What is ICD? Different uses of ICD. Evolution and changes in ICD. New features in ICD 11. How it will help in healthcare.

1. International
Classification of Diseases
Presented by: Dr Arijit Kundu
Guided by: Prof. Sumitra Pattanaik

2. WHO Family of International Classifications
The WHO Family of International Classifications (WHO-FIC) is
comprised of classifications to describe various aspects of the health
and the health system in a consistent manner.
The purpose of FIC is to assist the development of reliable
statistical systems at local, national and international levels, with the
aim of improving health status and health care.

3. Family of International Classification (FIC)
I nternational
C lassification of
D iseases
I nternational
C lassification of
F unctioning,
D isability & Health
I nternational
C lassification of
H ealth
I nterventions
(under development)
RELATED Classifications
International Classification of
Primary Care (ICPC)
International Classification of
External Causes of Injury
(ICECI)
The Anatomical, Therapeutic,
Chemical (ATC) classification
system with Defined Daily
Doses (DDD)
ISO 9999 Technical aids for
persons with disabilities –
Classification and
Terminology
DERIVED Classifications
International Classification of
Diseases for Oncology,
Third Edition (ICD-O-3)
The ICD-10 Classification of
Mental and Behavioural
Disorders
Application of the International
Classification of Diseases to
Dentistry and Stomatology,
Third Edition (ICD-DA)
Application of the International
Classification of Diseases to
Neurology (ICD-10-NA)
ICF, Children & Youth Version
(ICF -CY)
REFERENCE
Classifications

4. Population Health
• Births
• Deaths
• Diseases
• Disability
• Risk factors
ICD
ICF
ICHI
Classifications
Clinical
• Decision Support
• Integration of care
• Outcome
• Research
Administration
• Scheduling
• Resources
• Billing
• Policy Making
Reporting
• Cost based
• Needs based
• Outcome based
Applications of Classification

5. International Classification of Diseases is the international
"standard diagnostic tool for epidemiology, health
management and clinical purposes."
Can be defined as a system of categories to which morbid entities
are assigned according to established criteria.
Used to translate diagnoses of diseases and other health problems
from words into an alphanumeric code.
Introduction

6. Why to use classification ?
• To allow easy storage, retrieval and analysis of data
• To allow systematic recording, analysis, interpretation and
comparison of mortality and morbidity data between hospitals,
provinces and countries
• To allow comparisons in the same location across different
time periods

7. The International Classification of Diseases (ICD) is a
system, developed collaboratively between the World Health
Organization (WHO) and 10 international centers so that the
medical terms reported by physicians, medical examiners, and
coroners on death certificates can be grouped together for
statistical purposes.
Development of ICD

8. Evolution of ICD
• First attempts to systematically classify diseases were made in 17th & 18th
century.
• During 17th century, John Graunt recognized the need to organize
mortality data into some logical form and therefore developed the first
statistical study of disease, called the London Bills of Mortality.
• In this work, Graunt classified the deaths of all children who were born
alive but who died before they reached the age of six.
• Resulting classifications were considered to be of little utility, due to
inconsistencies in nomenclature and poor statistical data.

9. First medical statistician of
the General Register Office
of England and Wales
submitted his Report in
1855 on nomenclature and
statistical classification of
diseases,
in which
he included most of those
fatal diseases that affect
health.
William Farr
(1807-1883)
Evolution of ICD

10. A Beginning of Modern
Classification
Jacques Bertillon(1851-1922)
Chief of Statistical
Services of Paris,
prepared classification
based on the principle of
distinguishing between
general diseases and those
localized to a particular
organ or anatomical site.
This was adopted in 1893.

11. ICD: History (cont.)
1893 ISI adopted 1st edition of international
classification system: The International List
of Causes of Death
1899 “Causes of Death” adopted by some
American and European countries
New ICD edition approximately every 10
years
ICD-2 (1910-1920) renamed: International
Classification of Causes of Sickness and
Death
ICD-4 (1930-1938), transfer to
categories based on etiology

12. ICD: History (cont.)
ICD-5 (1939-1948), comparability between
successive ICD versions
ICD-6 (1949-1957), WHO entrusted ICD as its criterion: International
Classification of Diseases, Injuries, and Causes of Death:
• For the first time included morbidity
• New main category: Mental, Psychoneurotic, and Personality Disorders
ICD-7 Seventh Revision Conference was held in
Paris in 1955 and, the revision was limited to
essential changes.
ICD-8 (1968-1978) Expanded cross-indexing
hospital clinical records

13. ICD: History (cont.)
ICD-9 (1979-1994) Included narrative MBD descriptions
similar to DSM-II language.
• 1978 refined classification and diagnosis of mental disorders
• 1982 diagnostic instruments and algorithms shaped and refined
ICD-10 was endorsed by the Forty-third World Health
Assembly in May 1990 and came into use in WHO
Member States as from 1994.
India adopted this classification in 2000.
ICD-11 launched on 18th June,2018.

14. 120+ years of ICD History
ICD-1
International List
of Causes
of Death
1893
ICD- 2
International List
of Causes
of Sickness
and Death
1909 1929
ICD- 4
Categories
based on
etiology
ICD- 6
International
Classification of
Diseases, Injuries
and Causes of Death
1948
Mental, Psychoneurotic
and Personality Disorders
1975
ICD- 9
Narrative descriptions
of Mental & Behavioral
disorders
1990
ICD- 10
ICD- 11
2017-2018

15. Primary users
Users include
 Physicians,
 Nurses,
 Health workers,
 Researchers,
 Health information managers,
 Policy-makers,
 Insurers and
 National health program managers

16. Structure and Principles of ICD
Originally conceived by William Farr
 The Classification is grouped as below:
Epidemic diseases
Constitutional or general diseases
Local diseases arranged by site
Developmental diseases
Injuries.

17. ICD-9 & ICD-10
 Much larger than ICD-9
 ICD-10 has 21 chapters against 17 Chapters in ICD-9
 Numeric codes ( 001-999 ) were used in ICD-9 where as an
alphanumeric coding, (A00-Z99) has been adopted in ICD-10.
 It enlarged the number of categories available for the classification.
 Further detail by means of decimal numeric subdivisions at the
four character level.

18. Volumes of ICD-10
 Volume 1: Tabular list
 Volume 2: Instruction
manual
 Volume 3: Alphabetical
Index

19. Volume 1: Tabular list
An alphanumeric listing of
diseases and disease groups, along
with inclusion and exclusion notes,
some coding rules, special
tabulation lists for mortality and
morbidity, definition and
regulation.

20. Volume 2: INSTRUCTION MANUAL
It provides
Instructions on how to use
volume 1 and 3.
Guidelines for certification
and rules for mortality coding
Guidelines for recording and
coding for morbidity coding
Statistical presentation

21. Volume 3: Alphabetical index
Is the comprehensive
Alphabetical index of the
diseases and conditions
found in the tabular list

22. Chapters of ICD-10
The ICD-10 contains 21 chapters, each of which identified by a
Roman numeral.
Chapters I to XVII: Diseases and other morbid conditions.
Chapter XVIII: Symptoms, signs and abnormal clinical and
laboratory findings, not elsewhere classified.
Chapter XIX: Injuries, poisoning and certain other consequences
of external causes.
Chapter XX: External causes of morbidity and mortality.
Chapter XXI: Factors influencing health status and contact with
health services.

23. Chapters of ICD-10
15 of the chapters have a single letter assigned to them and
use most of the 100 categories available
Chapters have a smaller range of categories assigned to
them and share letters
4 chapters use more than one letter in defining the scope of
their categories

24. Chapter Chapter Title Codes
I Infectious and parasitic diseases A00-B99
II Neoplasms C00-D49
III Diseases of the blood & blood-forming organs & disorders of the
immune mechanism
D50-D59
IV Endocrine, nutritional and metabolic diseases E00-E99
V Mental and behavioral disorders F00-F99
VI Diseases of the nervous system G00-G99
VII Diseases of the eye and adnexa H00-H59
VIII Diseases of the ear and mastoid process H60-H99
IX Diseases of the circulatory system I00-I99
X Diseases of the respiratory system J00-J99
XI Diseases of the digestive system K00-K99
XII Diseases of the skin and subcutaneous tissue L00-L99
Tabular List of Chapters

25. Chapter Chapter Title Codes
XIII Diseases of the musculoskeletal system & connective tissue M00-M99
XIV Diseases of the genitourinary system N00-N99
XV Pregnancy, childbirth and the puerperium O00-O99
XVI Certain conditions originating in the perinatal period P00-P99
XVII Congenital malformations, deformations, and chromosomal
abnormalities
Q00-Q99
XVIII Symptoms & abnormal clinical & lab findings, not elsewhere
classified
R00-R99
XIX Injury, poisoning and certain other consequences of external
causes
S00-T99
XX External causes of morbidity and mortality V00-Y99
XXI Factors influencing health status & contact with health services Z00-Z99
Tabular List of Chapters

26. Basic coding guidelines
The basic ICD is a single coded list of three- character
categories, each of which can be further divided into up to 10 four-
character subcategories.
Three-character categories is mandatory level of coding for
international reporting to the WHO mortality database and for
general international comparisons.
Tenth Revision uses an alphanumeric code with a letter in the first
position and a number in the second, third and fourth positions.

27. Some three-character categories have been left vacant for
future expansion / Revision
Codes U00–U49 are to be used by WHO for the provisional
assignment of new diseases of uncertain etiology.
Codes U50–U99 may be used in research, e.g. when testing
an alternative sub-classification for a special project.
Basic coding guidelines

28. The fourth character follows a decimal point.
Possible code numbers therefore range from A00.0 to
Z99.9.
Fill fourth position with X , when sub-division is not there, so
that the codes are of a standard length for data-processing.
A N N . N
Basic coding guidelines

29. Structure of ICD-10 Codes
 The chapters are subdivided into homogeneous "blocks" of three-
alphanumeric character categories.
 Example:
Chapter I: (A00-B99): Certain infectious and parasitic disease
A00-A09 Intestinal infectious diseases
A15-A19 Tuberculosis
A20-A28 Certain zoonotic bacterial diseases
A30-A49 Other bacterial diseases

30. Structure of ICD-10 Codes
The classification itself at the three character level
 Certain infectious and parasitic diseases (A00-B99)
 Intestinal infectious diseases (A00-A09)
A00 Cholera
A01 Typhoid and paratyphoid fevers
A02 Other salmonella infections
A03 Shigellosis
A04 Other bacterial intestinal infections
A05 Other bacterial foodborne intoxications
A06 Amoebiasis
A07 Other protozoal intestinal diseases
A08 Viral and other specified intestinal infections
A09 Diarrhoea & gastroenteritis of presumed infectious origin

31.  Classification at the four character level
Amoebiasis (A060 to A069)
A06.0 Acute amoebic dysentery
A06.1 Chronic intestinal dysentery
A06.2 Amoebic non-dysenteric colitis
A06.3 Amoeboma of intestine
A06.4 Amoebic liver abscess
A06.5† Amoebic lung abscess (J99.8*)
A06.6† Amoebic brain abscess (G07*)
A06.7 Cutaneous Amoebiais
A06.8 Amoebic infection of other parts of body
A06.9 Amoebiais unspecified
Structure of ICD-10 Codes

32. 1. Dagger and Asterisk
2. Inclusion Terms
3. Exclusion Terms
4. Parentheses ( )
5. Square Brackets [ ]
6. Colon :
7. Brace }
8. Not Otherwise Specified NOS
9. Not Elsewhere Classified NEC
10. AND in code titles
11. Point Dash
12. Additional codes
Special signs

33. 1. The “dagger and asterisk” system
 Additional codes for fine tuning
 Dagger (†) - Used for the underlying disease
It points at the root cause/main condition
 Asterisk (*) - Manifestation of primary disease
i.e. it points at the secondary cause
• The dagger & asterisk code should be used together and the dagger
code is preferred as main code.
• ICD-10 classification suggests that the “Main Condition” can be
made more specific by addition of another code.
Special signs

34. Example:
Amoebiasis (A060 to A069)
A06.0 Acute amoebic dysentery
A06.1 Chronic intestinal dysentery
A06.2 Amoebic nondysenteric colitis
A06.3 Amoeboma of intestine
A06.4 Amoebic liver abscess
A06.5† Amoebic lung abscess (J99.8*)
A06.6† Amoebic brain abscess (G07*)
A06.7 Cutaneous amoebiasis
A06.8 Amoebic infection of other parts
A06.9 Amoebiais unspecified
Intracranial & intraspinal abscess (G07*)
Abscess of Brain
• Amoebic brain abscess (A06.6 †)
• Gonococcal abscess (A54.8 †)
• Tuberculous abscess (A17.8 †)
Dagger (†) - Used for the root cause
Asterisk (*) – Used for the
secondary cause

35. 2. Inclusion Terms
Usually listed within the three and four character categories, may also
be at block or chapter level
Examples of the different conditions or synonyms for the condition
coded to that category
Not a sub-classification
3. Exclusion Terms
List of conditions that are to be coded elsewhere, not to the code being
looked at.
The correct code is in parentheses.
Special signs

36. Tuberculosis (A15-A19)
Incl.: Infections due to Mycobacterium tuberculosis and
Mycobacterium bovis
Excl.: congenital tuberculosis (P37.0)
human immunodeficieny [HIV] disease resulting in
tuberculosis (B20.0)
pneumoconiosis associated with tuberculosis (J65)
sequelae of tuberculosis (B90.-)
silicotuberculosis (J65)
Example:

37. 4. Parentheses ( )
Enclose supplementary words
Enclose the code for the exclusion term
Enclose the three character codes of categories in a block
Enclose the dagger code in an asterisk category or the asterisk
code in a dagger term
Special signs

38. 5. Square Brackets [ ]
 For enclosing synonyms, alternative words or explanatory
phrases
 For referring to notes
 For referring to fourth character subdivisions common to a
number of categories
Special signs

39. 6. Colon :
Used in lead terms and listings of inclusion and exclusion terms
when the words in the list need an essential modifier to allow
assignment of the specified code
Example:
G71.0 Muscular dystrophy :
• autosomal recessive
• benign [Becker]
• distal
Special signs

40. 7. Brace }
 Used to link a series of terms
 Each term on the left of the brace must be modified by at
least one of the terms to the right of the brace before the
specific code can be assigned
Special signs

41. 8. Not Otherwise Specified (NOS)
 Means unspecified or unqualified
 Only used if no other information exists to allow assignment of
a more specific code
 Example:
K14.9 Disease of tongue, unspecified
Glossopathy NOS
Special signs

42. 9. Not Elsewhere Classified (NEC)
 Used as a warning that specific types of the condition being
coded appear elsewhere in the classification
 If more specific information is available, a different code may
be selected
 Example:
K73.2 Chronic hepatitis, not elsewhere classified
Special signs

43. 10. “AND” in code titles
 "and" stands for "and/or” in code titles
 Example: S49.9 Unspecified injury of shoulder and upper arm
 Means that here we can code the following:
unspecified injury of shoulder
unspecified injury of upper arm
unspecified injury of shoulder and upper arm
Special signs

44. 11. Point Dash .-
 Indicates to the coder that a fourth character exists and should be
sought at category, block or chapter level
 Example: D59.1 Other autoimmune haemolytic anaemias
Excludes: haemolytic disease of fetus and newborn (P55.-)
Tabular List Conventions

45. 12. Additional codes
 ICD-10 sometimes indicates when coding can be made more
specific by the addition of another code
 instructions such as
use additional external cause code, if desired, to
identify cause
use additional code (B95-B97) to identify infectious
agent
Tabular List Conventions

46. Volume 3 (Alphabetical index)
 Volume 3 is divided into three sections as follows:
 Section-I lists all the terms classifiable to Chapters I-XIX and
Chapter XXI, except drugs and other chemicals.
 Section II is the index of external causes of morbidity and mortality
and contains all the terms classifiable to Chapter XX, except drugs
and other chemicals.
 Section III gives Table of Drugs and Chemicals lists for substance
the codes for poisonings & adverse effects of drugs (under Chapter
XIX )

47.  Size of the Classification
 No formal training
 No user-friendly software to guide
 Inadequate staff in MRD
 Use of nonstandard abbreviations
 Delay/ incomplete case sheets
 Procedure (instead of diagnosis) are written
 Manually done – very slow and difficult
Problem encountered

48. ICD - 11
 Need for an 11th Revision
• ICD-10, despite the updating process, ICD-10 was clinically outdated
• Structural changes were needed to some chapters
• Increasing need to operate in an electronic environment
• Need to capture more information for morbidity
Launched on 18th June, 2018.

49. ICD-11: Features
About 300 specialists of 55 countries, organized in 30 main working groups
have provided their input to make ICD-11 scientifically up-to-date, and
structural problems that became apparent using ICD-10 have been solved.
ICD-11 is much easier to use than ICD-10.
The systematic reliance on the use of code combinations and extension codes
makes ICD finally clinically relevant.
Primary care, cancer coding, traditional medicine and a section for assessment
of functioning are now included.

50. ICD-11: Features
Special versions, as for mental health, primary care, or dermatology are
produced.
ICD-11 is truly multilingual.
ICD-11 is based on the electronic foundation component that contains all
content, structural information, references in a machine readable format. The
content is then rendered for machine or human use, electronically or in print.
ICD-11 is digital health: The system allows connection of any software
through a standard API. The same package is also prepared for offline use.

51. ICD-11: Features
In ICD-11, each disease entity has a description that give key descriptions
and guidance in meaning of the entity/category is in human-readable terms,
to guide users.
Definitions have a standard structure according to a template with standard
definition templates and further features exemplified in a "Content Model".
The Content Model is a structured framework that captures the knowledge
that reinforces the definition of an ICD entity.
Each ICD entity can be seen from different dimensions or "parameters".

52.  For example, there are currently 13 defined main parameters in the Content
Model to describe a category in ICD:
1) ICD Entity Title - Fully Specified Name
2) Classification Properties - disease, disorder, injury, etc.
3) Textual Definitions - short standard description
4) Terms - synonyms, other inclusion and exclusions
5) Body System/Structure Description - anatomy and physiology
6) Temporal Properties - acute, chronic or other
ICD-11: Features

53. 7) Severity of Subtypes Properties - mild, moderate, severe, or other scales
8) Manifestation Properties - signs, symptoms
9) Causal Properties - etiology: infectious, external cause, etc.
10)Functioning Properties - impact on daily life: activities and participation
11)Specific Condition Properties - relates to pregnancy etc.
12)Treatment Properties - specific treatment considerations: e.g. resistance
13)Diagnostic Criteria - operational definitions for assessment
ICD-11: Features