ICD-10 diagnosis and procedure codes:
enhanced safety surveillance in U.S. healthcare databases
April 20, 2016
M I C H A E L B U LG R I E N , S E N I O R A N A LY S T
G R E T C H E N D I E C K , V I C E P R E S I D E N T, S A F E T Y, E P I D E M I O L O G Y A N D R I S K M A N A G E M E N T
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1
Presentation Overview
Michael L. Bulgrien
ICD-10-CM/PCS: History,
Description, and Enhancements
Analytic Scenarios that Integrate
ICD-9 and ICD-10 Codes
Translation Tools (Crosswalks)
that Map Between ICD-9/10
Gretchen S. Dieck, Ph.D.
Enhancements with ICD-10 for
Active Drug Safety Surveillance
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2
ICD-10 / GEMs Overview
ICD-10 Challenges for Data Analytics
Translating, Mapping & Grouping
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3
Preparing for ICD-10: A look back through time
Did you know?
World Health Organization began work on ICD-10
33 years ago
The 1st U.S. prototype of ICD-10-CM was created
22 years ago
ICD-10-PCS was formally tested
19 years ago
ICD-10-PCS training material and crosswalk to
ICD-9-CM (Volume 3) procedure codes was finalized
18 years ago
ICD-10 mortality reporting was implemented
15 years ago
ICD-10-CM was formally tested
13 years ago
ICD-10-PCS received 12 years of annual updates
ICD-10-CM received 7 years of annual updates
Prior to 2010
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(partial code freeze)
4
A New United States National Coding Standard
U.S. national coding standard
for
Diagnoses (ICD-10-CM)
and
Hospital Inpatient Procedures (ICD-10-PCS)
with
Dates of Service
or
Dates of Discharge
on or after
October 1st 2015
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5
Benefits of the New ICD-10-CM Coding System
IDC-9-CM
IDC-10-CM
001.xx
⁞
999.xx
October
1st
• Outdated (40 years old)
• Limited room for
code set expansion
• Lacking laterality
• Limited specificity
2015
A00.xxxx
⁞
Z99.xxxx
• Updated
annually
• Expandable Left
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Right
(Laterality)
6
Organizational Similarities & Differences
14,025 codes
(3-5 characters)
thinkstockphotos.com (494120597, 139676789).
69,823 codes
(3-7 characters)
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7
Organizational Similarities & Differences
3,882
codes
(3-4 characters)
thinkstockphotos.com (494120597, 516901238, 146927182).
71,924
codes
(7 characters)
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8
Organizational Similarities & Differences
001-139
Ch. 1 (A00-B99)
140-239
Ch. 2 (C00-D49)
240-279
Ch. 3 (D50-D89)
280-289
Ch. 4 (E00-E89)
290-319
Ch. 5 (F01-F99)
320-389
Ch. 6 (G00-G99) Nervous system
Ch. 7 (H00-H59) Eye & adnexa
Ch. 8 (H60-H95) Ear & mastoid process
390-459
Ch. 9 (I00-I99)
460-519
Ch. 10 (J00-J99)
520-579
Ch. 11 (K00-K95)
Infectious/parasitic diseases
Neoplasms
Neoplasms
Endocrine/nutritional/metabolic
& immunity disorders
Blood, blood-forming organs
Mental, behavioral,
Neurodevelopmental
Respiratory system
Digestive system
Blood, blood-forming organs
& immunity disorders
Endocrine/nutritional/metabolic
Neurodevelopmental
Nervous system & sense organs
Circulatory system
Infectious/parasitic diseases
Circulatory system
Respiratory system
Digestive system
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9
Organizational Similarities & Differences
001-139
Ch. 1 (A00-B99)
140-239
Ch. 2 (C00-D49)
240-279
Ch. 3 (D50-D89)
280-289
Ch. 4 (E00-E89)
290-319
Ch. 5 (F01-F99)
320-389
Ch. 6 (G00-G99) Nervous system
Ch. 7 (H00-H59) Eye & adnexa
Ch. 8 (H60-H95) Ear & mastoid process
390-459
Ch. 9 (I00-I99)
460-519
Ch. 10 (J00-J99)
520-579
Ch. 11 (K00-K95)
Infectious/parasitic diseases
Neoplasms
Neoplasms
Endocrine/nutritional/metabolic
& immunity disorders
Blood, blood-forming organs
Mental, behavioral,
Neurodevelopmental
Respiratory system
Digestive system
Blood, blood-forming organs
& immunity disorders
Endocrine/nutritional/metabolic
Neurodevelopmental
Nervous system & sense organs
Circulatory system
Infectious/parasitic diseases
Circulatory system
Respiratory system
Digestive system
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10
General Equivalency Mappings
Q. How can I translate between ICD-10 and ICD-9?
World Health
Organization
A. It is not possible to convert ICD-9 data
sets into ICD-10 data sets or vice versa.
http://www.who.int/classifications/help/icdfaq/en/
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11
General Equivalency Mappings
General Equivalency Mappings
Q. How can I translate between ICD-10 and ICD-9?
United States standard for translating between ICD-9 and
ICD-10 diagnosis and procedure codes in either direction
GEMs will be maintained for at least 3 years beyond October 1st, 2015
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12
General Equivalency Mappings
*1 to many includes 1 to 1 approximate
matches with multiple choices
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13
General Equivalency Mappings
Not intended for:
Coding medical records
Case-by-case crosswalking
Designed for:
Translating large batches of data
Useful for:
• Linking data in clinical studies spanning Oct 1st, 2015
• Analyzing data collected before and after Oct 1st, 2015
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14
ICD-10 Challenges for Data Analytics
Challenges ahead - shutterstock.com (89664115).
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15
ICD-10 Challenges for Data Analytics - Examples
Laterality Codes
Because ICD-9-CM
doesn’t differentiate
on laterality…
Translations from ICD-9
exclude ICD-10 laterality
codes.
Direction Matters
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16
GEMs Translations - Direction Matters
ICD-9
174.4
1 to 1
ICD-10
(ICD-9 GEMs Diagnosis)
Malignant neoplasm of upper-outer
quadrant of female breast
ICD-9 code: 174.4
ICD-10 code: C50.419 (“unspecified” laterality)
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17
GEMs Translations - Direction Matters
ICD-9
174.4
1 to 1
ICD-10
(ICD-9 GEMs Diagnosis)
Malignant neoplasm of upper-outer
quadrant of female breast
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18
GEMs Translations - Direction Matters
ICD-9
174.4
1 to 1
ICD-10
(ICD-9 GEMs Diagnosis)
Malignant neoplasm of upper-outer
quadrant of female breast
The “GEMs diagnosis” Person Counts are less than the sum of
the individual ICD-9 & ICD-10 diagnosis code Person Counts.
Persons with both ICD-9 & ICD-10 coded events in their medical
histories are not double-counted.
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19
GEMs Translations - Direction Matters
ICD-9
C50.419
1 to 1
ICD-10
(ICD-10 GEMs Diagnosis)
Malignant neoplasm of upper-outer
quadrant of unspecified female breast
In the opposite direction, a GEMs translation of the ICD-10
code with “unspecified” laterality has identical Person Counts.
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20
GEMs Translations - Direction Matters
ICD-9
C50.419
1 to 1
ICD-10
(ICD-10 GEMs Diagnosis)
Malignant neoplasm of upper-outer
quadrant of unspecified female breast
In the opposite direction, a GEMs translation of the ICD-10
code with “unspecified” laterality has identical Person Counts.
ICD-10 laterality codes for the right and the left breast exist,
but are not included in the translation.
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21
GEMs Translations - Direction Matters
ICD-9
many to 1
ICD-10
C50.41* (ICD-10 GEMs Subcategory)
Malignant neoplasm of upper-outer
quadrant of breast, female
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22
GEMs Translations - Broader Outcome Definitions
Higher Level GEMs Translations
= Broader Outcome Definitions
Broad outcome definition
GEMs (category level)
Anatomic specificity added
GEMs (higher sub-category)
Gender added
GEMs (lower sub-category)
Laterality added
GEMs (diagnosis code level)
Specific diagnosis
Narrow outcome definition
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23
GEMs Translations - Broader Outcome Definitions
ICD-9
many to 1
ICD-10
C50.41* (ICD-10 GEMs Subcategory)
Malignant neoplasm of upper-outer
quadrant of breast, female
An ICD-10 GEMs translation at the Subcategory level
adds laterality and increases person counts by about ⅓.
3 ICD-10 codes; 1 ICD-9 code.
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24
GEMs Translations - Broader Outcome Definitions
ICD-9
many to many
ICD-10
C50* (ICD-10 GEMs Category)
Malignant neoplasm of breast
An ICD-10 GEMs translation at the Category level maps all
ICD-9 and ICD-10 codes for “Malignant neoplasm of breast”
irrespective of gender, laterality and anatomical specificity
(where the tumor manifested in the breast).
53 ICD-10 codes; 9 ICD-9 codes.
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25
GEMs Diagnoses - Evaluating Risk
Target Cohort:
Comparator Cohort:
Tricyclic antidepressants (TCAs)
Selective serotonin reuptake inhibitors (SSRIs)
Risk of adverse outcomes between TCA & SSRI patients was evaluated by
comparing Screening Rate Ratios (SRR) in UBC Simulated claims data.
Without GEMs, the SRR calculation was misrepresented for
ICD-9 diagnoses (too high) and for ICD-10 diagnoses (too low).
GEMs mappings (both directions) yielded the corrected SRR.
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GEMs Diagnoses - Time to Onset
A Time to Onset analysis
was performed measuring
the mean days between
the initial drug exposure
and the 1st occurrence of:
Acute salpingitis
and oophoritis
within 90 days of exposure.
Time to Onset Calculations:
ICD-9 Calculation:
11 days
ICD-10 Calculation: 89 days
GEMs Calculation: 26.6 days
The IDC-9 calculation
did not account for events
after the transition to ICD-10.
The ICD-10 calculation
did not account for events
before the transition to ICD-10.
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27
ICD-9 / ICD-10 Organizational Differences
ICD-10-CM
ICD-9-CM
250 – Diabetes mellitus
250.0 – without mention
of complication
250.00 – Type II or unspecified
250.01 – Type I (juvenile type)
250.02 – Type II or unspecified,
uncontrolled
250.03 – Type I (juvenile type),
uncontrolled
E10 – Type 1 diabetes mellitus
E10.0
⁞
E10.xxx – Type 1 diabetes
mellitus diagnosis codes
E10.9 – without complications
E11 – Type 2 diabetes mellitus
E11.xxx – Type 2 diabetes
mellitus diagnosis codes
250.1
E11.0
250.9
E11.9 – without complications
⁞
⁞
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28
Translating, Mapping and Grouping
UMLS
Unified Medical Language System
ICD-9
ICD-10
MedDRA
Medical Dictionary for Regulatory Activities
• ICD to MedDRA alignment is essential when using clinical data for drug safety monitoring.
• UMLS provides ICD-9 and ICD-10 mappings to MedDRA preferred terms.
• ICD to MedDRA mappings are reliable for simple relationships
where ICD-9 and ICD-10 codes map to the same MedDRA preferred term.
• ICD-10 to MedDRA mappings are less comprehensive than ICD-9 to MedDRA mappings,
and organizational differences between ICD-9 and ICD-10 can cause some generally
equivalent codes to map to different MedDRA preferred terms.
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29
Translating, Mapping and Grouping
E10.0
⁞
E10.9
E11.0
⁞
E11.9
250.0
250.2
E10.xxx – Type 1 diabetes
mellitus diagnosis codes
E11.xxx – Type 2 diabetes
mellitus diagnosis codes
250.0x – Type 1 diabetes
mellitus diagnosis codes
250.0x – Type 2 diabetes
mellitus diagnosis codes
250.2x – Type 1 diabetes
mellitus diagnosis codes
250.2x – Type 2 diabetes
mellitus diagnosis codes
UMLS maps ICD-10 Type 1 codes to:
10067584 “Type 1 diabetes mellitus”
UMLS maps ICD-10 Type 2 codes to:
10067585 “Type 2 diabetes mellitus”
UMLS maps the intermixed ICD-9
Type 1 and Type 2 diabetes mellitus
codes to common MedDRA PT:
10012601 “Diabetes mellitus”
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30
Translating, Mapping and Grouping
Code grouping in data analytics
GEMs
• U.S. Standard for translating between ICD-9 & ICD-10
• Can be leveraged to group ICD-9 & ICD-10 diagnoses
at the category, sub-category or individual code level
Watch out for:
• Nonreciprocal translations
• Dropped laterality and/or specificity
when translating from ICD-9 to ICD-10
MedDRA PTs
• Can be leveraged as health outcome definitions bridging
Spontaneous healthcare data & Administrative claim data
Watch out for:
• PTs that don’t map to both ICD-9 and ICD-10 codes
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31
Enhancements with ICD-10 for
Active Drug Safety Surveillance
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32
Analytic Challenge:
Longitudinal Studies that Span October 1, 2015
“Any studies that use ICD codes for recording data over a period of
time will need to incorporate some sort of mapping from ICD-9 to
ICD-10…
or it will seem that certain diseases are eradicated on October 1,
2015, just as new epidemics erupt on that date as well.”
Disease Prevalence
June 2015 - November 2015
50
40
30
20
10
0
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Vulcano D. ICD-10 Conversion and the Impact on Clinical Research. Journal of Clinical Research Best Practices, Vol. 11, No. 1, January 2015.
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Key Benefits of ICD-10 to Health Care Research
Improved specificity and more precise clinical details
increases our ability to:
• Monitor trends in disease incidence and prevalence
• Measure quality of healthcare
• Assess drug safety
• Conduct clinical research
• Monitor resource utilization
• Quantify impact of health care services.
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34
Limited Advice Available to Researchers on the Impact of
Integrating ICD-9 and ICD-10 Codes into Retrospective Analyses
Important Issues to Think About:
 Will my analysis span the timeframe of transition: October 2015?
 How will I create code definitions for my study population and/or study
outcome that reliably integrates ICD-9 and ICD-10?
 How early do I need input by clinical experts on ‘best’ mapping?
 Are there published studies that already provide ‘clinically acceptable’
ICD-10 disease definition?
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35
Healthcare Analyses Impacted by Introducing ICD-10 Codes
Drug Safety Evaluation
Change in Prevalence Rates Over Time
Comparison of Health Care Utilization Pre- vs.Post-Drug Launch
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Generated using UBC’s SÆfetyWorks™ and CEWorks ™ products. http://www.ubc.com/services/risk-management-pharmacovigilance/signal-detection-surveillance
36
Active Monitoring of Drug Safety
Pharmaceutical companies and regulatory agencies actively
monitor product safety in the post-marketing environment using
observational databases.
FDA
We always have to keep in mind, however, that the effectiveness of
active surveillance with electronic data depends on the accuracy,
specificity, and completeness of:
Drug Exposure Data
Diagnosis (Outcome) Data
http://www.ohdsi.org/. Accessed April 11, 2016.
www.fda.gov/downloads/Safety/.../UCM233360.pdf. Accessed April 11, 2016.
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37
ICD-10-CM: Diagnosis Codes
Chapter XIX
Chapter XX
Injury, poisoning and certain other
consequences of external causes
(letters S and T)
Injury, external causes of
morbidity and mortality
(letters V, W, X and Y)
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Chapter XIX: T36-T40: Poisoning by Drugs,
Medicaments and Biological Substances
4th characters specifies a drug exposure
T36 Poisoning by Systemic Antibiotics
T36.0 Penicillins
T36.1 Cefalosporins and other beta-lactam antibiotics
T36.2 Chloramphenicol group
T36.3 Macrolides
T36.4 Tetracyclines
T36.5 Aminoglycosides
T36.6 Rifamycins
T36.7 Antifungal antibiotics, systemically used
T36.8 Other systemic antibiotics
T36.9 Systemic antibiotic, unspecified
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Chapter XX: External Causes of Morbidity and Mortality
Y40-Y59 – Drugs, medicaments, and biological substances causing
adverse effects in therapeutic use
Y45 Analgesics, antipyretics
and anti-inflammatory drugs
Y52 Agents primarily affecting the
cardiovascular system
Y46 Anti-epileptics and
anti-parkinsonism drugs
Y45.0 Opioids and related analgesics
Y45.1 Salicylates
Y45.2 Propionic acid derivatives
Y45.3 Other nonsteroidal antiinflammatory drugs [NSAID]
Y45.4 Anti-rheumatics
Y45.5 Aminophenol derivatives
Y45.8 Other analgesics and
antipyretics
Y45.9 Analgesic, antipyretic and antiinflammatory drug, unspecified
Y52.0 Cardiac-stimulant glycosides and drugs of
similar action
Y52.1 Calcium-channel blockers
Y52.2 Other anti-dysrhythmic drugs, not
elsewhere classified
Y52.3 Coronary vasodilators, not elsewhere
classified
Y52.4 Angiotensin-converting-enzyme inhibitors
Y52.5 Other antihypertensive drugs, not
elsewhere classified
Y52.6 Anti-hyperlipidaemic and antiarteriosclerotic drugs
Y52.7 Peripheral vasodilators
Y52.8 Anti-varicose drugs, including sclerosing
agents
Y52.9 Other and unspecified agents primarily
affecting the cardiovascular system
Y46.0 Succinimides
Y46.1 Oxazolidinediones
Y46.2 Hydantoin derivatives
Y46.3 Deoxybarbiturates
Y46.4 Iminostilbenes
Y46.5 Valproic acid
Y46.6 Other and unspecified antiepileptics
Y46.7 Anti-parkinsonism drugs
Y46.8 Anti-spasticity drugs
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40
Most Common ICD-10 Codes to Identify Adverse Events
No universally accepted ICD-10 coding algorithms exist to ensure
consistent identification of adverse events in administrative data.
Canadian Study, 2014, first to evaluate literature:
Objective: Create a comprehensive set of ICD-10 codes used
by health researchers to identify adverse drug events.
Results: 827 individual ICD-10 codes used in the health
literature to identify adverse drug events:
 Majority (78.8%) were disease manifestation codes.
 Only 11.2% were external injury cause codes (ICD-10 Chapter XX).
Conclusions: Substantial variability exists in the methods used
to identify adverse drug events in administrative data.
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Hohl CM, et al. J Am Med Inform Assoc 2014;21:547–557. doi:10.1136/amiajnl-2013-002116
41
Enhanced Drug Safety Surveillance with ICD-10
“…..electronic medical record healthcare databases in the US
will now become a much richer data source to perform active
drug safety surveillance.”
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Hohl CM, et al. J Am Med Inform Assoc 2014;21:547–557. doi:10.1136/amiajnl-2013-002116 http://googglet.com/images/funny%20icd%209%20codes. Accessed April 11, 2016.
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43
Supplemental Slides:
ICD Historic Timeline
U.S. Adoption Timeline
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44
Historic Timeline (ILCD through ICD-9-CM)
International List of Causes of Death (ILCD)
1890
• 1st through 5th revisions published: 1900, 1909, 1920, 1929, 1938
International Classification of Diseases (ICD)
1948
• 6th revision published under auspices of World Health Organization
ICD 7th revision
1955
• Classification of Operations and Treatments added in 1962
ICD 8th revision
1965
• Constructed with hospital medical record indexing in mind
1975
ICD 9th revision
• ICD-9-CM (1979), HIPAA (1996), U.S. Compliance date: 1 Apr 2005
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Adoption Timeline (ICD-10-CM / ICD-10-PCS)
1983 – 1993
ICD 10th revision
World Health Organization
1983: 10th revision of ICD-10 construction begins
– 10 years –
1993: 10th revision of ICD-10 published by WHO
(Eventually to translated into 43 different languages)
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Adoption Timeline (ICD-10-CM / ICD-10-PCS)
1983 – 1993
ICD 10th revision
• Construction begins 1983
• Published by WHO in 1993
World Health Organization
(43 Languages)
1994 – 1996
• Czech Republic
Denmark
Netherlands (1994)
United Kingdom (1995)
1994: International migration to ICD-10 begins.
U.S. ICD-10-CM prototype is created.
U.S. HCFA announces plans for ICD-10-PCS.
1995: 3M Health Information Systems wins ICD-10-PCS
contract based on it’s prior 7-character prototype
and development continues via an open process.
1996: ICD-10-PCS is informally tested by AHIMA.
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47
Adoption Timeline (ICD-10-CM / ICD-10-PCS)
1983 – 1993
ICD 10th revision
• Construction begins 1983
• Published by WHO in 1993
World Health Organization
1994 – 1996
• Czech Republic
(43 Languages)
• ICD-10-CM prototype / ICD-10-PCS announced
• ICD-10-PCS development & informal testing
Denmark
Netherlands (1994)
United Kingdom (1995)
1997 – 1998
• Finland
S. Africa (1996)
France
Iceland
Norway
Sweden (1997)
1997: ICD-10-CM draft is posted for public comment.
Clinical Data Abstraction Centers (CDACs) begin
formal testing of ICD-10-PCS.
1998: ICD-10-PCS training materials & crosswalk posted.
ICD-10-PCS annual updates begin.
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48
Adoption Timeline (ICD-10-CM / ICD-10-PCS)
1983 – 1993
ICD 10th revision
• Construction begins 1983
• Published by WHO in 1993
World Health Organization
1994 – 1996
• Czech Republic
• ICD-10-CM prototype / ICD-10-PCS announced
• ICD-10-PCS development & informal testing
Denmark
Netherlands (1994)
United Kingdom (1995)
• ICD-10-CM draft posted for public comment
• ICD-10-PCS formal testing & annual updates
1997 – 1998
• Finland
(43 Languages)
S. Africa (1996)
France
Iceland
Norway
Sweden (1997)
1999 – 2002
•
Australia (1998,1999)
Belgium (1999)
Germany (2000 SGBV, 2003 GM)
1999: ICD-10 mortality reporting is implemented in the U.S.
2000-2002: NCHS updates ICD-10-CM following the open
comment period, then posts a pre-release draft.
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49
Adoption Timeline (ICD-10-CM / ICD-10-PCS)
ICD 10th revision
1983 – 1993
• Construction begins 1983
• Published by WHO in 1993
World Health Organization
1994 – 1996
• Czech Republic
• ICD-10-CM prototype / ICD-10-PCS announced
• ICD-10-PCS development & informal testing
Denmark
S. Africa (1996)
1999 – 2002
•
Netherlands (1994)
Australia (1998,1999)
France
Iceland
Norway
Sweden (1997)
• ICD-10 mortality reporting implemented
• ICD-10-CM updates & pre-release draft
Belgium (1999)
2003 – 2010
• Canada (2001-2005)
United Kingdom (1995)
• ICD-10-CM draft posted for public comment
• ICD-10-PCS formal testing & annual updates
1997 – 1998
• Finland
(43 Languages)
Germany (2000 SGBV, 2003 GM)
• ICD-10-CM AHA & AHIMA pilot test
• ICD-10-CM annual updates begin
China (2002)
Thailand (2007)
• Partial code freeze
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Korea (2008)
50
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