Each is accompanied by wording to clarify its meaning unambiguously followed by its price in euros and tariff details. Explicit hierarchical coding. CCAM codes are structured in a tree whose top-level comprises 19 chapters, organized mainly by large anatomical structure or function:. The second level separates the diagnostic and therapeutic procedures, it is optionally followed by one or more sub-levels. Some acts may receive more than their one or more main code details called Modifiers.
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This amount of information could be analyzed and used for clinical and medico-economic evaluation. But relevant and practical data searches are difficult.
In this paper we present a use case about searching for endoscopic activities in a case mix database to evaluate the relevance of the hierarchical organization and semi structured codes of CCAM in order to retrieve data already coded using this controlled vocabulary.
Precision was 0. France uses its own national coding system for surgical and interventional procedures. It is mainly used in hospitals since for DRG based funding from case mix databases and fee for service payment for private physicians outside hospitals. The terminology labels have been aligned to be conformant with the European standard on the Categorial Structure for Surgical procedures EN [ 2 ] and populated by the Galen Ontology driven tools [ 3 ]. This classification uses a semi-structured code with four letters and three numbers which allows a basic understanding of the multi axial structure by reading the code.
It is currently used to search through codes and analyze the encoded data in medico economic evaluation, for example to estimate the return on investment after buying a new expensive equipment or opening new hospital beds.
Practical experience shows that using CCAM in such studies is difficult and it is hard to find all the relevant procedures within all these medico economic studies. Several innovative methods have been proposed for assisting in coding information in the medical record especially for diagnoses using the International Classification of Diseases [ 4 — 6 ].
However, reporting on the searches for information once it is coded using a controlled terminology and stored in a database has been limited. Our objective was to evaluate the hierarchical organization and semi structured codes of CCAM for retrieving data already coded with this controlled vocabulary. In this article, we take as example the medico-economic evaluation of the renewal of endoscopy devices in a hospital. The purchase of endoscopes is conditioned by a study on the number of endoscopic procedures performed in the hospital.
In this scenario, the endoscopic department needs to evaluate endoscopic activity in the case mix database. In theory, it should be possible to search all CCAM codes corresponding to actions taken under endoscopy in the nomenclature. Practically the search for concepts within CCAM is incomplete and we consider new ways to identify additional codes. These search-modes are by: keyword, hierarchy, partial codes. New updates are made every year. CCAM codes have a defined 7-characters structure.
The first letter designates the system, tract or structure which the action concerns. The second letter provides additional detail such as a function or an organ.
Table 1 is an excerpt from the English translation for anatomical site. The letter H is related to Digestive System.
Descriptors describe both anatomical site e. HC: Salivary glands and functions e. HQ Swallowing. The third letter indicates the action. CCAM Action terms have been defined by grouping them according to action type; each is identified by an action verb, and then coded. The same code is often allocated to several action verbs, grouped together because of their technical similarity.
Table 2 is an example of actions from the Guide [ 9 ] that were translated in English. Several actions are grouped under the general category of Observation Actions. This general category is associated to several verbs e. Examine or Measure. The first column defines a verb e. Several descriptors are associated to each verb and English translations of the descriptors are proposed in the second column e.
Analysis , Exploration , Monitoring , etc. The third column shows the letter associated with the verb. The fourth letter indicates the access mode. Table 3 is an example of access mode from the Guide [ 9 ].
CCAM labels are divided into 18 chapters that are first levels in the hierarchical classification. These chapters are identified with 2 numeric characters and defined by the anatomophysiological system. Each chapter is subdivided into sub-chapters, coded with 2 numeric characters. Each sub-chapter is subdivided into paragraphs and some of them are segmented into subparagraphs.
The final level is the precise label procedure. Diagnostic procedures are ordered by technique and then by topography. Therapeutic procedures are ordered by topography then by action. Table 4 shows an example of a CCAM procedure with corresponding hierarchy and code. We excluded procedures by the means of laparoscopes. Endoscopic procedures are performed in the endoscopic department by using natural body openings whereas a laparotomy is a surgical procedure in the operating room involving an incision through the abdominal wall to gain access into the abdominal cavity.
We reviewed the 1, digestive procedures and manually selected endoscopic procedures using an expert approach 35 diagnostic procedures and 86 therapeutic procedures. This set of endoscopic procedures was our gold standard. These three complementary CCAM code-search strategies are:. Full-text search: a keyword search can be done on the procedure label.
Multiple criteria for words or partial keywords can be used with operators and, or, not. Indeed a specialized term is often chosen instead of endoscopy such as gastroduodenoscopy and can be retrieved using the —scopy suffix. Then we identified for each branch which procedures are performed by means of an endoscope and which procedures use other means.
We also performed a search on the hierarchical levels that subsume the branches selected at the previous step. Code search can be performed with a partial or complete code, e. We selected codes starting by H as a first letter without taking into account the second letter i. For each kind of search we distinguished between therapeutic and diagnostic procedures, and measured precision and recall.
Precision was defined as the number of relevant procedures retrieved by a search divided by the total number of procedures retrieved by that search, and recall was defined as the number of relevant procedures retrieved by a search divided by the total number of endoscopic procedures which should have been retrieved. Table 5 shows results using the three different strategies and their variants with precision and recall. TP means true positive and FP means false positive.
There are separate columns for diagnostic procedures, therapeutic procedures and both. For example recall was high when using parent categories of the selected branches but precision was very low. It was necessary to combine 22 different branches of Chapter 7 2 for diagnostic procedures and 20 for therapeutic procedures. The number of hierarchical levels that subsume these 22 branches was equal to 8. The best results were obtained with the transorifice endoscopic access precision 0.
Storing data in the computerized medical record using a controlled vocabulary should help to identify relevant information for clinical and medico economic studies [ 10 ]. The effort to improve quality of coding will facilitate the use of those data sets for such studies [ 11 ].
An appropriate knowledge representation is a requisite for an efficient retrieval of data and its transformation into new knowledge or information for policy making [ 12 — 13 ]. Medical procedures entered in the case mix database are a valuable tool for such studies.
In order to conduct efficient information searches it is necessary to combine several approaches, e. These methods are not effective in the case of procedures combining several actions or surgical approaches. In the case of hierarchical searches it is difficult to combine the content of 22 different branches. One convenient property of CCAM is that procedures that share common techniques such as endoscopes are usually grouped within a given anatomical part in the CCAM hierarchy.
Table 6 is a summary of the most important advantages and disadvantages of each method. We implemented a single scenario on endoscopic procedures, worked on a single axis related to equipment endoscopes , and used a single chapter digestive procedures. The hierarchical organization and semi structured codes may have other properties in other scenarios for example procedures performed in medico technical units radiology, operating room, interventional cardiology, functional explorations.
This work may benefit from better techniques for full text search using natural language processing. Variations at the semantic level require semantic and lexical resources for synonyms. In the next step we will apply the three search strategies to our hospital case mix database in order to measure the number of discharge datasets related to the selected CCAM codes and to assess the activity of the digestive endoscopy department.
When considering other multi axial terminologies results of the lexical and hierarchical searches may be compared but search by code is not relevant for terminologies that use non semantic Concept Identifiers. Logical Search should be substituted to search by code for such terminologies. We propose to develop tools and software for retrieving medical procedures in the case mix database.
The search would thus benefit from all relations and descriptors proposed for the description of the CCAM in the GALEN project whether for anatomy, action, technique or surgical approach with more granular descriptors and possibility of combining several anatomies, actions, techniques or surgical approaches.
There is currently no available intelligent tool for retrieving CCAM procedures that fits all kinds of needs for medico economic analysis of hospital activity.
None of the three search strategies is totally satisfying and this will lead to a new project for developing a new tool with better knowledge representation of medical procedures. National Center for Biotechnology Information , U. Author information Copyright and License information Disclaimer. Email: rf. This is an Open Access article: verbatim copying and redistribution of this article are permitted in all media for any purpose. This article has been cited by other articles in PMC.
Introduction France uses its own national coding system for surgical and interventional procedures. Open in a separate window. Table 4: Example of code reading. Methods We excluded procedures by the means of laparoscopes.
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