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Seminar on icd 10


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Seminar on icd 10

  1. 1. LOGO Seminar on ICD-10: An Overview :: Moderator :: Dr. J. N. Das Assistant Professor :: Speaker :: Dr. Santanu Ghosh Postgraduate Student Department of Psychiatry, Assam Medical College 2nd November, 2010 1
  2. 2. 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 2
  3. 3. 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 3
  4. 4. 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 4
  5. 5. 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. 5
  6. 6. 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) 6
  7. 7. 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. 7
  8. 8. Types of classification approaches Categorical vs. dimensional Descriptive vs. etiological Syndrome vs. symptom 8
  9. 9. 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 9
  10. 10. 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 10
  11. 11. Evolution of ICD 11
  12. 12. 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. 12
  13. 13. 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 13
  14. 14. 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 14
  15. 15. Historical background contd… 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 reduced list of 44 titles. 15
  16. 16. Historical background contd… 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. 16
  17. 17. Historical background contd… 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 17
  18. 18. Historical background contd… 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 18
  19. 19. 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. 19
  20. 20. ICD Revision Process Drafting  Taxonomic Guidelines  Definition, Diagnosis and Indexing / mapping guidelines Overall Structure Individual Chapters Overseeing the TOTAL ICD • ALPHA Draft – structured comments • BETA Draft – field testing Final Draft World Health Assembly Approval
  21. 21. 21
  22. 22. 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 22
  23. 23. 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. 23
  24. 24. The basic structures & Principles 24
  25. 25. 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 ( ), [ ], † , *, -
  26. 26. 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 26
  27. 27. Volumes: 27 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
  28. 28. 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 28
  29. 29. ICD 10 : Composition Of Chapters Chapter number an designation I Certain infectious and parasitic diseases II Neoplasms III Disease of the blood and blood forming organs and certain disorders involving the immune mechanism IV Endocrine, nutritional and metabolic diseases V Mental and behavioral disorders VI Diseases of the nervous system VII Diseases of the eye and adnexa VIII Diseases of the ear and mastoid process IX Diseases of the circulatory system X Diseases of the respiratory system Range of codes A00-B99 C00-D48 D50-D89 E00-E90 F00-F99 G00-G99 H00-H59 H60-H95 I00-I99 J00-J99
  30. 30. 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
  31. 31. 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
  32. 32. 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)
  33. 33. 33 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
  34. 34. 34 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
  35. 35. 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 35
  36. 36. 36 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
  37. 37. Additional nomenclature contd… 37  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
  38. 38. 38 Multi-axial presentation Published in 1997 Comprises of three axes: Axis I : Clinical diagnosis Axis II : Disability Axis III : Contextual factors
  39. 39. 39 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
  40. 40. 40 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.
  41. 41. 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 41
  42. 42. Problem encountered with ICD-10 • Developmental aspects not given due importance • Gaps in classification • Death of phenomenology • Difficulty of use in diverse populations & settings 42
  43. 43. Selected categories in the ICD-10 43
  44. 44. 44 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
  45. 45. 45 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.
  46. 46. 46 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
  47. 47. 47 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.
  48. 48. 48 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
  49. 49. 49 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
  50. 50. 50 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.
  51. 51. 51 F70 – F79: Mental Retardation  Describes mental retardation classification according to severity  Fourth character : degree of impairment of behaviour.  F74 - F77 : unassigned.
  52. 52. 52 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.
  53. 53. 53 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.
  54. 54. 54 Unspecified mental disorder (F99) Last category : F99 Left for "unspecified mental disorder" when required.
  55. 55. Controversy regarding few sections 55
  56. 56. 56 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.
  57. 57. 57 OCD Spectrum Disorders  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.
  58. 58. 58 OCD Spectrum Disorders  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.
  59. 59. 59 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.
  60. 60. Other versions of ICD 10 60
  61. 61. 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 61
  62. 62. 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 62
  63. 63. 63 ICD-10 Primary Health Care List of Categories Organic Disorders (F0) Dementia F00 Delirium F05 Psychoactive substance abuse (F1) Alcohol use disorders F10 Drug use disorders F11 Tobacco use disorders F17.1 Psychotic disorders (F2) Acute psychotic disorders F23 Chronic psychotic disorders F20 Mood, stress-related, and anxiety disorders (F3 and F4) Bipolar disorder F31 Depression F32 Phobic disorders F40 Panic disorders F41.0 Generalized anxiety F41.1 Mixed anxiety and depression F41.2 Adjustment disorder F43 Dissociative (conversion) disorders F44 Unexplained somatic complaints F45 Neurasthenia F48.0 Physiological disorders (F5) Eating disorders F50 Sexual disorders F52 Sleep Problems F51 Mental retardation (F7) Mental retardation F70 Childhood and adolescence (F9) Hyperkinetic disorder F90 Conduct disorders of childhood F91 Enuresis F98
  64. 64. 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 64
  65. 65. ICD-11 65
  66. 66. 66 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
  67. 67. 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 67
  68. 68. 68 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.
  69. 69. Future proposals contd… 69 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.
  70. 70. Conclusion 70 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.
  71. 71. 71 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  
  72. 72. Thank you 72