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Joaquim Cardoso MSc.
Chief Research Officer (CSO), Chief Editor
Chief Strategy Officer (CSO) and Senior Advisor
August 2, 2023
What is the message?
The ICD-11 has been redesigned by the World Health Organizarion (WHO) as a more comprehensive, fully digital system that, theoretically, could be used off-the-shelf without the need for additional modifications and that would be continually updated and harmonized with other medical information terminologies.
Three major benefits are worth mentioning.
First, ICD-11 introduces many specific diagnoses that were previously left out, enabling more precise and detailed data collection.
Second, ICD-11 introduces a novel clustered code structure comprised of a stem code joined to optional postcoordination codes.
Third, given its semantic linkage to the Systemized Nomenclature of Medicine Clinical Terms (SNOMED-CT), ICD-11 has the potential to support automated or artificial-intelligence–assisted coding.
Nothing comes without a price. First, the new ICD-11 code format requires sophisticated crosswalk mapping of more than 70 000 existing ICD-10-CM codes to their corresponding new ICD-11 codes.
Upgrading to ICD-11 will necessitate a minimum of 4 to 5 years of effort and resources due to its downstream dependencies.
Key takeaways:
- The International Classification of Diseases, 11th Revision (ICD-11) became available for global use on January 1, 2022. The ICD system, originally designed for epidemiological tracking of morbidity and mortality, has evolved to serve various purposes, including billing, reimbursement, health care quality, and research.
- Upgrading to ICD-11 will necessitate a minimum of 4 to 5 years of effort and resources due to its downstream dependencies. The WHO published reference and implementation guides, and extensive testing efforts have been made, but successful rollout in the US health care system requires ongoing and expanded efforts.
- ICD-11 offers several benefits, including more specific diagnoses, a flexible code structure with postcoordination codes, and potential support for automated coding. However, implementation comes with challenges, such as mapping existing ICD-10-CM codes to ICD-11, redesigning billing and quality measures, and updating data processing algorithms and software.
- To ensure preparedness for ICD-11, active exploration throughout the US health care system is essential, engaging all potential end users. Transition tools, such as crosswalk mapping files and dual-coded datasets, should be made available well in advance. Federal-state-industry partnerships and substantial funding are required to support training, implementation, and evaluation.
- Investing in and preparing for ICD-11 is crucial, and end users must assess how it will impact existing processes and share this knowledge within their fields. Standardization and minimization of transition work are essential to meet the diverse needs of ICD-11 end users and ensure a successful implementation.
DEEP DIVE
Preparing for the International Classification of Diseases, 11th Revision (ICD-11) in the US Health Care System
James A. Feinstein, MD, MPH1; Peter J. Gill, MD, DPhil, MSc2; Brett R. Anderson, MD, MBA, MS3
July 28, 2023
The International Classification of Diseases, 11th Revision (ICD-11) became available for use globally as of January 1, 2022.1 The ICD system was originally designed to enable disease-specific epidemiological tracking of morbidity and mortality. Over time, the ICD system has been leveraged for a variety of additional uses, most notably to support billing and reimbursement, health care quality and safety, and health services research (Figure).
Because of the many downstream dependencies, upgrading to the new and powerful ICD-11 system will require a minimum of 4 to 5 years of time, effort, and resources.2 In preparation, the World Health Organization (WHO) published reference and implementation guides, and there are extensive efforts to test ICD-11 before full-scale deployment.1–3
Nevertheless, the successful rollout of ICD-11 across the US health care system will require ongoing and expanded efforts to ensure that ICD-11 meets the diverse needs of its end users. We highlight the major changes in the ICD-11 system, several associated downstream challenges, and key strategies necessary to prepare for the full implementation of ICD-11.
Figure. The Many Uses of the ICD System in the US
This figure summarizes the major aspects of the US health care system that are currently dependent on the ICD system.
The Evolution of the ICD System
Created in the 1800s, the ICD system was initially used to classify causes of death. By 1948, the WHO adopted ICD-6, which formed the basis for the current-day ICD system.4 In 1962, the US Public Health Service began developing customized US-specific versions to increase the utility of the system for classifying hospitalizations and procedures.4
In 1977, the Centers for Medicare & Medicaid Services and the National Center for Health Statistics again adapted ICD-9 through a set of custom clinical modifications (CMs) to enhance diagnostic coding in the US. By 1983, the resulting ICD-9-CM system became integral for the calculation of Medicare payments using Diagnosis-Related Groups. In 2009, the US mandated that the Centers for Medicare & Medicaid Services adopt ICD-10-CM by 2015, which solidified our commitment to using the ICD system across many health care domains (Figure).
Benefits of the New ICD-11 System
Like the US, many other countries have made customized modifications to the ICD system, leading to inconsistent worldwide implementation.5 Consequently, the WHO redesigned ICD-11 as a more comprehensive, fully digital system that, theoretically, could be used off-the-shelf without the need for additional modifications and that would be continually updated and harmonized with other medical information terminologies.1
Three major benefits are worth mentioning. First, ICD-11 introduces many specific diagnoses that were previously left out, enabling more precise and detailed data collection. New classes of codes (eg, Diseases of the Immune System) and more than 5500 rare diseases are now represented.1
Second, ICD-11 introduces a novel clustered code structure comprised of a stem code joined to optional postcoordination codes.1 Multiple postcoordination codes can be combined to convey various clinical details, for example, laterality or severity. This makes the system flexible and clinically useful without the need for local customizations that are time-consuming, costly, and interfere with international comparisons.
Third, given its semantic linkage to the Systemized Nomenclature of Medicine Clinical Terms (SNOMED-CT, the international standard for the exchange of electronic clinical health information), ICD-11 has the potential to support automated or artificial-intelligence–assisted coding.2
Challenges Associated With ICD-11 Implementation
Nothing comes without a price. First, the new ICD-11 code format requires sophisticated crosswalk mapping of more than 70 000 existing ICD-10-CM codes to their corresponding new ICD-11 codes. This is not a straightforward 1-to-1 process. In a 2021 study, only 23.5% of ICD-10-CM codes could be fully represented by a single ICD-11 stem code, meaning that clinicians and coders will have to assign multiple postcoordination codes to capture the same level of information contained within single ICD-10-CM codes.6
Second, every ICD-dependent process will be affected. All billing and quality measures will require redesign. Data processing algorithms, statistical programs, and classification software that handle ICD codes will need to be updated. For example, the Healthcare Cost and Utilization Project maintains ICD-based analytical tools used to inform national health care decisions that have only recently finished being updated to ICD-10-CM; similar lags in translation to ICD-11 will have consequences.
Finally, the new clustered code structure has major ramifications. Data standards for electronic health record systems and databases will need to be modified to accommodate the longer character lengths necessary to store ICD-11 codes using the clustered code structure. Even with the correct technology, whether health care systems and bedside clinicians fully use clustered codes will depend on contextual reporting requirements, proper education, and the necessary information technology and workforce to implement ICD-11. Differences in implementation strategies between institutions could result in differential data quality and affect revenue, further exacerbating inequities across the health care system.
Ensuring Preparedness for ICD-11
More than 60 countries have already adopted ICD-11 and evaluated its performance across different scenarios, ranging from case-mix adjustment to adverse event reporting.3
As the US similarly implements ICD-11, several key strategies can promote success.
First, as recommended by the Department of Health and Human Services, active exploration of ICD-11 must continue broadly throughout the US health care system and should engage all potential end users.7
Although US governmental agencies have begun evaluations of major ICD-dependent processes, there are numerous other inconspicuous but important use cases; end users are best positioned to identify these for further attention.8–10
Second, many of the implementation endeavors rely on the availability of transition tools, like crosswalk mapping files, translation software, and dual-coded data sets (including both ICD-10-CM and ICD-11 codes). These should be created and made publicly available well before the anticipated transition date.
Finally, all of these efforts will require federal-state-industry partnerships, including substantial grant funding and project resources, to support the training, implementation, and evaluation of the transition to ICD-11 across all aspects of health care.8
Conclusions
Because the ICD system provides the disease classification infrastructure for the US health care system, we must continue to invest in and prepare for ICD-11. End users should consider how ICD-11 will affect existing ICD-dependent processes within their fields and share this knowledge upward within health care systems. Solutions can then be tested and implemented to standardize and minimize the required transition work. This will ensure that ICD-11 meets the many needs of its end users.
References
See the original publication (this is an excerpt version)
Author
James A. Feinstein, MD, MPH, Adult and Child Center for Outcomes Research and Delivery Science (ACCORDS), University of Colorado, 1890 N Revere Ct, Third Level, Mail Stop F443, Aurora, CO 80045 (james.feinstein@cuanschutz.edu).
Originally published at https://jamanetwork.com
