For doctors

The practical activities of doctors have many aspects – in addition to purely diagnostic and therapeutic actions, they involve the maintenance of medical records and the use of special medical classifications that are designed to encode various data. A vivid example of such classifications is the International Classification of Diseases (ICD), implemented by the World Health Organization (WHO; hereinafter we will use the English-language abbreviations of this organization for a better understanding of other abbreviations). Doctors are already well aware of the principle and features of working with both ICD-10 and ICD-11 revisions. The relatively recent implementation of the CPCS-2 classification in the work of primary care providers has raised a wave of questions, some of which practitioners providing primary care could not find answers to on the page of the specialized online simulator. Let’s try to deal with the most common questions.

The ICPC is an acronym for the International Classification of Primary Care and is a classification that was introduced in 1987 by the World Organization of National Colleges, Academies and Academic Associations of General Practitioners/Family Physicians (WONCA) to analyze the frequency and distribution of health problems that are most commonly encountered in primary care, as well as to find out how primary care providers try to solve these problems. Almost 30 years of practical application of the first version of the IMRS revealed some shortcomings that were taken into account and corrected in the 2nd revision. The updated classification was called ISDS-2 and was approved by WONCA in 2016 [1]. It is this revision of the IPCS-2, or rather the IPCS-2-E (the additional letter E denotes the electronic version), that was approved by the Ministry of Health of Ukraine in 2018 for implementation in domestic medicine in order to harmonize it with the prevailing international standards (Order No. 13 of 13.01.2018 [2] and Order No. 504 of 19.03.2018 [3]). Thus, the CPMF-2 is mandatory for use.

The design, creation and implementation of international medical classifications are strictly regulated by the WHO. It was the WHO that introduced the ICD, which is now widely used, but the ICD is not the only classification system used in medicine. Currently, there are a large number of international medical classifications that WHO unites under the name “Family of International Classifications” (WHO-FIC) [4]. The main pillars of the WHO-FIC family are ICD-11 and the International Classification of Functioning, Disability and Health (ICF), which, by the way, is also used in Ukraine. In addition to these two main blocks, the WHO-FIC includes 8 other “related” classifications, including the ICF-2. A special page dedicated to CPCS-2, where WHO reveals the features of this classification, emphasizes the feasibility and necessity of its widespread use [5]. The ongoing cooperation between WONCA and WHO has allowed experts to make two such different, at first glance, classification systems (CPCS-2 and ICD, respectively) complementary. Currently, the CPCS-2 is used in many countries and has been translated into more than 22 languages [1]. The CPCS-2 is recommended and approved for use at the highest level and is supported by the world’s leading organizations.

Whereas ICD-10 is used as a reference classification for recording mortality and morbidity data [4], the CPM-2 is designed to analyze the frequency and reasons for visits to primary care physicians, and to identify ways in which primary care providers try to solve health problems [1]. The CPMI-2 is used to perform coding in conditions where it is very difficult or even impossible to make an accurate diagnosis. In addition, the CPMR-2 allows to take into account those cases of patient visits when the reason is not related to health problems, but is due to the need to obtain a certificate, prescriptions, clarify the results of examinations or explain the further plan of preventive examination. The need to analyze this component of the work is also extremely important, because, on the one hand, employees devote a lot of time to solving these issues, and on the other hand, this is very important information that is then subjected to careful analysis.

The information obtained in this way is used not only to maintain feedback between institutions of different levels of health care (primary, secondary), but also to present important data to health care managers, politicians, sponsors and health care providers to understand what epidemiological processes are taking place in society and what measures/amount of financial support can be used to improve health care at the initial stage. An additional bonus for doctors using the IRS-2 is the ability to significantly simplify their work due to the significant simplification of accounting and statistical forms, reducing the time required to fill them out.

ICPC-2 has several unique characteristics that distinguish it from other classifications. First, ICPC-2 focuses on the patient and their health problems rather than the statistical processing of various diseases. The volume of ICPC-2 is relatively small—it contains approximately 1,400 codes [1], whereas the well-known ICD-11 has around 15,000 codes [4].

Other distinguishing features of ICPC-2 include its simple coding system and topographic classification structure. The first step for a medical professional using ICPC-2 is to determine the likely location of the pathological process that caused the patient’s complaints or was the reason for the visit (e.g., cardiovascular system, respiratory system, nervous system, etc.). To do this, one of the 17 classification chapters is selected, along with the corresponding letter code (one of the capital letters A-Z, representing the required section). Then, using a set of numerical components, the primary reason for the visit is identified—complaints or symptoms (numbers 01-29), a request for an examination (30-49), a prescription request (50-59), obtaining test results (60-61), requesting a medical certificate (62), or a referral to another doctor (63-69). Another feature involves determining the probable diagnosis according to the family doctor’s assessment, again using a letter (to indicate the affected system) and numbers representing the probable diagnosis (70-99). Additionally, ICPC-2 characterizes the doctor’s actions: a letter represents the organ system, while numbers specify the procedures, actions, or interventions performed to address the patient’s problem [1]. Thus, in just three simple steps, ICPC-2 allows for coding the reason for the patient’s visit, the probable diagnosis according to the doctor’s opinion, and the actions taken to resolve the issue. More detailed and precise information on the fundamentals of using ICPC-2, case studies of its application, and an online training tool for working with the classifier can be found on the website of the Ministry of Health of Ukraine [6].

Both ICPC developers and national regulatory authorities provide answers to this question. On the specialized online portal for ICPC-3, WONCA experts emphasize that this classification system is “simple and convenient for use by primary care providers, including doctors, nurses, and other healthcare professionals, which increases the likelihood of consistent and accurate coding” [1].

A similar answer can be found in the Order of the Ministry of Health of Ukraine No. 504 dated March 19, 2018, which states: “Information on each case of primary medical care (PMC) provision is recorded in medical documentation according to ICPC-2-E by a doctor or another medical professional who is part of the PMC team” [3]. Based on definitions provided earlier in the same order, it can be concluded that the right to fill out ICPC-2 belongs to “primary care doctors,” including general practitioners, internists, and pediatricians, as well as members of the “primary care team,” such as general practice-family medicine nurses, midwives, paramedics, and others working alongside or under the supervision of a primary care doctor [3].

One of the key concepts used in ICPC-2 is the medical episode, which is understood as all patient consultations (visits) with a doctor for a single reason. The concept of a “visit” is interpreted by WONCA experts as any professional contact between a patient and a healthcare professional; this contact can be direct, when the patient visits the clinic or the doctor comes to the patient’s home, or indirect, when the patient and the healthcare professional communicate using remote communication tools [1].

It should be noted that there is no clear answer in the domestic regulatory framework on this issue yet, but the current Order of the Ministry of Health of Ukraine No. 504 of 19.03.2018 provides for the possibility of providing primary health care services “using technical means of electronic communication in accordance with the working hours of the primary health care provider” [2]. In addition, the official instructions for the ICPC-2 simulator, which is available on the website of the Ministry of Health of Ukraine, list the following indirect methods of contact between the patient and the healthcare professional: using telephone, mail, email, Skype [7]. Thus, an online patient consultation can be considered an indirect contact and coded in ICPC-2 as a full-fledged visit.

Although ICPC-2 is recognized as a full-fledged classification system, its compatibility with ICD-10 makes ICPC-2 even more advanced. The comparison of ICPC-2 and ICD-10 codes allows complementing the data of each of these classifiers without unnecessary competition. WONCA experts characterize the ability to compare ICPC-2 codes as a “primary health care lens” for ICD [1]. ICD, which has an extremely high level of diagnostic detail, is recognized as difficult to apply in practice at the primary health care level, as it contains a large number of codes that are not needed or necessary for primary care workers.

The Order of the Ministry of Health of Ukraine No. 504 of 19.03.2018 provides for the preferential use of ICPC-2 at the primary health care stage: “Information about each case of primary health care provision is reflected in the medical documentation by the doctor or other medical worker who is part of the primary health care team in accordance with ICPC-2-E and, if necessary, with the ICD of the corresponding revision.” Further, the Order does not explain what cases can be considered a “necessity” to provide an ICD code [2]. At the same time, another Order (No. 13 of 04.01.2018) approves a table for comparing ICPC-2-E and ICD-10 codes [3]. Thus, the current domestic regulations do not insist on the mandatory simultaneous use of two classifiers, but allow for the possibility of their joint use.

n such cases, a primary healthcare provider should first perform coding using ICPC-2. The process begins with determining the level of localization of the pathological process: in viral hepatitis, the digestive system is affected (D), tuberculosis is classified as a general condition (A), and HIV affects the immune system (B). Then, considering that each of these diseases is an infectious process, we use the yellow-colored guideline and find the full alphanumeric codes: D72, A70, and B90, respectively.

In such cases, indicating the ICD code can and should be considered necessary. Let’s focus on tuberculosis as an example. Using the code mapping table, we determine that ICPC-2 code A70 corresponds to ICD-10 codes A15.0–A19.9 (pulmonary tuberculosis, bacteriologically/histologically confirmed and unconfirmed, tuberculosis of the nervous system and other organs, miliary tuberculosis), B90.0–B90.9 (sequelae of tuberculosis), N74.0–N74.1 (tuberculous infection of the cervix, inflammatory diseases of the female pelvic organs of tuberculous etiology) [3]. If the physician has sufficient information to specify the condition in more detail, the corresponding ICD-10 code is recorded.

ICPC-2 was introduced into global clinical practice in 2016, and domestic doctors have been using it since 2018. As a result, it does not include recent updates, such as coding options for situations related to COVID-19. During the COVID-19 pandemic (2020–2023), WHO introduced various terms (including post-COVID syndrome) and implemented necessary changes in ICD-10 and ICD-11 [8]. Representatives of the Australian healthcare system developed a special extended version of ICPC-2, known as ICPC-2 PLUS [9]. This version is intended for use exclusively in Australia and includes additional codes for diagnosing COVID-19 (confirmed disease, risk group, suspected COVID-19, patient concerns about infection), post-COVID syndrome, prescribed examinations (hospital referrals, testing, swabs, serological studies, rapid tests, PCR), and treatment (consultations, immunization, education, hygiene, isolation) [9].

Representatives of WONCA have also introduced updates to the classification, presenting an updated version called ICPC-3 on a dedicated online portal, which features a separate section for “Emergency Codes.” These codes are designed “for use in emergency situations that pose an epidemiological risk (national or international) of infection spread” [1]. WONCA experts note that the emergency codes are regularly updated and align with emergency classifications in ICD-10 and ICD-11 [1].

ICPC-3 is not yet available in Ukraine. Therefore, for coding COVID-19, domestic specialists generally use the primary code R99 (other respiratory diseases) from ICPC-2. Additionally, medical professionals can apply various codes to document patient complaints related to post-COVID syndrome, such as muscle pain (A01, L01-L17, L18-L20, L29), fatigue (A04, A05, A28, A29), cough (R05), palpitations (K04, K05, K29), shortness of breath (R02), anxiety and depression (P03, P76, P01, P74), and reduced concentration and memory (P20), among others.

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1. https://www.icpc-3.info/ 
2. https://moz.gov.ua/uk/decrees/nakaz-moz-ukraini-vid-04012018–13-pro-dejaki-pitannja-zastosuvannja-ukrainomovnogo-variantu-mizhnarodnoi-klasifikacii-pervinnoi-medichnoi-dopomogiicpc-2-e 
3. https://zakon.rada.gov.ua/laws/show/z0348-18#Text 
4. https://www.who.int/standards/classifications  
5. https://www.who.int/standards/classifications/other-classifications/international-classification-of-primary-care 
6. https://moz.gov.ua/uk/icpc-2 
7. ТРЕНАЖЕР З ВИКОРИСТАННЯ МІЖНАРОДНОЇ КЛАСИФІКАЦІЇ ICPC-2. https://drive.google.com/file/d/13xiI36XjVhzTQbB8Toh9P540wjnxye5q/view 
8. Post COVID-19 conditions. https://www.who.int/teams/health-care-readiness/post-covid-19-condition 
9. ICPC-2 PLUS CONTENT FOR COVID-19.
   https://www.sydney.edu.au/content/dam/corporate/documents/faculty-of-medicine-and-health/research/corona-2019-march-2023-website.pdf