This web-exclusive Journal column highlights public policy initiatives at the federal- and state-level that impact the HIM profession, including news on AHIMA’s national and affiliated state advocacy initiatives, Congressional updates, news from federal regulatory agencies, public policy updates from state legislatures, and AHIMA’s public policy initiatives with other organizations.
By Sue Bowman, MJ, RHIA, CCS, FAHIMA
In June 2018, the World Health Organization (WHO) released a version of ICD-11 to allow countries to begin planning for implementation. This version came 18 years after WHO launched ICD-10. ICD-11 was adopted by the World Health Assembly on May 25, 2019 and will go into effect on January 1, 2022, which means that is the earliest any country can implement ICD-11. While there may be a few early adopters who implement ICD-11 soon after the effective date, many countries will not be ready to transition to ICD-11 until later.
Reasons WHO decided to move forward with development of an 11th revision of the International Classification of Diseases (ICD) included:
- ICD-10 is outdated both clinically and from a classification perspective
- Substantial structural changes were needed to some chapters
- Necessary changes could not be handled under the normal ICD-10 updating mechanisms
- There is an increasing need to operate in an electronic environment
- There was a recognized need to capture more information, especially for morbidity purposes
Historically, the ICD was intended for mortality data reporting, but has increasingly been used for morbidity data reporting applications. Previous revisions of the ICD responded to these expanding needs in an ad hoc fashion, but ICD-11 was designed to support multiple use cases.
ICD-11 has been updated for the 21st century and reflects critical advances in science and medicine. It is fully electronic and can be well integrated with electronic health applications and information systems. Major differences in ICD-11 include the use of extension codes to capture information such as temporality, severity, and anatomic detail, and the introduction of code clustering, or combining two or more codes in an explicit post-coordinated way to describe a diagnostic entity. For example, the code cluster DA63/ME24.90 represents the concepts of duodenal ulcer and associated acute gastrointestinal bleeding. Some chapters and sections in ICD-11 have been restructured (e.g., infectious diseases, HIV, valve diseases) and some diseases have changed location (e.g., cerebrovascular diseases moved from the circulatory to the nervous system chapter). There are six new chapters (Diseases of Blood and Blood-forming Organs, Disorders of the Immune System, Conditions Related to Sexual Health, Sleep-Wake Disorders, Extension Codes, and Traditional Medicine).
New and improved electronic tools have been developed to facilitate the use of ICD-11, including coding, browsing, and mapping tools. WHO has produced an ICD-11 implementation package, which includes an ICD-11 Browser, Coding Tool, Reference Guide, and a Transition Guide. The web-based browser tool allows the user to retrieve concepts by searching terms, anatomy, or another element in ICD-11. The browser also allows users to contribute to updates and continuous improvement of ICD-11 via a proposal platform. The Coding Tool works by searching ICD-11 content as the user types in a term. It generates a word list, and matches entities with a link to the Browser and the chapter(s) associated with the target term. The Reference Guide provides guidance on the structure, conventions, and use of ICD-11. The Transition Guide, which is still under development, outlines important issues that countries need to consider in the lead-up to and during transition from an existing ICD environment to eventual implementation of ICD-11.
A number of World Health Organization-Family of International Classifications (WHO-FIC) committees and workgroups contribute to the development and maintenance of ICD-11 and associated educational and implementation resources. One of these groups is the Morbidity Reference Group (MbRG), whose purpose is to improve international comparability of morbidity data and the application of ICD in morbidity. Sue Bowman, MJ, RHIA, CCS, FAHIMA, AHIMA’s senior director of coding policy and compliance, is a US representative to this group. The MbRG recently met in Malmo, Sweden, where one of the major topics was ICD-11 transition planning. A value proposition was also felt to be important in order help sell why countries should transition to ICD-11. Difficulty in “selling” the value of transitioning to ICD-10-CM/PCS was one of the major obstacles to the recent implementation of these code sets in the US. As part of the transition planning discussion at the MbRG meeting, individual countries reported on their ICD-11 transition planning activities to date. In general, most countries are in the process of reviewing projected timelines and resources needed, preparing translations if necessary, and discussing how and where ICD-11 will be used. There was general agreement that any implementation plan must include:
- An evaluation of ICD-11 for national purposes
- Impact analysis
- Value proposition for stakeholders
- Risk assessment
- Identification of stakeholders
- Resource planning
- Communication plan
- Training plan
These activities should sound familiar to AHIMA members, as they represent the same implementation planning processes undertaken for the recent US transition to ICD-10-CM/PCS. It was acknowledged by other MbRG members that the US implementation experience will provide useful information in terms of best practices and lessons learned for international ICD-11 transition planning. The MbRG discussed the importance of extensive and early communication targeted to different stakeholder groups.
Refinements to the ICD-11 Reference Guide were also discussed at the recent MbRG meeting. In particular, coding issues related to quality and patient safety were discussed, including the application of a three-part conceptual model. Under this model, ICD-11 codes are assigned for three components:
- Harm to the patient
- Cause or source of harm
- Mode or mechanism
Potential mapping initiatives were another topic covered during the meeting. There will be a need to develop a map between ICD-11 and ICD-10, SNOMED CT or other terminologies, and quality measures. MbRG members from Canada reported on a University of Calgary ICD-11 coding study to evaluate the quality of coding with ICD-11 compared to ICD-10 and assess ICD-11 training requirements. In this study, six coding experts coded 3,000 medical records using ICD-11 after receiving ICD-11 coding training. Feedback from study participants indicated that group discussions and lots of coding practice were beneficial in gaining proficiency in ICD-11 coding. Areas that participants found particularly challenging were mental health and patient safety-related codes. Finding medical record documentation for the cause and mode of harm in the three-part patient safety model was sometimes difficult. Knowing how much detail to code was also challenging, but country-specific coding guidelines will be helpful. One particularly interesting finding from this study was that coding productivity quickly returned to ICD-10 levels.
It is unknown when the US will implement ICD-11. Hopefully, the transition process will not take as long as the implementation of ICD-10-CM/PCS did. The National Committee on Vital and Health Statistics (NCVHS) sent a letter to the Secretary of Health and Human Services (HHS) recommending a simplified process for adopting new versions of ICD going forward. Specifically, the NCVHS recommended that HHS should use sub-regulatory processes to make version updates to the ICD in the same way it handles updates to all the other named HIPAA code set standards. The NCVHS also recommended in this same letter that HHS should invest now in a project to evaluate ICD-11 and develop a plan that will enable a smooth and transparent transition from ICD-10 to ICD-11 at the optimal time. Discussions around ICD-11 transition planning have already begun at the federal level. The NCVHS is holding an expert roundtable meeting, “Evaluating Pathways to ICD-11,” in Washington, DC in August. Bowman has been invited to participate on behalf of AHIMA.
Sue Bowman (firstname.lastname@example.org) is senior director, coding policy and compliance at AHIMA.