HHS Secretary Sebelius announces intent to delay ICD-10-CM compliance date

HHS Secretary Sebelius announces intent to delay ICD-10-CM compliance date

Post #142 Shortlink: http://wp.me/pKrrB-1Ux

Coverage today of the announcement by Health and Human Services (HHS) Secretary Kathleen G. Sebelius of intent to delay ICD-10-CM compliance date.

Will American Psychiatric Association Board of Trustees take this opportunity to delay its DSM-5 timeline, take a breathing space, and reconsider its controversial proposals for DSM-5, or submit them to independent scientific scrutiny?

Link to report at end of post also quotes Chris Chute, Chair, ICD-11 Revision Steering Group, on possible delay for completion of ICD-11 from 2015 to 2016 – no surprise that ICD Revision may be considering another shift of timeline given the technical ambitiousness of the revision project, the lack of resources and slipping targets for the Alpha and Beta drafts.

Tom Sullivan reports:

Should the U.S. delay the ICD-10 compliance deadline just one year, until 2014, then the WHO will have a beta of ICD-11 ready. And if Sisko’s gut is correct, and the new ICD-10 deadline flows into 2015, well, then a final version of ICD-11 will be fast-approaching.

When it arrives, currently slated for 2015 (but Chute said it could be 2016), the underlying structure of ICD-11 will be profoundly different than any anterior ICD.

“ICD-11 will be significantly more sophisticated, both from a computer science perspective and from a medical content and description perspective,” Chute explains. “Each rubric in ICD-11 will have a fairly rich information space and metadata around it. It will have an English language definition, it will have logical linkages with attributes to SNOMED, it will have applicable genomic information and underpinnings linked to HUGO, human genome standard representations.”

ICD-10, as a point of contrast, provides a title, a string, a number, inclusion terms and an index. No definitions. No linkages because it was created before the Internet, let alone the semantic web. No rich information space.”


HHS Secretary Kathleen Sebelius announces intent to delay ICD-10 compliance date

February 16, 2012 | Carl Natale, Editor, ICD10Watch

Health and Human Services (HHS) Secretary Kathleen G. Sebelius confirmed Wednesday that they will change the ICD-10 timeline.

A HHS press release stated they “will initiate the rulemaking process to postpone the date by which certain health care entities have to comply with International Classification of Diseases, 10th Edition diagnosis and procedure codes (ICD-10).”

On Tuesday, Marilyn Tavenner, the acting administrator of the Centers for Medicare and Medicaid Services (CMS), said the agency will examine the ICD-10-CM/PCS timeline. Tavenner made the statement at a conference of the American Medical Association (AMA) National Advocacy Conference. The AMA has declared vigorous opposition to the medical coding system citing the cost, complexity and lack of perceived benefit to patients… Read on


CMS Public Affairs Press Release:


News Release
Contact: CMS Public Affairs
(202) 690-6145

February 16, 2012

HHS announces intent to delay ICD-10 compliance date

As part of President Obama’s commitment to reducing regulatory burden, Health and Human Services Secretary Kathleen G. Sebelius today announced that HHS will initiate a process to postpone the date by which certain health care entities have to comply with International Classification of Diseases, 10th Edition diagnosis and procedure codes (ICD-10).

The final rule adopting ICD-10 as a standard was published in January 2009 and set a compliance date of October 1, 2013 – a delay of two years from the compliance date initially specified in the 2008 proposed rule. HHS will announce a new compliance date moving forward.

“ICD-10 codes are important to many positive improvements in our health care system,” said HHS Secretary Kathleen Sebelius. “We have heard from many in the provider community who have concerns about the administrative burdens they face in the years ahead. We are committing to work with the provider community to reexamine the pace at which HHS and the nation implement these important improvements to our health care system.”

ICD-10 codes provide more robust and specific data that will help improve patient care and enable the exchange of our health care data with that of the rest of the world that has long been using ICD-10. Entities covered under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) will be required to use the ICD-10 diagnostic and procedure codes.



Could the U.S skip ICD-10 and leapfrog directly to ICD-11?

February 16, 2012 | Tom Sullivan, Government Health IT

Practice Central on ICD-10-CM transition; APA Monitor and WHO Reed on ICD-11

Two articles on forthcoming classification systems: the first on ICD-10-CM from Practice Central; the second on ICD-11 from the February 2012 edition of the American Psychological Association’s “Monitor on Psychology”

Post #140 Shortlink: http://wp.me/pKrrB-1Tt

Update: Medicare could delay burdensome rules on doctors | Julian Pecquet, for The Hill, February 14, 2012

“The acting head of the Medicare agency said Tuesday that she is considering giving the nation’s doctors more time to switch to a new insurance coding system that critics say would cost millions of dollars for little gain to patients.

“Marilyn Tavenner, the acting administrator of the Centers for Medicare and Medicaid Services, told a conference of the American Medical Association (AMA) that her agency could delay adoption of the so-called ICD-10 system. Current law calls for physicians to adopt the new codes next year…

“…Speaking to reporters after her prepared remarks, Tavenner said her office would formally announce its intention to craft new regulations “within the next few days.”

ICD-10 Deadline Review Update | Andrea Kraynak, for HealthLeaders Media, February 15, 2012

“Big news regarding the ICD-10-CM/PCS implementation timeline came Tuesday morning during the American Medical Association (AMA) National Advocacy Conference in Washington, DC.”

“Per CMS acting administrator Marilyn Tavenner, CMS plans to revisit the current implementation deadline of October 1, 2013. Tavenner said CMS wants to reexamine the pace of implementing ICD-10 and reduce physicians’ administrative burden, according to an AMA tweet…”

Practice Central: Resources for Practicing Psychologists

Practice Central, a service of the APA Practice Organization (APAPO), supports practicing psychologists in all settings and at all stages of their career. APAPO is a companion organization to the American Psychological Association. Our mission is to advance and protect your ability to practice psychology.


Practice Update | February 2012

Transition to the ICD-10-CM: What does it mean for psychologists?

Psychologists should be aware of and prepare for the mandatory shift to ICD-10-CM diagnosis codes in October 2013

By Practice Research and Policy staff

February 9, 2012—Beginning October 1, 2013 all entities, including health care providers, covered by the Health Insurance Portability and Accountability Act (HIPAA) must convert to using the ICD-10-CM diagnosis code sets. The mandate represents a fundamental shift for many psychologists and other mental health professionals who are far more attuned to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM).

Most psychologists were trained using some version of DSM. For other health care providers, the World Health Organization’s International Classification of Diseases and Related Health Problems (ICD) – which contains a chapter on mental disorders – is the classification standard.

Over the years, efforts to harmonize these two classifications have resulted in systems with similar (often identical) codes and diagnostic names. In fact, even if psychologists record DSM diagnostic codes for billing purposes, payers recognize the codes as ICD-9-CM – the official version of ICD currently used in the United States. Since 2003, the ICD-9-CM diagnostic codes have been mandated for third-party billing and reporting by HIPAA for all…

Read full article here


Dr Geoffrey M. Reed, PhD, Senior Project Officer, WHO Department of Mental Health and Substance Abuse, is seconded to WHO through IUPsyS (International Union for Psychological Science). Dr Reed co-ordinates the International Advisory Group for the Revision of ICD-10 Mental and Behavioural Disorders.

Meetings of the International Advisory Group are chaired by Steven Hyman, MD, Harvard University, Cambridge, MA, a former Director of the National Institute of Mental Health (NIMH) and DSM-5 Task Force Member.

The Department of Mental Health and Substance Abuse will also be managing the technical part of the revision of Diseases of the Nervous System (currently Chapter VI), as it is doing for Chapter V.

February 2012 edition of the American Psychological Association’s “Monitor on Psychology”:



Improving disorder classification, worldwide

With the help of psychologists, the next version of the International Classification of Diseases will have a more behavioral perspective.

By Rebecca A. Clay

February 2012, Vol 43, No. 2

Print version: page 40

What’s the world’s most widely used classification system for mental disorders? If you guessed the Diagnostic and Statistical Manual of Mental Disorders (DSM), you would be wrong.

According to a study of nearly 5,000 psychiatrists in 44 countries sponsored by the World Health Organization (WHO) and the World Psychiatric Association, more than 70 percent of the world’s psychiatrists use WHO’s International Classification of Diseases (ICD) most in day-to-day practice while just 23 percent turn to the DSM. The same pattern is found among psychologists globally, according to preliminary results from a similar survey of international psychologists conducted by WHO and the International Union of Psychological Science.

“The ICD is the global standard for health information,” says psychologist Geoffrey M. Reed, PhD, senior project officer in WHO’s Department of Mental Health and Substance Abuse. “It’s developed as a tool for the public good; it’s not the property of a particular profession or particular professional organization.”

Now WHO is revising the ICD, with the ICD-11 due to be approved in 2015. With unprecedented input from psychologists, the revised version’s section on mental and behavioral disorders is expected to be more psychologist-friendly than ever—something that’s especially welcome given concerns being raised about the DSM’s own ongoing revision process. (See “Protesting proposed changes to the DSM” .) And coming changes in the United States will mean that psychologists will soon need to get as familiar with the ICD as their colleagues around the world…

Read full article here

For more information about the ICD revision, visit the World Health Organization.

Rebecca A. Clay is a writer in Washington, D.C

ICD Revision Process Alpha Evaluation Meeting 11-14 April: The Way Forward?

ICD Revision Process Alpha Evaluation Meeting 11 – 14 April 2011: The Way Forward?

Post #70 Shortlink: http://wp.me/pKrrB-ZN

The information in this mailing relates only to ICD-11, the revision of ICD-10 scheduled for completion and pilot implementation in 2014/15. It does not apply to the forthcoming US specific “Clinical Modification” of ICD-10, known as ICD-10-CM.

The Way Forward?

ICD-11 Revision maintains a website on a Google platform where key documents, agendas for iCAMP and workgroup meetings, background documents and presentations can be viewed and downloaded. Minutes or summaries of meetings aren’t usually posted publicly:

ICD-11 Revision: http://sites.google.com/site/icd11revision/home

An ICD Revision Process Alpha Evaluation Meeting was held in Geneva, last week, between 11-14 April, for discussing the status of the revision of ICD-10 and development of ICD-11, for both content and software development, and reviewing the ICD revision “Roadmap” and Timeline.

A copy of the Meeting Agenda can be downloaded from the ICD-11 Revision site here or opened on DSM-5 and ICD-11 Watch site here: ICD11 April 11 Meeting Agenda. There are some interesting comments in the Agenda Appendix on project funding, lack of resources, project management and lines of communication.

There are five PowerPoint presentations available to download from this page.

If you are interested in the ICD Revision process, in general, then I suggest visiting the site and viewing or downloading the following three presentations – these are slides only, with no notes or transcripts.

(The 2007 MS PowerPoint viewer is required to view presentations that have been created in .pptx format. A .pptx viewer can be downloaded free from the Microsoft site.)

.ppt file: The Way Forward

.pptx file: Can Celik’s Presentation: Public Tooling

.pptx file: Stanford’s Presentation: iCAT Beta

These three presentations can also be opened in the next post on DSM-5 and ICD-11 Watch site and selected slides have been posted here:

Post #71: ICD Revision Process Alpha Evaluation Meeting documents and presentations


“Community engagement”

In mid 2009, ICD Revision launched a number of platforms as channels of communication with the public and maintains a YouTube Channel, Facebook site, Twitter and blog. The ICD-11 blog has not been updated since October 2009 and queries left on the Facebook site by members of the public may take several months before a response is provided or may receive no response, at all.

The YouTube videos made to accompany various Geneva meetings can also be accessed on the ICD Revision YouTube page of my site. The two most recent videos give an overview of the iCAT drafting process and the extent of the ICD-11 “Content Model” – the 13 parameters through which ICD-11 categories can be described.


Visibility of iCAT drafting platforms

Following last week’s ICD Revision Process Alpha Evaluation Meeting, it is anticipated that ICD Revision may make a public announcement, within the next few weeks, clarifying how it intends to proceed in light of the fact that the timeline for the Beta drafting phase is slipping.

The meeting Agenda and PowerPoint slides suggest that ICD Revision is working towards making a version of the drafting platform publicly available around 16 May, this year, but that this may represent a compromise on previous plans and may be a “hybrid” between the Alpha and Beta drafting phases.

From the Agenda:

“Future Phases:

a. iCAT continued alpha development and evaluation ( 2010-11)

b. iCAT beta phase ( 2012-2015)

c. iCAT continuous maintenance phase ( 2015+)”

Earlier timelines had projected endorsement by the World Health Assembly (WHA) and pilot implementation of ICD-11 in the spring of 2014. But one presentation slide suggests approval by WHA in 2015.

It’s unconfirmed, but if the “Milestones” timeline has been revised to accommodate a later release of a Beta drafting phase platform and later publication of a Beta Draft, then WHO may have already decided to shift the pilot implementation date for ICD-11 by 12 months, to 2015.

That would mean that by the time ICD-11 is ready for dissemination, the American Psychiatric Association’s DSM-5 would have already been put to bed and out in print two years prior to ICD-11 implementation.

It is intended that for ICD-11, all three volumes will be electronically published and capable of continuous updating in response to scientific developments (unlike ICD-10 where there are annual updates); there will also be electronic translations and print editions. The three volumes of ICD-11 are intended to be integrable with each other and also with some other classification systems. 

The drafting platforms are based on Web 2.0 applications and it is proposed that there will be stakeholder and end user participation in the Beta drafting phase.

The IT work and software development for the various alpha and beta drafting platforms and final product platforms is enormously complex; there is also the potential for far more textual content in ICD-11 than there was in ICD-10 and overall, this revision project represents a huge undertaking by an under-resourced organization.


The ICD-11 Alpha/Beta drafting process

Topic Advisory Group (TAG) Managing Editors overseeing the revision of the various chapters of ICD-10 have responsibility for recruiting external experts, via networking. The function of the external experts is to peer review proposals being made by TAG members or submitted by external professional bodies and institutions and to review or assist with the generation of textual content.

[In late 2009, I approached the WHO’s Dr Robert Jakob to enquire whether and at what stage the names of external peer reviewers would be identified in the drafting platforms, as visible to the public. I also asked whether the reviewing of proposals as they progressed through the Workflow review system would be a transparent process that could be monitored by the public. Neither query produced a response from Dr Jakob.]

So there are many lines of communication to be maintained between WHO classification experts, IT consultants and technicians, Revision Steering Group members, TAG Managing Editors, TAG members and external experts. There is an ICD-11 Collaborative Authoring Workflow chart here: workflow-2.

At the Beta drafting stage, the proposal is that TAG Managing Editors will continue to recruit external peer reviewers to assist workgoups with reviewing of categories, proposals and generation of content, but that versions of the Beta drafting platform would be opened up to the public for viewing, and interested stakeholders would be able to register for limited input and interaction.

Stakeholders (or preferably, communities of stakeholders) would not have editing rights, per se, but the proposal is that they would comment on proposals, “score” proposals and make evidence-based suggestions which the TAG groups would then consider for approval, which would then be incorporated into the draft or rejected.  There has also been discussion of a “hierarchy” of levels of input according to professional status of stakeholders. How ICD Revision plans to verify the credentials of professionals isn’t clear, nor is it defined what would consitute a stakeholder “community”.

No static Beta Draft for public review and comment

Rather than release a static Beta draft for professional and public scrutiny in a feedback exercise for a pre-determined review period (as DSM-5 has already done and is scheduled to do again in August-September), the proposal appears to be for longer term feedback during an alpha/beta transition drafting phase on dynamic content that would be continuously updated, for example, on a four weekly cycle, to reflect the progress being made by the various Topic Advisory Groups in entering proposals for changes and populatation of textual content, and in response to external input.

So managing editors and members of the Topic Advisory Groups (mostly international clinicians and researchers juggling this work on top of their “day jobs”) are faced with maintaining lines of communication, largely via electronic means, between workgroup chairs, fellow workgroup members, external peer reviewers and WHO classification experts whilst also considering input from professional bodies, and working in the background on the drafting platform, while stakeholders are commenting and feeding suggestions into the process via the public versions of the drafting platforms. 

[Some organizations and professional bodies have been compiling and submitting proposals via an ICD Revision Proposal Form, since late 2009. There is no publicly available list of which institutions and bodies have been invited to submit proposals, which have responded, or where their submissions for changes to ICD-10 can be scrutinised, but copies of these submissions occasionally turn up online, having been published in the organs of these organizations.]

Selected slides from “Proposal for the ICD Beta Platform, Stanford team”:

Slide 11

Slide 12

Slide 42

Slide 43

Slide 45

Slide 46


“…who will do all this work?”

Presentations and video clips of the WHO’s Dr. Bedirhan Üstün suggest a man buzzed up on information and internet technology: “cloud sourcing”, portals, public commenting and “scoring” of proposals, wikis, blogs,  internal and public “user communities”, drawing in the involvement of “Wikipedians” and other existing “editing communities” (one questions whether Dr Üstün has any experience of how Wikipedia functions and the problems inherent with some Wikipedia admins and editors, particularly in relation to editing of controversial scientific and medical areas), message boards, Facebook integration, “community engagement”…

But as the closing slide of one of last week’s presentations ruefully comments, “And just a small detail: who will do all this work?” [6]

ICD Revision and its IT and informatics advisors seem eager to use these internet applications because they exist, without having given due consideration to whether the WHO can fund, manage and sustain this level of public participation and interaction or whether this is the best way to approach the revision of the ICD.

How does ICD Revision intend to finance and recruit the personnel needed to manage the opening up of the drafting process to multiple platforms for stakeholder participation, given WHO’s limited resources when already, no-one can evidently be spared to even keep the ICD-11 blog updated or to respond to queries that members of the public have posted on ICD Revision’s existing public platforms and where Topic Advisory Group Chairs approached for brief clarifications are not always providing a response nine months down the line?

Who is going to pull this most ambitious project back down to earth?

Insufficient funding allocated and no Project Manager

From the Appendix to the April meeting Agenda:

“TAGs were supposed to be self-financed.  The TAG chair was supposed to have funding to carry out their revision work.”

“As this is a core WHO activity, we should have regular budget funds for this project.  The scale of this project is too big not to have funding for a project manager.”

“Additionally, ALL relevant WHO departments should have designated some financial and some human resources to this project as part of the collaborative effort.”

“…communication between the TAGs is growing, and it is beginning to become overwhelming in addition to clinical responsibilities.”


ICD-11 proposals for PVFS, ME and Chronic fatigue syndrome

Until some form of Alpha/Beta transition drafting platform is back in the public domain, it won’t be evident how much further forward the population of content for Chapter 6 Diseases of the nervous system has progressed since last November. As more information becomes available, I will update, and I will be posting a summary of how things stood in the iCAT last November in Post #72.

The meeting Agenda, selected slides and three of the PowerPoint presentations can be viewed/opened from Post #71, on DSM-5 and ICD-11 Watch site, here:

ICD Revision Process Alpha Evaluation Meeting documents and presentations


Key documents and related posts:

1] ICD Revision Process Alpha Evaluation Meeting Agenda and background documents

2] Report, WHO FIC Council conference call, 16 February 2011, PDF format

3] Key document: ICD Revision Project Plan version 2.1 9 July 2010

4] Key document: Content Model Reference Guide version January 2011

5] PVFS, ME, CFS: the ICD-11 Alpha Draft and iCAT Collaborative Authoring Platform (DSM-5 and ICD-11 Watch report with screenshots from the iCAT): http://wp.me/pKrrB-KK

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

ICD-11 Content Model Reference Guide: version for December 2010

ICD-11 Content Model Reference Guide: version for December 2010

Post #62 Shortlink: http://wp.me/pKrrB-Xj

Update @ 1 March 2011

A more recent version of the Content Model document was uploaded to the ICD Revision site on 22 February.

It can be accessed here on the ICD Revision site:

View Word document

Download Word document

Or opened here on DSM-5 and ICD-11 Watch site: Content Model Reference Guide v January 2011

A revised version of the ICD-11 Content Model Reference Guide was uploaded to the WHO’s ICD Revision Google site in January.  This version of the document, dated 27 January 2011, replaces previous versions on DSM-5 and ICD-11 Watch site and on the ICD Revision Google site.

Content Model Reference Guide December 2010 v.1  27 Jan 2011

A copy of this 57 page document can be viewed on the ICD Revision Google site from this page:


View Word document

Download Word document

or open here on DSM-5 and ICD-11 Watch site: Content Model Reference Guide December 2010 [v.1]


Introductory pages

ICD-11 alpha

World Health Organization, Geneva

Content Model Reference Guide 11th Revision

December 2010

Table of Contents

Page 2

Introduction 3
What is the “Content Model”? 4
Explanations on the Content Model 5
Technical Specifications for the Content Model 7
ICD -11 Alpha Content Model 9

1. ICD Entity Title 9

2. Classification Properties 11

3. Textual Definition(s) 17

4. Terms 21

5. Body Structure Description 24

6. Temporal Properties 27

7. Severity Properties 31

8. Manifestation Properties 33

9. Causal Properties 35

10. Functioning Properties 38

11. Specific Condition Properties 42

12. Treatment Properties 44

13. Diagnostic Criteria 45

Section B 46

Appendices 48
Appendix 1: Body Systems Value Set 48
Appendix 2: Temporal Properties Value Set 49
Appendix 3: Temporal Properties Value Set and explanations 50
Appendix 4: Basic Aetiology Value Set 56
Appendix 5: Grammar Rules for Titles and Synonyms 57

Page 3

Reference Guide on the Content Model of the ICD 11α


This Reference Guide is intended to define and explain the Content Model used in the ICD-11 alpha draft in practical terms. It aims to guide users to understand the purposes and parameters of the Content Model.

The Reference Guide also informs users about the technical specifications of each parameter which the designers of the iCAT (the computer platform that is used to fill in the content model: international Collaborative Authoring Tool) took into account in building the software.

Accordingly, information on each parameter is given in two sections:

(1) Explanations
(2) Technical specifications

The purpose of this Reference Guide is to ensure that the Content Model and its different parameters are properly understood.

This document will be periodically updated in response to user needs and evolution of the content model.

Brief introduction to the ICD – International Classification of Diseases

The International Classification of Diseases (ICD) is the global standard to report and categorize diseases in order to compile health information related to deaths, illness and injury. The ICD content includes diseases and a range of health problems including disorders, syndromes, signs, symptoms, abnormal findings, complaints, social circumstances, and external causes of injury. The ICD is designed to promote international comparability in the collection, processing, classification, and presentation of these statistics.

In ICD there are multiple classification categories which are defined by explicit or implicit parameters such as: codes, titles, definitions and other characteristics. In ICD 11, we aim to formally represent all this classification knowledge in a systematic way. The Content Model serves this purpose.

Page 4

What is the “Content Model”?

The Content Model is a structured framework that defines “a classification unit” in ICD in a standard way in terms of its components that allows computerization.

A “model” is a technical term that refers to a systematic representation of knowledge that underpins any system or structure. Hence, the content model is an organized description of an ICD unit with its different parameters.

In the past, ICD did not explicitly define its “classification units” – in other words diseases were classified without defining “what is a disease?” (There have been efforts to provide some definitions, inclusions, exclusion information, and some coding rules in the instructions and in the index. Some chapters, such as mental health, oncology, or other groups of diseases have been elaborated with diagnostic criteria. All these efforts may be seen as implicit modelling.) In the ICD 11 revision process, deliberate action is being taken to define the ICD categories in a systematic way and represent the classification knowledge to allow processing within computer systems.

To achieve this aim, different ICD categories have been defined by user groups as to what they are. For example, first a disease was defined as follows:

A disease is a set of dysfunction(s) in any of the body systems defined by:

1. Symptomatology: manifestations: known pattern of signs, symptoms and related findings
2. Aetiology: an underlying explanatory mechanism
3. Course and outcome: a distinct pattern of development over time
4. Treatment response: a known pattern of response to interventions
5. Linkage to genetic factors: e.g., genotypes, patterns of gene expression
6. Linkage to interacting environmental factors

Then the key components of this definition have been operationally defined as different parameters which, as a whole, formed the Content Model.

Page 5

Explanations on the Content Model:

A classification unit in ICD is called an “ICD entity”. In other words, any distinct classification rubric is called an Entity. (The term “Entity” is used interchangeably – in the same meaning — with the term “ICD Concept”.

An ICD entity may be:

– A category
– A block
– A chapter

A category (which is the most common reference to an ICD class) may be a disease, disorder or syndrome; sign, symptom or other health problem such as injuries, or a combination of the above. In addition, ICD has also been used to classify “external causes” or “other reasons for encounter” which are different kinds of entities than the diseases. In other words, “Category” refers to the individual classes represented in the ICD-10 printed version.

The Content Model, therefore, allows the various classification categories to be represented more clearly so that users can identify the classification units in a scientific fashion.

The purpose of the content model is to present the knowledge that lies under the definition of an ICD entity. Each ICD entity can be seen from different dimensions. The content model represents each one of these dimensions as a “parameter”. For example, there are currently 13 defined main parameters in the content model to describe a category in ICD.

TABLE 1: The Content Model main parameters

For each category, various parameters are given different values. For example:

Category: Myocardial Infarction

Parameters:                       Value:
Body system                         Cardiovascular system
Body part                              Heart
Signs/symptoms                   Crushing chest pain, etc.
Investigation Findings           ST elevation in ECG

It is not necessary to describe all categories with all parameters. Only parameters that are relevant to the description of the category should be used. In certain instances such as External Causes, only a number of the parameters are valid for the description of these entities.

The full range of different values for a given parameter is predefined using standard terminologies and ontologies. The predefined values constitute a “value set”.

Read full document here: Content Model Reference Guide December 2010 [v.1]


Related documents:



A Content Model for the ICD-11 Revision

Samson W. Tu1, Olivier Bodenreider2, Can Çelik3, Christopher G. Chute4, Sam Heard5, Robert Jakob3, Guoquian Jiang4, Sukil Kim6, Eric Miller7, Mark M. Musen1, Jun Nakaya8, Jon Patrick9, Alan Rector10, Guillermo Reynoso11, Jean Marie Rodrigues12, Harold Solbrig4, Kent A Spackman13, Tania Tudorache1, Stefanie Weber14, Tevfik Bedirhan Üstün3

1Stanford Univ., Stanford, CA, USA; 2National Library of Medicine, Bethesda, MD, USA; 3World Health Organization, Geneva, Switzerland; 4Mayo Clinic College of Medicine, Rochester, MN, USA; 5Ocean Informatics, Chatswood, NSW, Australia; 6Catholic Univ. of Korea, Korea; 7Zepheira, Fredricksburg, VA, USA; 8Tokyo Medical and Dental Univ., Tokyo, Japan; 9Univ. of Sydney, Sydney, NSW, Australia; 10Univ. of Manchester, Manchester, UK; 11Buenos Aires, Argentina;12Université de Saint Etienne, Saint Priest en Jarez, France; 13IHTSDO, USA; 14DIMDI – German Institute of Medical Documentation and Information, Köln, Germany


The 11th revision of the International Classification of Diseases and Related Health Problems (ICD) will be developed as a collaborative effort supported by Webbased software. A key to this effort is the content model designed to support detailed description of the clinical characteristics of each category, clear relationships to other terminologies and classifications, especially SNOMED-CT, multi-lingual development, and sufficient content so that the adaptations for alternative uses cases for the ICD – particularly the standard backwards compatible hierarchical form – can be generated automatically. The content model forms the basis of an information infrastructure and of a webbased authoring tool for clinical and classification experts to create and curate the content of the new revision.

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

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

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

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

Medical Care

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


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]:


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:



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):


Other disorders of the nervous system



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

iCamp2 meeting and status of ICD-11 Alpha Draft

ICD Revision iCamp2 meeting, new documents and status of the ICD-11 Alpha Draft

Post #48 Shortlink: http://wp.me/pKrrB-O9

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

iCamp2: 27 September – 1 October 2010


The iCamp2 meeting, scheduled for April but postponed due to volcanic ash cloud disruption of air traffic, was held between 27 September – 1 October, in Geneva.

27 September – 1 October 2010 Geneva, Switzerland WHO Headquarters   

RSG 2010 [Revision Steering Group]
30 September – 1 October 2010 Geneva, Switzerland WHO Headquarters  

The revised Agenda for the meeting can be read here in html on the ICD Revision site.

Download here as a Word document from the ICD Revision site or open here iCamp2 Agenda September 2010 on DSM-5 and ICD-11 Watch site.

I will post a link for the minutes, summary or note of this meeting when these are available on the ICD Revision site.

Click here for a list and bios of Meeting Participants

ICD-11 iCamp2 on YouTube 

ICD-11 ICAMP2 Day 5

WHOICD11’s Channel  | 21  October 2010  |  9.53 mins

iCAMP2 Day 2

WHOICD11’s Channel  | 29 September 2010  |  7:32 mins


Status and format of the ICD-11 Alpha Draft

Slipping timeline

In his iCamp2 Introductory presentation, Dr Bedirhan Üstün says there are just seven months to go before the start of the ICD-11 beta drafting phase and 43 months to the final version. Beta drafting remains scheduled to begin in May 2011, even though targets for the drafting of content are slipping and an Alpha Draft has yet to be published.

The Beta Requirements Document says, “The Beta Phase will be open to [the] general public in May 2011 to enable structured input by interested parties subject to peer-review by relevant Technical Advisory Groups” and that the time until May 2011 “will be used to develop and test the Beta Draft software and procedures and make consultations with end users around key issues and basic questions.”

iCamp2 acknowledged that a considerable amount of work needs to be done in the interim if ICD Revision is going to meet its targets.

No detailed timeline for the development of ICD-11 is available on the WHO’s main website. But in March, an ICD Revision Project Plan document, published on the ICD Revision Google site, had projected an Alpha Draft release date of May 2010, with a Beta Draft ready by May 2012. [Source: Page 7, “Project milestones and budget, and organizational overview”.]

A press launch for the Alpha Draft had been tabled for discussion on the Agenda for the April iCamp2 meeting. In the event, the April meeting was postponed, but ICD Revision has issued no public explanation for why the anticipated Alpha Draft failed to be released in April/May, nor has the Steering Group issued a revised ETA.

From the ICD Revision Project Plan:

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. 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.

According to sources, in July, a print version of the Alpha Draft was expected to be made available around the time that the rescheduled iCamp2 meeting took place in September. Requests for clarification of the status and accessibility of an alpha draft have been left on ICD Revision Facebook site by several members of the public. When a response was eventually forthcoming, in August, it was confirmed that a “draft print version will be available in September 2010”.

iCamp2 is over now, but it remains unclear whether a print version has been produced, whether it is intended for internal use only or is going to be made available for public scrutiny, and if so, when, and in what format(s). ICD Revision has been asked to clarify.

This slide from a DSPIM presentation says the Alpha Draft was scheduled for completion by 27 September:

Source: Slide 9, PDF presentation slides: ICD-11 Revision: where are we now? Ontology driven tools and web platform. JM Rodrigues et al, DSPIM, University of Saint Etienne, WHO Collaborating Centre for International Classifications in French Language, Paris.


The WHO is promoting the development of ICD-11 as a transparent, collaborative and inclusive process

The Revision Steering Group (RSG) has launched a number of public interfaces – the ICD-11 Revision site (meeting agendas, minutes, documents and presentations), a YouTube channel, a blog (not updated since October 2009), a Facebook site, Twitter and an iCAT users Google Group, open to any stakeholders who register for access.  The iCAT Web 2.0 drafting platform is also viewable by the public and the production server can be accessed here: http://icat.stanford.edu/.

But little consideration appears to have been given to who should take responsibility for responding to questions from stakeholders or fielding queries left on the ICD Revision Facebook site, which rarely receive a reasonably prompt response, or any response, at all.

WHO Secretariat do not always acknowledge or respond to enquiries. A request for clarifications from a Topic Advisory Group (TAG) Chair, whilst acknowledged, has received no response after three months. The 5th meeting of the International Advisory Group for the Revision of ICD-10 Mental and Behavioural Disorders (currently ICD-10 Chapter V) was held on 28 – 29 September 2009. A year later, a Summary Report is still pending publication and no meeting summaries for TAG Mental Health have been published on the WHO website since the 4th Meeting 1 – 2 December 2008.

The WHO needs to decide whether, in launching public interfaces and using “social networking” for input and feedback from stakeholders it genuinely seeks to provide platforms for meaningful interaction with the public or whether these are tokenistic nods at “transparency”.

Content posted by ICD Revision admin on its Facebook Wall often lacks meaning and substance. What stakeholders really need to know is whether any form of alpha draft is going to be publicly released before the Beta phase – not photos of happy iCampers playing bassoons at musical soirées and iCamp bonding sessions.

I will update if and when any information is released on the status and public availability of an alpha draft, and what format(s) it will be available in.


Since 2007, it has been possible for stakeholders in the development of ICD to submit proposals and comments, supported by citations, via the ICD Update and Revision Platform Intranet. It was understood, last September, that for some Topic Advisory Groups (notably Chapters 5 and 6) 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 might be permitted to make use of any proposal forms already being issued or in preparation would also be welcomed from the Revision Steering Group or TAG managing editors.

Slipping targets

According to the iCamp2 PowerPoint presentation, Frequent Criticisms and this iCamp2 YouTube, targets for the population of content for the Alpha Draft have not been reached.

Less that 80% of Terminology Definitions have been uploaded to the iCAT and less than the 20% target for full Content Model completion for the many thousands of diseases and disorders classified within ICD has been met. [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 parameters of the Content Model are implemented yet. Not all Topic Advisory Groups are at a similar developmental stage; Beta Plans are behind schedule.

The Revision Steering Group identifies barriers to keeping this technically very ambitious project on track:  lack of finances; the sheer amount of time required for the drafting of definitions and population of textual content according to the complex ICD-11 Content Model; recruiting external experts for reviewing proposals and generating content; familiarising TAG workgroup members with the functionality of the iCAT, the collaborative authoring platform through which ICD-11 is being drafted, and with informatics; entering data into the iCAT; the paucity of face-to-face meetings for TAG managing editors and workgroup members who are scattered across the globe and undertaking these roles in addition to professional commitments; difficulties facilitating interaction between the various Topic Advisory Groups where diseases overlap with other chapters.

A number of new workgroups have recently been created (Paediatrics, Dentistry, E.N.T, Traditional Medicine and Communicable/Tropical Diseases).

Under “Overall Directions” in the Beta Requirements Document, it says:

The knowledge representation space is too large to be curated by a small number of experts (e.g. 20,000 ICD Categories, 15 parameters of CM [Content Model], each may have 1-20 entries – on average a relational database matrix with 300,000 entries).


Scaling up the process from the alpha phase to beta should be carefully planned and modelled. It is estimated that the alpha phase participants will be at the magnitude of 500-1000 persons. In beta phase it is expected to have 10-100 fold increase.

If the Revision Steering Group is already struggling to maintain motivation and interaction between the various Topic Advisory Groups, then management of the project once the beta phase is reached and the process opened up to stakeholders is going to present the Steering Group and TAG workgroup managing editors with considerable challenges.

The original dissemination date for ICD-11 had been 2012, with the timelines for the revision of ICD-10 and DSM-IV running more or less in parallel. The dissemination date for ICD-11 was later extended to 2014 and the publication date of the next edition of the DSM, DSM-5, extended to May 2013.

(John Gever, Senior Editor, MedPage Today, reported on 5 October that Testing of new diagnostic criteria proposed for DSM-5, the revision of the psychiatric profession’s manual for patient assessment, is finally underway, more than two months behind schedule.)

The development of ICD-11 is a hugely complex and technically ambitious undertaking; all three volumes will be electronically published, integrable and intended to be integrable with some other health classification publications; the scope of ICD-11 is far greater than that of the previous edition.

It may be that come May 2011, we might anticipate some scaling back of plans and/or possibly a shift in the release of the Beta Draft from May 2012 to 2013+, in response to the recognition that the WHO may have significantly overestimated its capacity for securing the funding and resources to complete the technical work on this project by 2012, if implementation of the final version is to take place in 2014.

The iCamp YouTube commentaries have an air of brittle optimism about them.

Coming up

In a forthcoming post, in lieu of an Alpha Draft, I shall be reporting on what can currently be seen in the ICD-11 iCAT drafting platform and associated Revision documents in relation to the three ICD-10 categories: “Postviral fatigue syndrome”, “Chronic fatigue syndrome” and “(Benign) myalgic encephalomyelitis” and why I have asked the Chair of the Topic Advisory Group for Neurology for a clarification.

iCamp2 meeting documents  and presentations

A number of new and existing ICD revision related documents have been published on the ICD-11 Revision Google site in association with the iCamp2 and RSG September meetings. Not all the documents listed have been uploaded to the ICD Revision site and several links are returning “File not found”.

Face-to-Face Meetings‎ > ‎iCamp2: 27 September – 1 October 2010‎

iCamp2 Agenda  [27 September – 1 October 2010]

Workflow  [PDF]

iCAT Progress Table  [Not currently available]
Alpha Draft Print Sample  [Not currently available]
iCAT Tool Documents  [Not currently available]

• User Manual  [Content Model User Guide, 53 pp Word doc]  Key ICD-11 document
• Issues and Feature Lists  [Not currently available]

Tasks Completed  [Not currently available]
Tasks In Progress/Pending  [iCAT Release Notes on iCAT Google Group platform]

Narrative Workflow Diagram  [Not currently available]

Standard Operating Procedures  [Not currently available]

Beta Requirements Document   [3 pp Word doc]


TAG HIM  [Not currently available]
RSG  [Not currently available]
TAGs  [Not currently available]

3 Component Content Model Description   [File not found]

• Linearization Component  [File not found]
• Foundation Component  [File not found]
• Ontology Component  [1 slide pptx + notes; PowerPoint slides require MS PP 2007 pptx reader]

Evaluation Strategy for Alpha Draft

Questions for Reviewers  [Not currently available]
Quality Assurance  [Not currently available]

Dagger-Asterisk Convention Abolition  [Not currently available]

DIFF File–Changes from ICD-10  [MS Excel doc. Retrieved 29.09.10; Not available on 01.10.10]

Field “A Type” specifies: new; unchanged; decision to be made; retired; real retired

[Note: ICD11 Alpha Codes may be temporary sorting codes; “FXC” against “G93.3” does not relate to the F Codes in ICD Chapter 5 (V); note also that Gj92 is an ICD-11 “Sorting label” not an ICD code.]

Extract Spreadsheet:


Frequent Criticisms   [11 slide pptx; PowerPoint slides require MS PP 2007 pptx reader]

Signs and Symptoms   [4 pp Word doc; Discussion document: Considerations for handling categories and concepts currently found in chapter 18 of ICD-10, “SYMPTOMS, SIGNS AND ABNORMAL CLINICAL AND
LABORATORY FINDINGS NOT ELSEWHERE CLASSIFIED”, (R-codes), authors: Aymé, Chalmers, Chute, Jakob.] Or open here: Discussion: Signs and Symptoms (Chapter 18)

PDF: https://dxrevisionwatch.files.wordpress.com/2018/08/icd-revision-signs-and-symptoms-discussion-document.pdf

Multisystem Chapter   [12 pp Word doc; Discussion document: Multisystem Chapter, authors: Aymé, Chalmers, Chute, Jakob.] Or open here: Discussion: Multisystem Chapter

PDF: https://dxrevisionwatch.files.wordpress.com/2018/08/icd-revision-multisystem-diseases-discussion-document.pdf

“ICD has traditionally grouped diseases by aetiology and by affected organ system.  For ICD­11 the creation of a new chapter for multisystem disorders has been proposed.  The following text sets out the rationale for and the possible scope of a multisystem disorders chapter.”

Contains Literature search reference at 119 to the Maes and Twisk paper, Treatment of myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), a multisystem disease, should target the pathophysiological aberrations (inflammatory and oxidative and nitrosative stress pathways), not the psychosocial “barriers” for a new equilibrium. 2010: Ireland. p. 148-9.

Contains Literature search reference at 118 to published response to Maes and Twisk paper by Luyten, P. and B. Van Houdenhove, Treatment of myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), a multisystem disease, should target the pathophysiological aberrations (inflammatory and oxidative and nitrosative stress pathways), not the psychosocial “barriers” for a new equilibrium – Response to Maes and Twisk. 2010, ELSEVIER IRELAND LTD, ELSEVIER HOUSE, BROOKVALE PLAZA, EAST PARK SHANNON, CO, CLARE, 00000, IRELAND. p. 147-147.

Presentations  [PowerPoint slides require the MS PP 2007 pptx reader unless identified as ppt]

Introduction (USTUN)  [14 slides]

Volume 1 (JAKOB)  [26 slides]

Volume 2 (JAKOB)  [11 slides]

Volume 3 (CELIK)  [6 slides + notes]

iCAT (TUDORACHE)  [26 slides PDF; iCAT Progress Update, Stanford Center for Biomedical Informatics Research]

iCAT & TAG Statistics (COTTLER)  [10 slides; New, Retired and Unchanged ICD Concepts (statistics)]

Rare Diseases (RATH)  [19 slides; Rare Diseases TAG feedback on ICD revision]

Dermatology (CHALMERS/WEICHENTHAL)  [ppt; 15 slides]

Ophthalmology (COLENBRANDER/KASHII)  [ppt; 3 slides]

Internal Medicine (SUGANO)  [10 slides]

Paediatrics (LINZER)  [ppt; 4 slides; Newly created TAG]

Musculoskeletal (SUNDBERG)  [ppt; 7 slides]

External Causes and Injuries  (HARRISON)  [ppt; 11 slides]

Maternal, Neonatal and Urogenital  (CHOU)  [ppt; File will not open at 01.10.10]

Socio-Technical Systems (STOREY)  [pptx; 31 slides]


TAG Neoplasms  [ppt; 105 slides]

Functioning TAG  [ppt; 21 slides]

TAG Morbidity  [ppt; 5 slides]

Additional documents  [All PDFs]

Ophthalmology TAG DRAFT
Pre001.2 Dermatology TAG
Rare Diseases Chapter 3 Haematological diseases DRAFT 2
Rare Diseases Chapter 3 Immunological Diseases DRAFT
Rare Diseases Chapter 4 Endocrine Diseases DRAFT
Rare Diseases Chapter 4 Metabolic Diseases DRAFT

Rare Diseases Chapter 4 Nutritional Diseases DRAFT
Rare Diseases Chapter 6 Neurological Diseases DRAFT



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

[2] User Manual [Content Model User Guide, 53 pp Word doc]  Key ICD-11 document
Identifies the basic properties needed to define any ICD concept (unit, entity or category) through the use of multiple parameters. Open here on DSM-5 and ICD-11 Watch: User Manual 20.09.10

[3] iCAT production server:
iCAT production server: http://icat.stanford.edu/

[4] iCAT Glossary

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