Allen Frances and Robert Spitzer on DSM-5 Scientific Review Work Group and DSM-5 Field Trials and deadlines

December 18, 2010 by

Allen Frances, MD and Robert Spitzer, MD write to the APA Board of Trustess re DSM-5 Scientific Review Work Group; Frances on DSM-5 Field Trials and deadlines

Post #54 Shortlink: http://wp.me/pKrrB-Ru

On 10 December 2009, the American Psychiatric Association (APA) issued a news release announcing a revised timeline for the publication of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The anticipated release date for DSM-5 was being shifted from May 2012 to May 2013.

According to the DSM-5 Development Timeline:

[Timeline superceded by revised Timeline]

But field trials are barely underway.

Allen Frances, MD, currently professor emeritus at Duke, had chaired the DSM-IV Task Force. Frances maintains the blog DSM5 in Distress at Pyschology Today and also writes for Psychiatric Times where he’s been documenting and commenting on the development of DSM-5 since June 2009. Robert Spitzer had chaired the DSM-III Task Force.

Links to two recent commentaries by Allen Frances on DSM-5 deadlines and a joint letter by Frances and Spitzer to the APA Board of Trustees in response to the APA’s appointment of a DSM-5 Scientific Review Work Group, below:

DSM5 in Distress

The DSM’s impact on mental health practice and research.
by Allen Frances, M.D.

Letter To Board Of Trustees of the American Psychiatric Association sent December 6, 2010

Published on December 13, 2010

We are delighted that you have appointed a DSM-5 Scientific Review Work Group and charged it with assessing the quality of evidence supporting the DSM 5 proposals. This is great news, probably the last hope to weed out proposals that could do great harm to the Association, our field, and to our patients. Our relief and hope are tempered only by several problems with the process as you have established it:

CONTINUED SECRECY: Given all of the negative publicity surrounding the DSM-5 confidentiality agreements, we are amazed to see the following statement in the charge to the Scientific Review committee: “Deliberations and reports to the BOT will be confidential. The existence of the committee (work group) will be public.” Why on earth is this case? What is the possible harm of making this esteemed committee’s final report public? While we can appreciate the need for the committee to be able to deliberate candidly and not feel constrained by the possibility that every aspect of their deliberations will be made public, it is essential that the final report containing the committee’s assessment of the scientific merits of the proposals be made public.

COMPOSITION OF WORK GROUP: The announcement makes an ambitious claim, namely, that this review will be equivalent to an independent NIMH peer review. This desirable standard cannot possibly be met by the DSM-5 Scientific Review Work Group as you have constituted it. The people chosen are all well-respected, but all but two of the committee members have been involved with DSM 5 or its oversight. To have credibility, a review committee must be completely unattached to the work that has already been done on DSM 5. Preferably, APA should contract out the review process to experts in evidence based medicine who would be both fully independent and also able to apply the standards of scientific proof used across all medical specialties. At the very least, the membership of the committee needs to be broadened to guarantee both the reality and the appearance of a truly unbiased and independent review process.

CHARGE: Although labeled a “Scientific Review Work Group”, the charge needs to go beyond just being a scientific review and include a thorough risk/ benefit analysis of all suggestions. That such an analysis is planned in suggested by the statement in the charge that “issues of clinical utility, public health, and potential impact on patients should also be considered.” We applaud this plan to conduct a risk/benefit analysis but are concerned that such a review requires broader experience in primary care, public policy, health economics, and forensics that goes beyond the current composition of the Workgroup. At a minimum, close consultation with such experts should be part of the planned review process.

METHOD: It appears the assessments will be limited to evidence already generated by the work groups, with no check to determine if their reviews have been comprehensive and balanced. Since there was no standard operating procedure in the literature review process, the work group reviews are variable in quality and method. A recheck to ensure that all pertinent references have been included is necessary.

TIMING: This scientific review is occurring unbelievably late in the DSM 5 process- it should have been completed more than a year ago, not after the field trials have already begun. There is little purpose to be doing expensive field testing on proposal likely to be eliminated because of limited scientific support. Every step in the DSM 5 process has missed its deadline, sometimes by a year or more. We are concerned that the momentum of the DSM 5 process and limited time left for its review will result in the rushed inclusion of proposals that are both risky and unsupported by evidence.

All these serious concerns notwithstanding, The DSM 5 Scientific Review Work Group has our very best wishes. It is in a key position to do a great service for our field and for our patients and to save APA from further embarrassment.

Robert Spitzer and Allen Frances

DSM5 in Distress

The DSM’s impact on mental health practice and research.
by Allen Frances, M.D.

DSM 5 Field Trials-Part 1 Missed Deadlines Have Troubling Consequences
DSM 5 is falling far behind its schedule.

Published on November 15, 2010

This is a sad tale of completely unrealistic timetables, poorly executed work effort, consistently missed deadlines, and what will undoubtedly be a rushed and botched DSM 5. It all started at the annual meeting of the American Psychiatric Association in May 2009, when the DSM 5 leadership blithely announced it was ready to begin field testing in the early summer of 2009…

…It was patently obvious from the moment of its announcements that the new DSM 5 field test timetable was also a product of fantasy that would not be met in the real world. First off, it should have been clear that the field trials could not possibly start on time two months after their announcement. Recruiting the sites, training the personnel, gaining human rights approvals, and pilot testing always take at least six months. Predictably, we are already in mid Nov 2010 and it is still not at all clear when the DSM 5 field tests will actually begin to enroll patients at all its sites.

Read full commentary: DSM 5 Field Trials-Part 1 Missed Deadlines Have Troubling Consequences

DSM5 in Distress

The DSM’s impact on mental health practice and research.
by Allen Frances, M.D.

The DSM 5 Field Trials, Part 2: Asking The Wrong Question Will Lead To Irrelevant Answers
A waste of talent, time, and money.

Published on November 23, 2010

…Field tests also fail to account for the pressures that will lead to systematic, future misuse-especially the drug company marketing of mental disorders that leads to over-diagnosis.

…What do I mean? DSM 5 has made a number of radical suggestions for change, particularly the inclusion of many new diagnoses at the threshold of normality. These have the potential to reclassify as mentally disordered tens of millions of people currently considered normal. The only relevant questions are the overall rates of these disorders in the general population and the risks of false negative over-diagnosis.

…At the end of the DSM 5 field trials, we will have no idea whatever whether its suggestions will create false epidemics of misidentified pseudo-patients.

Read full commentary: Part 2: Asking The Wrong Question Will Lead To Irrelevant Answers

ICD-11

Implementation of the WHO’s ICD-11 is scheduled for 2014. Earlier this year, I asked ICD Revision to clarify for stakeholders whether any form of Alpha Draft for ICD-11 will be placed in the public domain, when this will be released and in what formats. 

In October, ICD Revision stated via its Facebook site, that there will be no publication of an ICD-11 Alpha Draft for public scrutiny and that a public Beta Draft is still targeted for May 2011.

ICD-11 targets also slipping 

According to the September iCamp2 meeting PowerPoint presentation, Frequent Criticisms and this iCamp2 YouTube, targets for the population of content for the ICD-11 Alpha Draft had not been reached.   

Less that 80% of Terminology Definitions had been uploaded to the iCAT and less than the 20% target for full Content Model completion for the thousands of diseases and disorders classified within ICD had been met at that point. [The Content Model identifies the basic properties needed to define any ICD concept (unit, entity or category) through the use of multiple parameters.] Not all Topic Advisory Groups were at a similar developmental stage and ICD-11 Beta Plans were behind schedule.   (See Post #48)

International Advisory Group for the Revision of ICD-10 Mental and Behavioural Disorders

The APA participates with the WHO in the International Advisory Group for the Revision of ICD-10 Mental and Behavioural Disorders and the DSM-ICD Harmonization Coordination Group.

The International Advisory Group for the Revision of the ICD-10 Chapter for Mental and Behavioural Disorders (currently ICD-10 Chapter V but will be Chapter 5 in ICD-11) was constituted by the WHO with the primary task of advising the WHO on all steps leading to the revision of the mental and behavioural disorders classification in ICD-10, in line with the overall ICD revision process.

The Group is chaired by Steven E Hyman, MD, Harvard University, Cambridge, Massachusetts. Steven E Hyman, MD is also a member of the APA’s DSM-5 Task Force.

There is already a degree of correspondence between DSM-IV and Chapter V of ICD-10. For the next editions, the APA and the WHO have committed as far as possible:

To facilitate the achievement of the highest possible extent of uniformity and harmonization between ICD-11 mental and behavioural disorders and DSM-V disorders and their diagnostic criteria.

with the objective that

The WHO and APA should make all attempts to ensure that in their core versions, the category names, glossary descriptions and criteria are identical for ICD and DSM.

The Advisory Group has published no Summary Reports of its meetings since its fourth meeting in December 2008. A fifth meeting of the group was held on 28 – 29 September 2009.  Over a year later, no Summary Report has been published for that meeting. It is uncomfirmed whether any meetings of the Advisory Group were held in 2010.

Topic Advisory Group for Neurology

The lead WHO Secretariat for Topic Advisory Group (TAG) for Neurology is Dr Tarun Dua, Management of Mental and Brain Disorders, Department of Mental Health and Substance Abuse, WHO, Geneva.

The TAG for Neurology is chaired by Raad Shakir, MD, Imperial College London. For further information on TAG Neurology see this page.

Filed under American Psychiatric Association (APA), Clinical Modification, Criticism of DSM-V, DSM-5, DSM revision process, DSM-5, DSM-5 draft proposals, DSM-5 in the media, DSM-V, ICD-10-CM, ICD-11, ICD-11 Alpha Draft, Psychiatric Times, WHO (World Health Organization)

The Development, Evolution, and Modifications of ICD-10: Challenges to the International Comparability of Morbidity Data

October 29, 2010 by

The Development, Evolution, and Modifications of ICD-10: Challenges to the International Comparability of Morbidity Data

Post #52 Shortlink: http://wp.me/pKrrB-QX

Keywords
ICD, WHO, morbidity, ICD-10 clinical modifications, administrative data

Medical Care

POST AUTHOR CORRECTIONS, 25 October 2010
doi: 10.1097/MLR.0b013e3181ef9d3e
Original Article: PDF Only

The Development, Evolution, and Modifications of ICD-10: Challenges to the International Comparability of Morbidity Data

Published Ahead-of-Print

Abstract

Background: The United States is about to make a major nationwide transition from ICD-9-CM coding of hospital discharges to ICD-10-CM, a country-specific modification of the World Health Organization’s ICD-10. As this transition occurs, the WHO is already in the midst of developing ICD-11. Given this context, we undertook this review to discuss: (1) the history of the International Classification of Diseases (a core information “building block” for health systems everywhere) from its introduction to the current era of ICD-11 development; (2) differences across country-specific ICD-10 clinical modifications and the challenges that these differences pose to the international comparability of morbidity data; (3) potential strategic approaches to achieving better international ICD-11 comparability.

Literature Review and Discussion: A literature review and stakeholder consultation was carried out. The various ICD-10 clinical modifications (ICD-10-AM [Australia], ICD-10-CA [Canada], ICD-10-GM [Germany], ICD-10-TM [Thailand], ICD-10-CM [United States]) were compared. These ICD-10 modifications differ in their number of codes, chapters, and subcategories. Specific conditions are present in some but not all of the modifications. ICD-11, with a similar structure to ICD-10, will function in an electronic health records environment and also provide disease descriptive characteristics (eg, causal properties, functional impact, and treatment).

Conclusion: The threat to the comparability of international clinical morbidity is growing with the development of many country-specific ICD-10 versions. One solution to this threat is to develop a meta-database including all country-specific modifications to ensure more efficient use of people and resources, decrease omissions and errors but most importantly provide a platform for future ICD updates.

(C) 2010 Lippincott Williams & Wilkins, Inc.

Ed note: The forthcoming US “Clinical Modification”, ICD-10-CM, is country specific; it does not apply outside the US.

Current proposals for the US Clinical Modification ICD-10-CM, which is scheduled for implementation in October  2013, propose classifying Chronic fatigue syndrome in ICD-10-CM Chapter 18 at R53.82.

The proposed U.S. classification ICD-10-CM separates CFS and Postviral fatigue syndrome into mutually exclusive categories. “Chronic fatigue, unspecified | Chronic fatigue syndrome not otherwise specified” appear in Chapter XVII under R53.82.

“Postviral fatigue syndrome | Benign myalgic encephalomyelitis” appear in Chapter VI under G93.3.

The Chronic Fatigue Syndrome Advisory Committee (CFSAC) had previously recommended CFS to be placed under the same neurological code as ME and PVFS, G93.3.

For the most recent ICD-10-CM proposals see:

CDC site: International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) [1]:

http://www.cdc.gov/nchs/icd/icd10cm.htm

The Zipped file for the “2010 ICD-10-CM Tabular List of Diseases & Injuries” is not that easy to locate on the CDC site.

A non Zipped PDF of the most recent proposals can be downloaded here:

http://www.cms.gov/ICD10/12_2010_ICD_10_CM.asp#TopOfPage

http://www.cms.gov/ICD10/Downloads/6_I10tab2010.pdf

Page 325:

G93.3 Postviral fatigue syndrome
Benign myalgic encephalomyelitis
Excludes1: chronic fatigue syndrome NOS (R53.82)

Page 1165:

R53.82 Chronic fatigue, unspecified
Chronic fatigue syndrome NOS
Excludes1: postviral fatigue syndrome (G93.3)

The Canadian Clinical Modification (ICD-10-CA) has all three terms classified in Chapter VI: Diseases of the nervous system at G93.3:

Version 2009 ICD-10-CA Tabular List, Volume 1 PDF (4.9MB):

http://secure.cihi.ca/cihiweb/en/downloads/ICD-10-CA_Vol1_2009.pdf

Other disorders of the nervous system

(G90-99)

[…]

G93 Other disorders of brain

[…]

G93.3 Postviral fatigue syndrome
Includes: Benign myalgic encephalomyelitis
Chronic fatigue syndrome

Excludes: fatigue syndrome NOS (F48.0)

[1] Although this release of ICD-10-CM is now available for public viewing, the codes in ICD-10-CM are not currently valid for any purpose or use.

[2] More information on US “Clinical Modification” ICD-10-CM here, on DSM-5 and ICD-11 Watch site: http://wp.me/pKrrB-Ka

Filed under Clinical Modification, ICD revision process, ICD-10, ICD-10-CM, ICD-11, ICD-11 in the media, WHO (World Health Organization)

Update on the ICD-11 Alpha Draft 06.09.10

September 6, 2010 by

Update on the ICD-11 Alpha Draft at 06.09.10

Post #47 Shortlink: http://wp.me/pKrrB-MD

The information in this update relates only to proposals for ICD-11.

This information does not apply to ICD-10-CM, the forthcoming “Clinical Modification” of ICD-10, which is scheduled for implementation in October 2013 and is specific to the US.

Post #45 is intended to clarify any confusion between ICD-10, ICD-11 and the forthcoming US specific “Clinical Modification”, ICD-10-CM.

See: US “Clinical Modification” ICD-10-CM 

On 7 June, in Post #46, I published a report that includes 13 screenshots from the iCAT, the wiki-like Web 2.0 collaborative authoring platform through which ICD-11 is being drafted.

To view proposals as they currently appear in the iCAT, see the screenshots and my brief notes here:

PVFS, ME, CFS: the ICD-11 Alpha Draft and iCAT Collaborative Authoring Platform

Note that what currently appears in the iCAT and in my June report may be subject to revision by the ICD Revision Steering Group and Topic Advisory Groups prior to an alpha draft being publicly released or presented at the forthcoming September iCamp2 meeting.

 

Update on the ICD-11 Alpha Draft

ICD Revision maintains a website at: http://sites.google.com/site/icd11revision/

where the public can access minutes of iCamp and Topic Advisory Group (TAG) meetings, meeting agendas, key documents and presentations.

Text on this website had read:

“ICD-11 alpha draft will be ready by 10 May 2010
ICD-11 beta draft will be ready by 10 May 2011
ICD final draft will be submitted to WHA by 2014”

This text has recently been changed to read:

“ICD-11 alpha draft process began September 2009
ICD-11 beta draft process will begin in 2011
ICD final draft will be submitted to WHA by 2014”

No detailed timeline has been published but there is a “Project milestones and budget, and organizational overview” on page 7 of this document:

ICD-11 Revision Project Plan – Draft 2.0 (v March 10) PDF: ICD Revision Project Plan

or: http://www.who.int/classifications/icd/ICDRevisionProjectPlan_March2010.pdf

which projects a Beta Draft release for May 2012.

Release of ICD-11 Alpha Draft

No ICD-11 Alpha Draft was publicly released in May. But a hard copy “snapshot” of the alpha, as it stood at that point, was presented by the WHO at the 63rd World Health Assembly meeting, between 17 and 25 May.

September iCamp2 meeting

An ICD Revision iCamp2 meeting had been scheduled for April but was postponed. The meeting has been rescheduled for later this month.

iCamp2 is now scheduled for 27 September – 1 October 2010, in Geneva.

The revised Agenda for this meeting is here:

http://sites.google.com/site/icd11revision/home/face-to-face-meetings/icamp2-2010

http://sites.google.com/site/icd11revision/home/face-to-face-meetings/icamp2-2010/icamp-2-agenda

Following iCamp meetings, PowerPoint presentations are sometimes made publicly available on the website.

According to sources, the print version of the alpha draft is now expected to be made available around the time that the iCamp2 meeting takes place, later this month.

ICD Revision maintains a blog, here, which hasn’t been updated since last October and a Facebook presence here

In response to some questions raised several months ago, ICD Revision confirmed, on 6 August, that:

“A draft print version will be available in September 2010.”

On 7 August, I raised the following:

“ICD Revision has clarified that a draft print version will be available in September 2010.

Clarification would also be welcomed on whether this Alpha Draft will be available for internal use only or intended for public viewing, and if for public viewing, in what format(s)?

According to the Revision document ICD Revision Project Plan [1], published on the ICD Revision Google site, in March:

‘The Alpha draft will be produced in a traditional print and electronic format. The Alpha Draft will also include a Volume 2 containing the traditional sections and including a section about the new features of ICD-11 in line with the style guide [2]. An index for print will be available in format of sample pages. A fully searchable electronic index using some of the ontological features will demonstrate the power of the new ICD.’

Since 2007, it has been possible for stakeholders in the development of ICD-11 to submit proposals and comments, supported by citations, via the ICD Update and Revision Platform Intranet. It was understood last year, that for some Topic Advisory Groups a proposal form for ICD-11 was being prepared for use by stakeholders. Information about the availability of proposal forms for the various Topic Advisory Groups, up to what stage in the development process timeline these might be used, and which stakeholders would be permitted to make use of proposal forms would be welcomed.

It remains unclear what will be ready by September, whether it will be available for public scrutiny, and in what format(s), and by what various means stakeholders might submit proposals prior to and following the release of an Alpha Draft.”

This request for clarification has yet to receive a response.

 

Current proposals for the classification and coding of PVFS, ME and CFS for the ICD-11 Alpha Draft

On my DSM-5 and ICD-11 Watch website, at Post #46, is a report I published on 7 June that includes screenshots from the iCAT, the wiki-like collaborative authoring platform through which ICD-11 is being drafted.

To view what is currently visible in the iCAT, see the screenshots and my brief notes here:

PVFS, ME, CFS: the ICD-11 Alpha Draft and iCAT Collaborative Authoring Platform, 7 June 2010

Caveat

For better understanding, it is important that the brief iCAT Glossary page is read in conjunction with the iCAT screenshots, especially the Glossary entries for ICD-10 Code; ICD Title; Definition; Terms: Synonyms, Inclusions and Exclusions [4].

Read the iCAT Glossary here: http://apps.who.int/classifications/apps/icd/icatfiles/iCAT_Glossary.html

Secondly, it needs to be understood that the alpha draft is a “work in progress”. Not all content will have been compiled yet and entered into the iCAT and there are many blank fields awaiting population for all chapters and for all categories. It also needs to be understood that some text already entered into the various “Details” fields may still be in the process of internal review and subject to revision.

Because Topic Advisory Groups are still in the process of entering content into the iCAT not all listings and content that is intended to be included in the print version of the alpha draft may be visible to us, at this point, in the iCAT drafting platform.

ICD-10 > ICD-11

One of the biggest changes between ICD-10 and ICD-11 is that in ICD-11, Categories will be defined through the use of multiple parameters.

In ICD-10, there is no textual content for the three terms “Postviral fatigue syndrome”, “Benign myalgic encephalomyelitis” and “Chronic fatigue syndrome”. There are no definitions and the relationship between the three terms is not specified.

But in ICD-11, categories will be defined through the use of multiple parameters: Title & Definition, Terms: Synonyms, Inclusions, Exclusions, Clinical Description, Signs and Symptoms, Diagnostic Criteria and so on, according to a common “Content Model” [2] and as evidenced by the screenshots.

So have a look at Post #46 if you have not already done so. Or have a poke around in the iCAT wiki production server. The public has no editing rights so you can’t break anything [3].

 

Request for clarification to Advisory Group for Neurology

On 28 June, I contacted Dr Raad Shakir who chairs the ICD Revision Topic Advisory Group for Neurology, for clarifications in respect of current proposals for ICD-11 Chapter 6 (VI).

Dr Shakir has been asked if he would disambiguate current proposals for ICD-11 for the classification of, and relationships between the three terms, “Postviral fatigue syndrome”, “Chronic fatigue syndrome” and “Benign myalgic encephalomyelitis”, since this is not explicit from the information as it currently displays in the iCAT, nor from the Discussion Note for “Gj92 Chronic fatigue syndrome”, which has been listed in Chapter 6 (VI) under

Chapter 6 (VI) Disorders of the nervous system

             > GN Other disorders of the nervous system

(“Gj92” is a “Sorting label”. It is understood that a “Sorting label” is a string that can be used to sort the children of a category and is not the ICD code.)

I was advised by Dr Shakir, on 5 July, by email, that my queries have been passed to the Advisory Group for a response. I have yet to receive a clarification.

To: Dr Raad Shakir, West London Neurosciences Centre, Charing Cross
Hospital, Fulham Palace Road, London W6 8RF raad.shakir@imperial.nhs.uk

Re: Query in relation to Topic Advisory Group for Neurology proposals for ICD-11 Chapter 6 (VI)

28 June 2010

Dear Dr Shakir,

I am writing to you in your capacity as Chair, ICD Revision TAG Neurology, with a request for clarification of current proposals for the restructuring of categories classified in ICD-10 under G93 Others disorders of brain, specifically those at G93.3. That is:

Diseases of the nervous system (G00-G99)

      > Other disorders of the nervous system (G90-99)

             > G93 Other disorders of brain

[…]

G93.3 Postviral fatigue syndrome
Benign myalgic encephalomyelitis

(with Chronic fatigue syndrome indexed to G93.3 in ICD-10: Volume 3: The Alphabetical Index)

In the absence of the release of an ICD-11 Alpha Draft, I rely on information as it currently displays in the ICD Categories listed in the iCAT production server at: http://icat.stanford.edu/

My understanding is that what is being proposed at this point for ICD-11 is that ICD categories coded between G83.9 thru G99.8 in ICD-10 Chapter VI: Diseases of the nervous system, are being reorganised.

That in ICD-11, Chapter 6 (VI) codings beyond G83.9 are represented by new parent classes numbered GA thru to GN thus:

Chapter 6 (VI) Disorders of the nervous system

[…]
G80-G83 Cerebral palsy and other paralytic syndromes
GA Infections of the nervous system
GB Movement disorders and degenerative disorders
GC Dementias
[…]
GN Other disorders of the nervous system

That “GN Other disorders of the nervous system” is parent to five child classes that are assigned the “Sorting labels” Gj90-Gj94.

(It is understood that a “Sorting label” is a string that can be used to sort the children of a category and is not the ICD code.)

At Gj92, sits “Chronic fatigue syndrome”

That “Gj92 Chronic fatigue syndrome” displays no child classes of its own.

The Category Note associated with “Gj92 Chronic fatigue syndrome” records a Change in hierarchy for class: G93.3 Postviral fatigue syndrome because its parent category (G93 Other disorders of brain) is removed.*

[*Ed: Note that the removal of the parent “G93 Other disorders of brain” affects many other categories also classified under G93 in ICD-10, not just G93.3, which have also been assigned “Sorting labels”.]

According to the iCAT ICD Categories “Details for Gj92 Chronic fatigue syndrome”

“Gj92 Chronic fatigue syndrome” displays as a ICD Title term.

“Gj92 Chronic fatigue syndrome” has a Definition field populated.**

[**Ed: Which may be subject to revision and in response to proposals.]

It has an External Definitions field populated which includes definitions imported from other classification systems, the text of which includes “Also known as myalgic encephalomyelitis”.

It has “Benign myalgic encephalomyelitis” specified under Inclusions.

It has no Synonyms, Exclusions or other descriptor fields populated yet.

That at this point and as far as the iCAT version displays, there is no explicit accounting for “Postviral fatigue syndrome”, as an entity, other than that “Postviral fatigue syndrome” is specified under Exclusions to Chapter 5 (V) F48.0 Neurasthenia and to Chapter 18 (XVIII) R53 Malaise and fatigue and is referenced in these chapters as

            postviral fatigue syndrome G93.3 -> Gj92 Chronic fatigue syndrome

It is further understood, from the iCAT Glossary at
http://apps.who.int/classifications/apps/icd/icatfiles/iCAT_Glossary.html

that:

“Inclusion terms appear in the tabular list of the traditional print version and show users that entities are included in the relevant concept. All of the ICD-10 inclusion terms have been imported and accessible in the iCat. These are either synonyms of the category titles or subclasses which are not represented in the classification hierarchy. Since we have synonyms as a separate entity in our ICD-11 content model, the new synonyms suggested by the users should go into the synonyms section. In the future, iCat will provide a mechanism to identify whether an inclusion is a synonym or a subclass.”

I should be most grateful if you could clarify the following for me:

1] In ICD-10 Volume 3: The Alphabetical Index, “Chronic fatigue syndrome” is indexed to G93.3 but does not appear in the Tabular List.

In ICD-11, is it being proposed that “Chronic fatigue syndrome” will be included in the Tabular List in Chapter 6 (VI) Diseases of the nervous system under “(GN) Other disorders of the nervous system”?

2] In ICD-11, is it being proposed that rather than “Postviral fatigue syndrome” being the ICD Category Title term (previously coded at G93.3, but which has now lost its parent class, G93) that “Gj92 Chronic fatigue syndrome” is proposed as a new ICD Category Title term?

If this is the case, what is the current proposed relationship between the terms “Postviral fatigue syndrome” and “Gj92 Chronic fatigue syndrome”?

That is, is it proposed that in the tabular list, “Postviral fatigue syndrome” would still appear as a discrete Category Title term or is it intended that it should be subsumed under “Gj92 Chronic fatigue syndrome” or become a Subclass of, or Synonym to “Chronic fatigue syndrome”, or to have some other relationship?

3] In the iCAT, the term “Benign myalgic encephalomyelitis” (previously coded at G93.3, but which has now lost its parent class G93) is listed as an Inclusion under “Details for Gj92 Chronic fatigue syndrome” but does not appear listed under “GN Other disorders of the nervous system” in the ICD Category List with a Sorting label of its own, nor as a child to “Gj92 Chronic fatigue syndrome”.

What is currently being proposed for ICD-11 for the classification and coding of “Benign myalgic encephalomyelitis”, as an entity, and its relationship to “Chronic fatigue syndrome”?

Since this is not explicit from the information as it currently displays in the iCAT, nor from the Discussion Note to Gj92, I should be pleased if you could disambiguate current proposals for the classification of, and relationships between these three terms for ICD-11.

Sincerely,

etc

 

I will update when a response has been received and when further information about a print version of the alpha draft becomes available.

Other than making general enquiries around the development of ICD-11 and the operation of the iCAT and this request for clarification of current proposals, I have made no representations to any ICD Topic Advisory Group, nor submitted any proposals through any means nor have I had any discussions with WHO personnel or Topic Advisory Group members in relation to current or future proposals for the three terms of interest to us.

References:

PVFS, ME, CFS: the ICD-11 Alpha Draft and iCAT Collaborative Authoring Platform, 7 June 2010, Post # 46: http://wp.me/pKrrB-KK

[1] ICD-11 Revision Project Plan – Draft 2.0 (v March 10):
Describes the ICD revision process as an overall project plan in terms of goals, key streams of work, activities, products, and key participants: ICD Revision Project Plan
http://www.who.int/classifications/icd/ICDRevisionProjectPlan_March2010.pdf

[2] Content Model Specifications and User Guide (v April 10):
Identifies the basic properties needed to define any ICD concept (unit, entity or category) through the use of multiple parameters: http://tinyurl.com/ICD11ContentModelApril10

[3] iCAT production server and Demo and Training iCAT Platform:
http://sites.google.com/site/icd11revision/home/icat
iCAT production server: http://icat.stanford.edu/

[4] iCAT Glossary
http://apps.who.int/classifications/apps/icd/icatfiles/iCAT_Glossary.html

Filed under American Psychiatric Association (APA), Clinical Modification, iCAT, ICD revision process, ICD-10, ICD-10-CM, ICD-11, ICD-11 Alpha Draft, ICD-11 consultation, ICD-11 revision docs, Somatic Symptom Disorder, Somatoform Disorders, WHO (World Health Organization), WHO Somatisation Project

US “Clinical Modification” ICD-10-CM

June 6, 2010 by

US “Clinical Modification” ICD-10-CM

Post #45 Shortlink: http://wp.me/pKrrB-Ka

This post is intended to clarify any confusion between ICD-10, ICD-11 and the forthcoming US Clinical Modification of ICD-10, ICD-10-CM.

The WHO published ICD-10 in 1992. The current version of ICD-10 (Version for 2007) is used in the UK and in many countries throughout the world.

ICD-10 is under revision and the development of the structure and content of ICD-11 has been underway since 2007. ICD-11 is scheduled for completion in 2014.

 
Clinical Modifications

Several countries are permitted to publish adaptations of the ICD called “Clinical Modifications” (sometimes known as “national modifications”).

Countries using Clinical Modifications of ICD-10 include Canada (ICD-10-CA), Australia (ICD-10-AM) and Germany (ICD-10-GM).

The United States currently uses an adaptation of the WHO’s now retired ICD-9, called ICD-9-CM, and has been slow to move onto ICD-10.

Rather than skip ICD-10 and move straight onto ICD-11 in 2014+, the US CDC has been developing a modification of ICD 10 called ICD-10-CM which will replace ICD-9-CM.

ICD-10-CM is US specific and is due for implementation in October 2013.

According to one report, the US should not expect to move on to ICD-11 (or a modification of ICD-11) until well after 2020, assuming that ICD-11 is published around the 2014-2015 projection:

Why move to ICD-10, if ICD-11 is on the horizon?
http://www.healthcarefinancenews.com/news/why-move-icd-10-if-icd-11-horizon
 

What are the proposed classifications and codings for PVFS, (Benign) ME and Chronic fatigue syndrome for ICD-10-CM?

In March 2001, the document:

“A Summary of Chronic Fatigue Syndrome and Its Classification in the International Classification of Diseases Prepared by the Centers for Disease Control and Prevention, National Center for Health Statistics, Office of the Center Director, Data Policy and Standards”

provided a concise “summary of the classification of Chronic Fatigue Syndrome in the International Classification of Diseases (ICD), ninth and tenth revisions, and their clinical modifications.”

That document is archived here: http://www.co-cure.org/ICD_code.pdf

In 2001, the proposal had been:

“In keeping with the placement in the ICD-10, chronic fatigue syndrome (and its synonymous terms) will remain at G93.3 in ICD-10-CM.”

So at that point, it was being proposed for the forthcoming US ICD-10-CM that PVFS, (Benign) ME and Chronic fatigue syndrome would be coded at G93.3, which would have placed all three terms in Chapter VI: Diseases of the nervous system (the Neurological chapter).

But the current proposals for ICD-10-CM propose classifying Chronic fatigue syndrome in Chapter 18, under R53 Malaise and fatigue, at R53.82.

The “R” codes are classified under

CHAPTER 18 (XVIII)
Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99)

This chapter includes symptoms, signs, abnormal results of clinical or other investigative procedures, and ill defined conditions regarding which no diagnosis classifiable elsewhere is recorded…

Note: this is not the ICD-10-CM Mental and Behavioural chapter, which is:

CHAPTER 5 (V)
Mental and behavioral disorders (F01-F99)
Includes: disorders of psychological development
Excludes2: symptoms, signs and abnormal clinical laboratory findings, not elsewhere classified (R00-R99)

which specifically excludes the R00-R99 codes.

So the current proposal for ICD-10-CM separates CFS and Postviral fatigue syndrome into mutually exclusive categories:

“Chronic fatigue, unspecified” and “Chronic fatigue syndrome not otherwise specified” appear in Chapter 18, under R53 Malaise and fatigue, at R53.82.

Whilst “Postviral fatigue syndrome” and “benign myalgic encephalomyelitis” appear in Chapter 6, under G93 Other disorders of brain, at G93.3.

At some point before October 2013, ICD-10-CM revision will be “frozen” for Centers for Medicare and Medicaid Services (CMS) and insurance companies to prepare for the October 1, 2013 implementation.

See Tom Sullivan at ICD10 Watch.com (no connection with my site) here:

CMS, CDC call for ICD-9 and ICD-10 code freeze
http://icd10watch.com/headline/cms-cdc-call-icd-9-and-icd-10-code-freeze

“CMS, the Centers for Medicare and Medicaid Services, along with CDC, the Centers for Disease Control and Prevention, proposed that both ICD-9-CM and ICD-10-CM/PCS code sets be frozen two years before the compliance deadline.

“What that means: As of October 1, 2011, only limited updates would be instituted into the code sets so that providers, payers, clearinghouses, and health IT vendors, will not have to simultaneously keep pace with code updates while also reconfiguring their existing systems for ICD-10-CM/PCS.” ICD10 Watch.com

During the last ten minutes of the CFSAC meeting on Monday, 10 May, Dr Lenny Jason raised his concerns with the committee that the placement of CFS in ICD-10-CM in the Chapter 18 “R” codes could be problematic.

Videocast of full CFSAC meeting here:
http://videocast.nih.gov/Summary.asp?File=15884

In August 2005, CFSAC had submitted the following recommendation to the Secretary:

http://www.hhs.gov/advcomcfs/recommendations/082005.html

“Recommendation 10: We would encourage the classification of CFS as a ‘Nervous System Disease,’ as worded in the ICD-10 G93.3.”

I suggest that US advocates with concerns about current proposals for the placement of CFS within ICD-10-CM keep a close eye on decisions about the date by which ICD-10-CM is to be frozen.

For the most recent ICD-10-CM proposals see:

http://www.cdc.gov/nchs/icd/icd10cm.htm

The 2010 update of ICD-10-CM is now available and replaces the July 2009 version.

The file for the Tabular List is in a Zipped file which is not that easy to locate on the site. A non Zipped PDF can be downloaded from this site:

http://www.cms.gov/ICD10/12_2010_ICD_10_CM.asp#TopOfPage
http://www.cms.gov/ICD10/Downloads/6_I10tab2010.pdf

or open the PDF on my DSM-5 and ICD-11 Watch site, here
https://dxrevisionwatch.com/wp-content/uploads/2009/12/i10tab2010.pdf

ICD-10-CM CHAPTER 18

Tabular List of Diseases and Injuries Page 1165 (Update for 2010)

      R53 Malaise and fatigue

      […]

      R53.8 Other malaise and fatigue

          Excludes1: combat exhaustion and fatigue (F43.0)
          congenital debility (P96.9)
          exhaustion and fatigue due to:
          depressive episode (F32.-)
          excessive exertion (T73.3)
          exposure (T73.2)
          heat (T67.-)
          pregnancy (O26.8-)
          recurrent depressive episode (F33)
          senile debility (R54)

      R53.81 Other malaise

          Chronic debility
          Debility NOS
          General physical deterioration
          Malaise NOS
          Nervous debility
          Excludes1: age-related physical debility (R54)

     R53.82 Chronic fatigue, unspecified

          Chronic fatigue syndrome NOS
          Excludes1: postviral fatigue syndrome (G93.3)

      R53.83 Other fatigue

          Fatigue NOS
          Lack of energy
          Lethargy
          Tiredness

 

ICD-10-CM CHAPTER 6 Page 325 (Update for 2010)

Diseases of the nervous system (G00-G99)

Excludes2:

[…]
symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R94)

     […]

     G93 Other disorders of brain

      […]

      G93.3 Postviral fatigue syndrome

          Benign myalgic encephalomyelitis
          Excludes1: chronic fatigue syndrome NOS (R53.82)

For comparison:

German Modification ICD-10-GM
http://www.dimdi.de/static/de/klassi/diagnosen/icd10/htmlgm2010/block-g90-g99.htm

ICD-10-GM Version 2010

Kapitel VI
Krankheiten des Nervensystems
(G00-G99)

G93.- Sonstige Krankheiten des Gehirns

[…]

G93.3 Chronisches Müdigkeitssyndrom

Benigne myalgische Enzephalomyelitis
Chronisches Müdigkeitssyndrom bei Immundysfunktion
Postvirales Müdigkeitssyndrom

For comparison:

Canadian Modification ICD-10-CA

(Version 2009 of ICD-10-CA/CCI replaces version 2006)

http://secure.cihi.ca/cihiweb/dispPage.jsp?cw_page=codingclass_e

Version 2009 ICD-10-CA Tabular List, Volume 1 PDF (4.9MB)
http://secure.cihi.ca/cihiweb/en/downloads/ICD-10-CA_Vol1_2009.pdf

Version 2009 ICD-10-CA Alphabetical Index, Volume 2 PDF (4.3MB)
http://secure.cihi.ca/cihiweb/en/downloads/ICD-10-CA_Vol2_2009.pdf

Chapter VI

Diseases of the nervous system
(G00-G99)

Other disorders of the nervous system
(G90-99)

[…]

G93 Other disorders of brain

[…]

G93.3 Postviral fatigue syndrome

Includes: Benign myalgic encephalomyelitis
Chronic fatigue syndrome

Excludes: fatigue syndrome NOS (F48.0)

For comparison with WHO ICD-10:

Current ICD-10 codings for the three terms are set out on my site, here, together with extracts from Chapter V (the “F” codes) and Chapter XVIII (the “R” codes):

https://dxrevisionwatch.wordpress.com/icd-11-me-cfs/

or go here for the full ICD-10 Volume 1: Tabular List

http://apps.who.int/classifications/apps/icd/icd10online/

ICD-10 Version for 2007 online
http://apps.who.int/classifications/apps/icd/icd10online/?gg90.htm+g933

Chapter VI

Diseases of the nervous system
(G00-G99)

Other disorders of the nervous system
(G90-99)

[…]

G93 Other disorders of brain

[…]

G93.3 Postviral fatigue syndrome
           Benign myalgic encephalomyelitis

Note that in ICD-10, Chronic fatigue syndrome is not included in Volume 1: The Tabular List, Chapter VI under the parent term:

             G93 Other Disorders of brain

but “Chronic fatigue syndrome” does appear in Volume 3: The Alphabetical Index, where it is indexed to G93.3.

In a forthcoming post, I shall be publishing important information about proposals for parent terms, classifications and codings in the ICD-11 Alpha Draft.

 

Related material:

ICD-9-CM

For information on the current codings in ICD-9-CM (US Clinical Modification) see the NAME U.S. page:  WHO ICD Codes section

American Psychiatric Association on DSM-5

In a 10 December Press Release, the American Psychiatric Association said:

“Extending the timeline [for DSM-5] will allow more time for public review, field trials and revisions”

and

“The extension will also permit the DSM-5 to better link with the U.S. implementation of the ICD-10-CM codes for all Medicare/Medicaid claims reporting, scheduled for October 1, 2013. Although ICD-10 was published by the WHO in 1990, the “Clinical Modification” version (ICD- 10-CM) authorized by the U.S. Centers for Medicare and Medicaid Services (CMS) and the Centers for Disease Control (CDC) is not being implemented in the U.S. until 23 years later.

“The ICD-10-CM includes disorder names, logical groupings of disorders and code numbers but not explicit diagnostic criteria. The APA has already worked with CMS and CDC to develop a common  structure for the currently in-use DSM-IV and the mental disorders section of the ICD- 10-CM.

“The International Classification of Diseases (ICD) is published by the WHO for all member countries to classify diseases and medical conditions for international health care, public health, and statistical use. The WHO plans to release its next version of the ICD, the ICD-11, in 2014.

“APA will continue to work with the WHO to harmonize the DSM-5 with the mental and behavioral disorders section of the ICD-11. Given the timing of the release of both DSM-5 and ICD-11 in relation to the ICD-10-CM, the APA will also work with the CDC and CMS to propose a structure for the U.S. ICD-10 CM that is reflective of the DSM-5 and ICD-11 harmonization efforts. This will be done prior to the time when the ICD-10-CM revisions are “frozen” for CMS and insurance companies to prepare for the October 1, 2013, adoption.”

Filed under American Psychiatric Association (APA), CFSAC meetings, Clinical Modification, DSM-5, DSM-V, ICD-10, ICD-10-CM, ICD-11, ICD-11 Alpha Draft, WHO (World Health Organization)

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