| Code | Primary | Secondary | Tertiary | Quaternary | Generic type | Comments | Frequency (%) |
| 1.1.1.1 | diagnosis | cause/ interpretation of clinical finding | symptom | What is the cause of symptom x? OR What is the differential diagnosis of symptom x? OR Could symptom x be condition y or be a result of condition y? OR What is the likelihood that symptom x is coming from condition y? | In 1.1.x.1, you start with a finding and you want to know what condition is causing it. You know what the finding is, you don’t know what the condition is. See comment 1.2.1.1 | 115 (8.2) | |
| 1.1.2.1 | diagnosis | cause/ interpretation of clinical finding | sign | What is the cause of physical finding x? OR What is the differential diagnosis of physical finding x? OR Could physical finding x be condition y or be a result of condition y? OR What is the likelihood that sign x is coming from condition y? OR At what level does physical finding x become clinically important? OR What is considered normal for physical finding x? | In 1.1.x.1, you start with a finding and you want to know what condition is causing it. You know what the finding is, you don’t know what the condition is. See comment 1.2.1.1 | 67 (4.8) | |
| 1.1.3.1 | diagnosis | cause/ interpretation of clinical finding | test finding (lab, ECG, imaging, biopsy, skin test, etc.) | What is the cause of test finding x? OR What is the differential diagnosis of test finding x? OR Could test finding x be condition y or be a result of condition y? OR What is the likelihood that test finding x is coming from condition y? OR How should I interpret test finding(s) x? OR How should I use test finding x in my decision? OR At what level does the value of test x become clinically important? OR What are the normal values (reference range) of test x? | In 1.1.x.1, you start with a finding and you want to know what condition is causing it. You know what the finding is, you don’t know what the condition is. See comment 1.2.1.1 | 64 (4.6) | |
| 1.1.4.1 | diagnosis | cause/ interpretation of clinical finding | unspecified findings or multiple categories of findings | Could this patient have condition y (given findings x1, x2, . . ., xn)? OR What is the likelihood that this patient has condition y (given findings x1, x2, . . ., xn)? OR What does this patient have (given findings x1, x2, . . ., xn)? OR What is the differential diagnosis of these findings? | In 1.1.x.1, you start with a finding and you want to know what condition is causing it. You know what the finding is, you don’t know what the condition is. See comment 1.2.1.1 | 51 (3.7) | |
| 1.2.1.1 | diagnosis | criteria/ manifestations | What are the manifestations (findings) of condition y? OR What is condition y? OR What does condition y look like? OR What are the criteria for diagnosis of condition y? OR How do I diagnose condition y (based on information I have or could get)? OR How do I distinguish between conditions y1, y2, …yn (based on information I have or could get)? OR How can you tell if the patient has condition y (based on information I have or could get)? OR Can condition y cause manifestation (finding) x? OR How does condition y cause manifestation (finding) x? OR Why did condition y cause manifestation (finding) x? OR Can condition y present with (as) manifestation (finding) x? | In 1.2.1.1, you start with a condition and you want to know if findings x1, x2, . . ,xn could be manifestations of that condition. You know what the condition is, you don’t know if findings x1, x2, . . . , xn could be manifestations of that condition. See comment 1.1.x.1. The focus is on the condition, not the test: "How do I diagnose condition y?" could be either 1.3.1.1 or 1.2.1.1 depending on this focus. See comment 1.3.1.1. | 30 (2.2) | ||
| 1.3.1.1 | diagnosis | test (lab, skin test, biopsy, imaging, element of physical exam, etc) | indications/ efficacy | Is test x indicated in situation y? OR What test (or evaluation, or work up), if any, is indicated/appropriate in situation y or with clinical findings x1, x2, . . , xn? OR What is the best test in situation y? OR Do the benefits of doing test x (work up x) outweigh the risks? OR How do I diagnose condition y (meaning what test(s) or work up should I do)? OR How do I distinguish between conditions y1, y2, …yn (meaning what test(s) or work up should I do)? OR How can you tell if the patient has condition y (meaning what test(s) or work up should I do)? OR Should this kind of patient have screening test x? OR What screening tests should this patient have? | The primary question is "What test should I do?" without regard to the quality/accuracy/performance characteristics of the test itself. The focus is on the indications for doing the test, not the characteristics of the test (see comment 1.3.2.1.) Also the focus is on the test, not the condition: "How do I diagnose condition y?" could be either 1.3.1.1 or 1.2.1.1 depending on the focus. See comment 1.2.1.1. Do not use this category for tests mandated by nonmedical organizations (5.2.1.1) and do not use it for drug levels (2.1.11.1) | 112 (8.0) | |
| 1.3.2.1 | diagnosis | test (lab, ECG, imaging, biopsy, skin test, element of physical exam, etc) | accuracy | How good is test x in situation y? OR What are the performance characteristics (sensitivity, specificity, etc.) of test x in situation y? OR What is the efficacy of screening with test x? OR What is the efficacy of screening for condition y? | The primary question is "How good is the test?" without regard to the indications for doing it. The focus here is on the characteristics of the test, not the indications for using it. See comment 1.3.1.1. | 14 (1.0) | |
| 1.3.3.1 | diagnosis | test (lab, ECG, imaging, biopsy, skin test, element of physical exam, etc) | timing/ monitoring | When (timing, not indications) should I do test x? OR When (timing, not indications) should I do test x to monitor condition y? OR When (timing, not indications) or how often should screening test x be done? OR When (timing, not indications) or how often should you screen for condition y? | Do not use for drug levels (2.1.11.1). | 31 (2.2) | |
| 1.3.4.1 | diagnosis | test (lab, ECG, imaging, biopsy, skin test, element of physical exam, etc) | preparation | What is the preparation for test x? | This category refers to what the patient must do before the test is performed. See comment 1.3.5.1. | 3 (0.2) | |
| 1.3.5.1 | diagnosis | test (lab, ECG, imaging, biopsy, skin test, element of physical exam, etc) | method | How do you do test x? OR What is the best way (best technique, best method) to do test x or screening test x? | This category refers to what the provider does during the performance of the test; how the test is done. See comment 1.3.4.1. | 6 (0.4) | |
| 1.4.1.1 | diagnosis | name finding | body part (anatomy) on physical exam or imaging study | What is the name of this body part? OR What is the anatomy here? | 8 (0.6) | ||
| 1.4.2.1 | diagnosis | name finding | condition | What is the name of that condition? | I know what the condition is, I just don’t know its name. See comment 1.5.1.1 | 6 (0.4) | |
| 1.4.3.1 | diagnosis | name finding | test | What is the name of that test? | I know what the test is, I just don’t know its name. See comment 1.5.2.1 | 2 (0.1) | |
| 1.5.1.1 | diagnosis | orientation | condition | What is condition y? | I know the name of the condition, but I don’t know what it is. See comment 1.4.2.1. This code will never be used in any analysis; all 1.5.1.1 codes will be converted to 1.2.1.1. It is included here only as an aid to the coder. | 5 (0.4) | |
| 1.5.2.1 | diagnosis | orientation | test | What is test x? | I know the name of the test, but I don’t know what it is. See comment 1.4.3.1 | 1 (0.1) | |
| 1.6.1.1 | diagnosis | inconsistencies | Why were this patient’s findings (or course) inconsistent with usual expectations? | 8 (0.6) | |||
| 1.7.1.1 | diagnosis | cost | What is the cost of test x? | 1 (0.1) | |||
| 1.8.1.1 | diagnosis | not elsewhere classified | Generic type varies. | In a broad sense, the question is about diagnosis, but it does not fit any other diagnosis category. | 1 (0.1) | ||
| 2.1.1.1 | treatment | drug prescribing | how to prescribe | undifferentiated | How do you prescribe/administer drug x (in situation y)? | 10 (0.7) | |
| 2.1.1.2 | treatment | drug prescribing | how to prescribe | dosage | What is the dose of drug x (in situation y)? OR Should I change the dose of drug x (in situation y)? OR What is the maximum dose of drug x (in situation y)? OR What are equivalent doses among members of drug class x? | 94 (6.7) | |
| 2.1.1.3 | treatment | drug prescribing | how to prescribe | timing | When (timing, not indication) or how should I start/stop drug x? OR How long should I give drug x? OR When (timing, not indication) should I give drug x (in situation y)? | Includes preventive drug treatment (and immunizations). | 27 (1.9) |
| 2.1.2.1 | treatment | drug prescribing | efficacy/ indications/ drug of choice | treatment | Is drug x (or drug class x) indicated in situation y or for condition y? OR What are the indications for drug x? OR Is any drug indicated for situation y? OR Does drug x work for condition y? OR How effective is drug x for condition y? OR What is the drug of choice for situation y or for condition y? OR What are the options for drug treatment of situation y or condition y? OR Is drug x1 better than drug x2, x3, . . ., xn for condition y? OR Is drug x1 just as effective as drug x2 (in situation y)? OR Does the benefit of giving drug x outweigh the risk? | Use 2.2.1.1 if treatments other than drugs could be considered. When the question does not specify drug treatment, the distinction between 2.2.1.1 (treatment in general) and 2.1.2.1 (drug treatment) can be difficult. The coder must judge whether nondrug treatment is a reasonable consideration. | 150 (10.7) |
| 2.1.2.2 | treatment | drug prescribing | efficacy/ indications/ drug of choice | prevention | Should this kind of patient get prophylactic drug x to prevent condition y? OR Is prophylactic drug x indicated to prevent condition y? OR What prophylactic drug should I give to prevent condition y? OR How effective is prophylactic drug x in preventing condition y? OR For how long is drug x effective in preventing condition y? OR Is prophylactic drug x1 better than prophylactic drug x2 in preventing condition y? | Immunizations are drugs. Timing questions should be coded as 2.1.1.3. | 40 (2.9) |
| 2.1.3.1 | treatment | drug prescribing | adverse effects | findings caused by drug/ adverse effects of drug | Could finding y be caused by drug x? OR Does drug x cause finding y? OR What are the adverse effects of (or risks of using) drug x? OR What is the likelihood (incidence) of adverse effect(s) y resulting from drug x? OR How long do the adverse effects from drug x last after stopping it? OR Which drug has the fewest adverse effects? OR Are there differences among drugs x1, x2, . . ., xn in their likelihood of causing adverse effect(s) y? | 59 (4.2) | |
| 2.1.3.2 | treatment | drug prescribing | adverse effects | administration in face of adverse effects | How can drug x be administered without causing adverse effect y or minimizing adverse effect y or in spite of adverse effect y? OR What dose of drug x would cause adverse effect y or any adverse effect? | 3 (0.2) | |
| 2.1.3.3 | treatment | drug prescribing | adverse effects | safety/ contraindications (includes pregnancy and breast feeding) | Is drug x safe to use in situation y? OR Is drug x contraindicated in situation y? | 24 (1.7) | |
| 2.1.4.1 | treatment | drug prescribing | interactions | Is it OK to use drug x with drug y? OR Are there any interactions between drug x1 and drug (or food) x2, x3, . . . Xn? | 28 (2.0) | ||
| 2.1.5.1 | treatment | drug prescribing | name finding | What is the name of that drug? | I know what the drug is, I just don’t know its name. See comment 2.1.6.1. | 12 (0.9) | |
| 2.1.6.1 | treatment | drug prescribing | orientation/ composition | What is drug x? OR What is in drug x (or dietary product x)? OR How much of component y is in drug x? | I know the name of the drug but I don’t know what it is. See comment 2.1.5.1. | 26 (1.9) | |
| 2.1.7.1 | treatment | drug prescribing | physical characteristics | What are the physical characteristics (dosage forms, tablet/liquid characteristics, container characteristics) of drug x? | 26 (1.9) | ||
| 2.1.8.1 | treatment | drug prescribing | pharmaco-dynamics/ absorption | What are the pharmacodynamic/ absorption characteristics of drug x? OR How do the pharmacodynamic/ absorption characteristics of drugs x1, x2, . . ., xn compare? | 2 (0.1) | ||
| 2.1.9.1 | treatment | drug prescribing | mechanism of action | What is the mechanism of action of drug x? OR How does drug x work? | 3 (0.2) | ||
| 2.1.10.1 | treatment | drug prescribing | cost | What is the cost of drug x? OR How does the cost of drug x1 compare with the cost of drug x2, x3, . . . , xn? | 11 (0.8) | ||
| 2.1.11.1 | treatment | drug prescribing | serum levels | What are the indications for getting a drug serum level or what time should it be drawn or how often should it be drawn? | 1 (0.1) | ||
| 2.1.12.1 | treatment | drug prescribing | availability | Is drug x available yet? OR Is drug x available over-the-counter? | 4 (0.3) | ||
| 2.2.1.1 | treatment | not limited to but may include drug prescribing | efficacy/ indications | treatment | How should I treat finding/condition y (given situation z)? OR Should I use treatment/procedure x for condition/finding y? OR What is the efficacy of treatment/procedure x (for condition y)? OR Does procedure/treatment x work (for condition y)? OR Is treatment/procedure x indicated (for condition y)? OR What is the best treatment/procedure to do (for condition y)? OR Does the benefit of treatment/procedure x outweigh the risk? OR What are the options for treatment of condition y (in situation z)? OR Is there any treatment for condition y? OR What is the goal of treatment of condition y? OR At what level of severity of condition y is treatment indicated? | When the question does not specify drug treatment, the distinction between 2.2.1.1 (treatment in general) and 2.1.2.1 (drug treatment) can be difficult. The coder must judge whether nondrug treatment is a reasonable consideration. | 82 (5.9) |
| 2.2.1.2 | treatment | not limited to but may include drug prescribing | efficacy/ indications | prevention | Should this kind of patient get prophylactic treatment (intervention) x to prevent condition y? OR Is prophylactic treatment (intervention) x indicated to prevent condition y? OR What prophylactic treatment (intervention) should I give to prevent condition y? OR Does treating condition y1 help prevent condition y2? | 1 (0.1) | |
| 2.2.2.1 | treatment | not limited to but may include drug prescribing | timing | When (or how) should I start/stop treatment x? OR When (timing, not indication) should I use treatment x (in situation y)? OR How long should I continue treatment x for condition y? | 2 (0.1) | ||
| 2.2.3.1 | treatment | not limited to but may include drug prescribing | how to do it | How do you do treatment/procedure x? OR What is the best way to do treatment/procedure x? | Do not use for diagnostic methods (1.3.5.1). | 1 (0.1) | |
| 2.2.4.1 | treatment | not limited to but may include drug prescribing | principles/ rationale | What are the principles (or rationale) behind therapy x? OR How does therapy x work? | 1 (0.1) | ||
| 2.3.1.1 | treatment | not elsewhere classified | Generic type varies | In a broad sense, the question is about treatment, but it does not fit any other treatment category. | 4 (0.3) | ||
| 3.1.1.1 | management (not specifying diagnostic or therapeutic) | condition/ finding | How should I manage condition/finding/situation y? (not specifying diagnostic or therapeutic management) OR What management options are there in situation y? OR How aggresive/conservative should I be in situation y? | Do not use this code for questions about only diagnosis (1.3.1.1) or only treatment (2.2.1.1). Do not use this code if you know the diagnosis. Go with the meaning, not with the words: If the questioner says "management," but treatment is the only reasonable kind of management (the diagnosis is not in question), do not use this code. | 67 (4.8) | ||
| 3.2.1.1 | management (not specifying diagnostic or therapeutic) | other providers | practices of other providers | Why did provider x treat the patient this way? OR How do other providers manage condition y? | 12 (0.9) | ||
| 3.2.2.1 | management (not specifying diagnostic or therapeutic) | other providers | referral | When should you refer in situation y? | 8 (0.6) | ||
| 3.2.3.1 | management (not specifying diagnostic or therapeutic) | other providers | community services | What social services (or support groups, community groups) are available for condition/situation y? | 5 (0.4) | ||
| 3.3.1.1 | management (not specifying diagnostic or therapeutic) | doctor-patient communication | how to advise | How should I advise the patient/family in situation y? | 8 (0.6) | ||
| 3.3.2.1 | management (not specifying diagnostic or therapeutic) | doctor-patient communication | how to approach difficult issue | What is the best way to discuss or approach discussion of difficult issue x? | 5 (0.4) | ||
| 3.3.3.1 | management (not specifying diagnostic or therapeutic) | doctor-patient communication | patient compliance | How can I get the patient/family to comply with my recommendations or agree with my assessment? | 21 (1.5) | ||
| 3.4.1.1 | management (not specifying diagnostic or therapeutic) | not elsewhere classified | Generic type varies | In a broad sense, the question is about management, but it does not fit any other management category. | 0 (0.0) | ||
| 4.1.1.1 | epidemiology | prevalence/ incidence | What is the incidence/prevalence of condition y (in situation z)? OR Why is the incidence/prevalence of condition y changing? | This category is plain incidence or plain prevalence. I am not interested in associations between risk factors and conditions. I am not interested in associations among different conditions. See comments 4.2.1.1 and 4.3.1.1. | 14 (1.0) | ||
| 4.2.1.1 | epidemiology | etiology | causation/ association | risk factors/ disease agents | Is x a risk factor for condition y? OR Is x associated with condition y? OR Is condition y1 associated with condition y2, y3, . . . yn (all conditions present at the same time)? OR Can finding or disease-agent x cause condition y? OR What are the causes of condition y? OR What conditions or risk factors are associated with condition y? OR Why did the patient get condition y? | This category asks about associations between a risk factor and a condition (the risk factor occurring before the condition) or between 2 or more conditions (that are present at the same time). Do not use this code for 2 elements that are part of the same disease process (which is 4.3.1.1). Instead, use it when one element, which is not part of the disease process, is a risk factor for the condition (disease). See comments 4.1.1.1 and 4.3.1.1. Do not use this category for adverse drug reactions (2.1.3.1). | 40 (2.9) |
| 4.2.1.2 | epidemiology | etiology | causation/ association | genetics | Is condition y hereditary? | 2 (0.1) | |
| 4.3.1.1 | epidemiology | course/ prognosis | What is the usual course (or natural history) of condition y? OR What is the prognosis (or likelihood of complications) of condition/situation y? OR Can condition y1 lead to condition y2, y3, . . . yn (condition y1 occurs before conditions y2, y3, . . ., yn)? | This category asks what happens to a patient over time. It includes plain prognosis questions as well as associations between 2 conditions, where one condition occurs before the other. See comments 4.1.1.1 and 4.2.1.1). | 25 (1.8) | ||
| 4.4.1.1 | epidemiology | not elsewhere classified | Generic type varies. | In a broad sense, the question is about epidemiology, but it does not fit any other epidemiology category. | 1 (0.1) | ||
| 5.1.1.1 | nonclinical | education | provider | continuing medical education | I need to learn more about topic x. OR I need to review topic x. | 8 (0.6) | |
| 5.1.1.2 | nonclinical | education | provider | information source | Where can I find or how can I get information about topic x? OR Is there any information on topic x? | 5 (0.4) | |
| 5.1.1.3 | nonclinical | education | provider | trainee | How can I better teach this trainee (medical student, resident, other provider)? | 1 (0.1) | |
| 5.1.2.1 | nonclinical | education | patient | What patient education materials are available for situation y? OR Where can I get patient education materials on topic x? | 3 (0.2) | ||
| 5.2.1.1 | nonclinical | administration | What are the administrative rules/ considerations in situation y? OR What are the local requirements and issues relevant to situation y? OR What are the safety issues for health care workers in situation y? | Examples: disease codes, procedure codes, HMO rules, insurance company rules, employer rules, government rules. Distinguish between guidelines primarily based on clinical issues where the patient’s welfare is the primary concern (consider other codes) versus guidelines designed to meet the goals of the organization. | 13 (0.9) | ||
| 5.3.1.1 | nonclinical | ethics | What are the ethical considerations in situation y? | 4 (0.3) | |||
| 5.4.1.1 | nonclinical | legal | What are the legal considerations in situation y? | 1 (0.1) | |||
| 5.5.1.1 | nonclinical | frustration | Generic type varies. Not a true question, but rather an expression of frustration or an unanswerable dilemma. | 15 (1.1) | |||
| 5.6.1.1 | nonclinical | not elsewhere classified | In a broad sense, the question is nonclinical, but it does not fit any other nonclinical category. | 2 (0.1) | |||
| 6.1.1.1 | unclassified | Generic type varies. Unable to classify | 0 (0.0) |