GE TC GET-C Gastrointestinal Endoscopic Terminology Coding GET-C Extension of the ICD-10 M. Groenen W. Hirs, H. Becker, E. Kuipers, G. van Berge Henegouwen, P. Fockens, R. Ouwendijk

Cancer in Europe 2000 n= United European Gastroenterology Federation, 2003

No information of endoscopic diagnosis in Europe COUNTRIES AustriaBelgiumDenmarkFinlandFranceGermanyGreeceIreland Practice in GE Endoscopies Number Colonoscopy Total number of procedures per year Number of diagnostic procedures unknown Number of therapeutic procedures unknown United European Gastroenterology Federation, 2003

Need for databases Surveillance –Polyps –Ulcers and Barrett oesophagus –Inflammatory Bowel Diseases Epidemiology Quality control Research

Endoscopic data that need a specific code Indication Endoscopic diagnosis Therapeutical interventions Advice Therapy Complications

D12 Benign neoplasm of colon, rectum, anus and anal canal ICD-10 D12.0 Benign neoplasm of cecum D12.1 Benign neoplasm of appendix D12.2 Benign neoplasm of ascending colon D12.3 Benign neoplasm of transverse colon D12.4 Benign neoplasm of descending colon D12.5 Benign neoplasm of sigmoid colon D12.6 Benign neoplasm of colon, unspecified D12.7 Benign neoplasm of rectosigmoid junction D12.8 Benign neoplasm of rectum D12.9 Benign neoplasm of anus and anal canal

Important for polyps (1) Appearance of the polyp –XXX.X1Pedunculated polyp –XXX.X2Sessile polyp –XXX.X3Villous adenoma –XXX.X4Flat adenoma –XXX.X5Hyperplastic polyp –XXX.X6Incipient polyp Therapy, prognosis and follow up

Important for polyps (2) Number of polyps –XXX.XX1One polyp –XXX.XX2Two polyps –XXX.XX3More polyps < 2 polyps Surveillance endoscopy 6 years > 2 polyps Surveillance endoscopy 3 years

Benign neoplasm of descending colon D12.4 Benign neoplasm of desc. Colon D12.41 Pedunculated polyp in desc. colon D One ped. polyp in desc. colon D Two ped. polyps in desc. colon D Several ped. polyps in desc. colon D12.42 Sessile polyp in descending colon D One sessile polyp in desc. colon D Two sessile polyps in desc. colon D Several sessile polyps in desc. colon D12.43 Villous adenoma in desc.colon D One villous adenoma in desc. colon D Two villous adenomas in desc. colon D Several villous aden. in desc. colon D12.44 Flat adenoma in descending colon D One flat adenoma in desc. colon D12.442Two flat adenomas in desc. colon D12.443Several flat adenomas in desc. Colon D12.45 Hyperplastic polyp in desc.colon D12.451One hyperplastic polyp in desc. colon D12.452Two hyperplastic polyps in desc. colon D12.453Several hyperpl. polyps in desc. Colon D12.46 Incipient polyp in descending colon D12.461One incipient polyp in descending colon D12.462Two incipient polyps in desc. colon D12.463Several incipient polyps in desc. colon

K25 Gastric ulcer ICD-10 K25.0 Acute gastric ulcer with hemorrhage K25.1 Acute gastric ulcer with perforation K25.2 Acute gastric ulcer with both hemorrhage and perforation K25.3 Acute gastric ulcer without hemorrhage or perforation K25.4 Chronic or unspecified gastric ulcer with hemorrhage K25.5 Chronic or unspecified gastric ulcer with perforation K25.6 Chronic or unspecified gastric ulcer with both hemorrhage and perforation K25.7 Chronic gastric ulcer without hemorrhage or perforation K25.9 Gastric ulcer, unspecified as acute or chronic, without hemorrhage or perforation

Important for ulcers (1) Forrest Classification IaAcute spurting bleeding IbNon-spurting active bleeding IIaVissible vessel IIbOverlying clot IIcHaematin covered basis IIIClean ulcer –Prognosis –Treatment –Follow up

Extension of ICD-10 to GET-C

Important for ulcers (2) Number of ulcers at one location –XXX.XX1One ulcer –XXX.XX2Two ulcers –XXX.XX3Several ulcers

Important for ulcers (3) Location of ulcers in stomach –XXX.XXX1Cardia of stomach –XXX.XXX2Fundus of stomach –XXX.XXX3Corpus of stomach –XXX.XXX4Angulus of stomach –XXX.XXX5Antrum of stomach –XXX.XXX6Pyloric region –XXX.XXX8Whole stomach

New Gastrointestinal Endoscopic Terms New chapter with character μ Adaptations and extensions performed by gastroenterologists More new techniques expected in near future

GE TC(GET-C) Gastrointestinal Endoscopic Terminology Coding (GET-C) Developed by TRANS.IT working group Accepted by Dutch Society of Gastroenterologists Revised by Dutch translation board of ICD-10 Submitted for publication international journal Important for Epidemiology and Mortality statistics