Submission: Proposal: Add Somatic symptom disorder as inclusion term to ICD-10-CM

Post #309 Shortlink: http://wp.me/pKrrB-3WD

You have until Friday in which to submit comments on any of the numerous diagnosis proposals presented at the March ICD-10-CM Coordination and Maintenance Committee meeting.

Comments should be sent to NCHS, preferably by email, by June 20th deadline: nchsicd9CM@cdc.gov

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The next public meeting of the ICD-10-CM/PCS Coordination and Maintenance Committee is scheduled for September 23–24, 2014. If you are planning to attend the meeting in person you will need to register online by September 12. Registration opens on August 15.

New proposals for the September 23–24, 2014 meeting must be received by July 18.

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September 2013 meeting Diagnosis Agenda

The fall meeting of the ICD-9-CM/PCS Coordination and Maintenance Committee took place on September 18–19.

The Diagnosis Agenda had included the proposals to add the new DSM-5 disorder terms: Somatic symptom disorder and Illness anxiety disorder to the ICD-10-CM Tabular List and the Alphabetical Index.

Note that the proposal was to add the terms as Inclusion Terms under existing ICD-10-CM Chapter 5 codes, not to create unique new codes for these two terms, or to replace or subsume any existing categories:

ICD10CM 4

Source: Page 45, Diagnosis Agenda (Topic Packet), September 18–19, 2013 ICD-10-CM/PCS Coordination and Maintenance Committee Meeting

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March 2014 meeting Diagnosis Agenda

The spring C & M Committee meeting took place on March 19–20, 2014. I was unable to attend either meeting as I live in the UK, and it is not feasible for me to participate in these public meetings via phone link.

The March Diagnosis Agenda included reiteration of the September proposal to add Somatic symptom disorder to the ICD-10-CM Alphabetical Index, coded to F45.1. (But did not include a resubmission to add to the Tabular List.) The reason for its reiteration in the March Agenda is unclear.

When the March Agenda requests for additions and modifications to the Tabular List were reached, CDC’s Beth Fisher had remarked that some of the proposals for additions to the Tabular List may have been proposed at the September 2013 meeting (though no explanation was given for why some of these September proposals were being duplicated in the March Agenda).

Evidently some Index proposals from the September meeting were also duplicated in the March Agenda, including SSD, but not Illness anxiety disorder.

There were no comments or queries from the floor in relation to proposals for SSD. There were no queries about whether NCHS decisions had already been reached on the requests for additions and modifications submitted via the September meeting.

It remains unclear whether the duplications in the March Agenda were due to administrative oversight, were being included for procedural reasons, or were being re-presented in response to NCHS committee decisions made following the September meeting, to which APA, but not the public at large, might be party to. (The outcome of both the September and March proposals may not be evident until 2015, when the next Addendum is posted.)

March Agenda proposal: Add Somatic symptom disorder to the Index as “– somatic symptom F45.1″ under “Disorders”:

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March14 ICD-10-CM Cand M SSD to Index

Source: Diagnosis Agenda (Topic Packet) Page 89, March 19-20, 2014 ICD-10-CM/PCS Coordination and Maintenance Committee Meeting; Screenshot Videocast Three

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F45.1 (SSD) and F45.21 (Illness anxiety disorder) are the ICD-10-CM codes to which these two new APA disorders are already cross-walked in the DSM-5:

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SSDcrosswalk

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If NCHS rubber stamps the addition of Somatic Symptom Disorder to the ICD-10-CM it could leverage future proposals (either by NCHS/CMS or by external requestors) for the replacement of some or all of the existing Somatoform disorders categories with this new, single SSD diagnostic construct, in order to bring ICD-10-CM in line with DSM-5.

There are implications for ICD-11, too. Once SSD is inserted into ICD-10-CM, the presence of this term within the U.S. adaptation of ICD-10 may make it easier for the ICD-11 Revision Steering Group to justify proposals to replace the existing ICD-10 Somatoform disorders categories with a single, new ICD construct incorporating SSD-like characteristics, to facilitate harmonization between ICD-11 and DSM-5 disorder terms and diagnostic criteria.

Comments by June 20th deadline, preferably by email, to: nchsicd9CM@cdc.gov

Below is my own submission to NCHS in PDF

Click link for PDF document   NCHS Submission Chapman June 14

and as text:


To: NCHS  nchsicd9CM@cdc.gov

Re: Comment on proposals, March 19-20, 2014 meeting of ICD-10-CM Coordination and Maintenance Committee.

Diagnosis Agenda Page 89: Under “Proposed Index Modifications”: Add Somatic symptom disorder to ICD-10-CM Alphabetical Index (F45.1)

Proposal requestor: Unspecified

Comment submitted by Suzy Chapman DipAD, [Address redacted]

Date submitted: June 15, 2014

I write in objection to the proposed addition of Somatic symptom disorder to the ICD-10-CM Alphabetical Index for consideration for implementation on October 1, 2015 [or on and after October 1, 2016 after the partial code freeze has ended, as applicable].

This March 19-20, 2014 meeting proposal duplicates the request at the September 18-19, 2013 meeting for the addition of Somatic symptom disorder to the ICD-10-CM Index (and to the Tabular List) as an Inclusion Term to existing code, F45.1 Undifferentiated somatoform disorder.

Somatic symptom disorder is a new disorder conceptualization created by the American Psychiatric Association (APA) for DSM-5.

For DSM-5, the Somatoform Disorders have been dismantled. Four DSM-IV categories: somatization disorder [300.81], some presentations of hypochondriasis [300.7], pain disorder, and undifferentiated somatoform disorder [300.82] are eliminated and replaced with a single new diagnosis, Somatic symptom disorder (SSD), cross-walked in DSM-5 to ICD-9 300.82 (ICD-10-CM F45.1).

The Somatic symptom disorder construct de-emphasizes “medically unexplained” as the central defining feature of this disorder group. Instead, the focus shifts away from somatic symptoms to emotional, cognitive and behavioral disturbances and “maladaptive” responses to symptoms: high levels of health anxiety; disproportionate and persistent concerns about the medical seriousness of the symptom(s); or an excessive amount of time and energy devoted to symptoms and health concerns.

Symptoms may or may not be associated with another medical condition: SSD allows for the application of a mental disorder diagnosis in patients with “established general medical conditions or disorders” like diabetes, heart disease and cancer or presenting with “somatic symptoms of unclear etiology” if the clinician considers the patient otherwise meets the new criteria.

To meet the requirements for DSM-IV’s Somatization disorder, a rigorous criteria set needed to be fulfilled: a history of many medically unexplained symptoms before the age of thirty, resulting in treatment sought or psychosocial impairment. And a high diagnostic threshold: a total of eight or more medically unexplained symptoms from four, specified symptom groups, with at least four pain, two gastrointestinal, one psychosexual and one pseudoneurological symptom.

In DSM-5, the requirement for eight symptoms has been dropped to just one or more persistent, non specific, distressing somatic symptoms and the clinician’s perception of “excessive” or “maladaptive” response to the symptom or symptoms.

• These changes for DSM-5 represent a radical restructuring of the DSM-IV Somatoform disorders framework and introduce a new construct for which much remains to be determined.

On Day Two of the September 18-19, 2013 ICD-9-CM Coordination and Maintenance Committee meeting, Dr Darrel Regier had presented and discussed rationales, coding proposals and timings for six new DSM-5 disorders that APA has proposed for insertion into ICD-10-CM. But the Diagnosis Agenda proposals to add the new DSM-5 Somatic symptom disorder and Illness anxiety disorder category terms as inclusion terms to ICD-10-CM did not form part of Dr Regier’s presentation.

As it was unspecified within the Diagnosis Agenda and during the meeting presentations, it is unclear whether these two proposals are being requested by APA, by NCHS/CMS, or by other parties or individuals.

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• My first concern is that no description of Somatic symptom disorder, no rationale for why this ICD-10-CM modification is needed (including clinical relevancy) and no supporting clinical and literature references for the validity of Somatic symptom disorder as a new disorder were published in the Diagnosis Agenda for either the September or March meeting.

At the public meeting, no presentation had been made on behalf of APA, or by representatives of NCHS or CMS, or by anyone else for the specific Agenda proposal to add Somatic symptom disorder as an inclusion term under an existing ICD-10-CM Somatoform disorders code and there was no discussion of this proposal during the course of the meeting [1][2].

There is an expectation that the committees overseeing the development and revision of the draft for ICD-10-CM will give due consideration to the applicability, clinical utility, safety and reliability of any proposal for the inclusion of a new disorder construct before granting approval for its addition to the Tabular List and Index, and that the comments and objections received during the public response period will also be considered. The lack of rationales and references for supportive evidence provided by the requestors hinders public participation in the response process.

• The absence from the Diagnosis Agendas and meeting presentations of rationales, clinical relevancy and supporting clinical and literature references to enable proper public scrutiny, consideration and informed responses to this proposal should disqualify Somatic symptom disorder from consideration for implementation once the partial code freeze has lifted.

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The burden of proof before introducing any new diagnosis into a classification system is that it has a favourable risk to benefit ratio. This new diagnostic construct created by APA and introduced into DSM-5 merits the same level of scrutiny and risk to benefit evaluation as would be expected to be applied to any proposed new disorder/disease that is under consideration for inclusion in any chapter of ICD, whether this is for the updating of the ICD-10-CM draft, updating of WHO’s ICD-10, updating of clinical modifications of ICD-10, or drafting of ICD-11.

A number of papers have noted the paucity of rigorous evidence for the validity, reliability, acceptability, safety and utility of the application of the Somatic symptom disorder construct in adults and children across diverse clinical settings and by a spectrum of health and allied professionals. There is no significant body of published research on the epidemiology, clinical characteristics or treatment of the Somatic symptom disorder construct [3][4][5].

In a paper published in the Journal of Psychosomatic Research, September 2013, the DSM-5 Somatic symptom disorder Work Group concedes the lack of clinical evidence for its new construct and acknowledges the “small amount of validity data concerning SSD” and “that much remains to be determined” about the utility and reliability of the specific SSD criteria and its thresholds when applied in busy, general clinical practice, and there are “vital questions that must be answered” as they go forward [6].

• As an under researched, poorly validated disorder construct, Somatic symptom disorder does not meet NCHS/CMS criteria for new diseases/new technology procedures, and any minor revisions to correct reported errors in these classification and should be rejected for consideration for implementation during a partial code freeze and also rejected for consideration for implementation on or after October 1, 2015 [October 1, 2016].

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Concerns for the looseness of the Somatic symptom disorder definition and the ease with which these new criteria can be met have been discussed in a number of published papers and commentaries [7][8][9][10].

The over-inclusiveness of the SSD diagnosis is borne out by the results of the DSM-5 field trial study reported by Joel E Dimsdale, MD, chair of the Somatic symptom disorder Work Group, at the 2012 annual meeting of the American Psychiatric Association.

15% of the ‘diagnosed illness’ study group, comprising patients with cancer or coronary disease, were caught by SSD and would meet the criteria for application of an additional mental disorder diagnosis.

26% of the ‘functional somatic’ study group, comprising patients with irritable bowel syndrome or chronic widespread pain, met the SSD criteria.

SSD has a high false positive rate – capturing 7% of the ‘healthy’ field trial control group.

It is disturbing that the SSD Work Group (which had included no primary care physicians or pediatricians) appears not to have undertaken any field trials into the safety of application of the SSD criteria in children and adolescents.

NCHS/CMS provides no references for data for the application of SSD in children within the Diagnosis Agenda, although the DSM-5 text clearly indicates APA’s intention that SSD is a diagnosis that may also be applied to children with persistent, distressing somatic symptoms.

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Potential implications for the application of a diagnosis of SSD:

I am not persuaded that the new SSD diagnosis can be safely applied outside the optimal conditions of field trials, in settings where practitioners may not necessarily have adequate time for, or instruction in administration of diagnostic assessment tools, and where decisions to code or not to code may hang on the arbitrary and subjective perceptions of a wide range of end-users who may lack clinical training in the application of mental disorder criteria.

Misapplication of highly subjective and loose, easily met criteria, especially in busy primary care practice, may result in inappropriate diagnoses of mental disorder and inappropriate medical decision making, with considerable implications for patients [11].

A recent study (Plouvier et al, 2014) found more frequent presentation with functional somatic symptoms and multiple prodromal symptoms in the two year period prior to diagnosis with Parkinson’s disease than controls [12].

Incautious application or a pre-existing diagnosis of SSD in the patient’s notes may blunt clinician alertness and receptivity to emerging prodromal symptomotology of serious disease.

Patients with chronic, multiple bodily symptoms due to rare diseases, difficult to diagnose conditions, or multi system diseases like Behçet’s disease, for which it can take several years to arrive at a diagnosis, may be especially vulnerable to missed diagnosis or to misdiagnosis with a mental disorder, impeding access to testing, investigations, timely diagnosis and early intervention (and may result in increased claims against practitioners for medical negligence).

With the elimination of the requirement that symptoms be “medically unexplained” and inclusion of the presence of a co-occurring physical health condition, a mental disorder diagnosis of SSD can be applied as a “bolt-on” to any chronic medical diagnosis: to patients with diabetes, angina, cancer, MS, cardiovascular disease, ME and CFS, IBS, chronic widespread pain (aka fibromyalgia), chronic pain conditions or persistent symptoms of unclear etiology.

Patients with Chronic fatigue syndrome (CFS), “almost a poster child for medically unexplained symptoms as a diagnosis,” according to the SSD Work Group chair, or with chronic Lyme disease, Gulf War illness, chemical injury and chemical sensitivity; women with potential symptoms of gynecological disease, like ovarian cancer – already often late-diagnosed because persistent symptoms had been initially dismissed as IBS or a menopausal-related bladder complaint; or women with endometriosis or interstitial cystitis may be particularly vulnerable to misapplication or misdiagnosis with a mental health disorder under SSD criteria.

(There is also a Brief somatic symptom disorder in DSM-5, cross-walked to ICD-9 F45.8, that can be applied where duration of symptoms is less than 6 months. Just one somatic symptom and one “disproportionate” psychobehavioral response to that symptom, for less than 6 months chronicity, now ticks the box for a mental health diagnosis.)

There has been considerable opposition to the introduction of this new, poorly tested construct into the DSM-5 amongst patients, carers, advocates, consumer organizations, mental health practitioners and clinicians and considerable concern for the implications for diverse patient populations that the Somatic Symptom Disorder category will provide a “dustbin diagnosis” for the so-called “functional somatic syndromes,” for those living with chronic pain and for patients with persistent, but as yet undiagnosed, symptoms of disease.

• NCHS/CMS has published no independent field trial data and provided no rationales or clinical and literature references to inform public responses.

Given the lack of published evidence for the validity and safety of SSD, there is insufficient basis for the approval of SSD for inclusion within ICD-10-CM and it would be scientifically unsafe, premature and against the public interest to include this new diagnostic construct within ICD.

The proposal for the addition of Somatic symptom disorder to the ICD-10-CM as an inclusion term to the Index and Tabular List should be rejected. There should be no implementation in October 2016 as an inclusion term to F45.1, or to any other existing code, or with a unique code created.

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Appendix:

Incautious, inept application of criteria resulting in a “bolt-on” psychiatric diagnosis of Somatic symptom disorder has far-reaching implications for diverse patient populations:

Application of highly subjective and difficult to measure criteria could potentially result in misdiagnosis with a mental disorder, misapplication of an additional diagnosis of a mental disorder or missed diagnoses through dismissal and failure to investigate new or worsening somatic symptoms.

Patients with cancer and life threatening diseases may be reluctant to report new symptoms that might be early indicators of recurrence, metastasis or secondary disease for fear of attracting a diagnosis of SSD or being labelled as “catastrophizers.”

Application of an additional diagnosis of SSD may have implications for the types of medical investigations, tests and interventions that clinicians are prepared to consider and for which insurers are prepared to fund.

Application of an additional diagnosis of SSD may impact payment of employment, medical and disability insurance and the length of time for which insurers are prepared to pay out.

 An SSD diagnosis may negatively influence the perceptions of agencies involved with assessment and provision of social care packages, disability adaptations, workplace accommodations, provision of education arrangements tailored to the needs of children with chronic illness, and the perceptions of medical staff during hospital and accident and emergency admission, and prejudice future employment options.

Patients prescribed psychotropic drugs for perceived unreasonable levels of “illness worry” or “excessive preoccupation with symptoms” may be placed at risk of iatrogenic disease or subjected to inappropriate and costly behavioural therapies.

Multi-system diseases like Multiple Sclerosis, Behçet’s disease or Systemic lupus can take several years before a diagnosis is arrived at. In the meantime, patients with chronic, multiple somatic symptoms who are still waiting for a diagnosis would be vulnerable to being labelled with a mental disorder.

The burden of the DSM-5 changes to Somatoform disorders will fall particularly heavily upon women who are more likely to be casually dismissed when presenting with physical symptoms and more likely to be prescribed inappropriate antidepressants and anti-anxiety medications for them.

Somatic symptom disorder allows for the application of a diagnosis of SSD in children and where a parent is perceived as being excessively concerned about a child’s symptoms.

The diagnostic term “Somatic Symptom Disorder” is already being applied to children despite the lack of a body of evidence for the reliability, safety and validity of the DSM-5 SSD criteria [13].

I am deeply concerned that NCHS/CMS is considering inclusion of a new diagnostic term within ICD when no studies have been carried out into the safety of its application in children and adolescents.

Families caring for children and young people with any chronic disease or condition may be placed at increased risk of wrongful accusation of “over-involvement” with their child’s symptomatology.

Where a parent is perceived as responsible for, or encouraging maintenance of “sick role behavior” or “secondary gains” in a child, this can trigger social services investigation, or court intervention for the forced removal of a sick child out of the home environment and into foster care or in-patient rehabilitation, or placement of the child on the “at risk register.”

This is already happening to families in the U.S., UK and Europe with a child or young adult with chronic illness, notably with Chronic fatigue syndrome or ME. It may happen more frequently with a diagnosis of SSD or of chronic childhood illness + SSD.

Where there are disputes between the family and clinicians over an assigned diagnosis or where there is disagreement between clinicians over the etiology of a child’s symptoms, an earlier or concurrent diagnosis of SSD may prejudice the family’s rights and the rights of the child or young person to determine what treatments are administered, where and by whom; or may be used to override or attempt to override the right to consent to treatments, or as a means of limiting parental access to the child and parental involvement in a treatment plan.

A diagnosis of SSD may also impact on a child’s access to suitable educational arrangements, including part-time school attendance, rest periods, reduced curriculum, home tutoring, examination concessions, provision of an amanuensis etc. and access to disability aids and adaptations, or to unhindered use of existing aids, such as wheelchairs.

Again, there is insufficient basis for the approval of SSD for inclusion within ICD-10-CM for application in children or adults. It is scientifically unsafe, premature and against the public interest to include this poorly tested diagnostic construct within ICD.

Thank you for your consideration.

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References:

1.Diagnosis Agenda,September 18-19, 2013 meeting of the ICD-9-CM Coordination and Maintenance Committee.

2.Summary of Diagnosis Presentations, September 18-19, 2013 meeting of the ICD-9-CM Coordination and Maintenance Committee.

3. DSM-5 Somatic Symptom Disorders Work Group Disorder Descriptions and Justification of Criteria – Somatic Symptoms, published May 2011, for second DSM-5 stakeholder review.

4. Robert L. Woolfolk and Lesley A. Allen (2012). Cognitive Behavioral Therapy for Somatoform Disorders, Standard and Innovative Strategies in Cognitive Behavior Therapy, Dr. Irismar Reis De Oliveira (Ed.), ISBN: 978-953-51-0312-7

5. Ghanizadeh A, Firoozabadi A. A review of somatoform disorders in DSM-IV and somatic symptom disorders in proposed DSM-V. Psychiatr Danub. 2012 Dec;24(4):353-8.

6. Dimsdale JE, Creed F, Escobar J, Sharpe M, Wulsin L, Barsky A, Lee S, Irwin MR, Levenson J. Somatic Symptom Disorder: An important change in DSM. J Psychosom Res. 2013 Sep;75(3):223-8. Epub 2013 Jul 25.

7. Frances A. The new somatic symptom disorder in DSM-5 risks mislabeling many people as mentally ill. BMJ. 2013 Mar 18;346:f1580. doi: 10.1136/bmj.f1580.

8. Frances A. DSM-5 Somatic Symptom Disorder. J Nerv Ment Dis. 2013 Jun;201(6):530-1. doi: 10.1097/NMD.0b013e318294827c.

9. Frances A, Chapman S. DSM-5 somatic symptom disorder mislabels medical illness as mental disorder. Aust N Z J Psychiatry. 2013 May;47(5):483-4. doi:10.1177/0004867413484525.

10. Wolfe F, Walitt BT, Katz RS, Häuser W. Symptoms, the nature of fibromyalgia, and diagnostic and statistical manual 5 (DSM-5) defined mental illness in patients with rheumatoid arthritis and fibromyalgia. PLoS One. 2014 Feb 14;9(2):e88740. doi: 10.1371/journal.pone.0088740. eCollection 2014.

11. Dimsdale JE. Medically unexplained symptoms: a treacherous foundation for somatoform disorders? Psychiatr Clin North Am 2011;34:511-3.

12. Plouvier AO, Hameleers RJ, van den Heuvel EA, Bor HH, Olde Hartman TC, Bloem BR, van Weel C, Lagro-Janssen AL2. Prodromal symptoms and early detection of Parkinson’s disease in general practice: a nested case-control study. Fam Pract. 2014 May 28. pii: cmu025. [Epub ahead of print]

13. Commonwealth of Massachusetts Juvenile Court Department, Court document, Honourable Joseph Johnston, March 25, 2014, Re: Care and Protection of Justina Pelletier: http://cbsboston.files.wordpress.com/2014/03/scan.pdf

Interest:

Carer/advocate for adult with long-term medical condition. Owner of website Dx Revision Watch, Monitoring the revision of DSM-5 and ICD-11. Co-author, journal papers and commentaries on the SSD construct (with Professor Allen Frances).

 

CMS posts ICD-10-CM Release for 2015; confirms Partial Code Freeze extension; reminder, SSD proposals

Post #306 Shortlink: http://wp.me/pKrrB-3SJ

This report updates on the revised implementation date for ICD-10-CM, the revised Partial Code Freeze timeline, the ICD-10-CM Release for 2015 files, and a reminder of the deadline for objections to the insertion of DSM-5′s Somatic symptom disorder into ICD-10-CM.

[For reminder of deadline for objections to proposed insertion of Somatic symptom disorder into ICD-10-CM, skip to red subheading.]

On April 1, 2014, Bill H.R. 4302, known as the PAM Act (Protecting Access to Medicare Act), was signed into law by President Obama.

As a result of a quietly inserted clause piggybacking on this Bill, implementation of ICD-10-CM was delayed by a further year. Centers for Medicare & Medicaid Services (CMS) has confirmed that the effective implementation date for ICD-10-CM is now October 1, 2015.

Until that time, the codes in ICD-10-CM (the U.S. specific adaptation of the WHO’s ICD-10) are not valid for any purpose or use.

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Partial Code Freeze

CMS has announced that the partial code freeze on updates to the ICD-9-CM and ICD-10-CM diagnosis and procedure codes will continue until October 1, 2015.

Between October 1, 2011 and October 1, 2016 revisions to ICD-10-CM/PCS will be for new diseases/new technology procedures, and any minor revisions to correct reported errors in these classifications. Regular (at least annual) updates to ICD-10-CM/PCS will resume on October 1, 2016.

The Partial Code Freeze document has been updated to reflect the revised Timeline and can be accessed here in PDF format Partial Code Freeze for ICD-9-CM and ICD-10

or text, below:

Partial Code Freeze for ICD-9-CM and ICD-10

The ICD-10 Coordination and Maintenance Committee (formerly the ICD-9-CM Coordination and Maintenance Committee) implemented a partial freeze of the ICD-9-CM and ICD-10 (ICD-10-CM and ICD-10-PCS) codes prior to the implementation of ICD-10 which would end one year after the implementation of ICD-10. There was considerable support for this partial freeze. On April 1, 2014, the Protecting Access to Medicare Act of 2014 (PAMA) (Pub. L. No. 113-93) was enacted, which said that the Secretary may not adopt ICD-10 prior to October 1, 2015. Accordingly, the U.S. Department of Health and Human Services expects to release an interim final rule in the near future that will include a new compliance date that would require the use of ICD-10 beginning October 1, 2015. The rule will also require HIPAA covered entities to continue to use ICD-9-CM through September 30, 2015. When published, links will be provided to this interim final rule at http://www.cms.gov/Medicare/Coding/ICD10/Statute_Regulations.html

The partial freeze will be implemented as follows:

• The last regular, annual updates to both ICD-9-CM and ICD-10 code sets were made on October 1, 2011.

• On October 1, 2012, October 1, 2013, and October 1, 2014 there will be only limited code updates to both the ICD-9-CM and ICD-10 code sets to capture new technologies and diseases as required by section 503(a) of Pub. L. 108-173.

• On October 1, 2015, there will be only limited code updates to ICD-10 code sets to capture new technologies and diagnoses as required by section 503(a) of Pub. L. 108-173. There will be no updates to ICD-9-CM, as it will no longer be used for reporting.

• On October 1, 2016 (one year after implementation of ICD-10), regular updates to ICD-10 will begin.

The ICD-10 Coordination and Maintenance Committee will continue to meet twice a year during the partial freeze. At these meetings, the public will be asked to comment on whether or not requests for new diagnosis or procedure codes should be created based on the criteria of the need to capture a new technology or disease. Any code requests that do not meet the criteria will be evaluated for implementation within ICD-10 on and after October 1, 2016 once the partial freeze has ended.

CDC has not yet updated its webpages to reflect the ICD-10-CM implementation delay or the revised Partial Code Freeze timeline.

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SSD and ICD-10-CM/PCS Coordination and Maintenance Committee proposals

At the September 2013 and March 2014 Coordination and Maintenance Committee meetings, the American Psychiatric Association (APA) submitted numerous requests for addenda changes for new index entries and tabular inclusion terms for evaluation for implementation on October 1, 2015.

It is unclear whether requests for modifications submitted by APA and other requestors via these September and March meetings will be rolled forward for evaluation for implementation on and after the revised date of October 1, 2016 or whether these proposals will now need to be resubmitted at future C & M Committee meetings. (The next public meeting takes place September 23–24, 2014.)

I have approached NCHS for clarification.

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If the proposals from these two meetings do require resubmitting, this would provide another opportunity to comment on the proposal to add the DSM-5′s new disorder term, Somatic symptom disorder, to the ICD-10-CM.

See earlier post: Update on proposal to add DSM-5′s Somatic symptom disorder to ICD-10-CM

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At the public Coordination and Maintenance Committee meeting on September 18–19, 2013, a proposal had been submitted to add Somatic symptom disorder (SSD) as an inclusion term to existing ICD-10-CM code F45.1 Undifferentiated somatoform disorder in the Tabular List Addendum (this also included addition to the Index).

Note: Proposal is not to create a unique code for SSD or to replace any of the existing ICD-10-CM somatoform disorders with SSD, but to add SSD as an inclusion term under an existing ICD-10-CM code, F45.1.

September 18–19, 2013 meeting Agenda, Page 45: PDF Agenda

ICD10CM 4

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The proposal to add somatic symptom disorder to the Index (under Disorder), was resubmitted at the public meeting on March 19–20, (reason unclear but a number of proposals for modifications to both the Tabular List and the Index from the September 2013 meeting were also duplicated at the March 2014 meeting).

March 19–20, 2014 meeting Agenda, Page 89: PDF Agenda

March14 ICD-10-CM Cand M SSD to Index

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Any decisions made on the considerable number of proposals requested at last year’s September meeting are yet to be posted and possibly won’t be evident until the relevant Addendum is released.

In the DSM-5, Somatic symptom disorder is already cross-walked to ICD-9 code 300.82 (ICD-10-CM F45.1):

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DSM-5 (Page 311)

SSDcrosswalk

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Given that APA worked with CDC on the cross-walk between the new DSM-5 disorder terms and ICD-9/ICD-10-CM equivalent codes, NCHS’s Director will likely rubber stamp the APA’s proposals for insertion of SSD and a number of other new DSM-5 categories.

Nevertheless, I shall be putting in another objection before the June 20 deadline and I hope all stakeholders with concerns will strongly oppose the incorporation of this controversial new disorder construct into ICD-10-CM.

The deadline for comments on proposals requested at the March meeting is June 20th.

Send comments, by email, to NCHS to nchsicd9CM@cdc.gov

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Not a small thing

Between 2010 and 2012, the SSD Work Group attracted considerable opposition across three stakeholder reviews to its radical proposals for a replacement for the somatoform disorders.

In late 2012 and early 2013, we saw a good deal of “outrage” in comments to articles by Allen Frances and myself here and here at Psychology Today and here in the BMJ, in response to the cavalier decision by the Task Force to barrel through with the SSD Work Group’s poorly validated disorder construct.

But I see little evidence of sustained opposition from U.S. professionals and patients over the September and March NCHS/CMS update and revision meeting proposals to insinuate SSD into ICD-10-CM.

At the moment, the proposal is for inserting SSD as an inclusion term under an existing category – not to create a unique code for SSD and not to replace the existing framework with SSD. At the September meeting, CDC’s Donna Pickett said:

“…And just to complete the package, there are other Tabular List proposals that appear on Page 45 and 46 that we would also invite your comments on. And again, with some of the terminology changes that Dr Regier has described the intent here is to make sure that if those terms are being used, that they do have a home somewhere within ICD-10-CM to facilitate people looking these up. So we invite comments…”

Sounds almost cosy. But if NCHS does rubber stamp the addition of Somatic symptom disorder to ICD-10-CM, it could leverage future replacement of the existing Somatoform disorders categories with this new, single diagnostic construct, bringing ICD-10-CM’s framework in line with DSM-5.

There are implications for ICD-11, too.

Once SSD is inserted into ICD-10-CM, the presence of this term within the U.S. modification of ICD-10 may make it easier for ICD-11 Revision Steering Group to justify approving proposals to replace the existing ICD-10 Somatoform disorders categories with a single, new disorder construct that would mirror SSD’s defining characteristics – its positive psychobehavioural features, its simplified criteria, its de-emphasis on “medically unexplained” and facilitate harmonization between ICD-11 and DSM-5 disorder terms.

Christopher Chute, Mayo, chairs the ICD-11 Revision Steering Group. Chute has suggested that following implementation, ICD-10-CM might be brought gradually in line with ICD-11 through a series of annual updates, for smoother transition to ICD-11-CM.

Inserting the SSD term into ICD-10-CM paves the way for disorder construct congruency between DSM-5, ICD-10-CM, ICD-11, and eventually, the ICD-11-CM modification.

Send comments, by email, by June 20, to NCHS at nchsicd9CM@cdc.gov

 

CMS posts files for ICD-10-CM Release for 2015

On May 15, CMS posted the ICD-10 Procedure Coding System (ICD-10-PCS) files for 2015, download files here:

On May 19, CMS posted the ICD-10-CM and GEMs files for 2015:

These files (some of which are large ZIP files) include:

2015 Code Descriptions in Tabular Order

2015 Code Tables and Index – Updated 5/22/14 (includes Tabular List, and Index in PDF format)

2015 ICD-10-CM Duplicate Code Numbers

2015 Addendum

2015 General Equivalence Mappings (GEMs) – Diagnosis Codes and Guide

2015 Reimbursement Mappings – Diagnosis Codes and Guide

According to the Addendum, “There were no changes to the 2014 ICD-10-CM, therefore there are no 2015 ICD-10-CM Addenda.”

These ICD-10-CM Release for 2015 files are not yet available on the CDC site but when they are posted, they should be accessible from this page: http://www.cdc.gov/nchs/icd/icd10cm.htm

 

Further reading

Justina Pelletier: The Case Continues Phil Hickey, April 4, 2014
Objection to proposal to insert DSM-5′s Somatic symptom disorder into ICD-10-CM Suzy Chapman, Public submission, ICD-9-CM/PCS Coordination and Maintenance Committee Meeting September 18-19, 2013
Somatic Chapter Drops Centrality Of Unexplained Medical Symptoms Psychiatric News, Mark Moran, March 1, 2013
Somatic Symptoms Criteria in DSM-5 Improve Diagnosis, Care David J Kupfer, MD, Chair, DSM-5 Task Force, defends the SSD construct, Huffington Post, February 8, 2013
The new somatic symptom disorder in DSM-5 risks mislabeling many people as mentally ill Allen Frances, MD, BMJ 2013;346:f1580 BMJ Press Release PDF for full text
Somatic Symptom Disorder could capture millions more under mental health diagnosis Suzy Chapman, May 26, 2012
Mislabeling Medical Illness As Mental Disorder Allen Frances, MD, Psychology Today, DSM 5 in Distress, December 8, 2012
Why Did DSM 5 Botch Somatic Symptom Disorder? Allen Frances, MD, Psychology Today, Saving Normal, February 6, 2013
New Psych Disorder Could Mislabel Sick as Mentally Ill Susan Donaldson James, ABC News, February 27, 2013

Extension to timeline official: ICD-11 rescheduled for 2017

Post #292 Shortlink: http://wp.me/pKrrB-3H9

Update at February 8, 2014: ICD Revision has now updated its Timeline page:

May 2017 Present the ICD-11 to the World Health Assembly”

ICD-11_20177

In the last day or so, edited text on two WHO webpages confirms a decision by ICD Revision to postpone release of ICD-11 by a further two years, from 2015 to 2017.

From WHO site: “The International Classification of Diseases 11th Revision is due by 2017″

Also ICD Information Sheet: “…The development phase will continue for three years and ICD-11 will be finalized in 2017.”

And from a note accompanying a slide presentation: “…Now ICD 11 is scheduled in 2017 and ICD-10-CM can be made as a National Linearization.” Bedirhan Üstün, January 29, 2014 [1]

ICD-11 Revision has yet to issue a formal announcement or news release or update its Timeline page to reflect this decision.

There are no reports on the revised schedule on ICD-11 on Facebook or Twitter @WHOICD11 – all very low key.

Delaying the release of ICD-11 has been under consideration for several months.

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Slipping targets

The development process for ICD-11 began in April 2007, with ICD-11 scheduled for dissemination by 2012 and the timelines for the development of ICD-11 and DSM-5 running more or less in parallel [2,3].

Early on in the revision process, the ICD-11 dissemination date was extended. By 2009, the final draft was scheduled for World Health Assembly (WHA) approval in 2014. The WHA approval date was subsequently shunted to 2015 – four years later than originally planned.

ICD-11 is now scheduled for finalization in 2017.

Rationales for extending the timeline:

Pages 8-10: Committee for the Coordination of Statistical Activities, Twenty-second Session 4-6 September 2013, Items for discussion and decision: Item 8 of the provisional agenda, 3 September 2013 [4].

Slide presentation, Bedirhan Üstün, September 9-10, 2013, Slides 29-35: [5].

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Related reports from Dx Revision Watch

January 22, 2014: WHO Collaborating Centre confirms Revision Steering Group seriously considering extension to ICD-11 timeline: http://wp.me/pKrrB-3E8

September 15, 2013: WHO considers further extension to ICD-11 development timeline: http://wp.me/pKrrB-3sc

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References

1. Slideshare: AHIMA ICD-10 ICD-11 switch to ICD-10-CM in the USA, presentation note, Bedirhan Üstün, Coordinator at World Health Organization, January 29, 2014

2. Agenda Item No. 25: Revision of the International Classification of Diseases (ICD-10) and Involvement of Psychology International Union of Psychological Science Committee on International Relations Action, March 28–30, 2008
IUPsyS Mar 08 Agenda Item 25 ICD-10

3. Letter Saxena, WHO, to Ritchie, IUPsyS (International Union for Psychological Science), August 2007
Exhibit 1 WHO Letter Aug 07

4. Committee for the Coordination of Statistical Activities, Twenty-second Session 4-6 September 2013, Items for discussion and decision: Item 8 of the provisional agenda, 3 September 2013, Pages 8-10:
http://unstats.un.org/unsd/accsub/2013docs-22nd/SA-2013-12-Add1-Health-WHO.pdf

5. Slide presentation: ICD Revision: Where are we? Bedirhan Üstün, World Health Organization Classifications, Terminologies, Standards, ICD Revision: Quality Safety Meeting 2013, September 9-10, 2013, Slides 29-35:
http://www.slideshare.net/ustunb/icd-2013-qs-tag-260276686

Reminder: Next meeting of ICD-10-CM/PCS Coordination and Maintenance Committee: March 19-20, 2014

Post #290 Shortlink: http://wp.me/pKrrB-3F1

Update at February 15, 2014:

Tentative diagnosis agenda posted for March 19–20, 2014 meeting on CDC site:

This list of tentative diagnosis agenda topics is not final. The final topics material will be available electronically from the NCHS web site prior to the meeting.

If you are unable to attend the meeting in person there will be conference lines available on the day of the meeting. Individuals do not need to register on line for the meeting if planning to dial in.

NCHS/CMS will be broadcasting the meeting live via Webcast at: http://www.cms.gov/live/

The next meeting of the ICD-10-CM/PCS Coordination and Maintenance Committee is scheduled for March 19–20, 2014. If you are planning to attend the meeting in person you will need to register, online, by March 14.

ICD-10-CM/PCS Coordination and Maintenance Committee Meeting

Public forum to discuss proposed changes to ICD-10-CM and ICD-10-PCS

Wednesday, March 19, 2014 – Thursday, March 2o, 2014

CMS Auditorium, Baltimore, MD

Agendas for the meeting will be posted in February 2014.

If phone lines and live webinar are made available the information will be posted closer to the meeting date.

Day One | Time: 03/19/2014 9:00 AM – 5:00 PM CMS Auditorium

Session: ICD-10-CM/PCS Coordination and Maintenance Committee Meeting
The first day of the meeting, March 19, 2014, will be devoted to procedure code issues.

Day Two | Time: 03/20/2014 9:00 AM – 5:00 PM CMS Auditorium

Session: ICD-10-CM/PCS Coordination and Maintenance Committee Meeting
The second day of the meeting, March 20, 2014 will be devoted to diagnosis code topics.

+++
The National Center for Health Statistics (NCHS) and the Centers for Medicare and Medicaid Services (CMS) are the U.S. governmental agencies responsible for overseeing all changes and modifications to the ICD-9-CM and draft ICD-10-CM/PCS.

NCHS is also responsible for the development of ICD-10-CM, adapted from the WHO’s ICD-10 for U.S. specific use.

The 2014 release of the draft ICD-10-CM (which replaces the July 2013 release) can be viewed or downloaded here.

ICD-10-CM is scheduled for implementation on October 1, 2014. Until that time the codes in ICD-10-CM are not valid for any purpose or use.

New concepts are added to ICD-10-CM based on the established update process for ICD-9-CM (the ICD-9-CM Coordination and Maintenance Committee) and the World Health Organization’s ICD-10 (the Update and Revision Committee).

Meetings of the Coordination and Maintenance Committee are co-chaired by a representative from NCHS and from CMS. Responsibility for  maintenance of the ICD-9-CM is divided between these two agencies, with classification of diagnoses by NCHS and procedures by CMS.

The name of the Committee will change to the ICD-10-CM/PCS Coordination and Maintenance Committee with the March meeting, as the last updates to ICD-9-CM/PCS took place on October 1, 2013.

Meetings are held twice yearly, in public, at CMS headquarters in Baltimore, MD. The next meeting is scheduled for March 19–20, 2014. The fall meeting is scheduled for September 23–24, 2014.

+++

Coordination and Maintenance Committee

The Committee provides a public forum to discuss proposed modifications, code changes, updates and corrections to the diagnosis codes in ICD-10-CM and procedural codes in ICD-10-PCS.

Public participation can also take place via phone conference link and live webinar. (Details for both in the Agenda documents.)

Agendas are posted approximately one month prior to the meetings. Diagnostic and procedural proposal Topic Packets, meeting materials, hand outs and presentation slides are posted on the CDC and CMS websites shortly before a meeting.

Up until 2011, transcripts of meeting proceedings were provided. Provision of transcripts is now replaced with videocasts for the full, two-day proceedings, available from the CMS website and posted on YouTube, and a brief Meeting Summary report, available from the CDC site shortly after the meeting.

For attendance in person, prior registration is required, via the CMS meeting registration website. Registration opens approximately one month  prior to a meeting and closes a few days before Day One of a meeting.

+++

Proposals for modifications, additions, corrections

Suggestions for modifications to ICD-10-CM/PCS come from both the public and private sectors. Since the draft ICD-10-CM is adapted from the WHO’s ICD-10, which is subject to an annual update process, some proposed modifications to ICD-10-CM may reflect updates to the ICD-10.

Interested parties (requestors) must submit proposals for modifications prior to a scheduled meeting and by a specific date. Proposals should be consistent with the structure and conventions of the classification. See Submission of Proposals for submission requirements and proposal samples.

Once proposals have been reviewed, requestors are contacted as to whether their proposal has been approved for presentation at the next Coordination and  Maintenance Committee meeting or not.

Approved proposals are presented at the meetings by representatives for professional bodies, advocacy organizations, clinicians, other professional stakeholders or members of the public with an interest, or are sometimes presented by an NCHS/CMS representative on behalf of a requestor.

No decisions on proposed modifications are made at the meetings. Recommendations and comments are reviewed and evaluated, once the comment period has closed, before final decisions are made.

The Coordination and Maintenance Committee’s role is advisory. All final decisions are made by the Director of NCHS and Administrator of CMS.

Final decisions are made at the end of the year and become effective October 1 of the following year.

+++

Submitting written comment on proposals presented at meetings

Comments on proposals are invited, at the meeting, at the end of each presentation, or may be submitted in writing following the meeting, during a one to two month duration public comment period.

Addresses for submitting comments are included in the Agenda Topic Packets published before the meetings. NCHS/CMS state that electronic submissions are greatly preferred over snail mail in order to ensure timely receipt of responses.

+++

Partial code freeze and timing of proposals

According to the Summary of Diagnosis Presentations for the September 18–19, 2013 meeting (for which the comment period closed on November 15):

“Except where noted, all topics are being considered for implementation on October 1, 2015. The addenda items are being considered for implementation prior to October 1, 2014.”

(“ICD-10-CM TABULAR OF DISEASES – PROPOSED ADDENDA” Tabular and Index modification proposals are set out on Diagnosis Agenda Pages 60-66.)

Note that some proposals in the Diagnosis Agenda were requested for insertion in October 2014 as Inclusion Terms to existing codes, with new codes proposed to be created for October 2015, notably, the 6 proposals to insert new DSM-5 disorders into ICD-10-CM presented by Darrel Regier, MD, on behalf of the American Psychiatric Association (Diagnosis Agenda Pages 32-44).

Whether the 17 modifications proposed on Pages 45-46 under “Additional Tabular List Inclusion Terms for ICD-10-CM” which were presented en masse by CDC’s, Donna Pickett, (which include the proposals to add the new DSM-5 “Somatic symptom disorder” and “Illness anxiety disorder” as Inclusion Terms to existing ICD-10-CM F45.x codes) are intended for implementation in October 2014 or in October 2015 is not explicit in the Diagnosis Agenda.

For the September 18–19, 2013 meeting, when submitting written comments, responders were asked to consider the following:

Whether they agree with a proposal, disagree (and why), or have an alternative proposal to suggest. But were also invited to comment on the timing of those proposals that were being requested for approval for October 2014:

Does a request for a new diagnosis or procedure code meet the criteria for implementation in October 2014 during a partial code freeze* based on the criteria of the need to capture a new technology or disease; or should consideration for approval be deferred to October 2015? And separately, to comment on the creation of a specific new code for the condition effective from October 1, 2015 (where requested).

Any code requests that do not meet the criteria [for inclusion during a partial freeze] will be evaluated for implementation within ICD-10-CM on and after October 1, 2015 once the partial freeze has ended and regular (at least annual) updates to ICD-10-CM/PCS resume.

*Partial Code Freeze of Revisions to ICD-9-CM and ICD-10-CM/PCS

  • October  1, 2011 is the last major update of ICD-9-CM. Any further revisions to ICD-9-CM will only be  for a new disease and/or a  procedure  representing new technology.  Revisions will  be posted on this website as addenda (revisions to procedures are posted on  the CMS website).
  • After  October 1, 2011 there will be no further release of ICD-9-CM on CD-ROM.
  • October  1, 2011 is the last major update of ICD-10-CM/PCS until October 1, 2015.
  • Between  October 1, 2011 and October 1, 2015 revisions to ICD-10-CM/PCS will be for new  diseases/new technology procedures, and any minor revisions to correct reported errors in these classifications.
  • Regular (at least annual) updates to ICD-10-CM/PCS will resume on October 1, 2015.

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Public comments not made public

Note that written public comments received by NCHS (Diagnosis) and CMS (Procedural) on proposals requested via these meetings are not aggregated and made publicly accessible. Nor are the names of organizations, professional bodies, individuals or others who have submitted comments listed publicly. It is not possible to scrutinize the number, provenance or substance of the comments received in support of, or in opposition to requests for modifications to ICD-10-CM presented via these meetings. Nor are NCHS/CMS’s rationales for the approval or rejection of requests for modifications to diagnosis or procedural codes on public record.

+++

September 18–19, 2013 meeting

A substantial number of modifications were proposed via the September 2013 meeting for both procedural and diagnosis codes. These are set out in the Agenda/Topic Packet PDF documents:

Diagnosis Codes Agenda

Procedural Codes Agenda

Meeting Materials

Videocasts for full two day meeting proceedings and Meeting Materials (collated on Dx Revision Watch site)

Summary of Diagnosis Presentations 

The ICD-9-CM timeline (for the remainder of its life) and the ICD-10-CM/PCS timeline are set out on Pages 3-8 of the Diagnosis Agenda.

+++

Key dates for the forthcoming March 19–20, 2014 meeting

January 17, 2014: deadline for submitting topics to be discussed at the March 19–20, 2014 ICD-10-CM/PCS Coordination and Maintenance Committee (reached).

February 14: registration for attendance opens.

March 14: deadline for registration.

Go here for registration details. (CMS confirmed to me via email on 01.23.13 that the deadline for registration is March 14, not February 14, as incorrectly published in the Diagnosis Agenda timeline.)

April 18, 2014: deadline for receipt of public comments on proposed codes and modifications tabled for March meeting. (Note there is only a 4 week period following this meeting during which written comments can be submitted.)

+++

Key ICD-10-CM/PCS Timeline dates extracted from full timeline, Pages 3-8, September 18-19, 2013 Diagnosis Agenda

March 19–20, 2014: ICD-10-CM/PCS Coordination and Maintenance Committee meeting.

April 1, 2014: There will be no new ICD-9-CM codes to capture new diseases or technology on April 1, 2014, since the last updates to ICD-9-CM will take place on October 1, 2013.

April 2014: Notice of Proposed Rulemaking to be published in the Federal Register as mandated by Public Law 99-509. This notice will include references to the complete and finalized FY 2015 ICD-10-CM diagnosis and ICD-10-PCS procedure codes. It will also include proposed revisions to the MS-DRG system based on ICD-10-CM/PCS codes on which the public may comment. The proposed rule can be accessed at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/index.html?redirect=/AcuteInpatientPPS/IPPS/list.asp

April 18, 2014: Deadline for receipt of public comments on proposed code [at March meeting.]

June 2014: Final addendum posted on web pages as follows:

Diagnosis addendumhttp://www.cdc.gov/nchs/icd/icd10cm.htm

Procedure addendumhttp://cms.hhs.gov/Medicare/Coding/ICD10/index.html

September 23–24, 2014: ICD-10-CM/PCS Coordination and Maintenance Committee 2014 meeting.

October 1, 2014: New and revised ICD-10-CM and ICD-10-PCS codes go into effect along with DRG changes. Final addendum posted on web pages as follows:

Diagnosis addendumhttp://www.cdc.gov/nchs/icd/icd9cm_addenda_guidelines.htm

Procedure addendumhttp://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/addendum.html

November 2014: Any new ICD-10 codes required to capture new technology that will be implemented on the following April 1 will be announced. Information on any new codes to be implemented April 1, 2015 will be posted on the following websites:

http://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/addendum.html

http://www.cdc.gov/nchs/icd/icd9cm_addenda_guidelines.htm

WHO Collaborating Centre confirms Revision Steering Group seriously considering extension to ICD-11 timeline

Post #289 Shortlink: http://wp.me/pKrrB-3E8

Update at January 30, 2014:

ICD-11 Revision has confirmed that a decision has now been taken to postpone ICD-11 by a further two years, from 2015 to 2017.

From WHO site: “The International Classification of Diseases 11th Revision is due by 2017″

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Information in this report relates to the development of the World Health Organization’s ICD-11. It does not apply to the forthcoming US specific, NCHS developed, clinical modification of ICD-10, known as ICD-10-CM.

Ustun 34

Source: Slide 34: Where are we? What remains to be done? Shall we have ICD WHA submission in 2015 or later? B Üstün, World Health Organization Classifications, Terminologies, Standards ICD Revision: Quality Safety Meeting, September 2013

+++
The December newsletter of the WHO Collaborating Centre for the Family of International Classifications (FIC) in the Netherlands reports that ICD-11 Revision Steering Group (RSG) is reviewing options for a further extension to the ICD-11 development timeline [1]:

Newsletter on the WHO-FIC, Volume 11, Number 2, 2013, Latest News, Page 3 [PDF]

The Revision Steering Group and WHO Secretariat seriously consider amending the timeline of submitting the ICD-11 for endorsement by the World Health Assembly to allow more time for field testing in multiple countries and settings, and following up on resulting edits. WHO currently discusses options and scenarios with stakeholders.

This announcement from WHO-FIC’s Marijke de Kleijn-de Vrankrijker reinforces information and resources provided in my September report (WHO considers further extension to ICD-11 development timeline) – that ICD-11 Revision is failing to meet development targets and delaying submission of ICD-11 for WHA for approval until 2016, or alternatively, extending the timeline by a further two years, for WHA approval in 2017, is under consideration.

+++

ICD-11 already four years behind original targets

The revision of ICD-10 and development of the structure for ICD-11 began in 2007. WHO’s original goal had been to complete the revision and release of ICD-11 by 2011-12, Archived documents [2] [3].

By 2009, the date for submission of ICD-11 for WHA approval had been extended to 2014. The launch of the public version of the Beta drafting platform was later postponed from May 2011 to May 2012.

The current projection for submission of ICD-11 for approval to WHA is May 2015, with dissemination in 2015+ [4].

Mayo’s Christopher Chute, MD, chairs the ICD-11 Revision Steering Group. According to Chute, in this paper published in March 2012, publication of ICD-11 is “expected around 2016″:

Chute CG, Huff SM, Ferguson JA, Walker JM, Halamka JD. There Are Important Reasons For Delaying Implementation Of The New ICD-10 Coding System. Health Aff March 2012 DOI: 10.1377/hlthaff.2011.1258
+++

ICD Revision considers its options

In September, WHO posted this meeting materials document [5] and this slide presentation [6]. The document summarized, inter alia, ICD-11′s progress, current development status, timelines for finalization date and approval by WHO Governing Bodies, and rationales and options for a further shift in the timeline.

You can read extracts from the document and view slides setting out the options currently under consideration in this report: WHO considers further extension to ICD-11 development timeline, selected of which I am appending to this post.

The earliest ICD-11 might be ready for dissemination is late 2015/16 – which may require some further scaling back of the project’s goals.

But if ICD-11 Revision Steering Group does elect to postpone submission for World Health Assembly approval until May 2017, dissemination of ICD-11 may not be viable before 2018.

I will update this post if and when WHO or ICD-11 Revision Steering Group publish a statement of clarification on the WHO website or issue a news release, or if other information becomes available that confirms a revision to the timeline.

Implementation date

I’ve noted some confusion in reporting and comments around ICD-11 approval by WHA and dissemination and implementation dates.

Unlike the U.S. specific ICD-10-CM, there is no mandatory date by which Member States must switch from using ICD-10 to ICD-11.

World Health Assembly adoption of ICD-11 and ICD-11 implementation dates are separate. WHA adoption enables official use for countries who wish to move on to the next edition. But Member States using ICD-10 will transition to the next version at their own convenience [6].

Once approved, prepared for implementation and released, global adoption of ICD-11 isn’t going to happen overnight. It may take several years before WHO Member States transition from ICD-10 to ICD-11. Low resource and developing countries may take longer to prepare for and transition to the new edition.

The annual update process for ICD-10 will continue during the creation of ICD-11.

Extracts from document [5] setting out the rationale and options for postponement of WHA Approval:

[...]

3. Progress and Current Status of ICD Revision:

[...]

BETA PHASE:

At this point in time, 1 September 2013, an ICD2013 Beta version has been produced for review purposes and field trials after 6 years of drafting phases.

The current ICD 2013 Beta version has relatively stable classification lists (i.e. linearizations) for Mortality and Morbidity recording. It will be reviewed by the specific Mortality Reference Group and the Morbidity Reference Group to see how well it fits the purpose and proposed transition from ICD‐10.

In addition, the Beta version has planned processes for:

(i) Systematic international scientific peer review (ii) Submission of additional proposals from public groups and scientists (iii) Conducting field trials for its applicability and reliability (iv) Production support in multiple languages (translations) starting with WHO official languages (v) Preparations for transitions from ICD‐10 to ICD‐11.

[...]

6. Timelines

The current ICD Revision Process timeline foresees that the ICD is submitted to the WHA in 2015 May and could then be implemented. Between now and 2015, there remains 20 months to conduct the remaining tasks summarized above as: 1. Reviews, 2. Additional Proposals, 3. Field Trials, 4. Translations, and 5. Transition Preparations.

Given the technical requirements these steps could be expedited in the next 20 months. The experience obtained thus far, however, suggests that this timeframe will be extremely tight for paying due diligence to the work especially in terms of: appropriate consultations with expert groups; communication and dissemination with stakeholders; and sufficient time for field testing in multiple countries and settings, and carrying out the resulting edits.

WHO Secretariat would like to discuss this with all stakeholders and evaluate the possible options:

a. Keep ICD submission to WHA to 2015 as originally planned and implementation / adoption date may be free by any Member State (current position – no change).

b. Postpone submission to WHA to a later year to allow longer time for field trials and other transition preparations.

[...]

In conclusion:

(a) WHO Secretariat could produce an ICD 2015 ready including Mortality and Morbidity Linearizations, Reference Guide and Index with the appropriate resolution to go to the World Health Assembly. This timeframe, however, is extremely tight for paying due diligence to the work especially in terms of: appropriate consultations with expert groups; and sufficient time for field testing in multiple countries and settings, and carrying out the resulting edits

(b) If the timeline is advanced to 2016, there will be more time to have ICD 2016 version with more translations and incorporations of some field tests results.

(c) If the timeline is advanced to 2017, ICD 2017 will be ready with most Field Test results incorporated and maintenance scheme tested.

[...]

Slide presentation: B Üstün, World Health Organization Classifications, Terminologies, Standards, ICD Revision: Quality Safety Meeting 2013 September 9-10

Where are we? What remains to be done? Shall we have ICD WHA submission in 2015 or later?

Slide 34:

Ustun 34rule

Slide 35: [WHA Approval timeline - options under consideration]

Ustun 35rule

+++

References:

1. Newsletter on the WHO-FIC, Volume 11, Number 2, 2013, Latest News, Page 3. WHO Collaborating Centre for the Family of International Classifications (FIC) in the Netherlands.

2. IUPsyS Mar 08 Agenda Item 25 ICD-10 International Union of Psychological Science COMMITTEE ON INTERNATIONAL RELATIONS ACTION, March 28–30, 2008, Agenda Item No. 25: Revision of the International Classification of Diseases (ICD-10) and Involvement of Psychology.

3.  Exhibit 1 WHO Letter Aug 07 Letter Saxena, WHO, to Ritchie, IUPsyS (International Union for Psychological Science), August 2007.

4. ICD-11 Timeline: http://www.who.int/classifications/icd/revision/timeline/en/index.html

5. Committee for the Coordination of Statistical Activities, Twenty-second Session 4-6 September 2013, Items for discussion and decision: Item 8 of the provisional agenda, 3 September 2013, Pages 8-10: http://unstats.un.org/unsd/accsub/2013docs-22nd/SA-2013-12-Add1-Health-WHO.pdf

6. Slide presentation: ICD Revision: Where are we? Bedirhan Üstün, World Health Organization Classifications, Terminologies, Standards, ICD Revision: Quality Safety Meeting 2013, September 9-10, 2013, Slides 29-35: http://www.slideshare.net/ustunb/icd-2013-qs-tag-260276686

WHO considers further extension to ICD-11 development timeline

Post #275 Shortlink: http://wp.me/pKrrB-3sc

Information in this report relates to the World Health Organization’s ICD-11, currently under development. It does not apply to the current ICD version (ICD-10) or to the forthcoming US specific “clinical modification” of ICD-10, known as ICD-10-CM.

Timeline slippage

Documents posted recently by the World Health Organization (WHO) indicate that ICD Revision is failing to meet development targets and a further extension to the ICD-11 timeline is under consideration.

ICD serves as the international health information standard for the collection, classification, processing and presentation of disease-related data in national and global health statistics.

The 10th edition (ICD-10) was adopted by the World Health Assembly in 1990.

The development process for the next edition (ICD-11) began in April 2007, with ICD-11 scheduled for dissemination by 2012 and the timelines for the development of ICD-11 and DSM-5 running more or less in parallel [1] [2].

Early on in the revision process, the ICD-11 dissemination date was extended. By 2009, the final draft was scheduled for World Health Assembly (WHA) approval in 2014. In order to be ready for global implementation in 2015, the technical work on ICD-11 would need to be completed by 2012 [3].

The WHA approval date was subsequently shunted from 2014 to 2015 – four years later than originally planned and the current, projected implementation date is 2016+.
+++

“…And just a small detail: who will do all this work?” [4]

ICD-11 is a very ambitious and under-resourced project. Given the scale of the undertaking, the technical complexity, the limited funding and human resources, the feasibility of the project reaching its targets by May 2015 has proved unrealistic.

I have written a number of times on this site that I did not envisage dissemination of ICD-11 by 2016 without some scaling back of the project’s scope – or an announcement, at some point this year, of a further extension to the timeline.

ICD-11 Revision Steering Group considers its options

WHO has recently posted a meeting materials document [5] and a slide presentation [6] which summarize, inter alia, ICD-11′s progress, current development status and timelines for finalization date and approval by WHO Governing Bodies.

ICD Revision is considering extending the timeline by up to a couple of years.

This 14 page document Committee for the Coordination of Statistical Activities, Twenty-second Session 4-6 September 2013, Items for discussion and decision: Item 8 of the provisional agenda can be downloaded here

or opened on Dx Revision WatchPDF: SA-2013-12-Add1-Health-WHO

It summarizes the status of the ICD Revision process under section headings:

1. Background: need and mandate
2. General organization structure of the multiple streams of work
3. Progress and current status
4. The remaining steps
5. Further maintenance of ICD after finalization
6. Timelines for the finalization date and approval by WHO Governing Bodies

Extracts from the document setting out the rationale and options for postponement of WHA Approval:

[...]

3. Progress and Current Status of ICD Revision:

[...]

BETA PHASE:

At this point in time, 1 September 2013, an ICD2013 Beta version has been produced for review purposes and field trials after 6 years of drafting phases.

The current ICD 2013 Beta version has relatively stable classification lists (i.e. linearizations) for Mortality and Morbidity recording. It will be reviewed by the specific Mortality Reference Group and the Morbidity Reference Group to see how well it fits the purpose and proposed transition from ICD‐10.

In addition, the Beta version has planned processes for:

(i) Systematic international scientific peer review
(ii) Submission of additional proposals from public groups and scientists
(iii) Conducting field trials for its applicability and reliability
(iv) Production support in multiple languages (translations) starting with WHO official languages
(v) Preparations for transitions from ICD‐10 to ICD‐11.

[...]

6. Timelines

The current ICD Revision Process timeline foresees that the ICD is submitted to the WHA in 2015 May and could then be implemented. Between now and 2015, there remains 20 months to conduct the remaining tasks summarized above as: 1. Reviews, 2. Additional Proposals, 3. Field Trials, 4. Translations, and 5. Transition Preparations.

Given the technical requirements these steps could be expedited in the next 20 months. The experience obtained thus far, however, suggests that this timeframe will be extremely tight for paying due diligence to the work especially in terms of: appropriate consultations with expert groups; communication and dissemination with stakeholders; and sufficient time for field testing in multiple countries and settings, and carrying out the resulting edits.

WHO Secretariat would like to discuss this with all stakeholders and evaluate the possible options:

a. Keep ICD submission to WHA to 2015 as originally planned and implementation / adoption date may be free by any Member State (current position – no change).

b. Postpone submission to WHA to a later year to allow longer time for field trials and other transition preparations.

[...]

In conclusion:

(a) WHO Secretariat could produce an ICD 2015 ready including Mortality and Morbidity Linearizations, Reference Guide and Index with the appropriate resolution to go to the World Health Assembly. This timeframe, however, is extremely tight for paying due diligence to the work especially in terms of: appropriate consultations with expert groups; and sufficient time for field testing in multiple countries and settings, and carrying out the resulting edits

(b) If the timeline is advanced to 2016, there will be more time to have ICD 2016 version with more translations and incorporations of some field tests results.

(c) If the timeline is advanced to 2017, ICD 2017 will be ready with most Field Test results incorporated and maintenance scheme tested.

[...]

If WHO/ICD-11 Revision Steering Group does elect to postpone submission for WHA approval until May 2017, dissemination of ICD-11 may not be scheduled before 2018.

Once approved and released, adoption of ICD-11 won’t happen overnight. It may take several years before WHO Member States adopt ICD-11. Low resource and developing countries may also take longer to prepare for and transition to the new edition.

Note for US readers: According to Page 3332 of DHSS Office of Secretary Final Rule document (Federal Register / Vol. 74, No. 11 / Friday, January 16, 2009 / Rules and Regulations):

“…We [ICD-9-CM Coordination and Maintenance Committee] discussed waiting to adopt the ICD-11 code set in the August 22, 2008 proposed rule (73 FR 49805)…

“…However, work cannot begin on developing the necessary U.S. clinical modification to the ICD-11 diagnosis codes or the ICD-11 companion procedure codes until ICD-11 is officially released. Development and testing of a clinical modification to ICD-11 to make it usable in the United States will take an estimated additional 5 to 6 years. We estimated that the earliest projected date to begin rulemaking for implementation of a U.S. clinical modification of ICD-11 would be the year 2020.” [7]

This projection, in early 2009, would have been based on the assumption that ICD-11 was anticipated to be finalized and submitted for WHA Approval by 2014 (now potentially shifting to 2017).

An additional two year delay in the finalization of the ICD-11 code sets would likely impact on the development process for a clinical modification of ICD-11 for US specific use, kicking adaptation and implementation of an ICD-11-CM even further down the road.

+++
This slide presentation, below, was uploaded to Slideshare on September 9 by Dr Bedirhan Üstün, Coordinator, Classification, Terminology and Standards, World Health Organization, and also sets out the postponement options now under consideration:

Slide presentation: World Health Organization Classifications, Terminologies, Standards

ICD Revision: Quality Safety Meeting 2013 September 9-10

Where are we? What remains to be done? Shall we have ICD WHA submission in 2015 or later?

http://www.slideshare.net/ustunb/icd-2013-qs-tag-26027668

Slide 29:

Ustun 29rule

Slide 30:

Ustun 30rule

Slide 34:

Ustun 34rule

Slide 35: [WHA Approval - options under consideration]

Ustun 35rule
+++

References

1. Agenda Item No. 25: Revision of the International Classification of Diseases (ICD-10) and Involvement of Psychology International Union of Psychological Science Committee on International Relations Action, March 28–30, 2008 IUPsyS Mar 08 Agenda Item 25 ICD-10

2. Letter Saxena, WHO, to Ritchie, IUPsyS (International Union for Psychological Science), August 2007 Exhibit 1 WHO Letter Aug 07

3. Dr Geoffrey Reed, Ph.D., May 2009, personal correspondence.

4. Closing remarks, PowerPoint presentation: “Proposal for the ICD Beta Platform”, Stanford team, 12.04.11, WHO, Geneva.

5. Committee for the Coordination of Statistical Activities, Twenty-second Session 4-6 September 2013, Items for discussion and decision: Item 8 of the provisional agenda, 3 September 2013 Full document in PDF format

6. Slide presentation: ICD Revision: Where are we? Bedirhan Ustun, World Health Organization Classifications, Terminologies, Standards, ICD Revision: Quality Safety Meeting 2013, September 9-10, 2013 http://www.slideshare.net/ustunb/icd-2013-qs-tag-26027668

7. DHSS Office of Secretary Final Rule document (Federal Register / Vol. 74, No. 11 / Friday, January 16, 2009 / Rules and Regulations), Page 3332.

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