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    • Diagnosis Coding Systems
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  • Overview | Diagnosis

Overview | Diagnosis

A diagnosis is applied in the process of determining which disease or condition explains a person’s symptoms. Diagnoses can be associated with a patient in two ways: at the point of care or during billing for hospital or physician.

The concepts in this folder focus on specific standardized codes that are used for identifying diagnoses within a patient’s medical record. Additionally, there are diagnosis modifiers that allow you to specifically target how a diagnosis is associated with the patient.

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The North Carolina Translational and Clinical Sciences (NC TraCS) Institute
at the University of North Carolina at Chapel Hill

The content of this website is solely the responsibility of the University of North Carolina at Chapel Hill
and does not necessarily represent the official views of the NIH.

Questions? Contact nctracs@unc.edu

  • Home
  • Introduction
    • Data Timeline
    • Update Frequency
    • Appendix
  • COVID-19
  • Patient Demographics
    • Current Age
    • Ethnicity
    • Marital Status
    • Race
    • Vital Status
    • Gender
    • Home Location
  • Encounter Details
    • Discharge Disposition
    • Encounter/ADT Status
    • Encounter Specific Dates
    • Encounter Type
    • Inpatient Hospital Service
    • Length of Stay (Inpatient)
    • Age at Visit
    • Patient Class (OP/IP/ED)
  • Diagnosis
    • Diagnosis Coding Systems
    • Diagnosis Type
  • Procedures
    • Procedure Coding Systems
  • Point of Care Location
  • Patient Vitals
    • Blood Pressure
    • Body Mass Index (BMI)
    • Body Surface Area (BSA)
    • Height
    • Pulse
    • Respiratory Rate
    • Temperature
    • Weight
  • Laboratory Tests
    • Common Lab Panels
    • Common Lab Tests
    • LOINC Dictionary
  • Medication Orders
    • Special Epic versus Legacy Considerations
    • RxNorm Code Set
    • Medication Modifiers
  • Social History
    • Alcohol Use
    • Birth Control Use
    • Tobacco Use
  • Insurance Payers
    • Patient’s Current Insurance
    • Encounter Specific Insurance