# Presentation: 174181

## The International Classification of Diseasesand Patient Medical Record Information Office of Data  Standards, Program Development and Extramural ProgramsNational Center for Health StatisticsDavid Berglund,  MD, MPH

**CDC**
- Centers for Disease Control and Prevention

**nchs**

## The International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Clinical Modification 

- ICD-10-CM is based on ICD-10 from the World Health Organization (WHO), and it also draws from ICD-9-CM.  It will be completed later this year.
- ICD-9-CM is currently the de facto standard for representing diagnoses in the U.S.

## World  Health Organization

- As of October 1998, 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 are expected to implement ICD-10 by Year 2000.
- ICD-10 was implemented for mortality reporting in the United States starting 1/1/99.

## ICD-10 Major Changes

- Alphanumeric codes
- 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:

## Patient Medical Record Information

- Includes all the information in the medical record, such as:
- 	Physicians’ notes
- 	Nurses’ notes
- 	Laboratory reports
- 	Radiology reports
- 	Other information
- Note that the ICD is not intended to capture all the information in the medical record.

## Uses of Patient Medical Record Information

- Patient Medical Record Information (PMRI) has many uses, with different levels of detail necessary for different uses.
- For clinical treatment, the entire medical record must be available.
- Uses which look at multiple patients need comparable PMRI from different sources.

## Uses of Patient Medical Record Information

- Some areas which may require PMRI from multiple patients include:
- 	Public Health
- 	Research
- 	Tracking
- The PMRI must be comparable for results to be reliable.  How comparable depends on the specific use.

## Role of the ICD--a Classification

- Designed for collection of aggregate data for national and international comparisons
- Both ICD-9-CM and ICD-10-CM are medical classifications that provide a code for every condition but not necessarily a unique code for each condition
- Place terminology within a hierarchical structure

## Current uses of ICD-9-CM

- Public Health
- Tracking
- Research
- Billing

## Domain of the ICD

- The clinical domain of the ICD is primarily diagnoses and reasons for encounters with the health care system.
- The scope also includes secondary areas such as signs and symptoms, as well as some medical test results, and nursing diagnoses.

## Settings for ICD Use

- Settings where ICD-9-CM is used include both inpatient and outpatient health care settings, as well as long term care and home care, clinical and epidemiological research studies, and public health reporting.

## Expansion of the ICD

- While ICD-9-CM is widely used, some users have requested additional detail in the classification.
- ICD-10-CM is a major expansion, with increased specificity and revisions in many areas throughout the classification.
- There are no plans to make major changes to ICD-9-CM.

## Why the Clinical Modification of ICD-10 ?

- Need to remove certain codes:
- Codes unique to mortality coding
- Procedure codes
- “Multiple” codes which would cause loss of data (e.g., “multiple injury” codes)
- Combine dagger and asterisk codes
- Return specificity of ICD-9-CM for certain conditions
- Modify language for U.S. clinical practice

## Basic Principles for creating ICD-10-CM

- All changes must conform to  W.H.O. conventions
- Limited modification at three-digit and four-digit code level
- Title changes cannot alter meaning of category or code

## Creating the Clinical Modification

- Further evaluation of ICD-10 categories to provide codes for ambulatory and managed care encounters, clinical decision-making and outcomes research
- Evaluation of residual categories (“Other Specified”) to determine whether further specificity is needed

## Focused Reviews

- Review of previous Coordination and Maintenance Committee recommendations that could not be incorporated into           ICD-9-CM due to space limitations
- Consultation with physician groups and others to assure clinical accuracy

## ICD-10-CM Partial List Phase II Reviewers

- American Academy of Dermatology
- American Academy of Neurology
- American Academy of Oral & Maxillofacial Surgeons
- American Academy of Pediatrics
- American Burn Association
- American College of Obstetricians and Gynecologists

## ICD-10-CMPartial List Phase II Reviewers(continued)

- American Diabetes Association
- American Nursing Association
- American Psychiatric Association
- American Urological Association
- ANSI Z16.2 Workgroup (Workers Comp)
- Nat’l Assoc. of Childrens Hospitals & Related Institutions

## ICD-10-CMMajor   Modifications

- Addition of sixth character
- Creation of full code titles (incorporating common 4th and 5th digit subclassifications)
- Addition of Laterality
- Combining dagger/asterisk codes
- Created combination diagnosis / symptoms codes

## ICD-10-CM Major Modifications, continuedExpansions

- 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 injury codes
- Further expanded post-operative complication codes

## 6th characterExample

- S32.0 Fracture of lumbar vertebra
- 	S32.00 Closed fracture lumbar 		vertebra
- 		S32.001 Closed fracture of 			lumbar vertebra with cauda 			equina  injury

## LateralityNeoplasm

- C40.0 Malignant neoplasm of scapula and long bones upper arm
- 	C40.00 Malignant neoplasm of scapula 	and long bones of upper arm, unspecified 	side
- 	C40.01 Malignant neoplasm of scapula 	and long bones of right upper arm
- 	C40.02 Malignant neoplasm of scapula 	and long bones of left upper arm

## Diagnosis/ SymptomCombination Codes

- I25.12 Atherosclerotic heart disease with unstable angina
- K71.51 Toxic liver disease with chronic active hepatitis with ascites
- K50.02 Crohn’s disease of small intestine with intestinal obstruction
- N41.01 Acute prostatitis with hematuria

## Trimesters

- O15 Eclampsia
-     O15.0  Eclampsia in pregnancy
- 	O15.00 Eclampsia in pregnancy, 			unspecified trimester
- 	O15.02 Eclampsia in pregnancy, second 	trimester
- 	O15.03 Eclampsia in pregnancy, third 		trimester

## 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 DM issued by the American Diabetes Association

## InjuriesExample Open Wounds

- Laceration without foreign body
- Laceration with foreign body
- Puncture wound without foreign body
- Puncture wound with foreign body
- Bite

- Example:	S31.14 Puncture wound with foreign		body of abdominal wall

## Relationship of ICD to other Terminologies 

- As both ICD-9-CM and ICD-10-CM are designed for collection of aggregate data, they represent data at a coarser level of granularity than certain other clinical terminologies and nomenclatures.
- There often are mappings made from other systems to the ICD, such as in the UMLS Metathesaurus by the National Library of Medicine.

## Relationship of ICD to Message Format Standards

- ICD-9-CM is referenced by HL-7 and X-12 message format standards for diagnosis information.
- It is the de facto standard method of representing diagnoses in both HL-7 and
- X-12.

## Medical Terminology Issues Deserving Government Attention

- 1.  Maintain ICD-9-CM until ICD-10-CM implementation can begin.
- 2.  Move to ICD-10-CM for reporting diagnoses as soon as this can be done reasonably (note that the U.S. now uses
- ICD-10 for mortality).

## Medical Terminology Issues Deserving Government Attention

- 3.  Facilitate coordination with W.H.O. in relation to international terminology use and statistical reporting.  Note that under treaty, the U.S. must report morbidity and mortality to W.H.O. using the ICD.
- 4.  Facilitate standards for electronic interchange of detailed medical information.

## Issues Related to Comparability of Patient Medical Record Information

- 1.  PMRI has many different uses, some of which need greater detail than others.
- 2.  Concerns about privacy may favor use of systems with less detail as being more acceptable when the full detail of the medical record is not necessary.

## Issues Related to Comparability of Patient Medical Record Information

- 3.  Some health care payers have issued instructions on code use which conflict with official coding guidelines.  This is detrimental to the comparability of PMRI.  Under HIPAA, it will be reasonable to require use of official coding guidelines for the coding system in use.

## Issues Related to Comparability of Patient Medical Record Information

- 4.  Increased coordination among terminology developers would be beneficial for the health care industry.  Such coordination may be encouraged by government specification of standard ways to access and express PMRI.

## Issues Related to Comparability of Patient Medical Record Information

- 5.  Coordination between terminology developers and message standard developers may be especially important for more detailed nomenclatures, particularly when these may be compositional and thus require longer strings of unpredictable length.  As this can be an issue for any terminology and message format, relevant standards must have input from developers in both areas.

## ICD and Patient Medical Record Information

- In research use of PMRI, inclusion criteria for a study must be strictly defined.  When ICD-9-CM codes are used for this purpose, many studies will include multiple codes to capture all cases of interest.
- The ICD has been designed to capture data which is comparable and of value for public health.

## ICD and Patient Medical Record Information

- The ICD by itself will not meet all the needs of research or of public health.
- However, in relation to capturing diagnoses, ICD-9-CM meets most needs already, and ICD-10-CM will have increased specificity which will even better meet the needs of users.

## ICD-10-CM Open Comment Period12/97 through 2/98

- 1,200  comments from  22 organizations & individuals
- 	238	No further action
- 	448	Incorporation
- 	  77	Require further study
- 	480	Inconsistent with  structure/ 			conventions

## ICD-10-CMNext Steps

-  Complete review of contractor's report and  recommendations
-  Finalize Tabular List revisions
-  Revise Index & Crosswalks
-  Revise guidelines
-  Develop training materials
-  Formal testing
-  Comparability study
-  Tools beyond a print version:  database

## NCHS Web Site 

- 	Classification of Disease page:
- http://www.cdc.gov/nchswww/about/otheract/icd9/icd9hp2.htm
-          Information about ICD-9-CM and ICD-10-CM
-          Links to information about ICD-9 and ICD-10,
- 		for mortality