INTERNATIONAL

CLASSIFICATION
OF DISEASES 10
SETH GSMC & KEM Hospital Mumbai
Presenters:- Dr Rukman Mecca
Dr Ambika Bhaskar
Dr Chandrika Dandekar
Dr Pratik Borkar
Dr Pradnya Shinde
 TYPES OF CLASSIFICATION IN WHO-FIC
(FIC-Family of International Classification)

• REFERENCE CLASSIFICATION

• DERIVED CLASSIFICATION

• RELATED CLASSIFICATION
 REFERENCE CLASSIFICATION

• Covers the main parameter of the health system, such as

death, disease, functioning disability, health and health
interventions.

• Achieved broad acceptance and official agreement for use

• Approved as guidelines for international reporting on

health

Eg:

International Classification of Diseases (ICD)

International Classification of Functioning, Disability and

Health(ICF)

International Classification of Health(ICH)

DERIVED CLASSIFICATION
Prepared either by-

• Adopting the reference classification structure

or through rearrangement or aggregation of
items from one or more reference classifications

It includes speciality based adaptations of ICF

and ICD, such as :

• International Classification of Diseases for

Oncology

• ICD 10 for Mental and behavioural disorders

 RELATED CLASSIFICATION

• They are partially related to reference classifications or,

associated with reference classification

at specific level

Eg:

International Classification of Primary

care(ICPC-2)

International Classification of External

causes of Injury(ICECI)
• Introduction
ICD is the abbreviation of the International statistical
classification of diseases and related health problems
• This is the global health information standard for
mortality and morbidity statistics implemented in
nearly 110countries
• ICD is the foundation for the identification of health
trends and statistics globally, and the international
standard for reporting diseases and health conditions.
• Standard for all clinical and research purposes.
 It allows for:
1. easy storage, retrieval and analysis of health
information for evidenced-based decision-making;
2. sharing and comparing health information between
hospitals, regions, settings and countries;
3. data comparisons in the same location across
different time periods.
History
• Francois Bossier de Lacroix (1706-1777)
-Conceived the idea of classification of diseases &
published it under the title Nosologia methodica
• Linnaeus (1707-1778)- a great methodologist and
contemporary of Lacroix published his work under
the title Genera morborum
• William Cullen (1710-1790) - simplified the system
for general use & published it under the title
Synopsis nosologiae methodic
• William Farr (1807-1883) first medical statistician in 1855 submitted
report on nomenclature and statistical classification of diseases, in which
he included most of those diseases that affect health and that are fatal.
• Jacques Bertillon(1851-1922) in 1893 began a modern
Classification 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
• The Sixth Decennial Revision Conference in 1948
recommended the adoption of a comprehensive
programme of international cooperation in the field of
vital and health statistics(ICD 6)
• The Seventh Revision Conference was held in Paris in
1955 and, the revision was limited to essential changes-
ICD 7
• The Eighth Revision Conference was convened by WHO in
Geneva in 1965 which was much more extensive- ICD 8
• The International Conference for the Ninth Revision
(ICD 9) was convened by WHO in Geneva in 1975
and it came into effect from 1979.
• Due to limited accuracy of clinical data coding and
limitation in the number of new codes that can be
created, got replaced.
• ICD-10 was endorsed by the 43rd World Health
Assembly in May 1990 and came into use in WHO
Member States as from 1994. India adopted this
classification in the year 2000.
ICD-11 is here!
A version released on 18 June 2018 is
available for Member States and other
stakeholders to use in order to begin
preparations for implementation in their
country, such as preparing translations.
• The ICD 10 uses an alphanumeric code with a letter
in the first position and a number in the second, third
and fourth positions.
• A decimal point after third character.
• Possible code numbers therefore range from A00.0 to
Z99.9
NB:- The letter U is not used
 So whats ICD CM ?

The (ICD) is the classification used to code and classify data

from death certificates.
The (ICD-CM) is used to code and classify morbidity data
from the inpatient and outpatient records and physician
offices
• ICD 10 (2015 update ICD 10) is modified further into
A. ICD-10 CM -Clinical modification/ diagnostic coding used by health care
providers
B. ICD-10-PCS- In-patient procedure reporting used by hospitals
Major differences from
ICD 9
1.ICD-10 is printed in a three-volume set compared with ICD-9's two-
volume set
2.ICD-10 has alphanumeric categories rather than numeric
categories.
3.Some chapters have been rearranged, some titles have changed,
and conditions have been regrouped
4.ICD-10 has almost twice as many categories as ICD-9.
5.Some fairly minor changes have been made in the coding rules for
mortality.
Structure
ICD‑10 comprises three volumes:
• Volume 1 contains the main classifications;
• Volume 2 provides guidance to users of the ICD;
• Volume 3 is the Alphabetical Index to the classification.
ICD 10 CM has 2 volumes- preferentially called as
1. Index-Alphabetical list of terms and its codes
2. Tabular list- sequential alpha-numeric list of codes
divided into 21 chapters
CHAPTERS:

The classification is divided into 21 chapters.

• Chapters I–XVII relate to diseases and other morbid conditions
• Chapter XVIII covers Symptoms, signs and abnormal clinical
and laboratory findings, not elsewhere classified.
• Chapter XIX to injuries, poisoning and certain other
consequences of external causes.
• Chapter XX, External causes of morbidity and mortality, was
traditionally used to classify causes of injury and poisoning.
• Chapter XXI, Factors influencing health status and contact with
health services
CONVENTIONS &
CHAPTERS OF ICD
10
Conventions used in ICD -10
The Alphabetic Index and Tabular List
• The ICD-10-CM is divided into the Alphabetic Index, an
alphabetical list of terms and their corresponding code,
and the Tabular List, a structured list of codes divided into
chapters based on body system or condition.
• The Alphabetic Index consists of the following parts:
• SECTION I: the Index of Diseases and Injury,
• SECTION II: the Index of External Causes of Injury,
• SECTION III: the Table of Neoplasms and the Table of Drugs
and Chemicals
Parentheses ( )
• Parentheses are used in Volume 1 in four important
situations
(a) Parentheses are used to enclose supplementary words,
which may follow a diagnostic term without affecting the
code number to which the words outside the parentheses
would be assigned.
(b) Parentheses are also used to enclose the code to which
an exclusion term refers. For example:
• H01.0 Blepharitis
• Excludes: blepharoconjunctivitis (H10.5).
 (c) Another use of parentheses is in the block titles, to enclose the
three character codes of categories included in that block.
(d) The last use of parentheses was incorporated in the Ninth
Revision and is related to the dagger and asterisk system.

Square brackets [ ] are used:

• (a) for enclosing synonyms, alternative words or explanatory
phrases; for
eg:A30 Leprosy [Hansen’s disease];
• (b) for referring to previous notes; for example:
C00.8 Overlapping lesion of lip [See note 5 at the beginning of
this chapter];
• (c) for referring to a previously stated set of fourth character
subdivisions common to a number of categories; for example:
• K27 Peptic ulcer, site unspecified [See before K25 for subdivisions].
Colon :
• A colon is used in listings of inclusion and exclusion terms when
the words that precede it are not complete terms for
assignment to that rubric.
• Eg: In K36, “Other appendicitis”, the diagnosis “appendicitis” is
to be classified there only if qualified by the words“chronic” or
“recurrent”.
Brace }
• A brace ( indicated by a vertical line ) is used in listings of
inclusion and exclusion terms to indicate that neither the words
that precede it nor the words after it are complete terms.
• O71.6 Obstetric damage to pelvic joints and
ligaments obstetric
Avulsion of inner symphyseal cartilage
Damage to coccyx
‘NOS’
• The letters NOS are an abbreviation for “not otherwise
specified”, implying “unspecified” or “unqualified”.
• For example, “mitral stenosis”.

“Not elsewhere classified”

• The words “not elsewhere classified”, when used in a
three‑character category title, serve as a warning that
certain specified variants of the listed conditions may
appear in other parts of the classification.
• For example: J16 Pneumonia due to other infectious
organisms, not elsewhere classified.
“And” in titles
• “And” stands for “and/or”. For example, in the rubric A18.0,
Tuberculosis of bones and joints, are to be classified cases of
“tuberculosis of bones”, “tuberculosis of joints” and
“tuberculosis of bones and joints”.

Point dash.-
• In some cases, the fourth character of a subcategory code is
replaced by a dash, e.g.:
• G03 Meningitis due to other and unspecified causes,
• Excludes: meningoencephalitis (G04.-).
•Cross references
• Cross references are used to avoid unnecessary duplication
of terms in the Index.
• The word “see” requires the coder to refer to the other
term; “see also” directs the coder to refer elsewhere in the
Index if the statement being coded contains other
information that is not found indented under the term to
which “see also” is attached.

• The unused ‘U’ codes

• 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.
 Placeholder character
• The ICD-10-CM utilizes a placeholder character “X”. The
“X” is used as a placeholder at certain codes to allow for
future expansion. An example of this is at the poisoning,
adverse effect and underdosing codes, categories T36-
T50.

7th Characters
• Certain ICD-10-CM categories have applicable 7th characters.
The applicable 7th character is required for all codes within
the category, or as the notes in the Tabular List instruct. The
7th character must always be the 7th character in the data
field. If a code that requires a 7th character is not 6
characters, a placeholder X must be used to fill in the empty
characters.
• Inclusion terms:
Within the three and four character rubrics(category or
subcategory),there are usually listed a number of other
diagnostic terms.

• Exclusion terms:
Certain rubrics contain lists of conditions preceded by
the word “Excludes”. These are terms which are classified
elsewhere.
Eg:
Incl:infection due to Entamoeba histolytica
Excl:other protozoal intestinal disease.
Two codes for certain conditions
The “dagger and asterisk” system
• there are two codes for diagnostic statements containing
information about both:
• an underlying generalized disease and
• a manifestation in a particular organ or site which is a
clinical problem in its own right.
- This convention was provided because coding to
underlying disease alone was often unsatisfactory for
compiling statistics relating to particular specialties
• The primary code is for the underlying disease and is
marked with a dagger (†);
• an optional additional code for the manifestation is marked
with an asterisk (*).
Eg:
A17.0† Tuberculous meningitis (G01*)

• it is a principle of the ICD that the dagger code is the

primary code and must always be used.
• For coding, the asterisk code must never be used alone.
• However for morbidity coding, the dagger and asterisk
sequence may be reversed when the manifestations of a
disease is the primary focus of care.
• Rubrics in which dagger‑marked terms appear may take one of three
different forms.
• (i) If the symbol (†) and the alternative asterisk code both appear in the
rubric heading, all terms classifiable to that rubric are subject to dual
classification and all have the same alternative code, e.g.:
• A17.0† Tuberculous meningitis (G01*)
• Tuberculosis of meninges (cerebral) (spinal)
• Tuberculous leptomeningitis.

• If the symbol appears in the rubric heading but the alternative asterisk
code does not, all terms classifiable to that rubric are subject to dual
classification but they have different alternative codes (which are listed
for each term), e.g:A18.1† Tuberculosis of genitourinary system
• Tuberculosis of:
• bladder (N33.0*)
• cervix (N74.0*)
• kidney (N29.1*)
 General Coding Guidelines
• To select a code in the classification that corresponds to a
diagnosis or reason, first locate the term in the Alphabetic Index,
and then verify the code in the Tabular List.
• Locate the lead term. For diseases and injuries this is usually a
noun for the pathological condition. However, some conditions
expressed as adjectives
• Read and be guided by any note that appears under the lead term.
• Read any terms enclosed in parentheses after the lead term (these
modifiers do not affect the code number), as well as any terms
indented under the lead term (these modifiers may affect the code
number), until all the words in the diagnostic expression have been
accounted for.
• 5. Follow carefully any cross‑references (“see” and “see also”)
found in the Index.
• Refer to the tabular list to verify the suitability of the code
number selected.
• Note that a three‑character code in the Index with a dash
in the fourth position means that there is a fourth
character to be found in Volume 1.
• Further subdivisions to be used in a supplementary
character position are not indexed and, if used, must be
located in Volume 1.
• Be guided by any inclusion or exclusion terms under the
selected code or under the chapter, block or category
heading
• Assign the code.
 CHAPTERS OF ICD 10
CHAPTERS SYSTEMS
CHAPTER I Certain infectious and parasitic diseases(A00-B99)

CHAPTER II Neoplasms(C00-D49)

CHAPTER III Diseases of the blood and blood-forming organs and

certain disorders involving the immune mechanism
(D50-D89)

CHAPTER IV Endocrine, nutritional and metabolic diseases(E00-

E89)
CHAPTER V Mental and behavioural disorders(F01 – F99)

CHAPTER VI Diseases of the nervous system(G00-G99)

CHAPTER VII Diseases of the eye and adnexa (H00-H59)

CHAPTER VIII Diseases of the ear and mastoid process(H60-H95)

CHAPTERS SYSTEMS
CHAPTER IX Diseases of the circulatory system(I00-I99)

CHAPTER X Diseases of the Respiratory System (J00-J99)

CHAPTER XI Diseases of the Digestive System (K00-K95)

CHAPTER XII Diseases of the Skin and Subcutaneous Tissue (L00-

L99)
CHAPTER XIII Diseases of the Musculoskeletal System and
Connective Tissue (M00-M99)
CHAPTER XIV Diseases of Genitourinary System (N00-N99)

CHAPTER XV Pregnancy, Childbirth, and the Puerperium (O00-O9A)

CHAPTER XVI Certain Conditions Originating in the Perinatal Period
(P00-P96)
CHAPTER XVII Congenital malformations, deformations, and
chromosomal abnormalities (Q00-Q99)
CHAPTER XVIII Symptoms, signs, and abnormal clinical and laboratory
findings, not elsewhere classified (R00-R99)
CHAPTERS SYSTEMS
CHAPTER XIX Injury, poisoning, and certain other
consequences of external causes (S00-T88)

CHAPTER XX External Causes of Morbidity (V00-Y99)

CHAPTER XXI Factors influencing health status and contact

with health services (Z00-Z99)
 Rules and guidelines for
mortality
and morbidity coding
This section concerns the rules and guidelines adopted by the World Health
Assembly regarding the selection of a single cause or condition for routine
tabulation from death certificates and morbidity records.
 Definition:

 Cause of death has been defined as “all those diseases, morbid

conditions or injuries which either resulted in or contributed to death and the
circumstances of the accident or violence which produced any such injuries”.
 definition does not include symptoms and modes of dying, such as heart
failure or respiratory failure

 Underlying cause has been defined as

 (a) the disease or injury which initiated the train of morbid events leading
directly to death, or
 (b) the circumstances of the accident or violence which produced the fatal
injury.
 When only one cause of death is recorded, this cause is selected for tabulation.

 When more than one cause of death is recorded, the first step in selecting the underlying
cause is to determine the originating antecedent cause proper to the lowest used line in Part
I of the certificate by application of the General Principle or of selection rules 1, 2 and 3.

 The rules are based on the concept of the underlying cause of death.

 The next step therefore is to determine whether one or more of the modification rules A to
F , which deal with the above situations, apply.

 The resultant code number for tabulation is that of the underlying cause.
 Where the originating antecedent cause is an injury or other effect of an external cause
classified to Chapter XIX, the circumstances that gave rise to that condition should be
selected as the underlying cause for tabulation and coded to V01–Y89.
 The code for the injury or effect may be used as an additional code.
DIFFERENT SECTIONS FOR CAUSE OF DEATH IN RBD
ACT

 Section 10 – In the event of death of any person, who during his last illness
(7 Days), was attended by a medical practitioner, he shall, after the death
of that person, forthwith, issue without charging any fee, a certificate in
the prescribed form.

 The Section 10(2) of the Act empowers State Governments to enforce the
provision relating to MCCD in specified areas taking into consideration the
availability of medical facilities.

 Section 10(3) of the Act, provides for issuing a certificate free of cost, of
the cause of death by the medical practitioner who attended on the
deceased at the time of death.
Section 17(b): The Act also incorporates a clause about the confidentiality of
the information on cause of death; forbidding disclosing this in any extract
provided from the registration records.

Section 23(3): Any Medical Practitioner who neglects or refuses to issue a

certificate under Section 10(3) and any person who neglects or refuses to
deliver such certificate shall be punishable with fine

Section 30 (2) (k): All information received by the Registrar u/s 8 & 9 and the
certificate as to the cause of death, furnished under the Act shall form an
integral part of the register & shall not be destroyed.
The condition recorded on the lowest used line of Part I of the certificate is usually the underlying cause of death
used for tabulation
expression originating antecedent cause (originating cause) will be used to refer to the condition proper to the
last used line of Part I of the certificate,
and the expression underlying cause of death will be used to identify the cause selectedfor tabulation.
 Example of Death Certificate:
 If there is only one step in the chain of events, an entry at line I(a) is sufficient.
 If there is more than one step, the direct cause is entered at (a) and the originating antecedent cause is
entered last, with any intervening cause entered on line (b) or on lines (b) and (c).
 An example of a death certificate with four steps in the chain of events leading directly to death is:
(a) pulmonary embolism
(b) pathological fracture
(c) secondary carcinoma of femur
(d) carcinoma of breast.
 Part II is for any other significant condition that contributed to the fatal outcome,
but was not related to the disease or condition directly causing death.
Rules for selection of the originating antecedent
cause
 Sequence
The term ‘sequence’ refers to two or more conditions entered on successive lines of
Part I, each condition being an acceptable cause of the one entered on the line
above it.
 General Principle
The General Principle states that when more than one condition is entered on the
certificate, the condition entered alone on the lowest used line of Part I should be
selected only if it could have given rise to all the conditions entered above it.
 Eg: Abscess of lung Hepatic failure
Lobar pneumonia Bile duct obstruction
Select lobar pneumonia (J18.1). Carcinoma of head of pancreas
Select carcinoma of head of pancreas
(C25.0)
 If the certificate has not been properly completed, the General Principle may
still apply provided that the condition entered alone on the lowest used line
of Part I could have given rise to all the conditions above it, even though the
conditions entered above it have not been entered in the correct causal
order.
 The General Principle does not apply when more than one condition has been
entered on the lowest used line of Part I, or if the single condition entered
could not have given rise to all the conditions entered above it.
Selection rules
 Rule 1. If the General Principle does not apply and there is a reported sequence terminating in the
condition first entered on the certificate, select the originating cause of this sequence. If there is more
than one sequence terminating in the condition mentioned first, select the originating cause of the
first‑mentioned sequence.
 Example: I (a) Bronchopneumonia
(b) Cerebral infarction and hypertensive heart disease
 Select cerebral infarction (I63.9). There are two reported sequences terminating in the condition first
entered on the certificate; bronchopneumonia due to cerebral infarction, and bronchopneumonia due to
hypertensive heart disease. The originating cause of the first ‑mentioned sequence is selected.
 Example : I (a) Oesophageal varices and congestive heart failure
(b) Chronic rheumatic heart disease and cirrhosis of liver
 Select cirrhosis of liver (K74.6). The sequence terminating in the condition first entered on the certificate
is oesophageal varices due to cirrhosis of liver
Rule 2 :
If there is no reported sequence terminating in the condition first entered on the certificate, select
this first‑mentioned condition.
Example: I (a) Pernicious anaemia and gangrene of foot
 (b) Atherosclerosis
 Select pernicious anaemia (D51.0). There is no reported sequence terminating in the first entered
condition.
 Example 17: I (a) Rheumatic and atherosclerotic heart disease
 Select rheumatic heart disease (I09.9). There is no reported sequence; both conditions are on the
same line.
Rule 3 :
If the condition selected by the General Principle or by Rule l or Rule 2 is obviously a direct consequence of
another reported condition, whether in Part I or Part II, select this primary condition.

 Assumed direct consequences of another condition:

 Example : I (a) Kaposi sarcoma
II AIDS
Select HIV disease resulting in Kaposi sarcoma (B21.0).
 Example : I (a) Cancer of ovary
II HIV disease
Select malignant neoplasm of ovary (C56).
Modification rules:

The modification rules that follow are intended to improve the usefulness and
precision of mortality data and should be applied after selection of the
originating antecedent cause.
 Rule A. Senility and other ill ‑defined conditions

 The following conditions are regarded as ill-defined:

I46.1(Sudden cardiac death, so described);
I46.9 (Cardiac arrest, unspecified);
I95.9(Hypotension, unspecified);
I99 (Other and unspecified disorders of circulatory system);
J96.0 (Acute respiratory failure);
J96.9 (Respiratory failure, unspecified);
P28.5 (Respiratory failure of newborn);
R00–R94 and R96–R99 (Symptoms,signs and abnormal clinical and laboratory findings, not elsewhere
classified).
Note that R95 (Sudden infant death syndrome) is not regarded as ill-defined.
 If all other conditions reported on the certificate are ill-defined or trivial, the cause of death should not be
reselected. That is, Rule A does not apply.
Example: I (a) Senility and hypostatic pneumonia
(b) Rheumatoid arthritis
Code to rheumatoid arthritis (M06.9). Senility, selected by Rule 2, is ignored and the General Principle applied.
Rule B. Trivial conditions
(A) Where the selected cause is a trivial condition unlikely to cause death and a more serious condition (any condition
except an ill-defined or another trivial condition) is reported, reselect the underlying cause as if the trivial condition
had not been reported.
Example:I (a) Dental caries
II Diabetes
Code to diabetes (E14.9). Dental caries, selected by the General Principle, is ignored.
(B) If the death was the result of an adverse reaction to treatment of the trivial condition, select the adverse reaction.
Example: I (a) Intraoperative haemorrhage
(b) Tonsillectomy
(c) Hypertrophy of tonsils
Code to haemorrhage during surgical operation (Y60.0). Code to the adverse reaction to treatment of the hypertrophy of
tonsils, selected by the General Principle.
(C) When a trivial condition is reported as causing any other condition, the trivial condition is not discarded, i.e. Rule B
is not applicable.
Example: I (a) Respiratory insufficiency
(b) Upper respiratory infections
Code to upper respiratory infection (J06.9). The trivial condition selected by the General Principle is not discarded since it is
reported as the cause of another condition.
 Rule C. Linkage
 Where the selected cause is linked by a provision in the classification or in the notes for use in
underlying cause mortality coding with one or more of the other conditions on the certificate, code
the combination.
 Where the linkage provision is only for the combination of one condition specified as due to another,
code the combination only when the correct causal relationship is stated or can be inferred from
application of the selection rules.
 Where a conflict in linkages occurs, link with the condition that would have been selected if the
cause initially selected had not been reported. Make any further linkage that is applicable.
Eg:I (a) Intestinal obstruction
(b) Femoral hernia
Code to femoral hernia with obstruction (K41.3).
 Rule D. Specificity

 Where the selected cause describes a condition in general terms and a term that provides more
precise information about the site or nature of this condition is reported on the certificate,
prefer the more informative term.
 This rule will often apply when the general term becomes an adjective,qualifying the more
precise term.
Eg:I (a) Rheumatic heart disease, mitral stenosis
Code to rheumatic mitral stenosis (I05.0).
Rule E. Early and late stages of disease

 Where the selected cause is an early stage of a disease and a more advanced stage of the same
disease is reported on the certificate, code to the more advanced stage.
 This rule does not apply to a ‘chronic’ form reported as due to an ‘acute’form unless the
classification gives special instructions to that effect.
 Eg: I (a) Tertiary syphilis
(b) Primary syphilis
 Code to tertiary syphilis (A52.9).
 I (a) Chronic myocarditis
(b) Acute myocarditis
Code to acute myocarditis (I40.9).
 Rule F. Sequelae
 Where the selected cause is an early form of a condition for which the
classification provides a separate “Sequelae of ...” category, and there is
evidence that death occurred from residual effects of this condition rather
than from those of its active phase, code to the appropriate“Sequelae
of ...” category
 “Sequelae of ...” categories are as follows: B90–B94, E64.‑, E68, G09, I69,O97
and Y85–Y89.
 Eg:I (a) Bronchopneumonia
(b) Curvature of spine
(c) Rickets in childhood
Code to sequelae of rickets (E64.3).
Malignant neoplasms:

 Coding malignant neoplasms is no different from coding other conditions.

 Important to consider information on behaviour, morphology and site.
 The following ICD grouping refers to behaviour:
C00–C96 Malignant (invades surrounding tissue or disseminates from its point of origin and begins to
grow at another site)
D00–D09 In situ (malignant but still confined to the tissue in which it originated)
D10–D36 Benign (grows in place without the potential for spread)
D37–D48 Uncertain or unknown behaviour (undetermined whether benign or malignant)
Coding for Malignant Neoplasms:
A) Using the Alphabetic Index
The entry “Neoplasm” in the Volume 3 Alphabetical Index gives guidance notes, listing of sites,
and up to five codes depending on the behaviour of the neoplasm. However, it is important to
look up the morphological type in the Alphabetical Index before referring to the listing under
“Neoplasm” for the site.
The entry for the morphological type will either state a code to use, or direct you to the
correct entry under the main term “Neoplasm”.
B) Selection Rules
Note that a malignant neoplasm does not automatically take precedence over other causes of
death mentioned on the death certificate. A death should be assigned to a malignant neoplasm
only if the selection rules, strictly applied, lead to the selection of the neoplasm as the
underlying cause of death.
 Example 1: I (a) Liver cirrhosis
(b) Viral hepatitis
II Hepatocellular carcinoma
Code to viral hepatitis (B19.9). Viral hepatitis is selected by the General Principle. It is not an
obvious consequence of hepatocellular carcinoma, which should not be selected as the
underlying cause of death.
C) Implication of malignancy:
A mention anywhere on the certificate that a neoplasm has produced secondaries means that the neoplasm must be
coded as malignant, even though the neoplasm without mention of metastases would be classified differently.
Example: I (a) Brain metastasis
(b) Lung tumour
Code to malignant lung cancer (C34.9). The lung tumour is considered malignant since it has produced brain metastasis.
D) Infectious diseases and malignant neoplasms:
(a) Infections due to malignant neoplasm:
 I (a) Zoster
(b) Chronic lymphocytic leukaemia
Chronic lymphocytic leukaemia could cause a zoster infection . The sequence is accepted, and chronic lymphocytic
leukaemia (C91.1) is selected as the underlying cause of death
(b) Malignant neoplasm due to infections:
 I (a) Kaposi sarcoma
 (b) HIV
HIV is accepted as causing malignant neoplasms. First, use the General Principle to select HIV as the temporary
underlying cause. Then use Rule C (Linkage) to code HIV disease resulting in Kaposi sarcoma (B21.0) as underlying cause
of death.
Perinatal mortality: guidelines for
certification and rules for coding
 Whenever possible, a separate certificate of cause of perinatal death should
be completed, in which the causes are set out as follows:
(a) main disease or condition in fetus or infant
(b) other diseases or conditions in fetus or infant
(c) main maternal disease or condition affecting fetus or infant
(d) other maternal diseases or conditions affecting fetus or infant
(e) other relevant circumstances.
For a thorough analysis of perinatal mortality, the following data on both mother and child are needed, in
addition to information about the causes of death, not only in the case of perinatal death, but also for all live
births.
 Mother
 Date of birth
 Number of previous pregnancies: live births/stillbirths/abortions
 Date and outcome of last previous pregnancy: live birth/stillbirth/abortion
 Present pregnancy:
• first day of last menstrual period (if unknown, then estimated duration of pregnancy in completed weeks)
• antenatal care – two or more visits: yes/no/not known
• delivery: normal spontaneous vertex/other (specify)
 Child
 Birth weight in grams
 Sex: boy/girl/indeterminate
 Single birth/first twin/second twin/other multiple birth
 If stillborn, when death occurred: before labour/during labour
Coding of causes of death:
 Each condition entered in sections (a), (b), (c) and (d) should be coded separately.
 Maternal conditions affecting the infant or fetus, entered in sections (c) and (d),should be
coded to categories P00–P04 and these codes should not be used for sections (a) and (b).
 Conditions in the infant or fetus, entered in section (a), can be coded to any categories
other than P00–P04 but will most often be coded to categories P05–P96 (Perinatal
conditions) or Q00–Q99 (Congenital anomalies).
 Only one code should be entered for sections (a) and (c), but for sections (b) and(d) as
many codes should be entered as there are conditions reported.

Section (e) is for review of individual perinatal deaths and will not normally need to be
coded.
2018 UPDATES TO ICD-10-
CM
 ICD CHANGES FOR 2018

• Implemented on 1st October, 2017

• New, changed and deleted codes
• 360 new ICD-10-CM codes, 226 code titles revised, 142 codes
deleted
• Changes to the tabular list
• Changes to the alphabetic index
• Guideline changes
• Coding clinic changes
 CHAPTER 1- CHANGE

• A04.7 Enterocolitis due to clostridium difficile – deleted

• 5th character for specificity added
• A04.71 enterocolitis due to clostridium difficile recurrent
• A04.72 enterocolitis due to clostridium difficile, not specified as recurrent
 CHAPTER 2 CHANGES

• C96.2 Malignant Mast Cell Tumor – deleted and new codes

created with specificity. They are Malignant Mast Cell Neoplasm
Unspecified (C96.20); Agressive Systemic Mastocytosis (C96.21),
Mast Cell Sarcoma(C96.22), & Other Malignant Mast Cell
Neoplasm (C96.29)

• D47.0 Histocytic and Mast Cell Tumors of Uncertain behaviour

deleted and new codes with addition of 5th character for
specificity has created.
• D47.01 For Cutaneous astocytosis , D47.02 for systemic
mastocytosis and D47.09 other mast cell neoplasm.
 CHAPTER 4 ADDITIONS

• Addition of two new diabetes codes

• E11.10 – type 2 diabetes with ketoacidosis without coma
• E11.11 - type 2 diabetes with ketoacidosis with coma

• E85.8 other amyloidosis deleted and addition of 5th character for specificity.
• They are Light Chain (AL) (E85.81); Wild-Type Transthyretin-Related (ATTR)
(E85.82); & Other Amyloidosis (E85.89)
 CHAPTER 5
• ADDITIONS – 9 new substance abuse codes added that specify ‘in
remission’. Like alcohol abuse in remission (F10.11), opiod abuse
in remission (F11.11), cannabis abuse in remission (F12.11) and so
on for sedative, hypnotic or anxiolytic-related, cocaine, hallucinogen,
inhalant, nicotine, and other psychoactive substance related
disorders. The new “in remission” codes all end with 11.
• Addition of F50.82 code for avoidant or restrictive food intake
disorder
 CHAPTER 7
ADDITIONS – The second most code additions -55
• First group of additions specifies degenerative myopia with other
conditions.
• H44.2A1- H44.2E9 for degenerative myopia with choroidal
neovascularisation, macular hole retinal detachment foveoschisis,
maculopathy or other maculopathy with laterality specification for each
eye.
• Blindness both eyes code deleted and new codes created with addition of
5th 6th and 7th characters for specificity.
• Blindness and low vision have been expanded to include different
category levels of vision for each eye and whether they are the same or
different in each eye.
 CHAPTER 9
• CODE I27.20 – I27.24 & I27.29 are added for different types of
secondary pulmonary hypertension
• Addition of new Myocardial Infarction codes
• Myocardial Infarction type 2 (I21.A1) and other myocardial infarction
type (I21.A9).
• A type 2 MI describes a myocardial infarction due to demand ischemia.
• In addition, notes added under ST-elevation MI codes (I21.0–I21.4)
clarify that the condition is a type1 MI.

cont..
 CHAPTER 9
• Addition of Eisenmenger’s Syndrome (I27.83)

There are several new codes for different types of heart failure such
as:
• Acute right heart failure (I50.811)
• Acute on chronic right heart failure (I50.813)
• Right heart failure due to left heart failure (I50.814)
• High output heart failure (I50.83)
• End-stage heart failure (I50.84)
 CHAPTER 11
• Gingival Recession code K06.0 was expanded to specify localized
(K06.010–K06.013) or generalized (K06.020– K06.023).

• Intestinal Adhesions (bands) with Obstruction (postinfection) (K56.5)

expanded to specify partial (K56.51) & complete (K56.52) obstruction

• Unspecified Intestinal Obstruction (K56.600 – K56.609) and post-

procedural intestinal obstruction (K91.30 – K91.32) are further
classified into different types
• CHAPTER 12 - Most additions done
• 72 new codes for Non Pressure Chronic Ulcers L97.105- L98.498 For
different body parts & severity

• CHAPTER 13- Addition of 3 codes related to Myopathy M33.03,

M33.13 & M33.93

M48.06 – DELETED
M48.061 & M48.062 for Spinal Stenosis, Lumbar region without
Neurogenic Claudication & with Nurogenic Claudication respectively
 CHAPTER 14
• An unspecified breast lump (N63) deleted
• New code
• N63.0 Unspecified lump in unspecified breast
• N63.10 - N63.42 Specify laterality & location of the lump
 CHAPTER 15
• Tubal pregnancy without intrauterine pregnancy - right O00.101, left
O00.102, Unspecified o00.109
• Tubal pregnancy with intrauterine pregnancy O00.111, O00.112 &
O00.119
• Ovarian pregnancy without intrauterine pregnancy O00.201, O00.202,
O00.209
• Ovarian pregnancy with intrauterine pregnancy O00.211, O00.212 &
O00.219

• New codes for maternal care for abnormalities of fetal heart rate or
rhythm in the first trimester (O36.831-), second trimester (O36.832-),
third trimester (O36.833-), or unspecified trimester (O36.839-)
 CHAPTER 16
• Certain conditions originating in the perinatal period added new codes
• Pulmonary hypertension of the newborn (P29.30) and other persistent fetal circulation
(P29.38).
• Alloimmune liver disease with code P78.84- totally new code
• Code p83.8 other specified conditions of integument specific to newborn – deleted
• New codes - P83.81 umbilical granuloma & P83.88, other specified conditions of
integument specific to newborn.
• P91.8 deleted to create new codes for neonatal encephalopathy in diseases classified
elsewhere (P91.811)
P91.819 neonatal encephalopathy, unspecified and
P91.88, other specified disturbances of cerebral status of newborn
• In CHAPTER 17 Abdominal testis unilateral & bilateral has deleted & more
specified as Unilateral Intra-Abdominal Testis (Q53.111); Unilateral Inguinal
Testis (Q53.112) & Unilateral high scrotal testis (Q53.13)
• Similarly also classified for bilateral side.

• CHAPTER 18 new code for Acute Respiratory Distress (R06.03) and two new
codes to describe Unilateral or Bilateral Non-palpable testicle(s) (R39.83 and
R39.84).

• CHAPTR 19 – in this chapter all codes related to injury are deleted &
classified in more simplified way by adding 6 th & 7th character. For example
T14.90 injury unspecified – deleted & new codes for Injury Unspecified -
T14.90XA for initial encounter, T14.90XD for subsequent encounter &
T14.90XS for sequela has added.
• CHAPTER 20 -54 new codes added to specify accidents involving 3
or 4 wheel ATVs & dirt bikes. Code range V86.05XA – V86.96XS

• CHAPTER 21 The antenatal screening code (Z36) in chapter 21

expanded to increase reporting options.
• Coding professionals will be able to report specific screening tests
administered to pregnant patients, such as antenatal screening for
fetal growth retardation (Z36.4) and antenatal chromosomal
abnormalities (Z36.0) with 17 new Z codes.
• New codes are Z36.0 to Z36.5; Z36.81 to Z36.89; Z36.8A &
Z36.9
 CODE DESCRIPTION REVISION

• 226 codes revisions in this update

• All are minor changes such as punctuation or adding or
removing non essential words
 NEW ICD 10 GUIDELINES

• The new guidelines are available at

https://www.cdc.gov/nchs/data/icd/10cmguidelines fy2018
• Narrative changes appear in bold text
• Items underlined have been moved within the guideline since
FY2017 version
• Italics are used to indicate revisions to heading changes
 I.A.15 “WITH”

• This guideline added the word “in” to have the same meaning as “with.”
 I.C.4.A.3 DIABETES MELLITUS AND THE USE
OF INSULIN AND ORAL HYPOGLYCEMICS
“An additional code assigned from category Z79 to identify the long-term
(current) use of insulin or oral hypoglycemic drugs.”

The guideline further clarifies that if the patient is treated with both oral
medications and insulin, only code Z79.4 (long-term (current) use of
insulin) should be assigned and that code Z79.4 should not be assigned if
insulin is given temporarily to bring a type 2 patient’s blood sugar under
control during an encounter.
This same clarification was also added to I.C.4.A.6 for secondary diabetes
mellitus
 I.C.5.B.1 IN REMISSION

• This guideline clarified that the appropriate codes for “in remission”
are assigned based on provider documentation “unless otherwise
instructed by the classification.”

• It goes on to state that

“mild substance use disorders in early or sustained remission are
classified to the appropriate codes for substance abuse in
remission,
and moderate or severe substance use disorders in early or
sustained remission are classified to the appropriate codes for
substance dependence in remission.”
 I.C.7.B BLINDNESS

• “If ‘blindness’ or ‘low vision’ of both eyes is documented but

the visual impairment category is not documented, assign
code H54.3, Unqualified visual loss, both eyes.
• If ‘blindness’ or ‘low vision’ in one eye is documented but
the visual impairment category is not documented, assign a
code H54.6, Unqualified visual loss, one eye.
• If ‘blindness’ or ‘visual loss’ is documented without any
information about whether one or both eyes are affected,
assign code H54.7, Unspecified visual loss.”
 I.C.9.A.11 PULMONARY HYPERTENSION

• Pulmonary hypertension is classified to category I27, Other

pulmonary heart diseases.

• For secondary pulmonary hypertension (I27.1, I27.2), code

also any associated conditions or adverse effects of drugs
or toxins.
 I.C.9.E ACUTE MYOCARDIAL INFARCTION (AMI)

• This section of the guidelines added clarification related to the

types (1-5) of AMI and associated changes to the classification for
FY 2018.

• Portions of the revisions state: “type 2 myocardial infarction, and

myocardial infarction due to demand ischemia or secondary to
ischemic balance, is assigned to code I21.A1, myocardial
infarction type 2 with a code for the underlying cause. Do not
assign code I24.8, Other Forms of Acute Ischemic heart disease
for the demand ischemia.
cont..
• Sequencing of type 2 AMI or the underlying cause is dependent
on the circumstances of admission. When a type 2 AMI code is
described as NSTEMI or STEMI, only assign code I21.A1.

• Codes I21.01-I21.4 should only be assigned for type 1 AMIs.

• Acute Myocardial Infarctions Type 3, 4a, 4b, 4c and 5 are

assigned to code I21.A9, Other Myocardial Infarction Type.
 I.C.12.B NON-PRESSURE CHRONIC ULCERS

• This section is a brand new guideline for FY 2018.

• I.C.12.B.1 clarifies that a code is not assigned if the
documentation states that the non-pressure ulcer is
completely healed on admission

• I.C.12.B.2 states “non pressure ulcers described as healing,

should be assigned the appropriate non-pressure ulcer code,
based on the documentation in the medical record.
• If the documentation does not provide information about the
severity of the healing non-pressure ulcer, assign the appropriate
code for unspecified severity.
 cont…
• For ulcers that were present on admission but healed at the time of
discharge, assign the code for the site and severity of the non-
pressure ulcer at the time of admission.”

• I.C.12.B.3 indicates, “if a patient is admitted to an inpatient hospital

with a non-pressure ulcer at one severity level and it progresses to a
higher severity level, two separate codes should be assigned:
one code for the site and severity level of the ulcer on admission and
a second code for the same ulcer site and the highest severity level
reported during the stay.”
 II.K ADMISSIONS/ENCOUNTERS FOR
REHABILITATION
• This guideline clarifies the use of an injury code for admission for
rehabilitation.
• If the condition for which the rehabilitation service is being provided
is no longer present, “report the appropriate aftercare code as the
principal diagnosis”

• For rehabilitation services following active treatment of an

injury, the coding professional is instructed to “assign the injury
code with the appropriate seventh character for subsequent
encounter as the principal diagnosis.”
cont…
• “For example,
If a patient with severe degenerative osteoarthritis of the hip,
underwent hip replacement and the current admission is for
rehabilitation, report code Z47.1, aftercare following joint replacement
surgery, as the principal diagnosis.
If the patient requires rehabilitation post hip replacement for right
intertrochanteric femur fracture, report code S72.141D, displaced
intertrochanteric fracture of right femur, subsequent admission for
closed fracture with routine healing, as the principal diagnosis.
See section i.C.19.A for additional information about the use of 7th
characters for injury codes.”
ICD 11
EVOLUTION OF THE ICD
International List of Causes of Death : 1893

Revisions of 1900 (1st), 1910 (2nd), 1920 (3rd)

1929 (4th),1938 (5th)

International Classification of Diseases,

Injuries, and Causes of Death : 1946-1948
(6th)

1955 (7th) , 1965 (8th) ,

 EVOLUTION OF THE ICD

1975 (9th)

International Statistical Classification of

diseases and health related systems1989
(10th), 1994, 1996-2018

18th June 2018 (11th) : 2019 : 2022

 WHAT IS ICD 11?
Next version after ICD 10 with vast improvements

Key features of ICD 11:

Updated for the 21st century and reflects critical

advances in science and medicine.

Well integrated with electronic health applications and

information systems

Allows more detail to be recorded.

Produced through a transparent, collaborative manner

Easier to use
 HOW DID THE CHANGE HAPPEN?
• Revision process began in 2000 at the World Health
Assembly with the Joint Task Force (JTF).

• Interested parties were invited to send proposals :

More than 10000 proposals received till date.

• 31 countries were involved in ICD-11 field testing : A

total of 1,673 participants who have performed more
than 112,383 code assignments.

• Effective from 1st Jan 2022

• Time gap to adapt : large : ICD 10 - Thailand 1994,
India 2000, USA 2015
 REPORT OF THE JOINT TASK FORCE (JTF)
• Improving coder training and instructions : awareness and
adherence to coder instruction

• Generic line coding (morbidity): Coding was done using 298

diagnostic terms representing 47 ICD-11 MMS priority areas.
Each diagnostic term was assigned a code by raters using both ICD-
11 and ICD-10.
Following the code assignment, raters were asked to
• (i) report on difficulties encountered;
• (ii) assess the level of coding granularity; and
• (iii) identify problems with ambiguity, if present. All diagnostic
terms or statements used in testing were pre-coded in ICD-10
ICD 11 TO 10 MAPPING
 REPORT OF THE JOINT TASK FORCE (JTF)
• Specialty specific line and case coding : focused on specialty
areas of ICD-11 and used specialty specific diagnostic term sets and
case scenarios.
• Dermatology, Quality and Safety, Pain, Traditional Medicine,
Internal Medicine, etc

• Mortality line- and underlying cause coding.: Line coding will

serve to identify
(i) problems finding an appropriate term using the coding tool;
(ii) appropriateness (of any term found)
(iii) clarity of any coding instructions (e.g. 'code also' or 'use
additional code'); and
 REPORT OF THE JOINT TASK FORCE (JTF)
• Improving user guidance: number of index terms have been
added, terminology modified, and additional post-coordination
combinations identified and included.
 REPORT OF THE JOINT TASK FORCE (JTF)

• Refining ICD-11 Tools (Coding tool & Browser):

• (i)The ICD-11 Coding Tool now shows the codes of non-terminal
(non-codable) categories using a different style (i.e. grey coloured
background);
• (ii) the ICD-11 Browser identifies post-coordination combinations
e.g. Cholera due to Vibrio cholera 01, biovar eltor
• (iii)the browser will indicate that a precoordinated code is
available if a user attempts to create a concept using post-
coordination which does exist in the tabular list (e.g. Urinary tract
infection with Escherichia coli).
 MAJOR CHANGES OF ICD 11
ICD-11 Informatics Update :
https://icd.who.int/browse11/l-m/en
The ICD-11 Browser and Coding Tool are migrated to a
new infrastructure
ICD-11 Browser (updated daily)
https://icd.who.int/dev11
Coding Tool https://icd.who.int/ct11

Coding Notes added to the ICD-11 Browser : ICD-11

Browser now shows additional information on coding as in
the example.
MAJOR CHANGES OF ICD 11
 MAJOR CHANGES OF ICD 11
• Enhancements in the post-coordination mechanism
: Both the Coding Tool and the ICD-11 Browser can now
provide search results as stem code + post-coordination
value combination.
 MAJOR CHANGES OF ICD 11
• NEW CHAPTERS ADDED: 26 VS 22 :
Chapter 4 : Diseases of the immune system
Chapter 7 : Sleep wake disorders
Chapter 17 : Conditions related to sexual health :
GENDER INCONGRUENCE
Chapter 26 : Traditional Medicine conditions : disorders
described in ancient Chinese medicine, commonly used in
China, Japan, Korea, and other parts of the world

V : Supplementary section for functioning assessment :

X : Extension Codes
 MAJOR CHANGES OF ICD 11
• STROKE : circulatory vs neurological disease : key
implications for treating the disease and reporting deaths 

• GAMING DISORDER, HOARDING DISORDER : new

mental health conditions added

• ‘Excessive sexual drive’ has been reclassified as

‘COMPULSIVE SEXUAL BEHAVIOUR DISORDER’.

• CHAPTER 14 - DISEASES OF THE SKIN: categories

referring to ‘Dermatitis’ were grouped together, and post-
coordination now can be used to describe allergens;
MAJOR CHANGES OF ICD 11

• CHAPTER 23 - EXTERNAL CAUSES OF

MORBIDITY OR MORTALITY:
the number of precoordinated entities has been
substantially reduced,
the land transport section has been edited to place the on-
road/off-road distinction at the second level (after intent)
the chapter now makes greater use of extension codes and
the post-coordination mechanism
the section on substances, has been renamed
“Exposure to and harmful effects of substances”
with 16 broad categories of (precoordinated) substances
that can be expanded for extra detail using extension
codes, as desired;
MAJOR CHANGES OF ICD 11

• CHAPTER 24 - FACTORS INFLUENCING HEALTH

STATUS OR CONTACT WITH HEALTH SERVICES:
disease, disorder, or injury related categories were
parented elsewhere and only categories related to
reasons for encounter or influencing a health condition
remain; structural and terminological consistency of the
chapter was improved.
 MAJOR CHANGES OF ICD 11

• CHAPTER 25 : CODES FOR SPECIAL PURPOSES : This

chapter contains the following top level blocks:
International provisional assignment of new
diseases of uncertain aetiology 10 CODES (RA00 TO
RA09)
National provisional assignment of new diseases of
uncertain aetiology 7 CODES (RA20 TO RA26)

Coding Of Mental Health Conditions By Primary

Health Care Providers : attempt of statisticians to
simplify the codes as much as possible
 WHY IS ICD IMPORTANT?
• Provides a snapshot of a country’s wellbeing through its health
statistics. 

• Mapping of disease trends and causes of death around the world : key
indicators of :
Health of a population &
Social determinants that link closely to health, such as
the education, nutrition, and public infrastructure.

• In countries such as the USA, ICD codes are the foundation of health
insurance billing, and thus critically tied up with health care
finances. 

• Consequences of ICD coding on provision of care, health

financing and insurance: important to clinicians, patient
groups, and insurers : implications on coding of various conditions.
 WHY IS ICD IMPORTANT?

• The ICD provides a common vocabulary for recording, reporting

and monitoring health problems.
• Example: Fifty years ago, it would be unlikely that a disease such
as schizophrenia would be diagnosed similarly in Japan, Kenya and
Brazil.

• Each country or region would have its own classifications that

would be relevant where it is used. 

• Inclusion or exclusion is not a judgement on the validity of a

condition or the efficacy of treatment. Eg : Traditional Medicine,
Homosexuality

• Standardization is the key that unlocks global health data analysis.

 REFERENCES
1. Dates M, Dates T. ICD-11 Update. 2018;(October 2017).
2. Seg RSG. ICD-11 Governance and Process for ICD Revision.
2018;(January):11–3.
3. ICD-10. 2016;1.
4. ICD-10. 2016;2.
5. ICD-10. 2016;3
6. Record M. Letters to the Editor Implementation of ICD 10 :
A Study on the Doctors ’ Knowledge and Coding Practices
in Delhi. 2015;59(1):1–2.
7. Pamila NRJ, Prajwal S, Shreepathi U, Prabhakara B.
Implementation of International Classification of Diseases
10 : Preparedness for E-medical records and health
reporting. 2015;2(2):1–7.