seminar on icd-10

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LOGO

Seminar on ICD-10: An Overview

:: Moderator ::

Dr. J. N. DasAssistant Professor

:: Speaker ::Dr. Santanu Ghosh

Postgraduate Student

Department of Psychiatry, Assam Medical College

2nd November, 2010

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Layout of Presentation

• Introduction• What is classification?• Purpose of classification• International classification criteria• Problems of classification• Evolution of ICD• The basic structures & Principles of ICD• ICD Multi-axial presentation• ICD vs. DSM• Problems with ICD 10• Selected categories in the ICD-10• Controversy regarding few sections• Other versions of ICD 10• ICD 11• Conclusion• Bibliography

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Introduction

The International Statistical Classification of Diseases and Related

Health Problems 10th Revision (ICD-10) is a coding of diseases and

signs, symptoms, abnormal findings, complaints, social circumstances

and external causes of injury or diseases, as classified by the WHO.

The code set allows more than 14,400 different codes and permits the

tracking of many new diagnoses. As of October 1998, W.H.O. had

authorized the publication of ICD-10 versions in 37 languages, with 30

countries having implemented ICD-10 for mortality and/or morbidity

applications

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What is Classification ???

Classification is a method of grouping of items

scientifically according to purpose and codifying them with

numerical (or alpha-numerical) identification according to

certain principles

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Purpose Of Classification

Communication

• It enables users to communicate with each other about the disorders with which they deal.

• This involves using names of categories as standard shorthand ways of summarizing a great deal of information.

• When indicating that an individual has a particular disorder, this confers information about the cluster of clinical features that the individual is experiencing without listing all of the specific features that together constitute the disorder.

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PURPOSES OF CLASSIFICATION contd…

Control• It primarily refers to the prevention of their occurrence or the

modification of their course with treatment

• It refers to knowledge of the course of a condition, as this too is often important in clinical management

Comprehension• comprehension or understanding of the causes of mental disorders

and the processes involved in their development and maintenance

• usually leads to more effective treatment and prevention (i.e., better control)

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Criteria for International Classification :

BASIC ATTRIBUTES:

• It deals with a defined universe.

• It is designed for a specific purpose, which determines its scheme of organization.

• It groups the objects, using as few groups as consistent with its purpose. In public health and epidemiology, classifications are designed primarily for compilation of statistics.

• It uses a schema that depends on the logic of its author

• It must accommodate all the objects in its universe and as a result always has one or more categories termed other, which are often called wastebasket categories.

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Types of classification approaches

Categorical vs. dimensional

Descriptive vs. etiological

Syndrome vs. symptom

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Criteria for good psychiatric classification

• Reliability: How far errors of measurement have been excluded from assessment

• Validity: Actuality measures what it is supposed to measure

• Utility: Use, decision making process & clinical outcome

• Ease of use

• Applicability across settings & cultures

• Meet the needs of various user

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Problems unique to of classifying Psychiatric disorders

• Patient’s own subjective report of symptoms & the doctor’s observation of patient behavior to arrive at a diagnosis

• Psychiatry lacks objective & independent criteria for sorting out Psychiatric disorder

• Difficult to define normal human behavior

• Psychiatric symptoms are highly nonspecific & quite unstable over time

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Evolution of ICD

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ICD-10: Development

Work on the Tenth Revision of the ICD started in September 1983

when a Preparatory Meeting on ICD-10 was convened in Geneva.

The programme of work was guided by regular meetings of Heads

of WHO Collaborating Centers for Classification of Diseases.

Policy guidance was provided by a number of special meetings

including those of the Expert Committee on the International

Classification of Diseases

Meeting for Tenth Revision was held in 1984 and 1987.

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Historical background

1853

• Brussels: First International Statistical Congress requested William Farr (UK) & Marc d’Espine (Geneva) to prepare “a uniform nomenclature of causes of death…”

1855

• William Farr: five groups: epidemic, constitutional, local developmental diseases and diseases due to violence

• D’Espine: divided based on nature of diseases.• Adoption of compromise list of 138 categories

1864, 1874, 1880, 1886 • Revisions by Jacques Bertillon on the basis of

Farr’s classification in The International Statistical Institute,Vienna,1891

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Historical background contd…

1893

• Chicago: The Bertillon’s Classification of Causes of Death Generalized diseases and Localized diseases

1899• Recommendation to use the

classification for all statistical purposes

1900

• Paris: First international conference for revisions of the International Classification of Causes of Death(ICD- 1). Adoption of Bertillon’s classification

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1910

• ICD-2

1920

• ICD-3

1929

• ICD-4

1938

• ICD-5: Contained 200 titles, along with an intermediate list of 87 titles, and an abridged list of 44 titles.

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1948

• ICD-6• Renamed “Manual of the International Classification of

Diseases, Injuries, and causes of Death”. • Jointly published by WHO, International Statistical Institute• Mental Disorders first included:10 psychosis, 9 psychoneurosis, 7

disorders of character, behavior & intelligence.• Not accepted worldwide

1955

• ICD-7

1968

• ICD-8 • with supplement on brief descriptions of the categories of Chapter V

• In the 7th and 8th revision: basic structure maintained as ICD-6.

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1975

• ICD-9• Emphasis on psychiatric illnesses

• 30 categories (290-319)• provisions to further sub classify using

4th or fifth digit• Two additional segments introduced :

• The ICD ‘family’ of classifications,

• Classification of impairments and handicaps

• • Brief descriptions of the categories of

Chapter V within text.• First use of dagger (†) and asterisk (*) marks

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1979 but published in 1992

•ICD-10•8 Collaborating centers worldwide•Effort coordinated by WHO unit on Development of Epidemiological and Health statistical services.•Name changed to International Classification of Diseases and related health problems

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Revision of International List of Causes of Death

In this conference held in Paris on 21 August 1900 adopted a

resolution for a detailed classification of causes of death consisting of

179 groups and an shortened classification of 35 groups.

The First World Health Assembly was held in 1948 and endorsed the

Sixth Decennial Revision Conference marked the beginning of a new

era in international vital and health statistics. It recommended the

adoption of a comprehensive programme of international cooperation

in the field of vital and health statistics.

ICD Revision Process

Drafting

Taxonomic Guidelines Definition, Diagnosis and Indexing / mapping guidelines

Overall StructureIndividual Chapters

Overseeing the TOTAL ICD

• ALPHA Draft – structured comments• BETA Draft – field testing

Final Draft World Health Assembly Approval

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Why the long interval for ICD-11

Jablensky & Kendell proposed reasons:

• Frequent revision may undermine assimilation by clinicians, hamper progress of research & damage credibility of our discipline

• Possibility of major research breakthroughs that may have significant impact on nosology

• Satisfaction with performance of current systems

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LANGUAGE VERSIONS of ICD-10

ICD-10 is available in the six official languages of WHO (Arabic,

Chinese, English, French, Russian and Spanish) as well as in 31 other

languages.

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The basic structures & Principles

Structure of an ICD 10 code

• F20.00 Paranoid schizophrenia continuous course• Mental and Behavioral disorder

2= Section of Schizophrenia & related disorder

0 = Schizophrenia

.0= Paranoid type

0 = Continuous course

5, 6th character – for specific purpose/research

“U” codes – unused codes

Addition of signs/symbols ( ), [ ], † , *, -

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Structure of ICD code

Identifies mental disorder chapter

Indicates type of course = Continuous

Section of Schizophrenia & related disorder

Indicates type of schizophrenia= Paranoid

Schizophrenia

F 2 0 . 0 0

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Volumes:

Volume 1 : Introduction Tabular list Morphology of neoplasms Special tabulation lists for mortality and morbidity Definitions Regulations

Volume 2 : Instruction manual

Volume 3 : Alphabetical indexes

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Chapters:

• Divided in to 21 chapters

• The first character of ICD code is a letter which is associated with a particular chapter except for the letter

- D : used in both chapter II & III - H : used in both chapter VII & VIII

• Four chapters use more than one letter (I,II, XIX & XX) in the first position of their code

• Each chapter contains sufficient three- character categories to cover its content

• All available codes were not used allowing space for future revision & expansion

ICD 10 : Composition Of Chapters

Chapter number an designation

I Certain infectious and parasitic diseasesII NeoplasmsIII Disease of the blood and blood forming organs and certain

disorders involving the immune mechanismIV Endocrine, nutritional and metabolic diseases

V Mental and behavioral disordersVI Diseases of the nervous systemVII Diseases of the eye and adnexaVIII Diseases of the ear and mastoid processIX Diseases of the circulatory systemX Diseases of the respiratory system

Range of codes

A00-B99C00-D48D50-D89

E00-E90

F00-F99G00-G99H00-H59H60-H95I00-I99J00-J99

ICD 10 : COMPOSITION OF CHAPTERS contd…

Chapter number an designation

XI Diseases of the digestive system

XII Disease of the skin and subcutaneous tissue

XIII Diseases of the musculo-skeletal system and connective tissue

XIV Disease of the genito-urinary system

XV Pregnancy, childbirth and the puerperium

XVI Certain conditions originating in the perinatal period

XVII Congenital malformations, deformations, and chromosomal abnormalities

Range of codes

K00-K93

L00-L99

M00-M99

N00-N99

O00-O99

P00-P95

Q00-Q99

ICD 10 : COMPOSITION OF CHAPTERS contd…

Chapter number and designation

XVIII Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified

XIX Injury, poisoning and certain other consequences of external causes

XX External causes of morbidity and mortality

XXI Factors influencing health status and contact with health services

Range of codes

R00-R99

S00-T98

V01-Y98

Z00-Z98

chapter xxi factors influencing health status and contact with health services

Persons with potential health hazards related to socio economic circumstances (Z55-Z65)

Z55 Problems related to education and literacy Z55.3 Under achievement in school Z56 Problems related to employment and unemployment Z56.2 Threat of job loss Z60 Problems related to social environment Z60.3 Acculturation difficulty Z65 Problems related to other psychological circumstances Z65.4 Victim of crime and terrorism (Includes victim of torture)

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Contents of Chapter V

o Introduction

o Notes on selected categories

o List of categories (Including subcategories)

o Clinical descriptions and diagnostic guidelines

o Annexure : other conditions associated with mental and

behavioral disorders

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Major Categories of Mental and Behavioral Disorders in ICD-10

F00-F09 Organic disorders

F10-F19 Psychoactive substance use disorders

F20-F29 Schizophrenia and other psychotic disorders

F30-F39 Mood [affective] disorders

F40-F49 Neurotic and stress-related disorders

F50-F59 Physiological function disorders

F60-F69 Adult personality disorders

F70-F79 Mental retardation

F80-F89 Psychological developmental disorders of childhood

F90-F99 Behavioral and emotional disorders of childhood and adolescence

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Blocks of categories:

• Chapters subdivided in to homogeneous block of three categories

• Chapter:1- block title- two axes of classification: mode of transmission & infecting organisms

• Chapter:2- the axis is behavior of neoplasm

• It uses either three or four character categories

• Supplementary subdivisions for the use of fifth & subsequent character level: found in

Chap XIII: subdivisions of anatomical site Chap XIX: open & closed #, intracranial, intrathoracic & intrabdominal injuries Chap XX: type of activity being undertaken at the time of event

• The unused U code: U00- U49 for the new disease of uncertain etiology

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Additional nomenclature

The Dagger (†) and the Asterix (*):

†/* Dagger and asterisk used to designate the etiology code and the

manifestation code respectively, for terms subject to dual classification

# Attached to certain terms in the list of sites under "Neoplasm" to refer the

coder to Notes 2 and 3, respectively, at the start of that list

† indicates : primary disorder code and the supplementary code to which it may

be assigned is marked with an *

For statistical reporting usually codes with † marks used

ICD-10 allows dual diagnosis. 83 asterix categories at the 3-character level

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Additional nomenclature contd…

NOS = Not otherwise specified.

NEC = Not elsewhere classified

Added after terms classified to residual or unspecific categories Terms in themselves ill defined as a warning that specified forms of the

conditions are classified differently.

If the medical record includes more precise information the coding should be modified accordingly

Provisional : for future information which is yet to be added

Tentative : if further chance of information is unlikely

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Multi-axial presentation

Published in 1997 Comprises of three axes:

Axis I : Clinical diagnosis

Axis II : Disability

Axis III : Contextual factors

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Multi-axial presentation for Children and Adolescent

Published in 1996. It comprises of six axes:

Axis I : Clinical Psychiatric Syndrome.

Axis II : Specific disorders of psychological development.

Axis III : Intellectual level.

Axis IV : Medical conditions.

Axis V : Associated abnormal psychosocial situations.

Axis VI : Global assessment of psychosocial disability

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Integrate ICD & DSM

Research version of ICD & primary care version of DSM are hardly used.

Best option - drop them

This would have helped in integration of DSM & ICD.

Ideal situation- one international classification

It is early in the process, with critical decisions on most issues yet to be determined.

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ICD-10 vs. DSM IV

ICD-10 DSM-IV

International classification National classification

Several versions and languages Single version & language

Alphanumerical coding Numerical coding

10 major categories 17 major categories

It includes disorders of all medical specialties

Only mental disorders

Multi axial presentation: 3 axes(adult) : 6 axes (children)

Multi axial presentation: 5 axes

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Problem encountered with ICD-10

• Developmental aspects not given due importance

• Gaps in classification

• Death of phenomenology

• Difficulty of use in diverse populations & settings

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Selected categories in the ICD-10

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F00 – F09: Organic, including symptomatic mental disorders

o All disorders having an organic etiology are grouped in this section.

o Dementia: duration 6 months added.

o F08 remains unassigned.

o Further classification in four character level can be specified in most of the disorders

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F20 – F29: Schizophrenia, Schizotypal and Delusional Disorders

o Main contents of this subchapter are Schizophrenia, Acute and transient

psychotic disorders, Schizoaffective disorders, delusional disorders, and other

non-organic psychotic disorders.

o Schizophrenia 1 month duration unlike DSM IV.

4th character subtypes

5th character course specifier

o Acute and transient psychotic disorder

4th character subtypes

5th character with/ without stress

o F26 and F27 are unassigned.

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F20 – F29 (Contd..)

Simple schizophrenia (F20.6) Retained because of its continued use because of the uncertainty about its nature and its relationships to

schizoid personality

Schizoaffective disorders (F25.-) Controversy exists whether it is related to mood disorders other

psychosis or third psychosis. The final decision after field trial is to keep under F20-F29

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F30 – F39: Mood (affective) disorders

F35 – F37 unassigned.

All mood disorders are combined in this subchapter.

Neurotic Depression (ICD-9) omitted.

Recurrent manic Bipolar Disorders.

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F40 – F48: Neurotic, Stress related and somatoform Disorders

Term “neurosis” used

No differentiation between Dissociative states and conversion

The term “hysteria” is dropped

Mixed anxiety and depressive disorder retained

Disorders are subdivided into a large number of categories. e.g.

Dissociative disorders have 7 subcategories.

Somatoform disorders : New category introduced

Neurasthenia is retained

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F50 – F59: Behavioral Syndromes associated with physiological disturbances and physical factors

Contains eating disorders, non-organic sleep disorders, sexual dysfunction, and abuse of non-dependence producing substances.

Disorders associated with puerperium should be used only when cannot classified elsewhere

Psychosomatic disorders (F54) used for somatic diagnosis.

Gender identity disorders and disorders of sexual preferences are not included in this section.

Culture-specific disorders were included

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F60 – F69: Disorders of adult personality and behavior

Include a variety of severe problems, whose solution requires information

that can come only from extensive and time-consuming investigations.

Borderline personality disorder (F60.31) is a subcategory of emotionally

unstable personality disorder (F60.3)

Specific personality disorders except Cyclothymic personality disorder are

included here.

Factitious disorders, Enduring personality changes after catastrophic

experience / psychiatric illness (F62) are new addition.

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F70 – F79: Mental Retardation

Describes mental retardation classification according to severity

Fourth character : degree of impairment of behaviour.

F74 - F77 : unassigned.

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F80 – F89: Disorders of psychological development

24 disorders : onset specific to childhood.

The major disorders include Specific developmental disorders of speech and language, Disorders of scholastic skills, Dysfunction of motor function and PDD.

Oppositional Defiant Disorder : new category introduced

Rette and Asperger disorders are included.

F85 to F87 remain unassigned.

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F90-F98: Behavioural and emotional disorders with onset usually occurring in childhood and adolescence

Many important disorders are described in this block

Hyperkinetic disorders, Conduct disorders, Attachment disorders ,

Elective mutism, Tic disorders and Tourette's syndrome, Nonorganic

enuresis, Nonorganic encopresis, Feeding disorder etc.

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Unspecified mental disorder (F99)

Last category : F99

Left for "unspecified mental disorder" when required.

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Controversy

regarding few sections

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OCD Spectrum Disorders

OCD is currently conceptualized as an anxiety disorder.

Many disorders have similar phenomenology and psychobiology,

and sometimes respond to similar treatments, raise the question of

whether to create a new category of OCD spectrum disorders in

DSM-V and ICD-11.

The construct of an OCD spectrum has significant heuristic appeal,

in sofar as it encourages clinicians to screen for a range of neglected

disorders, and to consider the use of potentially effective treatments

that are also often ignored.

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There is a good deal of evidence that OCD is characterized by disruptions in striatally and serotonergically mediated control processes.

Such a view can potentially integrate a range of findings about compulsive and impulsive phenomena in OCD and related disorders, as well as about their underlying neurobiology.

In OCD, one cluster of co-morbid OC spectrum disorders comprises intermittent explosive disorder, kleptomanias, eating disorders, and stereotypic self-injurious behaviours.

In this view, compulsivity and impulsivity are not diametrically opposed, but rather may lie on orthogonal planes.

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Future work of cognitive-affective processes relevant to OCD may

ultimately result in a reconfiguration of the way in which we

currently view the OCD spectrum of disorders.

There is currently a good deal of excitement about advances in

understanding reward processes, and the possibility that these may

ultimately lead to a better way of conceptualizing and treatment of

these conditions.

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Schizophrenia & other Psychotic Disorders

The use of endophenotypes with specific neurocognitive, neurophysiological or neuroanatomical foundations as a more useful way of categorizing psychotic disorders than the current clinical classifications.

The genetic deconstruction of psychosis: broadening the phenotype of schizophrenia to include most non-affective psychotic disorders better fits genetic factors than more restrictive phenotypes.

The addition of a class to capture cases in prodromal phases will surely be an interesting challenge.

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Other versions of ICD 10

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Other versions of ICD10

ICD-10-DCR: Diagnostic Criteria for Research

Published in 1996.

Strict criteria suitable for research.

Derived from Chapter V of ICD 10.

Text contain General criteria ‘G’, Obligatory criteria A, B, C…., and non-essential

criteria a, b, c…. or 1, 2, 3

Exclusion criteria provided to clarify.

Psychosocial dysfunction are included as diagnostic criteria only if unavoidable e.g.

childhood disorders or personality disorders

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Other versions of ICD10 contd…

Diagnostic and Management guidelines for mental disorders in primary care:

Suitable for busy PHC doctors.

Corresponding codes for international report

Only 24 categories without any subdivision

Flow charts and educational materials

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ICD-10 Primary Health Care List of Categories

Organic Disorders (F0)Dementia F00 Delirium F05Psychoactive substance abuse (F1)Alcohol use disorders F10Drug use disorders F11Tobacco use disorders F17.1Psychotic disorders (F2)Acute psychotic disorders F23Chronic psychotic disorders F20Mood, stress-related, and anxiety disorders (F3 and F4)Bipolar disorder F31Depression F32Phobic disorders F40Panic disorders F41.0Generalized anxiety F41.1Mixed anxiety and depression F41.2Adjustment disorder F43Dissociative (conversion) disorders F44Unexplained somatic complaints F45Neurasthenia F48.0

Physiological disorders (F5)Eating disorders F50Sexual disorders F52Sleep Problems F51Mental retardation (F7)Mental retardation F70Childhood and adolescence (F9)Hyperkinetic disorder F90Conduct disorders of childhood F91Enuresis F98

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Other versions of ICD10 contd…

ICD-10-CM : Clinical modification of the WHO’s ICD-10, which consists of a diagnostic system

Consists of three to seven characters First digit is alpha All letters used except U Second and third digits are numeric Fourth, fifth, sixth, and seventh digits can be alpha or numeric Decimal placed after the first three characters

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ICD-11

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ICD-11 Revision

Goals Evolve an ontologically coherent classification Linked logically to underpinning terminologies Rubrics “defined” by aggregation logics Explicit language definitions Incorporate genomic disease definitions Longitudinal consistency

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ICD-11

The WHO is undergoing the 11th revision of the International Classification of

Diseases! This development of international health information standards is in

accordance with its constitution.

Mission:

To produce an international disease classification that is ready for electronic health

records that will serve as a standard for scientific comparability and communication.

Deliverables:

ICD-11 alpha draft process began September 2009

ICD-11 beta draft process will begin in 2011

ICD final draft will be submitted to WHA by 2014

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Future proposals:

o It will be more etiology based.

o It will incorporate more developmental and life cycle issues.

o Personality disorder and relational disorder will come to axis-I.

o Obsession will include spectrum disorder.

o Some change in Schizophrenia & Other Psychotic Disorders may

come.

ICD-11 is supposed to incorporate major paradigm shift in the thinking related to classification.

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Future proposals contd…

o Child psychiatry section will be reorganized.

o Somatoform disorder will become somatic symptom disorder.

o Understanding of sexual dysfunction will improve.

o Dimensional issues will be included to assist categorical classification

system.

o Issues related to sub threshold psychiatry will retain its place.

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Conclusion

Jasper was prophetic when he remarked, “ When we design a

diagnostic schema, we can only do so if we forego something at the

outset ... And in the face of facts we have to draw the line where none

exists …A classification has only provisional value. It is a fiction which

will discharge its function if it proves to be the most appropriate for the

time”. His words hold true even today and will continue to do so for all

subsequent classification in the future.

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Bibliography

Kaplan and Sadock’s Comprehensive Textbook of Psychiatry, 8th Edition ,2005,p1004-13

The International Statistical Classification of Diseases and related Health problems:1992: Tenth Revision; Vol: I – III

The ICD-10 Classification of Mental and Behavioural Disorders; First Indian Edition 2004 Diagnostic Criteria for Research

The ICD-10 Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines. 2002

N. Sartorius; Understanding the ICD-10 Clasification of Mental Disorders, A Pocket Manual; 2nd edition, 2002

www.wikipedia.org

www.indianpsychiatryj.org

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Thank you

seminar on icd-10

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