What a disease entity contains

More than a title and a code

Behind every category is more than a title and a code. There is a structured description of what it means.

Five main properties

WHO's content model gives every entity five main properties. A concept title. Its hierarchy, type and use. Textual definitions. The terms used for it. And clinical descriptions.

• Title · Concept title · The name of the entity.
• Definition · Textual · A short description and an optional detailed one.
• Terms · Synonyms · The terms used for the entity.

Short, and longer

There are two kinds of description. A short one, at most a hundred words, which says what is always true about the condition. And a detailed one, shown only in the electronic versions, which adds context such as typical circumstances.

• Short · 100 words · A description of at most 100 words, shown in the tabular list.
• Additional · Online only · A detailed description that appears only in the electronic versions.

Inclusions, exclusions, code also

Notes steer the coding. Inclusion terms are examples of what belongs, and are by no means exhaustive. Exclusion terms are classified elsewhere: the category for hyperfunction of the pituitary gland excludes Cushing syndrome. And code also notes tell you what else to code with the category.

• Inclusions · Examples · Terms classified here. Not a sub-classification, and by no means exhaustive.
• Exclusions · 5A60 · Terms classified elsewhere. This category excludes Cushing syndrome.
• Code also · Together · Additional information to be coded in conjunction with the category.

Descriptions guide; the record decides

One caution from WHO. The descriptions help you understand the meaning and scope of a category. But coders must not use them to choose a code. Codes are assigned from the diagnosis documented by the clinician.

• Use · Understanding · Descriptions show the intended meaning and scope of a category.
• Not for · Choosing codes · Coders are cautioned not to use descriptions for coding. Codes come from the diagnosis the clinician documented.

Keep these in mind

An entity has a title, definitions, terms and clinical descriptions. Read the inclusion, exclusion and code also notes. And descriptions guide, but the clinician's documentation decides.

• An entity has a title, definitions, terms and clinical descriptions
• Read the inclusion, exclusion and code also notes
• Descriptions guide; the clinician's documentation decides