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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/
