Family Practice Vol. 9. No.

3
© Oxford University Press 1992 Primed in Great Britain

The Conversion Between ICPC and

ICD-10. Requirements for a Family of
Classification Systems in the Next
Decade
M WOOD. H LAMBERTS*, JS MEIJER* AND I M HOFMANS-OKKES

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Wood M, Lamberts H, Meijer JS, Hofmans-OkkeslM. The conversion between ICPC and ICD-10. Require-
ments for a family of classification systems in the next decade. Family Practice 1992; 9: 340-348.
The International Classification of Primary Care (ICPC) was developed to order medical concepts into
classes that have been chosen for their relevance for family medicine. Family physicians use this to label
the most prevalent conditions in their practice as well as their patients' symptoms and complaints. At the
same time they do not want to be divorced from the needs of the medical community at large as these are
reflected in the most recent medical nomenclature: the Tenth Revision of the International Classification of
Diseases (ICD-10). A full conversion between all classes in the first and seventh component of ICPC
(n = 646) with those of ICD-10 {n = 1983), with the exception of the chapter on external causes, has been
prepared. It was concluded that ICD-10 at the three-digit level cannot function as a core classification for
an international primary care system. Of the three-digit ICD-10 rubrics only 120 are compatible on a one to
one basis with an ICPC rubric. A total of 114 three-digit ICD-10 rubrics have to be broken open into four-
digit rubrics to allow at least one compatible conversion to one or more ICPC rubrics. On this basis only
25% of the diagnostic classes in ICPC can be converted to a single three- or four-digit ICD-10 rubric
without lumping. The rest of ICD-10, either on the three- or on the four-digit level, has to be grouped into
combinations of classes (lumping) to allow compatible conversion to the remaining rubrics of ICPC. Even
though ICD-10 cannot serve as a core classification for primary care, a technical conversion between ICPC
and ICD-10 is practically always possible which allows primary care physicians to implement ICD-10 as a
contemporary nomenclature within the classification structure of ICPC.

INTRODUCTION be allocated to the correct class.3 A class (or a rubric)

Health information systems deal with data which have
been ordered and received a name, so that they can be
counted. That which has no name cannot be counted
and consequently has no impact. The practical result is
that both the labelling of patient problems and the
ordering of data in a patient record require feasible
and relevant tools.1 Among these tools are a
nomenclature which provides the concepts, designated
by terms and a classification system to order these
concepts.
Classification systems order objects in classes
according to established criteria.2 Identification of an
object requires it to obtain a name and subsequently to
Department of Family Practice, Medical College of Virginia, Virginia
Commonwealth University, USA and • Department of General Prac-
tice, University of Amsterdam, The Netherlands.
is characterized both by its code and its terminology. A
nomenclature, which is the collection of terms belong-
ing to the professional jargon is distinguished from a
classification and from a terminology, which is based
on the definitions (inclusion criteria) of each class or
rubric (Figure 1). A thesaurus is a storehouse of
knowledge like an exhaustive encyclopedia or a com-
puter tape with a large index and synonyms.
Sokal4 pointed out that a good classification helps
the user to: better define the structure of concepts;
simplify the variations between concepts; economize
the use of memory; and ease the manipulation and
retrieval of data. The relationship between a specially
designed primary care classification, like ICPC, and a
generally applied system like the International Classi-
fication of Diseases (ICD) should be established with
the above-mentioned principles in mind.

340
 CONVERSION BETWEEN ICPC AND ICD-10 341

CLASSIFICATION

ORDERING
OF OBJECTS DEFINITION
IN A STRUCTURE INCLUSION
WITH A CRITERIA
PURPOSE

PROFESSIONAL
JARGON NOMENCLATURE
TERMS WORDS

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ALL ENTRIES
AND SYNONYMS
WITH ONE
OR MORE
CODES

FIGURE 1 Differences between a nomenclature, a terminology, a classification and a

thesaurus.

ICPC three modes separately: as a reason for encounter

The International Classification of Primary Care
(ICPC) is a classification system developed to order
medical concepts into classes that have been chosen on
the basis of their relevance for family medicine.5'6 It is
a biaxial classification system based on chapters and
components and uses three-digit alphanumeric codes
with mnemonic qualities. Seventeen chapters each with
an alpha code, form one axis, while seven components
with rubrics bearing a two-digit numeric code form the
second axis. Component 1 incorporates symptoms and
complaints, and component 7 virtually all of the
disease rubrics of the International Classification of
Health Problems in Primary Care-2-Defined.7 This
allows the inclusion criteria of ICHPPC-2-Defmed to
be used in ICPC. Components 2-6 represent the pro-
cess elements in the classification.
ICPC has been constructed on the principles of con-
cepts, which incorporate symptoms, complaints,
reasons for encounter, interventions, diseases,
diagnoses; classes, in the form of rubrics biaxially
arranged over components and chapters; and criteria,
which cover relevance for primary care, localiza-
tion before aetiology, use of inclusion criteria
(terminology), hierarchy in specificity, and one single
nomenclature for reason for encounter, diagnosis and
process.5
The ICPC provides an instrument to identify and
order essential elements of primary care and can be
used both as a comprehensive system and in each of its
classification; as a diagnostic classification; or as a
process classification.
Used in its comprehensive form, ICPC enables
the clinician or researcher to move to an episode-
oriented epidemiology (Figure 2), in which the changes
(transitions) in the relations between reasons for en-
counter, diagnoses and interventions which occur dur-
ing an episode as it evolves over time, can be analysed.
ICD
Morbidity data derived from family practice settings
form an essential link in the chain of sources of in-
formation necessary for health statistics which, in
most countries, is based on the use of the ninth
revision of ICD (ICD-9)8 (Figure 3). ICPC relates to
ICD-9, and recently also to ICD-10, by means of a
technical conversion.'Interpretation of the differences
in prevalence, both within and between the links of the
information chain in Figure 3, has often proved to be
difficult. Understanding of the differences in clinical
judgement, and consequently of interventions, bet-
ween generalists and specialists when treating patients
with diseases such as diabetes, hypertension, depres-
sion, or chronic respiratory disease, is limited because
there is insufficient systematic knowledge of the course
of these diseases over time, analysed as complete
episodes of disease (Figure 2).
Since the introduction of ICD-9 in 1978 many have
focused their attention on the problems with the
342 FAMILY PRACTICE—AN INTERNATIONAL JOURNAL

PERCEIVED REASON FOR -*• -• START

PERCEIVED
NEED FOR ENCOUNTER OF AN
HEALTH DIAGNOSIS PROCESS
CARE DEMAND EPISODE
PROBLEM <- «-
FOR CARE

REASON FOR SECOND

ENCOUNTER
- * •
->
DIAGNOSIS ENCOUNTER
DEMAND PROCESS
OF SAME
FOR 4- <- EPISODE
CARE

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FOLLOWING ENCOUNTERS
OF AN EPISODE

FIGURE 2 Episode oriented epidemiology

Health. General Practice/ Specialized Categorical Mortality

Family Practice medicine care statistics
• sentinel • hospitals • < - • • cancer <-•
• complete • ambulatory registration
registration care
i

t t t
FIGURE 3 Chain of information sources in a health tare system

creation of a family of ICD-related classifica- four-digit level approximately 10000 different classes
tions. 10 " 12 HowcveT, the ICD revision conference in are available, which is 40"% more than ICD-9. ICD-10
September 1989 has accepted the tenth revision of the thus incorporates the changes in the medical nomencla-
International Statistical Classification of Diseases ture generated during the past 15 years and as such,
and related Health Problems (ICD-10) without any is a welcome update of the status of contemporary
essential restructuring.9 Consequently ICD-10 does not medicine which should also reflect on primary care
take into account the requirements of family medicine classifications, such as the ICPC.
any better than its predecessor.1 ICD-10 contains 1929
three-digit rubrics, which is 78% more than ICD-9, REQUIREMENTS FOR A FAMILY
which has 1081 three-digit rubrics (Figure 4). At the RELATIONSHIP BETWEEN ICPC AND ICD-10
Primary care physicians require a reliable classification
system which enables the labelling of the most
prevalent conditions extant in members of the com-
3 DIGIT 4 DIGIT munity as well as their symptoms and complaints,
while at the same time it does not divorce primary care
ICD 9 1081 ±6900 from the needs of the rest of the medical community,
as these are reflected in their common nomenclature.6
ICD 10 1929 ±9700 To achieve this there must be a detailed assessment
of the relationship between ICPC and ICD-10 in order
to make ICPC sufficiently compatible with ICD-10 to
+ 78% +43% facilitate the provision of primary care, to enhance
quality assessment and assurance and to allow easy
FIGURE 4 Available three- and four-digit classes in ICD-9 and reliable information retrieval, analysis and
and ICD-10 communication.
 CONVERSION BETWEEN ICPC AND ICD-10
ICD-10 with 1929 diagnostic classes at the three-
digit level is however, far more specific than any
primary care classification can afford to be and for
that reason it would be of great advantage if ICD-10 at
the three-digit level could function as a core classifica-
tion allowing a selection of ICD-10 rubrics to be
replicated in a primary care classification on a one-to-
one basis, while 'lumping' the remaining ICD-10
rubrics to a limited number of rubrics.12 In doing so
intermediate and frequently used classes in ICPC
(defining 'intermediate' as a rate of 1-5 occur-
rences/1000 patients/year and 'frequent' as ^ 5 or
more occurrences/1000 patients/year) could directly
relate with three-digit ICD -10 classes while meaningful
combinations of other rubrics ('lumping') would pro-
vide the rest of the structure for a conversion between
343
ICPC is based on the inclusion criteria listed in
ICHPPC-2-Defined while ICD-10 only contains in-
clusion criteria for the chapter on psychiatric
disorders.7 Consequently, the conversion between
ICD-10 and ICPC can only deal with compatible
classes: comparability is not implied.13
Often more than one ICD-10 rubric had to be con-
verted ('lumped') to one ICPC rubric (Tables 2 and 3).
In the instances where the three-digit ICD-10 rubric
could not be converted to a single ICPC rubric because
it contained in its four-digit form a subdivision which
could be converted to one or more ICPC rubrics, then
this ICD-10 rubric was broken open into two or more
four-digit rubrics (Tables 4, 5 and 6). As a result of
this, one or more four-digit ICD-10 rubrics relate
to one or more three-digit ICPC rubrics while a 're-

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an international primary care classification and ICD- mainder' of that ICD-10 rubric has to be converted to
10.6 another ICPC rubric (designated by 'R'). Whenever
With this as a background the following questions more than one rubric of one classification is converted
have been addressed. Firstly, can ICD-10, at the three- to one single rubric in the other, this is indicated by a
digit level, function as a core classification for an inter-
national classification to be used in primary care prac-
tice? Secondly, should this not be so, can a technical TABLE 2 Lumping of ICD-10 rubrics to one ICPC rubric
conversion between the two systems be developed with
enough compatibility so that the nomenclature of ICPC ICD-10
ICD-10 can be used when collecting medical and
administrative data which are classified with ICPC?
A73 Malaria - b 5 0 Plasmodium falciparum malaria

METHODS -b51 Plasmodium vivax malaria

A conversion between ICPC and all three-digit ICD-10 -b52 Plasmodium malariae malaria
rubrics (n = 1929), with the exception of the chapter
on external causes containing 100 classes which is not -b53 Other parasitol. confirmed malaria
reflected in ICPC, was carried out with the help -b54 Unspecified malaria
of a specially developed computer program. This is
illustrated with examples in Tables 1-9. All con-
versions had to be compatible in that they relate to one
TABLE 3 Lumping of ICD-10 rubrics to one ICPC rubric
another in a consistent manner. This was so when the
conversion occurred on a one-to-one basis: one three-
digit ICD-10 rubric compatible with one three-digit ICPC ICD-10
ICPC rubric (e.g. heartburn, mumps, malignant
neoplasm of stomach or essential hypertension) (Table D97 Cirrosis/
1). This, of course, does not imply that both classes are other liver
comparable in that their clinical content is equivalent. disease -b94.2 Sequelae virus hepatitis
The inclusion criteria for the use of a rubric in one
system can be different from those in the other system. -k70 Alcoholic liver disease
-k71 Toxic liver disease
-k72 Hepatic failure NEC
TABLE 1 One to one conversions between ICPC and ICD-10
-k73 Chronic hepatitis NEC

ICPC ICD-10 -k74 Rbrosis and cirrhosis

of liver

A71 Measles b05 Measles -k75 Other inflammatory

liver diseases
A72 Chickenpox bOl Varicella
-k76 OthCT diseases of liver
A74 Rubella bO6 Rubella (German measles)
-k77 LiveT disorders in
A75 Infectious b27 Infectious mononucleosis diseases classified
mononucleosis elsewhere
344 FAMILY PRACTICE—AN INTERNATIONAL JOURNAL
TABLE 4 Breaking open of ICD-10 rubrics and lumping in ICPC
1CPC ICD-10
A76 Other viral diseases -bO3 Smallpox
with exanthems
-bO4 Monkeypox infections

-bO8.2 Exanthema subitum

-bO8.3 Erythema infectiosum

-bO8.4 Hand, foot and mouth disease

-bO8.R Other specific viral infections characterized by skin & mucocutaneous lesions

-bO9 Unspecified viral infections characterized by skin & mucocutaneous lesions

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ICD-10 ICPC
bO8 Other viral infections characterized by skin and
mucocutaneous lesions, not elsewhere classified
b08.0(R) Other orthopox virus infections + A76/ + A77
bO8.1 Molluscum contagiosum S95
bO8.2 Exanthema subitum + A76
bO8.3 Erythema infectiosum + A76
bO8.4 Enteroviral vesicular stomatitis + A76
with exanthema
bO8.5 Herpes angina + A77
bO8.8(R) Other specified viral infections characterized + A76/ + A77
by skin and mucocutaneous lesions

minus-sign: each rubric has by definition a smaller
clinical content than the single rubric in the other
system. When a single rubric is distributed over more
than one rubric in the other system this is indicated
with a plus-sign: this rubric by definition has a larger
clinical content than each of the single rubrics to which
it has been converted (Tables 2-7).
Sometimes the conversion was complicated because
the ordering principles in both systems are different
(Table 8). Several ICD-190 rubrics in the last chapter
referring to encounters for other reasons have to be
converted to the process codes in chapter 2-6 of ICPC.
Very seldom (less than 1 °?o of all rubrics) a rubric in
one system contained concepts that were not reflected
in the other (Table 9).
RESULTS
Of all three-digit ICD-10 rubrics only 120 are com-
patible on a one-to-one basis with a three-digit rubric
in the first or seventh component of ICPC: i.e. a
straightforward and compatible conversion is possible
(Figure 5). A total of 114 three-digit ICD-10 rubrics
have to be broken open into four-digit rubrics to
allow at least one compatible conversion to one or
more ICPC rubrics (Tables 3,4,5). This results in an
additional 66 ICPC rubrics being converted to a single
four-digit ICD-10 rubric on a one-to-one basis. On this
basis approximately 25% of the diagnostic classes in
ICPC can be converted to a single three- or four-digit
ICD-10 rubric without 'lumping'. The rest of ICD-10,
either on the three- or on the four-digit level, has to be
grouped into a combination of classes ('lumping') to
allow compatible conversion to the remaining rubrics
of ICPC. This results in a conversion pattern in which
the rubric title of ICPC designates the clinical content
of several three- and four-digit ICD-10 rubrics
together. Technically this conversion practically
always was achievable.
Several ICPC rubrics are more specific, practically
all of them in component 1, because they cannot be
converted to one single ICD-10 rubric (Tables 5 and 7).
This situation is indicated by positioning a plus sign
before the code ICD-10.
Two conclusions are possible. Firstly ICD-10 at the
three-digit level cannot serve as a core classification
for primary care because too many (114) have to be
broken open into four-digit rubrics to allow com-
patible conversions. Secondly, a compatible con-
version between the classes of ICPC and of ICD-10 is
practically always possible.
 CONVERSION BETWEEN ICPC AND ICD-10 345
TABLE 5 Breaking open of ICD-JO rubrics: conversion to DISCUSSION
the first component of chapter H (ear) of ICPC The relevance of a classification system for primary
care does not only depend on its distribution of preva-
ICPC ICD-10 lences and on its diagnostic orientation towards symp-
toms and complaints.6 The frame of reference of family
HOI Earpain/earache h92.0 Otalgia
medicine/general practice as this develops over time
H02 Hearing complaints -h93.2 Other diseases and is shared by primary care physicians in various
(excl.deafness H84) of ear NEC countries in the form of a classification, should also
relate to ICD. ICD-10 provides the medical com-
H03 Ringing/buzzing/ -h93.1 Tinnitus munity with a new and up-to-date nomenclature which
tinnitus allows ICPC to group ICD-10 rubrics together in
classes which are clinically relevant for primary care.14
H04 Discharge from ear h92.1 Otorrhoea Both nomenclatures and classifications must change
(excl.blood H05)
over time because they only temporarily reflect the
H05 Blood in/from ear h92.2 Otorrhagia 'state of the art' in a profession. ICD-10 was not
designed to be used in primary care settings and to

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HI3 Plugged feeling
H15 Concern with
appearance of ear
H27 Fear of ear disease
H28 Disability/impairment
H29-Other symptoms/
complaints of ear
ICD-10
h93 Other disorders of ear NEC
h93.O Degenerative and vascular
disorders of ear
h93.1 Tinnitus
h93.2 Other abnormal auditory
perceptions
h93.3 Disorders of acoustic nerve
h93.8 Other specified disorders of ear
h93.9 Disorders of ear. unsDecified
+ h93.8 Other spec, cater for its classification needs. It is disappointing,
dis. ear however, that ICD-10 at the three-digit level cannot
function as a core for primary care because this would
+ h93.8 Other spec, have facilitated data collection and analysis in health
dis. ear
care information systems. However, the conversion bet-
+ z71.1 Fear spec.dis. ween ICD-10 and ICPC will allow the further develop-
ment of the concept of a family of classifications. l0~12
+ r68.8 Other gen.sympt. The technical conversion between ICD-10 and ICPC
cond.NEC can be especially useful for computerized patient
records which need a large nomenclature and also for
-b.93.9 Other disorder billing systems which have the same requirement.
ear unspecified
This conversion is too complicated for clinical use in
office settings and such use would embarrass the
ICPC
clinical assessement by primary care physicians. In
order to prevent new communication problems bet-
ween generalists and specialists in the future and to
support increasing collaboration between them it
+ H84 seems appropriate to embrace ICD-10 in all its
+ H03
specificity as the leading medical nomenclature. In
addition to this the development of a complete medical
+ H02 terminology with the definitions of all concepts in the
nomenclature is of considerable importance. Such a
development would allow classification systems to
+ H86 bring order in patient oriented data systems according
to established criteria.
- H13/-H15
For primary care there is an urgent need for the
+ H29 preparation of translations into various languages."

TABLE 6 Partial breaking of an ICD-10 rubric with the forming of a 'rest' (R)

r45 Symptoms and signs involving emotional

state
r45.0 Nervousness P01 Feeling anxious, nervous, tense
r45.1 Restlessness and agitation + P04 Feeling/behaving irritable/angry
r45.2 Unhappiness -P03 Feeling depressed
r45.4 Irritability and anger + P04 Feeling/behaving irritable/angry
r45.R Other symptoms involving emotional + P29 Other psychological symptoms/complaints
state (includes demoralization,
apathy, hostility, physical violence)
346 FAMILY PRACTICE—AN INTERNATIONAL JOURNAL
TABLE 7 ICPC more specific than ICD-10

ICD-10 ICPC

R53 Malaise and fatigue -A04 Geneial weakness/

tiredness/ill feeling
-A05 General deterioration

TABLE 8 Complicated conversion between ICD-IO and ICPC

ICD-10 ICPC

rO6 Abnormalities of breathing

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rO6.0 Dyspnoea R02 Dyspnoea
rO6.1(R) Stridor + R04 Other breathing problems
rO6.2 Wheezing R03 Wheezing
rO6.3(R) Periodic breathing + R04 Other breathing problems
rO6.4 Hyperventilation + R98 Hyperventilation
(excl. psychogenic)
rO6.5(R) Mouth breathing, snoring + R04 Other breathing problems
rO6.6 Hiccough + R29 Other symptoms respiratory system
rO6.7 Sneezing + R07 Sneezing, nasal congestion
rO6.8(R) Other and unspecified + R04 Other breathing problems
abnormalities of breathing

TABLE 9 Unattainable conversions of ICD-10 to ICPC

ICD-10 ICPC

f45 Somatoform disorders

f45.0 Somatization disorder + P75 Hypochondriacal disorder
f45.1 Undifferentiated somatoform disorder + P75 Hypochondriacal disorder
f45.2 Hypochondriacal disorder + P7J Hypochondriacal disorder

f45.3 Somatoform autonomic dysfunction

(e.g. palpitations, sweating, flushing
expression of fear, psychogenic cough
diarrhoea, flatulence, hiccough etc.)

f45.4 Persistent somatoform pain disorder Convert to the symptom or

(e.g. psychogenic backache, headache, complaint in ICPC without the
psychalgia) connotation 'Psychogenic'

f45.8 Other somatoform disorders

(e.g. psychogenic dysmenoiThoea, dysphagia,
pruritus, teeth grinding)

f43.9 Somatoform disorder unspecified Cannot be converted to ICPC

(e.g. psychosomatic disorder NOS)
 CONVERSION BETWEEN ICPC AND ICD-10 347

1st and 7th component of

all chapters of ICPC

A
685 3-digit rubrics
of ICPC

> f

120 66 499
one to one ICPC rubrics ICPC rubrics
conversion one to one converted to
conversion to more than one
a 4-digit rubric ICD-10 rubric
> A A i

1
114 1593

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3-digit rubrics 3-diglt rubrics
broken open in in ICD-10
ICD-10

t
1827 3-digit rubrics
of ICD-10

ICD-10-all chapters
(excl. external causes)

FIGURE 5 Conversion between ICPC and ICD-10

5
ICPC has already been translated into all eight official
languages of the European Community (EC) and also
into Finnish, Norwegian, Swedish, Basque, Hebrew
6
and Hungarian.16 The availability of this multi-
language layer of ICPC together with the conversion to
ICD-10 will allow the adoption of the translations of 7
ICD-10 and its index into other languages as a nomen-
clature within ICPC. Multi-language thesauri are
essential in standardized and compatible international
information systems.1516 This is especially important 8
for those countries which to date have not had much
9
opportunity to influence the direction of the inter-
national primary care classification systems by the
use of empirical data derived from their primary care
environments.
10
11
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1 12
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2 13
International Organization for Standardization. Principles
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M
1985. Lamberts H. Episode-oriented epidemiology in family
3
World Health Organization. International Nomenclature
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4
Sokal PR. Classification: purpose, principles, progress,
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Lamberts H, Wood M eds. The International Classifica-
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