Microsoft word - epicii_codes3.doc

EPIC II DIAGNOSES

100 Neurological:
101- Cerebrovascular accident: Recent stroke, by ischemic or hemorrhagic mechanism (non- traumatic), documented by CT scan and/or lumbar puncture or only by history and physical symptoms. 102- Intracranial tumor: tumor documented by CT scan or MRI, malignant (primary or secondary) 103- Degenerative disease: includes Alzheimer’s disease, Huntington’s chorea, amyotrophic lateral sclerosis, multiple sclerosis, Parkinson’s disease . 104- Idiopathic epilepsy: history of recurrent seizures with primary lesion not detected. 105- Myopathia, myasthenia gravis: acute exacerbation or progressive evolution of polymyositis, dermatomyositis, progressive muscular dystrophy, myasthenia. 106- Polyneuritis and polyradiculoneuritis: includes polyneuritis due to infection, inflammation, 107- Post-anoxic coma: cerebral damage from hypoxia induced by several clinical situations, e.g., respiratory-cardiac arrest, cardiac disease with arrest, central nervous system diseases that lead to respiratory arrest (epilepsy, trauma, stroke), CO poisoning, profound hypotension. 108- Delirium tremens: acute encephalopathy due to alcohol withdrawal. 109- Other 200 Respiratory:
201- Exacerbation of chronic pulmonary disease: exacerbation of respiratory failure in chronic pulmonary disease (either obstructive or non obstructive) due to progressive evolution. 202- Asthma attack: acute exacerbation inducing paroxysms of dyspnea, cough and wheezing. 203- Pulmonary embolism: partial or complete obstruction of the pulmonary arterial blood flow by a thrombus documented by pulmonary scintigraphy and/or pulmonary angiography. 204- Pleural effusion: air, blood, liquid, chyle in the pleural cavity documented by pleural tap, 205- Obstruction: obstruction of the upper or lower airways by a foreign body. Includes obstruction 206- Inhalation pneumonitis: induced by gastrointestinal contents, blood, smoke, and/or gases. 207- Tumor: Benign or malignant. 208- Other 300 Cardiovascular:
301- Acute myocardial infarction. 302- Unstable angina, myocardial ischemia induced by crescendo angina, repeated attacks of severe angina, recent onset angina or early return of angina after infarction. 303- Cardiopathy: includes ischemic, valvular, hypertensive, alcoholic and other, non infectious 400 Renal/genito-urinary tract:
401- Acute tubular necrosis: sudden onset of renal failure during or following an acute severe 402- Acute glomerulopathy: acute renal failure resulting from lesions in the glomeruli. 403- Interstitial nephropathy: renal failure resulting from lesions in the interstitium. 404- Vascular nephropathy: renal failure resulting from lesions in the arteries (intra or extra-renal). 405- Renal neoplasia 406- Gynecological diseases, non malignant: lesions of ovary, uterus, cervix, vulvae, vagina not 407- Gynecological diseases, malignant: lesions of ovary, uterus, cervix, vulvae, vagina due to 500 Hematological:
501- Transfusion reaction: includes all types of accident with transfusion of blood products. 502- Drug toxicity and secondary effects: includes toxicity or secondary effects of chemotherapy and/or immunosuppressant agents and hematological toxicity of any other drugs (inducing neutropenia, thrombocytopenia.). 503- Non malignant disease: includes anemia (acquired or congenital), aplastic anemia, methemoglobinemia, thrombocytopenia, congenital disorders of blood coagulation factors, hypersplenism (primary), sickle cell crisis. 504- Malignant disease: includes lymphoma, acute leukemia and multiple myeloma 505- Other 600 Digestive:
601- Cholecystitis, acute or chronic, with or without cholangitis. 602- Acute alcoholic hepatitis: with or without liver failure 603- Acute toxic, drug hepatitis: induced by drug (e.g., paracetamol/acetaminophen) or gas (e.g., 604- Pancreatitis: includes acute or recurrent acute pancreatitis, from pancreatic edema, to edema with fat necrosis, to necrosis with variable degrees of hemorrhage documented by laboratory data and abdominal CT scan. 605- Esophageal, gastric varices: documented by endoscopy or surgery. 606- Esophageal, gastric, duodenal ulcer: documented by endoscopy or surgery 607- Neoplasia of the upper digestive tract (esophageal, gastric or duodenal). 608- Neoplasia of the lower digestive tract (colon and rectum). 609- Other 700 Metabolic:
701- Drug overdose: includes all accidental or intentional drug intoxication (including overdose), 702- Other intoxication, acute: by alcohol, CO inhalation, industrial, domestic, vegetable, animal 703- Adverse effects of medication: acute disease due to a drug given in normal dosage (Lyell’s and Stevens-Johnson syndromes, malignant syndrome of neuroleptics). 704- Diabetic ketoacidosis. 705- Hyperosmolar diabetic coma. 706- Endocrinopathy: includes diseases of thyroid, pituitary gland, adrenal cortex, endocrine 800 Pregnancy:
801- Eclampsia, preeclampsia: Disorders encountered during the last trimester of pregnancy or shortly after delivery which are characterized by hypertension, edema, proteinuria (preeclampsia), convulsions and coma (eclampsia). 802- HELLP syndrome 803- Delivery hemorrhage 804- Other 900 Trauma:
901- Isolated brain trauma 902- Monotrauma, without brain trauma 903- Polytrauma, without brain trauma 904- Polytrauma, with brain trauma 905- Burn 906- Near-drowning 907- Other 000 Other diseases
SITE OF SURGERY

000 No surgery in the current hospital stay.
100 Neurosurgery:
101- Cerebrovascular accident: neurosurgery of intracranial hematoma or other non traumatic 102- Intracranial tumour: neurosurgery for any type of tumour primary or secondary 103-Spinal surgery 104-Ear, nose and throat surgery 105-Maxillo-facial surgery 106-Other 200 Thoracic surgery:
201- Pneumonectomy 202- Lobectomy 203- Pleural surgery: includes all surgery on pleura either for tumor or talcage/abrasion for 300 Cardiac surgery:
301- Valvular, without coronary artery by-pass graft (CABG): surgical treatment of valvulopathies 302- Valvular with CABG: valvular repair with coronary surgery. 303- CABG without valvular repair. 304- Other: pericardial effusion, congenital anomaly, ventricular aneurysm, neoplastic disease, 305- Heart transplantation 306- Heart & lung transplantation 307-Major aortic surgery: includes all surgery on aorta for dissection, atheroma, aneurysm. 308-Carotid endarterectomy: includes all surgery on the carotid artery 309-Other major vascular surgery: includes all surgery on intra thoracic or intra abdominal 310-Peripheral vascular surgery: includes all surgery on non-intracranial, non-intrathoracic, non- intraabdominal vessels, either arteries or veins with or without by-pass graft. 400 Renal-urinary tract:
401- Renal surgery 402- Urologic surgery - 500 Orthopedic (non trauma):
-
600 Digestive:
601- Upper gastro-intestinal surgery (up to and including the jejunum) 602- Lower gastrointesinal surgery 603- Biliary tract: surgery of gallbladder and/or biliary tract 604- Liver: partial hepatectomy, portal-systemic shunt surgery 605- Liver transplantation 606- Pancreas 700 Metabolic:
701- Endocrine surgery (thyroid, adrenal, pancreas etc) 800 Ob/gyn
801- Obstetric surgery: Cesarean section, surgery for ectopic pregnancy, peri- or post-partum 802- Gynecological surgery: surgery of uterus, ovaries, cervix, genitalia. 900 Trauma
901- Brain: surgery for subdural, epidural, intracerebral haematoma or skull fracture. 902- Thorax: surgery of intra-thoracic organs (either cardiac, respiratory or digestive tract) and 903- Abdomen 904- Limb 905- Multiple 906- Other 1000 Other surgery
Description:
For patients undergoing surgery the anatomical site of surgery should be indicated. Only one selection is possible. Invasive radiological procedures or definitive pacemaker insertions should not be considered as surgical procedures. REASON(S) FOR ICU ADMISSION

000 Surveillance/Monitoring only
100 Neurological:
101- Coma, stupor, obtunded patient, confusion, agitation, delirium 102- Seizures 103- Focal neurologic deficit (hemiplegia, paraplegia, tetraplegia) 104- Intracranial mass effect 105- Other 200 Respiratory:
201- ALI and ARDS: Syndrome of inflammation and increased permeability associated with clinical, radiological and physiologic abnormalities: arterial hypoxemia resistant to oxygen therapy (PaO2/FiO2 < 300 mmHg) and diffuse bilateral radiological infiltrates without signs of cardiac failure or pulmonary capillary hypertension (pulmonary artery occlusion pressure < 18 mmHg). 202- Acute respiratory failure on chronic pulmonary disease: Chronic pulmonary disease could be 203- Other: Impaired respiratory function less than that defined by ALI, due to pulmonary lesion or pleuritis, necessitating oxygen or mechanical ventilation. 300 Cardiovascular:
301- Cardiac arrest: Needing cardiopulmonary resuscitation (CPR) prior to admission to ICU. CPR must include chest compression, defibrillation or cardiac massage. 302- Shock: Defined by a systolic blood pressure (SBP) less than 90 mmHg or a drop in SBP of > 40 mmHg from baseline with presence of clinical signs of peripheral circulatory insufficiency (cold, moist skin, cyanosis) and organ hypoperfusion (oliguria, encephalopathy, metabolic acidosis.) requiring the use of inotropic/vasopressor agents. 303- Chest pain (with electrocardiographic changes compatible with either angina or acute 304- Hypertensive crisis 305- Arrhythmia: (due to heart rate or heart conduction disturbances) 306- Cardiac failure without shock either left, right or global 307- Other 400 Renal:
401- Pre-renal acute renal failure (induced by hypovolemia or shock.) 402- Obstructive acute renal failure (post-renal acute renal failure: obstruction of the urinary tract 403- Organic acute renal failure (resulting from lesions in the arteries (intra or extra-renal), in the 500 Hematological:
501- Hemorrhagic syndrome/disseminated intravascular coagulation: Induced by coagulation disorders, like thrombocytopenia and/or increase in prothrombin time and/or congenital disorders of blood coagulation factors and/or acquired disorders of blood coagulation factors. 600 Digestive/Liver:
601- Bleeding: Either upper or lower gastrointestinal tract 602- Acute abdomen: Related to infection, ischemia, perforation, inflammation, either upper or lower gastrointestinal tract. Excludes severe pancreatitis 603- Severe pancreatitis 604- Liver failure: hepatic failure inducing metabolic disturbances and/or encephalopathy. 605- Other 700 Metabolic:
701- Acid-base and/or electrolyte disturbance 702- Hypo and hyperthermia 703- Hypo and hyperglycemia (includes diabetic comas) 704- Other 800 Ob/gyn
900 Trauma
Description:
The reason of ICU admission should be recorded for all patients, independent of the surgical status. It is the acute (or acute on chronic) disease that best explains the reason(s) for admission. It can be medical or surgical. Only one choice is possible. MICROORGANISMS

Gram positive
101 Staphylococcus aureus sensitive to methicillin 102 Staphylococcus aureus resistant to methicillin 103 Staphylococcus coagulase negative (epidermidis, haemolyticus, hominis, …) sensitive to 104 Staphylococcus coagulase negative (epidermidis, haemolyticus, hominis, …) resistant to 105 Streptococcus D group (Entrococcus faecalis, faecium) sensitive to Vancomycin (see 115-) 106 Streptococcus, A, B, C, G group 107 Streptococcus pneumoniae 108 Streptococcus, others 109 Cocci Gram +ve, others 111 Moraxella (Moraxella catarrhalis, Moraxella spp) 112 Listeria monocytogenes 113 Neisseria gonorrhoeae 114 Bacillus Gram +ve, others (Bacillus cereus, Bacillus spp, Corynebacterium spp, Lactobacillus, Rhodococcus equi, Nocardia spp, other) 115 Streptococcus D group (Entrococcus faecalis, faecium) resistant to Vancomycin (see 105-) Gram negative (see 216)
201 Escherichia coli 202 Enterobacter (aerogenes, cloacae, agglomerans, .) 203 Klebsiella (Klebsiella pneumoniae or other) 204 Proteus (Proteus morganii, Morganella morganii, Proteus indole+, Proteus mirabilis, 205 Salmonella 206 Serratia (Serratia marcescens, Serratia spp) 207 Citrobacter (Citrobacter freundii, Citrobacter spp) 208 Pseudomonas aeruginosa 209 Pseudomonas, other 210 Stenotrophomonas maltophilia 211 Acinetobacter (baumannii or other) 212 Campylobacter (Helicobacter, Campylobacter spp, Brucella spp) 213 Haemophilus (influenzae or other) 214 Enterobacteria, other (Yersinia spp, Shigella spp, other) 215 Bacillus Gram -ve, other 216 (add this code if ESBL) 217 Neisseria meningitidis Anaerobes
301 Clostridium (Clostridium difficile, Clostridium perfringens, Clostridium spp, Actinomyces, 302 Anaerobe cocci (Peptococcus, Peptostreptoccus, Veillonella) 303 Bacteroides (Bacteroides fragilis, Bacteroides melaninogenicus, Capnocytophaga, Other organisms
401 Mycobacteria (tuberculosis or others) 402 Chlamydia 403 Rickettsia 404 Mycoplasma (Mycoplasma pneumoniae or hominis, Rochalimeae spp, Bartonella spp) 405 Legionella pneumoniae 501 Candida albicans 502 Candida non-albicans 503 Aspergillus 504 Fungi, other (Cryptoccus neoformans, Histoplasma spp…) Parasites
701 Plasmodium falciparum, Pneumocystis jiroveci (carinii), Toxoplasma gondii. ANTIBIOTICS
1 Cephalosporins
11 cefazolin 12 cefuroxime 13 ceftazidime 14 cefepime/cefpirome 15 other cephalosporin 2 Penicillins
21 benzyl penicillin 22 ampicillin 23 amoxy + clavulanate 24 pipera + tazo 25 oxa/cloxa/flucloxacillin 26 other penicillin 3 Other beta-lactams
31 temocillin 32 (imi/mero) penem 33 aztreonam 34 other 4 Aminoglycoside
5 Quinolone
6 Glycopeptides
7 Macrolides
71 erythromycin 72 other (clarithromycin, etc) 8 Other antibiotics
81 metronidazole 82 cotrimoxazole 83 oxazolidinone (Linezolid) 84 lipopeptide (Daptomycin) 85 tigecycline 86 other 9 Antifungal
91 fluconazole 92 amphotericin B 93 ampho lipid formulation 94 caspofungin 95 voriconazole 96 other 10 Antiviral
101 acyclovir
102 other
Infection Sites

Source: http://www.onetec.be/clinicalstudy/Documents/Codes.pdf