1 The International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Clinical Modification Donna Pickett, RHIA, MPH.

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The International Statistical Classification of Diseases and

Related Health Problems, Tenth Revision, Clinical Modification

Donna Pickett, RHIA, MPH

National Center for Health Statistics

Centers for Disease Control and Prevention

ASCX12N Meeting Oct. 7, 2002

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The International Classification of Diseases

• ICD is the standard used throughout the world for:– Classifying causes of mortality (death

registration)– Morbidity statistics

• Records and surveys

• Health care claims

• Basis for prospective payment

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ICD REVISIONS

ICDRevision

No.

Year ofConference

WhenAdopted

Year in Usein the U.S.

ICD, ClinicalModification

Year in Use in theU.S.

First 1900 1900-1909

Second 1909 1910-1920

Third 1920 1921-1929

Fourth 1929 1930-1938

Fifth 1938 1939-1948

Sixth 1948 1949-1957

Seventh 1955 1958-1967

Eighth 1965 1968-1978 ICDA-8HICDA-1HICDA-2

1968-19781968-19721973-1978

Ninth 1975 1979-1998 ICD-9-CM 1979-

Tenth 1989 1999- ICD-10-CM To be determined

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World Health Organization

As of July 2000, W.H.O. had authorized the publication of ICD-10 versions in 37 languages, with 30 countries having implemented ICD-10 for mortality and/or morbidity applications.

The remainder of the countries were expected to implement ICD-10 before end of 2000.

ICD-10 was implemented for mortality reporting in the United States 1/1/99.

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International Statistical Classification of Diseases and Health Related Problems,

Tenth Revision (ICD-10)

• Several countries use ICD-10 or a clinical modification in casemix and reimbursement systems– United Kingdom [1995]– Nordic countries (Denmark, Finland, Iceland,

Norway, Sweden) [1994-1997]– France [1997]– Australia [1998]– Belgium [1999]– Germany [2000]– Canada [2001]

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ICD-10 Major Changes

• Alphanumeric codes (A00-Z99)

• Restructuring certain chapters/ categories

• Addition of new features

• Expansion of detail (2,033 categories; 855 more than ICD-9)

ICD-10 represents the broadest scope of any ICD revision to date. Changes include:

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Expanded Detail in ICD-10

ICD-9-CM

250 Diabetes– 5th digit “1”

identified juvenile-onset

– 5th digit “0” identified adult-onset

ICD-10• E10 Insulin-

dependent• E11 Non-insulin

dependent• E12 Malnutrition-

related• E13 Other specified• E14 Unspecified

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Injuries Restructured

ICD-9

Fractures 800-829Dislocations 830-839Sprains/Strains 840-848

ICD-10

Injuries to head S00-S09Injuries to neck S10-S19Injures to thorax S20-S29

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Expanded Detail in ICD-10External Causes of Injuries

ICD-9 (E800-E999)

Transport accidents E800-E848 Intentional self-harm E950-E959 Complic. med/surg care E870-E876

ICD-10 (V00-Y98)

Transport accidents V01-V99 Intentional self-harm X60-X84 Complic. med/surg care Y40-Y84

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ICD-10 Evaluation Contract

In September 1994 NCHS awarded a contract to the Center for Health Policy Studies (CHPS) to evaluate the International Statistical Classification of Diseases and Related Health Problems (ICD-10).

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Contract Findings

• ICD-10 not significantly better than ICD-9-CM for morbidity applications to warrant implementation.

• A clinical modification of the ICD-10 would be a significant improvement and worth implementing.

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Why a Clinical Modification of ICD-10 ?

• Need to:– Expand distinctions for ambulatory and

managed care encounters – Expand to include new concepts – Expand to include emerging diseases and

more recent medical knowledge – Incorporate changes made to ICD-9-CM

since ICD-10 implementation

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ICD-10-CM Development

• Three phases of developmentPhase 1 -Prototype developed under contract

20 TAP members

Phase 2 - Enhancements by NCHS

C&M minutes, providers & other users

Phase 3 - Further enhancements based on public comments

22 organizations/individuals

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ICD-10-CM Development

• Consultation with:– Physician groups

• Dermatology, Neurology, Orthopedics, Pediatrics, Psychiatry, Obstetrics & Gynecology

– Professional organizations• ADA, AHA, AHIMA, ANA, NACHRI

– Other users of ICD-9-CM• federal agencies, Workers Comp, epidemiologists,

researchers

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ICD-10-CMMajor Modifications

• Addition of sixth character• Added code extensions for obstetrics, injuries and

external causes of injuries (7th character)• Addition of laterality• Created combination diagnosis / symptoms codes• Full code titles

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ICD-10-CM Major Modifications

[continued]

• Added trimesters to OB codes (fifth-digits from ICD-9-CM will not be used)

• Revised diabetes mellitus codes (5th digits from ICD-9-CM will not be used)

• Expanded codes (e.g., injury, diabetes, postoperative complications, alcohol/substance abuse)

• Added standard definitions for excludes notes

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Diabetes mellitus

• The common fifth-digit subclassification in ICD-9-CM for diabetes mellitus will not be used in ICD-10-CM

• The diabetes categories have been fully revised to reflect the recent revisions to the classification of diabetes issued by the American Diabetes Association

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Diabetes mellitus[continued]

ICD-9-CM250.X

4th digit identities type of complication

5th digit “1” identified juvenile-onset

5th digit “0” identified adult-onset

ICD-10E10 Insulin dependent

E11 Non-insulin

dependent

E12 Malnutrition related

E13 Other specified

E14 Unspecified

4th digit for type of complication

ICD-10-CME08 Diabetes due to

underlying

condition

E09 Drug or chemical

induced diabetes

E10 Type 1 diabetes

E11 Type 2 diabetes

E13 Other specified

diabetes mellitus

E14 Unspecified

4th digit body system with complication

5/6th digit specifics of complication

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ICD-10-CMDiabetes mellitus

E10.2 Type 1 diabetes mellitus with renal complications

– E10.21 Type 1 diabetes mellitus with diabetic nephropathy

– E10.22 Type 1 diabetes mellitus with Ebstein's disease

– E10.23 Type 1 diabetes mellitus with diabetic renal failure

– E10.29 Type 1 diabetes mellitus with other diabetic renal complication

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ICD-10-CMDiabetes mellitus

E10.6 Type 1 diabetes mellitus with other specified complications

– E10.61 Type 1 diabetes mellitus with diabeticarthropathy

• E10.610Type 1 diabetes mellitus with diabetic neuropathic arthropathy

• E10.618 Type 1 diabetes mellitus with other diabetic arthropathy

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Injury codes in ICD-9-CM & ICD-10

Open wounds– laceration w/foreign

body– laceration w/o foreign

body– puncture wound

w/foreign body– puncture wound w/o

foreign body– animal bite

Superficial wounds– abrasion

– blister

– contusion

– external constriction

– superficial foreign body

– insect bite

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ICD-9-CM Injury Codes

880 Open wound of shoulder and upper arm

880.0 Without mention of complication

880.1 Complicated

880.2 With tendon involvement

5th digit for site (shoulder, axillary, upper arm)

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ICD-10-CMExpanded Injury Codes

Detail for open wounds added at 5th digit:

S41.01 Laceration without foreign body of shoulder

S41.02 Laceration with foreign body of shoulder

S41.03 Puncture wound without foreign body of shoulder

S41.04 Puncture wound with foreign body of shoulder

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ICD-9-CMDecubitus ulcer

Decubitus ulcer of back 707.0

Bed sore

Decubitus ulcer [any site]

Plaster ulcer

Pressure ulcer

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ICD-10-CMDecubitus ulcer expanded codes

L89.011 Decubitus ulcer of right upper back limited to breakdown of skin

L89.012 Decubitus ulcer of right upper back with fat layer exposed

L89.014 Decubitus ulcer of right upper back with necrosis of bone

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ICD-9-CMPostoperative complications

• 998.1 Hemorrhage or hematoma or seroma complicating a procedure

• 998.2 Accidental puncture or laceration during a procedure

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ICD-10-CMPostoperative complications

• G97.3 Hemorrhage or hematoma complicating a nervous system procedure– G97.35 Postprocedural hemorrhage of nervous

system organ following nervous system procedure

– G97.36 Postprocedural hemorrhage of other organ following nervous system procedure

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ICD-10-CMPostoperative complications

• H95.3 Accidental puncture or laceration during an ear procedure– H95.31 Accidental puncture or laceration of

the ear during an ear procedure– H95.32 Accidental puncture or laceration of

other organ or structure during an ear procedure

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Poisoning/External Cause ICD-9-CM

Accidental poisoning by thyroid hormones

962.7 (Poisoning) Thyroid and thyroid derivatives

and

E858.0 Accidental poisoning, Hormones and synthetic substitutes

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Poisoning/External Cause ICD-10-CM Combination Codes

• T38.1x1 Poisoning by thyroid hormones and substitutes,accidental (unintentional)

• T38.1x2 Poisoning by thyroid hormones and substitutes,intentional self-harm

• T38.1x3 Poisoning by thyroid hormones and substitutes,assault

• T38.1x4 Poisoning by thyroid hormones and substitutes,undetermined

• T38.1x5 Adverse effect of thyroid hormones andsubstitutes

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Injury & External Cause Chapter Extensions in ICD-10-CM

a Initial encounter

d Subsequent encounter

q Sequelae

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Fracture Extensions ICD-10-CM

a Initial encounter for closed fracture

b Initial encounter for open fracture

d Subsequent encounter for fracture with routine healing

g Subsequent encounter for fracture with delayed healing

j Subsequent encounter for fracture with nonunion

q Sequelae

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Place of OccurrenceICD-9-CM

E849.0 Home

E849.1 Farm

E849.2 Mine and quarry

E849.3 Industrial place and premises

E849.4 Place for recreation and sport

E849.5 Street and highway

E849.6 Public building

E849.7 Residential institution

E849.8 Other specified places

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Place of OccurrenceICD-9-CM

E849.4 Place for recreation and sport

Amusement park

Baseball field

Basketball court

Football field

Golf course

Gymnasium

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Place of OccurrenceICD-10-CM

Y92.0x Non-institutional (private) residence

Y92.1x Institutional (nonprivate) residence

Y92.2x School, other institution and public administrative area

Y92.3xx Sports and athletics area

Y92.4xx Street, highway and other paved roadways

Y92.5xx Trade and service area

Y92.6x Industrial and construction area

Y92.7x Farm

Y92.8xx Other specified places

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Place of Occurrence ICD-10-CM

• Y92.310 Basketball court as place of occurrence of the external cause

• Y92.321 Football field as place of occurrence of the external cause

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Activity CodeICD-10-CM

Activity engaged in when injured -

Y93.0xx Sports activity

Y93.1x Activity primarily requiring repetitive use of fingers, hands and wrists

Y93.2x Personal hygiene and household activities

Y93.3 Caregiving activities

Y93.4x Strenuous physical activities

Y93.5x Electronic equipment usage

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Activity Codes Examples

Individual Activity

• Y93.010 Running

• Y93.013 Horseback riding

Group Activity

• Y93.020 Football

• Y93.022 Baseball

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Full code titlesICD-9-CM

143 Malignant neoplasm of gum

143.0 Upper gum

143.1 Lower gum

ICD-10-CM

C03 Malignant neoplasm of gum

C03.0 Malignant neoplasm of upper gum

C03.1 Malignant neoplasm of lower gum

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ICD-10-CMStatus

Complete incorporation of public comments Finalize Tabular List revisions Revise Index & Crosswalks Database (Alpha version) Revise guidelines Develop training materials Pre-release testing/Comparability study

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ICD-10-CM Pre-release Drafton NCHS web site

• Pre-release draft, May 2002, ICD-10-CM on NCHS web site at:http://cdc.gov/nchs/icd9.htm

• PDF (Adobe) format files:• Tabular• Index• External cause index• Table of Neoplasms

The codes in ICD-10-CM are not currently valid for any purpose or uses.

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ICD-10-CM Comparability Study

• New revisions can create discontinuities in trend data

• Discontinuities can be measured by comparability ratios– dual coding of data using old & new revision– express results of the comparison as a ratio for

a particular cause classified in ICD-10 divided by deaths expressed in ICD-9

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ICD-10-CM Comparability Study

• Assists users of coded data to discriminate between real changes in utilization by diagnosis and those resulting from artifacts of the coding system

• ICD-10/ICD-9 comparability study for mortality records (2.3m) nearly completed (preliminary posted on NCHS website)

• NCHS conducted study in 1979 when hospitals moved from ICDA-8 to ICD-9-CM

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Importance of the Improved Clinical Detail

• The creation, review and revision of health care policy relies on the availability of accurate and timely health care data generated by both providers and payers of health care and by statistical surveys and other research efforts.

• A critical element of these information systems is the classification used to interpret and analyze patients’ diseases and health conditions

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Uses of ICD-9-CM

• Tracking national trends - NCHS surveys • Tracking state trends - AHRQ HCUP• Tracking Medicare trends - Medpar• Quality Indicators JCAHO and HEDIS • Improved reimbursement (DRGs, APCs)• Bench marking• Research• Public health reporting• Strategic planning

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Disadvantages of Remaining with ICD-9-CM

• Due to the classification’s age (20+ years) and content it is no longer clinically accurate

• ICD-9-CM update process cannot keep pace with changes

• Inability to capture data relating to factors other than disease affecting health

• Non-comparability with State/National mortality data

• Non-comparability with international data

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ICD-10-CMBenefits of Enhancements

• Comprehensive scope of ICD-10-CM will contribute to:– More relevant data for epidemiological

research and decision-support purposes• Patient safety (medical errors)

• Ambulatory/managed care encounter

• Surveillance & prevention activities

• Outcomes research

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ICD-10-CMBenefits of Enhancements

• Comprehensive scope of ICD-10-CM will contribute to:– Increased sensitivity when making refinements in

applications such as grouping and reimbursement methodologies

– Reduction in additional information being forwarded to payers to adjudicate claims

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ICD-10-CMBenefits of Enhancements

• Harmonization with DSM-IV• Chapter 2 (Neoplasms) and morphology codes

correspond to ICD-O-2 which have been used by cancer registry programs since 1995

• Harmonization (90-95%) with NANDA nursing classification

• Greater flexibility to add new codes • Reflects current usage of medical terminology

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ICD-10-CMImplementation Issues

• Training: – Will be required for various users at various levels– Should not require extensive coder retraining

• Structure, conventions, coding rules basically the same

– Some short-term loss of productivity is expected during the learning curve

• Changes to data systems & software– Groupers, encoders, payment policy, performance

measurement systems

• Changes in data retrieval/analysis

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ICD-10 Implementation Experience in Other Countries

• Concerns:– Resources, cost of training, timing

• Training: – 2-3 day workshops for coders (new and experienced)– For clinicians, software suppliers and others– In HIM programs– Post implementation workshops – Six month learning curve

• Changes in data retrieval/analysis– Crosswalks, database versions

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HIPAA and ICD-10-CM Implementation

The Administrative Simplification (AS) provisions of Health Insurance Portability and Accountability Act of 1996 (HIPAA) are intended to reduce the costs and administrative burdens of health care by making possible the standardized, electronic transmission of many administrative and financial transactions that are currently carried out manually on paper.

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HIPAA and ICD-10-CMImplementation

• Implementation of ICD-10-CM tied to the standards adoption process specified in the Administrative Simplification provisions of HIPAA (1996)– Public hearings– Notice of Proposed Rulemaking (NPRM)– Public comment period– Final rule

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NCVHS Standards & Security Subcommittee Hearings on Replacements to ICD-9-CM

• Conducted public hearings on ICD-10-CM and ICD-10-PCS

– 4/9/02 ICD-10-PCS – 5/29/02 ICD-10-CM

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NCVHS Standards & Security Subcommittee Hearings on Replacements to ICD-9-CM

• IT Vendors and Provider Panel 5/29/02– Cerner, McKesson, 3M HIS, Gambro, Tenet

HealthSystems• Industry-wide challenge but doable• Recommended 2-3 year lead-time for

implementation of new code sets• 3 of the 5 testifiers have experience with

implementation of ICD-10 in other countries

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NCVHS Standards & Security Subcommittee Hearings on Replacements to ICD-9-CM

• There is an urgent need to begin the process to move to newer and better standards for diagnoses and procedures

• Replacing ICD-9-CM is essential, but it will take time & resources to implement system changes that will be required

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NCVHS Subcommittee on Standards & Security Hearings

Findings

• The replacement of the diagnosis and procedure classifications should occur simultaneously

• Some stakeholders believe there is a need to more fully explore issues related to costs, timing, & resources before publishing an NPRM

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8/29/02 NCVHS Subcommittee on Standards and Security

• Additional testimony was provided• NCVHS Subcommittee on Standards and Security

agreed to forward a recommendation to the full NCVHS – Propose that the Secretary of HHS issue an NPRM

for US adoption of ICD-10-CM and ICD-10-PCS (inpatient only).

– NPRM should include an in-depth impact analysis of the change

– Any change should not be required before October 2005.

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8/29/02 NCVHS Subcommittee on Standards and Security

• Subcommittee further recommended the NPRM allow those commenting to:– Comment on options of how and when HHS would

implement these coding standards

– Review cost estimates of such implementations

– Provide their own studies related to costs of implementation and value of making such a coding change

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9/25/02 NCVHS Full Committee

• NCVHS considered approval of the Subcommittee’s recommendation of issuance of NPRM for ICD-10-CM and ICD-10-PCS including:– Requirement of full impact analysis

– Invites comments from the public

– Requires the department to respond to the public comments

• No action taken on letter

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11/19-20/02 NCVHS Full Committee

• NCVHS to hear presentation by Standards & Security Subcommittee of issues related to migrating to ICD-10-CM and ICD-10-PCS including:– Pertinent background information– Intricacies of issues

• timing; cost/benefit analysis

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Web Site

NCHS Classification Home Page:ICD-9-CM, ICD-10, ICD-10-CM, and ICF

http://www.cdc.gov/nchs/icd9.htm

National Committee on Vital and Health Statistics:

http://ncvhs.hhs.gov/