Statistical classification systems of diseases date back to the 18th century, when François Bossier de Lacroix made the first attempt at systematically classifying disease in his publication Nosologia Methodica.1 In 1853, William Farr prepared a classification for the causes of death in 5 groups (epidemic diseases, constitutional diseases, local diseases arranged according to anatomical site, developmental diseases and diseases that are a result of trauma). Even today, it is easy to recognize this common core in the structure of current classifications. The International List of Causes of Death, designed by Bertillon in 1853, maintained the same organizational principle as Farr, and his following revisions were known as the International Classification of Causes of Death. In 1948, the 6th revision of the classification included morbidities treated in the hospital, and its purpose was to enable data to be compared between different hospitals or healthcare systems.
For many decades, the International Classification of Diseases2 has been an essential tool for comparing national and international public healthcare data. This statistical instrument has been revised every 10 years in order to incorporate advances made in medicine, but the current CIE9 does not provide for the precise coding of many diseases and procedures.
To date, the consequences of lack of information in medical documents have been limited and have not significantly influenced the ability of hospitals to code and classify the natures of surgical interventions. The immense majority of surgical report forms are highly detailed and follow a well-defined system, even for each subspecialty.
At the beginning of the 1980s, the WHO began the 10th revision of the CIE, which introduced a change to its traditional structure to provide flexibility and stability, enabling the inclusion of as many new codes as necessary to stay current with medical advances.
In Spain, starting in 2016 there has been a change to the hospital classification system used in the entire National Healthcare System, the CIE-10-ES, which is a translation of the ICD-10-CM and PCS developed in the United States.
One of the most important differences between the CIE-10-PCS and CIE-9 is that it includes a character in the code that specifies the affected body system, approach, techniques or implants. The advantage of this classification is that it allows for more precise and detailed coding, but this requires clinical information with details that were not previously considered. For proper coding, it is necessary, for instance, to identify the anatomical location of the intervention (including laterality), generic procedure type (resection, removal, etc.) and the exact nature of the devices used or implanted.
As surgeons, we should be aware of the importance of correct coding for the procedures we perform; operative data should be recorded with sufficient information to be able to classify cases with an optimal level of detail. This will affect proper data recording of our activities and the accessibility to this information, which is in the interest of all healthcare professionals, especially surgeons.
FundingThis study has received no funding.
Conflict of InterestsThe author has no conflict of interests to declare.
Please cite this article as: Soria-Aledo V. El CIE-10 y el protocolo quirúrgico. Cir Esp. 2016;94:425–426.
