World Health Assembly adopts ICD-11: When will member states start using the new edition?

Post #354 Shortlink:

On May 25, 2019, the 72nd World Health Assembly voted unanimously to adopt the ICD-11, the next edition of the International Classification of Diseases (ICD).

Endorsement won’t come into effect until January 1, 2022, which is the earliest date that member states can begin using ICD-11 for reporting data.

A stable version of the ICD-11 MMS was released in June 2018 to enable member states to begin planning for implementation.

ICD-11 is an electronic classification containing over 55,000 codes and a considerably more complex product than ICD-10. It has been designed to incorporate or link with other ICD classifications, such as the International Classification of Functioning, Disability and Health (ICF), the WONCA* developed International Classification of Primary Care (ICPC), and with the SNOMED-CT and OrphaNet terminologies.

Even the earliest implementers will need several years to evaluate the new edition, determine how they will use ICD-11, complete translations, produce training and implementation materials and prepare their health systems for migration. Japan is understood to be well advanced with translations and planning.

There is no mandatory implementation date: member states will migrate to ICD-11 at their own pace and according to their countries’ needs and resources but there is an expectation that countries will start planning for transition. Some member states may need to develop clinical modifications of ICD-11 for country specific use. A few countries still use ICD-9.

Global implementation of the new edition will be a patchy and prolonged process and during the transition period, WHO will be accepting data reported using both ICD-10 and the new ICD-11 code sets until the majority of member states have transitioned to the new edition. WHO has said that the last update to ICD-10 will be Version 2019.

No member states have announced timeline projections but below is a round-up of ICD-11 transition planning activities already in progress:

*World Organization of National Colleges, Academies and Academic Associations of General Practitioners/Family Physicians.


NHS England

NHS England mandates the use of ICD-10 in secondary care (currently using ICD-10 Version 2015).

As a WHO Collaborating Centre and designated UK Field Trial Centre, NHS Digital has taken part in ICD-11 Field Trials.

NHS Digital has said:

No decision has been made for the implementation of ICD-11 in England, however NHS Digital plan to undertake further testing of the latest release and supporting products that will inform a future decision.

NHS Digital Delen: ICD-11 resources page

Proposed Future Additions

Over the coming months, NHS Digital would like to engage and invite all users of ICD to participate and interact with the review process.

To support this, we are proposing to add the following information to our Delen site;

  • A mechanism for questions, issues, concerns and errors relating to ICD-11 to be raised to us as the UK Field Trial Centre.
  • A high-level overview of our future plans
  • Presentations providing more information on ICD-11
  • e-Learning materials to support familiarisation with ICD-11. Topics to include post coordination / cluster coding, chapter and code structure, chapter specific changes and notes, conventions etc
  • Further testing – parallel coding in ICD-10 in real-time. If you would be interested in taking part in this please let us know by emailing

Until NHS England has implemented ICD-11, the mandatory classification system for use in the NHS remains ICD-10.

Since April 2018, SNOMED CT (which replaces the Read Codes/CTV3 clinical terminology) has been the mandatory terminology system for use in NHS primary care at the point of contact and forms an integral part of the electronic patient record (EPR).

SNOMED CT terminology system is already used in some secondary care settings but is planned to be implemented across all secondary care, acute care, mental health, community systems, dentistry and other systems used in direct patient care by April 2020.

SNOMED CT terminology system and clinical classifications, like ICD-10, work together to fulfil different needs:

Source: Presentation: NHS Digital: Clinical Coding for non coders – Overview of clinical coding, how ICD-10 and SNOMED CT work together, and the role of the Clinical Classifications Service.

For more information on the planning that will be required before ICD-11 can be implemented within the NHS, see BETA – Clinical Information Standards, section: ICD-11 and the new Procedure Based Classification (PBC).


NHS Digital Delen Home Page

NHS Digital SNOMED CT resources

SNOMED CT UK Edition browser



Australia uses a modification of the WHO’s ICD-10, known as ICD-10-AM [1].

Australian classification standards and statistics agencies were well represented on the ICD-11 Joint Task Force, with 5 of the Joint Task Force’s 21 members representing Australia, plus co-chair (Dr James Harrison, Director, Research Centre for Injury Studies, Flinders University, Adelaide) and observer (Dr Richard Madden, Professor of Health Statistics and Director National Centre for Classification in Health, University of Sydney).

For comparison, the UK had only an observer on the Joint Task Force; the U.S. had 4 participants and an observer.

The Australian Institute of Health and Welfare (AIHW) has been conducting a review of ICD-11 to inform and assist decision-makers about the new edition and its potential for adoption in Australia, see Post: #349: Australia: Potential adoption of ICD-11: Pre-consultation for decision makers.

1 Australian Consortium for Classification Development



Canada uses a modification of the WHO’s ICD-10, known as ICD-10-CA, developed by Canadian Institute for Health Information (CIHI) [1].

CIHI is participating in the testing of ICD-11 and assessing the implications for potential implementation in Canada.

CIHI has said that no decision has been made for the implementation of ICD-11 in Canada and that they are currently working on a number of initiatives to better understand the differences between ICD-10-CA and ICD-11 to help inform the business and statistical implications of adoption.

April 15, 2019 webinar:

Canadian Institute for Health Information (CIHI) Webinar: Introduction to ICD-11

Introduction to ICD-11 — Part 1 Transcript and Recording

Introduction to ICD-11 — Part 2 Transcript and Recording


1 Version 2018 ICD-10-CA/CCI, Canadian Coding Standards and related products


United States

The National Center for Health Statistics (NCHS) is the federal agency responsible for the use of ICD-10 in the United States.

ICD-10 has been used in the U.S. to code and classify mortality data from death certificates since January 1999. NCHS developed a clinical modification of ICD-10 for morbidity purposes (ICD-10-CM) which replaced ICD-9-CM on October 1, 2015.

Since its initial launch, in 2007, the U.S. has maintained high level participation in the ICD-11 development process and its ongoing update and improvement:

The U.S. provided representatives from professional and scientific organisations, academics and practitioners for the ICD-11 Topic Advisory Groups (TAGs) and sub working groups. Stanford Center for Biomedical Informatics Research developed the web based iCAT Collaborative Authoring Platform on which ICD-11 was developed.

The U.S. has representatives on the ICD-11 governance committees via the WHO-FIC Network; the Medical Scientific Advisory Committee (MSAC); the Classifications and Statistics Advisory Committee (CSAC); the Mortality and Morbidity (MbRF) Reference Groups; and the Functioning and Disability Reference Group, which have oversight for the annual updating and ongoing improvement of the global ICD-11 edition.

Dr Geoffrey Reed (WHO, Geneva; Columbia University) is Senior Project Lead for the ICD-11 Mental Health chapter and a member of the MSAC; Steven Hyman, MD (former Director of the National Institute of Mental Health (NIMH) and former DSM-5 Task Force member) chaired the Topic Advisory Group for Mental Health; Michael B First, MD has served as a key external advisor to the Mental Health chapter.

Dr Christopher Chute (John Hopkins University) chaired the ICD-11 Revision Steering Committee, was a member of the Joint Task Force and now chairs the MSAC; Donna Pickett (Chief, Classifications and Public Health Data Standards, NCHS, Centers for Disease Control and Prevention, Head, Collaborating Center for the WHO-FIC in North America) co-chaired the Morbidity TAG, was a member of the Joint Task Force and is a member of the CSAC; Dr Robert Anderson (Chief, Mortality Statistics Branch Division of Vital Statistics, Centers for Disease Control and Prevention) was a member of the Joint Task Force and co-chaired the Mortality TAG; Cille Kennedy (ASPE) co-chaired the ICD-11 Functioning TAG; Sue Bowman (Senior Director of Coding Policy and Compliance, AHIMA) is a representative on the ICD-11 Morbidity Reference Group (MbRF).

Around 25 member states have modified ICD-10 for country specific use.

WHO is still formulating policies around the licensing of ICD-11 but it is understood that the intention is to limit development of national modifications.

See Presentation slides #36-38 for more information on licensing and the development of country modifications: Insights into the Next Revision: Like Texas, Everything is Bigger in ICD-11, Kathy Giannangelo, RHIA, CCS, CPHIMS, FHIMA, Texas Health Information Management Association.

It would be premature to speculate when the U.S. might be ready to migrate to ICD-11 for mortality (cause of death reporting) and whether ICD-11 will be adequate as a morbidity classification system for U.S. use or whether NCHS will need to develop a clinical modification, as it did for ICD-10.

It was put forward at the June 5-6, 2019 NCVHS meeting that the U.S. might potentially use ICD-11 unmodified if WHO were to incorporate some additional terms within the global ICD-11 edition.

NCVHS has initiated the process of planning for transition to ICD-11 at the federal level.

In February 2019, William W Stead, MD, Chair, NCVHS, sent a letter to the Secretary of Health and Human Services (HHS) recommending a simplified process for adopting future versions of ICD. The letter also recommended that HHS should invest now in an ICD-11 evaluation project and develop a plan to enable a smooth, transparent transition from ICD-10 to ICD-11 at the optimal time.


NCVHS meetings:

A National Committee on Vital and Health Statistics Full Committee Meeting was held on June 5-6, 2019.

Agenda: Full Committee Meeting-June 5-6, 2019

Presentations were given for Agenda item: ICD-11 Project:

Recording Mp3: Full Committee Meeting – Day 1 June 5, 2019

Agenda item: ICD-11 Project: presentations and discussions starts 2hrs: 50 mins in from start; closes 5hrs 55mins from start.

Recording Mp3: Full Committee Meeting – Day 2 June 6, 2019

Meeting summaries, transcripts, presentation slides may be available later.


ICD-11 Expert Roundtable Meeting August 6-7, 2019

National Committee on Vital and Health Statistics Subcommittee on Standards held an

ICD-11 Evaluation Expert Roundtable Meeting on August 6-7, 2019.

Mp3 recordings of this two day NICD-11 Expert Roundtable meeting are now available:


Recording Mp3 ICD-11 Expert Roundtable Meeting – Day 1 August 6, 2019

Recording Mp3 ICD-11 Expert Roundtable Meeting – Day 2 August 7, 2019


Transcript Day 1 –  August 6, 2019

Transcript Day 2 – August 7, 2019

These transcripts of the ICD-11 Roundtable two day meeting are 165 and 129 pages long and the files have only recently been posted on the NCVHS site.

I have not had time to review these yet, but they are essential reading for industry and public stakeholders in the U.S.’s potential adoption of ICD-11 or NCHS/CDC’s potential development of a clinical modification of ICD-11.

Meeting summaries and presentation slides may be available later.


1 WHO Group Discusses ICD-11 Transition Planning report by Sue Bowman, MJ, RHIA, CCS, FAHIMA for Journal of AHIMA (American Health Information Management Association)

2 Presentation: Status on ICD-11: The WHO Launch National Committee on Vital and Health Statistics, July 18, 2018, Donna Pickett, Chief, Classifications and Public Health Data Standards, Head, Collaborating Center for the WHO-FIC in North America; Robert N. Anderson, PhD Chief, Mortality Statistics Branch Division of Vital Statistics


WHO-FIC Africa

WHO-FIC Africa Collaborating Centre has said:

ICD-10 is the current standard for Morbidity (cause of illness) and Mortality (cause of death (COD) coding.

The ongoing implementation and maintenance of ICD-10 for mortality and morbidity coding remain a core focus of the WHO-FIC Collaborating Centre (African region). Following the release of ICD-11 MMS in June 2018, there will be increasing focus on ICD-11 in the work plan of the collaborating centre. Inputs to the development of ICD-11 are essential to ensure that the classification meets regional needs.

WHO-FIC Africa News: WHO on the Implementation of ICD-11, November 2018:

WHO-FIC collaborators met in Pretoria (South Africa) on 7 November 2018, discussing the implications for implementing ICD-11 and ICHI. We linked up with Nenad Kostanjsek from WHO (Geneva), who shared his thoughts about the preparation for implementation of ICD-11.

Download presentation slides


Other member states

This table from the eHealth DSI Semantic Knowledge Base project compiles information provided from a number of member states on their use of ICD (or a modification of ICD) and their plans regarding potential future implementation of ICD-11. Information provided by: Austria, Belgium, Croatia, Cyprus, Czech Republic, Estonia, France, Germany, Greece, Hungary, Ireland, Italy, Luxenbourg, Malta, Netherlands, Portugal, Slovenia and Spain.

Table: Current status of the use of ICD by eHDSI deploying countries (2018)


ICD-11: The 11th Revision of the International Classification of Diseases – Site maintained by eHealth DSI Semantic Community providing resources for ICD-10, ICD-11, ICD derivative classifications and other classification and terminology systems

Insights into the Next Revision: Like Texas, Everything is Bigger in ICD-11, Kathy Giannangelo, RHIA, CCS, CPHIMS, FHIMA, Texas Health Information Management Association


Comparison of Classification and Terminology Systems

Post #340 Shortlink:

We continue to see some confusion amongst ME and CFS patients, advocates and commentators around classification systems — what they are used for, whether they are mandatory for WHO member states, which terms are included in which systems and which countries use which versions.

In May, Suzy Chapman ( and Mary Dimmock prepared a document to assist stakeholders in navigating the complexities of the disease classification and terminology systems.


Comparison of Classification and Terminology Systems

The purpose of this document is to summarize the key classification and terminology systems that are used internationally to capture information about disorders and diseases for the purposes of global mortality and morbidity tracking. These systems are also used for medical records, including EMRs (electronic medical records), in primary and secondary care.


The most recent version of this document can be downloaded here Version 3 | July 2018


Document revision history:

Comparison of Classification and Terminology Systems Version 1

May 2018


Comparison of Classification and Terminology Systems Version 2

June 2018 – Updated to reflect release of an advance preview version of ICD-11 on June 18, 2018.


Comparison of Classification and Terminology Systems Version 3

July 2018 – Revised for clarity.

In Versions 1 and 2, we stated that the ICPC-2 Danish extension [1] included the term, Bodily distress syndrome. The document in reference [2] clarifies that whilst not included in the Danish extension, a diagnosis of functional disorder or a diagnosis of bodily distress syndrome can be coded for using the ICPC-2 P75 Somatoform forstyrrelse (Somatoform disorder) term.

1 ICPC-2 Danish extension
2 Funktionelle lidelser (Functional Disorders), Clinical guideline for general practice, Danish College of General Practitioners, 2013 (English translation, 2016). Page 8: What is the patient’s illness called?


HHS issue Final Rule: ICD-10-CM compliance deadline set for October 1, 2015

Post #314 Shortlink:

CMS Press Release:  Final Rule July 31, 2014

Coding industry and professional body reaction

ICD-10 Testing: Final rule overshadows CMS testing plans

ICD10 Watch | Carl Natale | August 2, 2014

Debunking Myths and Misperceptions of ICD-10 – Journal of AHIMA illustrates why it’s time for 10

AHIMA | News Release | July 30, 2014

DHHS final rule on ICD-10 delay ready for publication

ICD10Watch | Carl Natale | July 31, 2014

CMS Confirms ICD-10 Deadline

Health Leaders Media | Michelle Leppert | August 1, 2014

ICD-10 Final Rule Released, October 2015 Official Compliance Deadline

Journal of AHIMA | Mary Butler | July 31, 2014

ICD-10 Final Rule Stirs Angst, Apprehension

ICD10 Monitor | Chuck Buck | August 1, 2014

(From June 12, 2014)

SNOMED, ICD-11 Not Feasible Alternatives to ICD-10-CM/PCS Implementation

AHIMA | Sue Bowman | June 12, 2014

“For the US, [2017] is the beginning, not the end, of the process toward adoption of ICD-11.”


Federal Register: HHS ICD-10-CM Compliance FINAL RULE

45 CFR Part 162 [CMS-0043-F] RIN 0938-AS31
Administrative Simplification: Change to the Compliance Date for the International Classification of Diseases, 10th Revision (ICD–10–CM and ICD-10-PCS) Medical Data Code Sets

CMS Press Release:  Final Rule July 31, 2014


FOR IMMEDIATE RELEASE    Contact: CMS Media Relations

July 31, 2014                                   (202) 690-6145 or


Deadline for ICD-10 allows health care industry ample time to prepare for change

Deadline set for October 1, 2015

The U.S. Department of Health and Human Services (HHS) issued a rule today finalizing Oct. 1, 2015 as the new compliance date for health care providers, health plans, and health care clearinghouses to transition to ICD-10, the tenth revision of the International Classification of Diseases. This deadline allows providers, insurance companies and others in the health care industry time to ramp up their operations to ensure their systems and business processes are ready to go on Oct. 1, 2015.

The ICD-10 codes on a claim are used to classify diagnoses and procedures on claims submitted to Medicare and private insurance payers. By enabling more detailed patient history coding, ICD-10 can help to better coordinate a patient’s care across providers and over time. ICD-10 improves quality measurement and reporting, facilitates the detection and prevention of fraud, waste, and abuse, and leads to greater accuracy of reimbursement for medical services. The code set’s granularity will improve data capture and analytics of public health surveillance and reporting, national quality reporting, research and data analysis, and provide detailed data to enhance health care delivery. Health care providers and specialty groups in the United States provided extensive input into the development of ICD-10, which includes more detailed codes for the conditions they treat and reflects advances in medicine and medical technology.

“ICD-10 codes will provide better support for patient care, and improve disease management, quality measurement and analytics,” said Marilyn Tavenner, Administrator of the Centers for Medicare & Medicaid Services (CMS). “For patients under the care of multiple providers, ICD-10 can help promote care coordination.”

Using ICD-10, doctors can capture much more information, meaning they can better understand important details about the patient’s health than with ICD-9-CM. Moreover, the level of detail that is provided for by ICD-10 means researchers and public health officials can better track diseases and health outcomes. ICD-10 reflects improved diagnosis of chronic illness and identifies underlying causes, complications of disease, and conditions that contribute to the complexity of a disease. Additionally, ICD-10 captures the severity and stage of diseases such as chronic kidney disease, diabetes, and asthma.

The previous revision, ICD-9-CM, contains outdated, obsolete terms that are inconsistent with current medical practice, new technology and preventive services.

ICD-10 represents a significant change that impacts the entire health care community. As such, much of the industry has already invested resources toward the implementation of ICD-10. CMS has implemented a comprehensive testing approach, including end-to-end testing in 2015, to help ensure providers are ready. While many providers, including physicians, hospitals, and health plans, have completed the necessary system changes to transition to ICD-10, the time offered by Congress and this rule ensure all providers are ready.

For additional information about ICD-10, please visit:



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

Post #309 Shortlink:

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

Comments should be sent to NCHS, preferably by email, by June 20th deadline:

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

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

September 2013 meeting Diagnosis Agenda

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

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

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


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

March 2014 meeting Diagnosis Agenda

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

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

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

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

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

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

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

March14 ICD-10-CM Cand M SSD to Index

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

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


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

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

Comments by June 20th deadline, preferably by email, to:

Below is my own submission to NCHS in PDF

Click link for PDF document   NCHS Submission Chapman June 14

and as text:


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

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

Proposal requestor: Unspecified

Comment submitted by Suzy Chapman DipAD, [Address redacted]

Date submitted: June 15, 2014

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Potential implications for the application of a diagnosis of SSD:

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

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

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

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

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

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

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

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

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

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

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

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


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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Thank you for your consideration.


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

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

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

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

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

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

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

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

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

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

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

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

13. Commonwealth of Massachusetts Juvenile Court Department, Court document, Honourable Joseph Johnston, March 25, 2014, Re: Care and Protection of Justina Pelletier:


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


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

Post #306 Shortlink:

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

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

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

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

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


Partial Code Freeze

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

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

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

or text, below:

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

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

The partial freeze will be implemented as follows:

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

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

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

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

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

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


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

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

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

I have approached NCHS for clarification.

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

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

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

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

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


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

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

March14 ICD-10-CM Cand M SSD to Index

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

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

DSM-5 (Page 311)


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

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

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

Send comments, by email, to NCHS to

Not a small thing

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

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

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

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

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

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

There are implications for ICD-11, too.

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

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

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

Send comments, by email, by June 20, to NCHS at


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

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

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

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

2015 Code Descriptions in Tabular Order

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

2015 ICD-10-CM Duplicate Code Numbers

2015 Addendum

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

2015 Reimbursement Mappings – Diagnosis Codes and Guide

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

These ICD-10-CM Release for 2015 files are not yet available on the CDC site but when they are posted, they should be accessible from this page:


Further reading

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

Global creep of DSM-5’s Somatic symptom disorder

Post #303 Shortlink:

Update at April 14, 2014:

Written response (April 10, 2014) from Independent Hospital Pricing Authority (IHPA) to request for clarification regarding the term ‘Somatic symptom disorder’ and Australia’s clinical modification of ICD-10, ICD-10-AM:

PDF: IHPA response re SSD and ICD-10-AM


As previously posted:

In the previous posting Update on proposal to add DSM-5′s Somatic symptom disorder to ICD-10-CM I reported that NCHS is preparing to rubber stamp proposals to insert Somatic symptom disorder into the U.S.’s forthcoming clinical modification of ICD-10.

Comments/objections to Diagnosis Agenda proposals submitted at the March meeting need to be sent by email to NCHS at by June 20th.

1] According to this Australian legislative document:

Australian Government, Statement of Principles concerning somatic symptom disorder No. 24 of 2014

for the purposes of the Veterans’ Entitlements Act 1986 and Military Rehabilitation and Compensation Act 2004

“Somatic symptom disorder attracts ICD-10-AM code F45.1.”

For the purposes of the Statement of Principles:

“ICD-10-AM code” means a number assigned to a particular kind of injury or disease in The International Statistical Classification of Diseases and Related Health Problems, 10th Revision, Australian Modification (ICD-10-AM), Eighth Edition, effective date of 1 July 2013, copyrighted by the Independent Hospital Pricing Authority, and having ISBN 978-1-74128-213-9;”

The Australian ICD-10-CM, Eighth Edition, July 2013 is not in the public domain. As I do not have access to a copy, I have contacted the relevant body for clarifications.

I have asked whether Somatic symptom disorder has been added to the Eighth Edition of ICD-10-AM as an Inclusion term to F45.1 Undifferentiated somatoform disorder in the Tabular List and Alphabetical Index.

Or, whether this legislative document relies on the ICD cross-walk codes as published in the DSM-5 in May 2013 for the cross-walk between DSM-5 disorders and the disorders in the U.S.’s ICD-9-CM and forthcoming ICD-10-CM.

Or, whether the legislative document relies on a cross-walk between DSM-5 disorders and ICD-10-AM codes developed specifically in relation to the ICD-10-AM Eighth Edition, July 2013.

I will update this post when I have received clarification.

According to this page:

“[Australia’s] ICD-10-AM has also enjoyed more widespread use, having been assessed, found suitable and adopted by many other countries, including: New Zealand, Ireland, Singapore, Slovenia.”

I am unable to confirm how many countries that have adopted ICD-10-AM have migrated from earlier editions to the July 2013 edition or are preparing to migrate to the most recent edition.

Other clinical modifications (CMs) of ICD-10:

Canada (ICD-10-CA): The most recent edition of ICD-10-CA is the 2009 edition Volume One: Tabular List 2009. Canada is anticipated to adopt a CM of ICD-11 before the U.S. does, but in meantime, an updated edition of ICD-10-CA might be anticipated, especially given the recent extension to the ICD-11 development timeline. Canadians will need to be alert to the potential for addition of SSD as an inclusion term to the next edition of ICD-10-CA.

Germany (ICD-10-GM): There is an ICD-10-GM version for 2014. There is no SSD under F45.x or under any other code, but watch for any updated versions released prior to transition to a CM of ICD-11.

Thailand (ICD-10-TM): There does not appear to be a more recent version of the Thai clinical modification than the online version for 2007, but watch for SSD in any updated versions prior to potential transition to a CM of ICD-11. ICD-10-TM Online version for 2007.

ICD-11 Beta drafting platform:

There is no documentary evidence of a proposal to add SSD, per se, to ICD-11. However, the wording for the Definition for Bodily distress disorder, as it currently stands in the Beta drafting platform, is drawn from the Gureje, Creed 2012 paper on the S3DWG sub working group’s emerging proposals for ICD-11 [1].

The paper described a simplified disorder framework – a construct into which DSM-5′s Somatic Symptom Disorder could be comfortably integrated, thus facilitating harmonization between the respective ICD-11 and DSM-5 disorder construct and criteria replacements for the Somatoform disorders classifications.

As with DSM-5′s SSD, for the emerging proposals for BDD, the focus was not on symptoms counts, or on strict symptom patterns or clusters from one or more body systems, or on whether symptoms were determined as being “medically explained” or “medically unexplained,” but on the perception of disproportionate or maladaptive psychobehavioural responses to, or excessive preoccupation with any troublesome chronic bodily symptom(s). And that in doing away with the “unreliable assumption of its causality” the diagnosis of BDD would not exclude the presence of a co-occurring physical health condition – which is very close to SSD’s defining characteristics.

1. Creed F, Gureje O. Emerging themes in the revision of the classification of somatoform disorders. Int Rev Psychiatry. 2012 Dec;24(6):556-67. [Abstract. Full text behind paywall]

2] On the site, a peer reviewed article on Somatic symptom disorder:

This article is not a recommendation and it draws heavily on the DSM-IV and current ICD-10 Somatoform disorders framework, criteria and literature. Though it does highlight that DSM-5 has a new, simplified framework and reformulated criteria that rely less on strict patterns of somatic symptoms and more on the degree to which a patient’s thoughts, feelings and behaviours about their symptoms are considered disproportionate or excessive; that for DSM-5, “medically unexplained” is de-emphasized – symptoms may or may not be associated with another medical condition and patients with organic comorbidities such as heart disease, osteoarthritis or cancer, who would have previously been excluded under DSM-IV, can now be included in the diagnosis of SSD.

There is little published research examining the reliability, utility, epidemiology, clinical characteristics or treatment of Somatic symptom disorder as a diagnostic construct and none of the article’s references are for papers specifically using the new Somatic symptom disorder criteria.

3] Somatic symptom disorder in a BMJ Rapid Response:

Rapid Response to: Clinical Review, Fibromyalgia by Anisur Rahman, Martin Underwood, Dawn Carnes [Full text for Clinical Review behind paywall]

Rapid Response: Fibromyalgia: an unhelpful diagnosis for both patients and doctors [Full text for Rapid Response accessible]

Christopher Bass, consultant in liaison psychiatry, John Radcliffe Hospital , Oxford OX3 9DU

Dr Max Henderson, senior lecturer in Epidemiology and Occupational psychiatry, Inststitute of psychiatry, Kings College London 

According to the authors, fibromyalgia ( coded in ICD-10 under Chapter XXIII Diseases of the musculoskeletal system and connective tissue, at M79.7 ) is more appropriately described in terms of “polysymptomatic distress”; “polysymptomatic distress has been recognised as a somatoform disorder, specifically as a somatic symptom disorder or SSD,” and that since “FM overlaps with other disorders with medically unexplained symptoms such as irritable bowel syndrome and chronic fatigue syndrome” it is more appropriate to treat them with multidisciplinary teams within the same specialised service in the general hospital.

4] This commentary by infectious disease specialist, Judy Stone, MD, at Scientific American blogs, mentions concerns around SSD:

Have Pain? Are You Crazy? Rare Diseases Pt. 2

By Judy Stone | February 18, 2014

“It’s all in your head,” patients with unexplained pain or unexpected symptoms often hear…

5] Halifax Somatic Symptoms Disorder Trial Identifier: NCT02076867

Sponsor: Capital District Health Authority, Canada

The purpose of this study is to compare the effectiveness of Intensive Short-Term Dynamic Psychotherapy (ISTDP) plus Medical Care As Usual (MCAU) compared to MCAU for Somatic Symptom and Related Disorders (SSRD). Consenting patients presenting to the emergency department with suspected SSRD will be randomly allocated to receive either 8 weekly individual sessions of ISTDP or to an 8-week wait list followed by ISTDP. MCAU including emergency department and/or family doctor consultation is available throughout trial participation. The primary outcome measure is participant self-reported somatic symptoms at week 8.


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