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
1
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
2
ICD REVISIONS
ICD
Revision
No.
First
Year of
Year in Use ICD, Clinical
Conference in the U.S. Modification
When
Adopted
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
Ninth
1975
1968-1978 ICDA-8
HICDA-1
HICDA-2
1979-1998 ICD-9-CM
1968-1978
1968-1972
1973-1978
1979-
Tenth
1989
1999-
To be determined
ICD-10-CM
Year in Use in the
U.S.
3
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.
4
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]
5
ICD-10 Major Changes
ICD-10 represents the broadest scope of any
ICD revision to date. Changes include:
•
•
•
•
Alphanumeric codes (A00-Z99)
Restructuring certain chapters/ categories
Addition of new features
Expansion of detail (2,033 categories; 855
more than ICD-9)
6
Expanded Detail in ICD-10
ICD-9-CM
250 Diabetes
– 5th digit “1”
identified juvenileonset
– 5th digit “0”
identified adult-onset
ICD-10
• E10 Insulindependent
• E11 Non-insulin
dependent
• E12 Malnutritionrelated
• E13 Other specified
• E14 Unspecified
7
Injuries Restructured
ICD-9
Fractures
800-829
Dislocations
830-839
Sprains/Strains
840-848
ICD-10
Injuries to head
Injuries to neck
Injures to thorax
S00-S09
S10-S19
S20-S29
8
Expanded Detail in ICD-10
External Causes of Injuries
ICD-9 (E800-E999)
Transport accidents
Intentional self-harm
Complic. med/surg care
E800-E848
E950-E959
E870-E876
ICD-10 (V00-Y98)
Transport accidents
V01-V99
Intentional self-harm
X60-X84
Complic. med/surg care Y40-Y84
9
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).
10
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.
11
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
12
ICD-10-CM Development
• Three phases of development
Phase 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
13
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
14
ICD-10-CM
Major 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
15
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
16
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
17
Diabetes mellitus
[continued]
ICD-9-CM
ICD-10
ICD-10-CM
250.X
4th digit
identities type of
complication
5th digit “1”
identified
juvenile-onset
5th digit “0”
identified adultonset
E10 Insulin dependent
E11 Non-insulin
dependent
E12 Malnutrition related
E13 Other specified
E14 Unspecified
E08 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 for type of
complication
4th digit body system
with complication
5/6th digit specifics of
18
complication
ICD-10-CM
Diabetes 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
19
ICD-10-CM
Diabetes mellitus
E10.6 Type 1 diabetes mellitus with other
specified complications
– E10.61 Type 1 diabetes mellitus with diabetic arthropathy
• E10.610Type 1 diabetes mellitus with diabetic neuropathic
arthropathy
• E10.618 Type 1 diabetes mellitus with other diabetic
arthropathy
20
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
21
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)
22
ICD-10-CM
Expanded 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
23
ICD-9-CM
Decubitus ulcer
Decubitus ulcer of back 707.0
Bed sore
Decubitus ulcer [any site]
Plaster ulcer
Pressure ulcer
24
ICD-10-CM
Decubitus 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
25
ICD-9-CM
Postoperative complications
• 998.1 Hemorrhage or hematoma or seroma
complicating a procedure
• 998.2 Accidental puncture or laceration
during a procedure
26
ICD-10-CM
Postoperative 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
27
ICD-10-CM
Postoperative 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
28
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
29
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 and
substitutes
30
Injury & External Cause Chapter
Extensions in ICD-10-CM
a
Initial encounter
d
Subsequent encounter
q
Sequelae
31
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
32
Place of Occurrence
ICD-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
33
Place of Occurrence
ICD-9-CM
E849.4
Place for recreation and sport
Amusement park
Baseball field
Basketball court
Football field
Golf course
Gymnasium
34
Place of Occurrence
ICD-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
35
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
36
Activity Code
ICD-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
37
Activity Codes
Examples
Individual Activity
• Y93.010 Running
• Y93.013 Horseback riding
Group Activity
• Y93.020 Football
• Y93.022 Baseball
38
Full code titles
ICD-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
39
ICD-10-CM
Status
 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
40
41
ICD-10-CM Pre-release Draft
on 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.
42
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
43
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
44
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
45
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
46
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
47
ICD-10-CM
Benefits 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
48
ICD-10-CM
Benefits 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
49
ICD-10-CM
Benefits 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
50
ICD-10-CM
Implementation 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
51
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
52
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.
53
HIPAA and ICD-10-CM
Implementation
• 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
54
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
– 5/29/02
ICD-10-PCS
ICD-10-CM
55
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
56
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
57
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
58
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.
59
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
60
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
61
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-10PCS including:
– Pertinent background information
– Intricacies of issues
• timing; cost/benefit analysis
62
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/
63