is build by collecting the GET-C codes that are linked to these reports. Yet, this new code-system can be implemented in every endoscopic database system. Conclusions Gastrointestinal Endoscopic Terminology Coding (GET-C) is a complete code system that can be used in every endoscopic database program. Each endoscopic term has its own specific code. Using this code-system it is possible to compare different endoscopic databases even internationally.