In May 2019, the World Health Assembly (WHO) adopted ICD-11 for implementation by member states from January 01, 2022.
In early 2019, the Australian Institute of Health and Welfare (AIHA) undertook a national consultation regarding ICD-11 to inform decisions on whether, when and how to implement ICD-11 in Australia.
The report of the AIHA was released on March 12, 2020:
In my report for the December edition of the ME Global Chronicle, I set out how the G93.3 terms:
Postviral fatigue syndrome
Benign myalgic encephalomyelitis
Chronic fatigue syndrome
are classified in the World Health Organization’s international version of ICD-10 and how these terms have been classified for ICD-11.
I have an update on ICD-10 and it’s good news!
In January, the WHO released ICD-10 Version: 2019. With ICD-11 on the horizon, this release will be the final update for the WHO’s international version of ICD-10, apart from corrections and exceptional additions.
In March 2016, a representative from the Canadian Institute for Health Information submitted a request and supporting rationale to the ICD-10 Update and Revision Committee (URC) for removal of the prefix “Benign” from “Benign myalgic encephalomyelitis”.
This request for a change was approved by the URC in September 2016 for implementation in the next release.
For ICD-10 Version: 2019, the G93.3 Tabular List inclusion term is now Myalgic encephalomyelitis.
(The term, “Benign myalgic encephalomyelitis” has been retained as an Index term.)
Note that for ICD-10, Chronic fatigue syndrome is not included in the Tabular List but is included in Volume 3: Index, where it is coded to the G93.3 Postviral fatigue syndrome concept title term.
For ICD-11, the WHO has retained Postviral fatigue syndrome as the concept title term in Chapter 08: Diseases of the nervous system under parent: Other disorders of the nervous system. The new code for ICD-11 is: 8E49.
Benign myalgic encephalomyelitis and Chronic fatigue syndrome are both specified as inclusion terms under Postviral fatigue syndrome in ICD-11’s equivalent to the Tabular List and take the 8E49 code. A number of historical and alternative terms are retained as index terms and all 14 index terms are coded to 8E49.
This is how the G93.3 terms are classified for ICD-10 Version: 2019:
The WHO expects Member States to be using the most recent release of ICD-10. But countries will implement the ICD-10 Version: 2019 release according to their own schedules.
NHS England and ICD-10:
NHS England currently uses ICD-10 Version: 2016. I have contacted NHS Digital’s classifications lead to establish whether NHS Digital intends to implement Version: 2019 or may be considering skipping the new release in preference to implementing ICD-11, at some point in the future.
If there is no mechanism for incorporating selected changes in a new release into earlier versions, NHS England might not be able to absorb this change into the version it is using.
Will this change be absorbed automatically for ICD-11?
This revision for the final release of ICD-10 sets a precedent for the national modifications of ICD-10, for example, the U.S. ICD-10-CM and Canadian ICD-10-CA, but also for ICD-11.
Proposals submitted in March 2017 by Chapman & Dimmock, and by the IACFS/ME for removing “Benign” from “Benign myalgic encephalomyelitis” were rejected by the WHO in early 2019.
In February, I submitted a new proposal for removal of the “Benign” prefix for ICD-11 citing the URC’s 2016 decision and the implementation of that decision for the final release of ICD-10.
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. This release was replaced in April 2019 with ICD-11 MMS Version: 04/2019.
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.
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 icd-11@nhs.net
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:
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).
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.
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.
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. Harold Pincus, MD co-chaired the ICD-11 Quality and Patient Safety Topic Advisory Group.
Dr Christopher Chute (John Hopkins University) chaired the ICD-11 Revision Steering Committee, was a member of the Joint Task Force and now co-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.
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:
The U.S. National Committee on Vital and Health Statistics (NCVHS) serves as the statutory public advisory body to the Secretary of Health and Human Services for health data, statistics, privacy, and national health information policy and the Health Insurance Portability and Accountability Act (HIPAA).
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.
Slide presentation: NCVHS Update, Rich Landen, Member, National Committee on Vital and Health Statistics, Co‐chair, Standards Subcommittee, August 2019:
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
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 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.
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.
On Saturday, May 25, 2019, member states meeting at the 72nd World Health Assembly voted unanimously to approve the draft resolution to adopt the Eleventh revision of the International Classification of Diseases. The resolution passed with no amendments.
Adoption comes into effect on January 1, 2022, subject to transitional arrangements. After this date, member states can start using or transitioning to the ICD-11 codes when they have prepared their health systems for migration from earlier editions.
This document is a part of the ICD11 implementation package¹ developed by the World Health Organization. This document also provides some background related to the development of the ICD11 and its components. The document outlines essential issues that countries need to consider in the lead up to and during the transition from an existing ICD environment to the eventual implementation of ICD11.
1 The ICD-11 implementation package comprises the Classification System, the Coding Tool, Browser and all supporting documents including the Reference Guide and Implementation Guide, and a set of tools. Source: ICD-11 Implementation or Transition Guide, Geneva: World Health Organization; 2019; License: CC BY-NC-SA 3.0 IGO.
The audience for this site is the maintainers, contributors and translators of the classification. The content of the Orange browser is not the released version of the classification. The content is updated on a daily basis to incorporate changes approved since the most recent release of the Blue ICD-11 browser for Mortality and Morbidity Statistics (MMS).
The Orange Maintenance Platform incorporates the ICD-11 Proposal Mechanism (a proposal and commenting tool for which registration is required). Once an account is registered, new proposals, comments and suggestions for changes and enhancements to existing content can be submitted and notifications set up. For help with submissions see: Maintenance Platform User Guide.
Specialty versions and derived classifications
Specialty versions provide more detail for particular user groups, such as Mental Health, Neurology, Dermatology and less detail for primary care or low diagnostic resource settings.
For ICD-11, the WHO Department of Mental Health and Substance Abuse has developed a companion publication to ICD-11 Chapter 06 for mental health professionals, general clinical, educational and service use.
The Clinical Descriptions and Diagnostic Guidelines for ICD‐11 Mental, Behavioural and Neurodevelopmental Disorders (CDDG) provides expanded disorder descriptions and includes: essential (required) features, severities, boundaries with other disorders and normality, differential diagnoses, additional features and culture-related features.
WHO has given no firm release date but says the CDDG will be published “as soon as possible” following approval of the overall system by the WHA¹.
Also under development is the ICD-11 PHC – a clinical guideline written in simpler language to assist non-mental health specialists, especially primary care practitioners and non medically trained health workers, and for use in low resource settings and low- to middle-income countries with the diagnosis and management of 27 mental disorders. No finalization and publication date is available. Like the ICD-10 PHC (1996), this revised edition will not be a mandatory classification for member states.
Linkages with other classifications and terminologies
ICD11 incorporates or links with the following classifications and terminologies through the ICD11 Foundation:
• International Classification of Disease for Oncology – ICD-O
• International Classification of External Causes of Injury – ICECI
• International Classification of Functioning, Disability and Health – ICF
• International Classification of Primary Care – ICPC [Ed: developed/maintained by WONCA]
• Other terminologies such as OrphaNet and SNOMED-CT
Source: ICD-11 Implementation or Transition Guide, Geneva: World Health Organization; 2019; License: CC BY-NC-SA 3.0 IGO.
Update: Draft resolution A72/29 Add.1 (ICD-11) passed without amendments
Item 12.7 Eleventh revision of the International Classification of Diseases was transferred from the Tenth meeting of Committee A to the Sixth meeting of Committee B, for consideration on Saturday 25 May. Item 12.7 was placed as the second agenda item.
Following statements from around 30 Member States reps and 1 Non-State actor (IOGT International), and a response from the Secretariat, the draft resolution to adopt the Eleventh revision of the International Classification of Diseases was passed, with no amendments, at 10:20 Geneva time.
After the meeting has closed, a webcast of the meeting will be available for 3 months (Select Tab for Committee B; Select Sixth meeting of Committee B, 25/05/2019 9:00-).
A Draft report of the Sixth meeting of Committee B will be available in the next day or two on the WHA72 Documents page and I shall post a copy at the top of this post.
——————————————————
The Seventy-second World Health Assembly (WHA72) opened this morning, in Geneva. This year’s Assembly runs from Monday 20 — Tuesday 28 May.
“The World Health Assembly is the decision-making body of WHO. It is attended by delegations from all WHO Member States and focuses on a specific health agenda prepared by the Executive Board. The main functions of the World Health Assembly are to determine the policies of the Organization, appoint the Director-General, supervise financial policies, and review and approve the proposed programme budget. The Health Assembly is held annually in Geneva, Switzerland.”
The Eleventh revision of the International Classification of Diseases is listed as Item 12.7 under Item 12 Other technical matters and is the purview of Committee A.
Item 12.7 is currently expected to be reached on Saturday, 25 May.
Note: Item 12.7 is now 3rd item on Committee A Agenda for Saturday, 25 May.
Live streaming of the Tenth Meeting of Committee A should be available via the webcast page on Saturday 25 May from 9:00 Geneva time. I shall be watching the segment for Item 12.7 when this is reached and will report on any significant discussions, decisions or amendments to the Draft Resolution recommending adoption of the ICD-11 MMS.
(Webcasts for Plenary, Committee A and Committee B meetings will be available for 3 months.)
The two key documents for Item 12.7 Eleventh revision of the International Classification of Diseases are:
A72/29
Eleventh revision of the International Classification of Diseases Report by the Director-General
and
A72/29 Add.1
Eleventh revision of the International Classification of Diseases Draft Resolution
Draft resolution for consideration by Committee A:
Page 1:
Page 2:
The 72nd Assembly closes on Tuesday, 28 May. Finalization of Committee A resolutions and reports is scheduled for the final day:
There are in the region of 55,000 codes in the Eleventh Edition of ICD compared with around 14,400 in ICD-10.
It is anticipated that some Member States and other bodies may continue to raise concerns over specific controversial additions, for example, the inclusion of Gaming disorder. There have also been statements of concern lodged by some Member States regarding the proposed timelines for adoption of ICD-11 and transitional arrangements.
I will update with any significant discussions or amendments to the draft resolution as it currently stands and will post the finalized reports and ICD-11 resolution, when these become available.
The Blue ICD-11 MMS platform:
The WHO released a stable version of the ICD-11 for Mortality and Morbidity Statistics (ICD-11 MMS) in June 2018 as a pre-implementation version to enable Member States to begin the process of evaluation, consultations, training, translations and preparing for eventual transition to the new edition.
This initial release was replaced with an updated release in December 2018. The December 2018 version was replaced by a further stable release, in April 2019.
It is unclear whether Version : 04 / 2019 is the version being recommended for adoption on Saturday 25 May, or whether the MMS will be updated this week to reflect the most recent content of the Orange Maintenance Platform, then frozen for presentation next Saturday. If WHO does issue a further release of the Blue Platform, this week, I will update this report.
“The Executive Board is composed of 34 individuals technically qualified in the field of health, each one designated by a Member State elected to do so by the World Health Assembly. Member States are elected for three-year terms.
“The Board meets at least twice a year; the main meeting is normally in January, with a second shorter meeting in May, immediately after the Health Assembly. The main functions of the Executive Board are to give effect to the decisions and policies of the Health Assembly, to advise it and generally to facilitate its work.”
These January Executive Board meetings generate a considerable number of documents. Documentation is available from this page EB144 Meeting Documents.
Key document for Recommendation for Adoption of ICD-11 at WHA72:
World Health Organization, EXECUTIVE BOARD 144th Session
Eleventh revision of the International Classification of Diseases
Draft resolution proposed by the Secretariat with amendments from Member States
World Health Assembly
The 72nd World Health Assembly takes place this month, in Geneva, from 20 — 28 May 2019.
“The World Health Assembly is the decision-making body of WHO. It is attended by delegations from all WHO Member States and focuses on a specific health agenda prepared by the Executive Board. The main functions of the World Health Assembly are to determine the policies of the Organization, appoint the Director-General, supervise financial policies, and review and approve the proposed programme budget. The Health Assembly is held annually in Geneva, Switzerland.”
Eleventh revision of the International Classification of Diseases
Report by the Director-General
Extract:
“1. The Executive Board at its 144th session considered an earlier version of this report,¹ containing a draft resolution.² The Board noted the report but agreed to suspend consideration of the draft resolution so that informal consultations could be held during the intersessional period prior to the Seventy-second World Health Assembly. A separate report will be submitted to provide details of the outcome of the consultations.³”
1 Document EB144/22.
2 See the summary records of the Executive Board at its 144th session, eleventh meeting and twelfth meeting, section 1.
3 Document A72/29 Add.1.
“1. In line with the course of action agreed by the Executive Board at its 144th session in January 2019,¹ the Secretariat convened informal consultations during the intersessional period in respect of a draft resolution on the eleventh revision of the International Classification of Diseases. The consultations took place in Geneva on 22 February, 7 March and 21 March 2019. The three sessions enabled the draft resolution to be revised.”
1 Document A72/29.
Should any additional documents relating to the presentation of ICD-11 for recommendation for adoption be posted on the WHA72 documents page I will update this post.
The most recent release of the ICD-11 MMS version for preparation for implementation, Coding tool, Reference Guide and additional materials can be viewed here:
If adopted, endorsement would not come into effect until 1 January 2022.
Information session on ICD-11 slides
Document EB144/22 (Report by the Director-General) included a link for slides from a presentation given by Dr Robert Jakob, Team Leader, WHO, Geneva, Classifications, Terminologies and Standards:
Presentation slides (Dr Robert Jakob, November 2018):
I have been unable to find a transcript or video for this presentation. The slides include an overview of the structure of ICD-11, timelines for preparation for adoption, overview of proposed draft resolution, implementation package, post-endorsement maintenance and update process etc.
Slide 20/31:
Slide #22 notes outcomes of several CSAC and MSAC reviews and decisions, including the decision in November 2018 to retain the ICD-10 G93.3 entities (Postviral fatigue syndrome; Benign myalgic encephalomyelitis; Chronic fatigue syndrome) in the Diseases of the nervous system chapter [1][2]:
dx revision watch 
