ICD-11 A User Guide

ICD-11
A User Guide
Cathy Eastwood, University of Calgary
Denise Cullen, Canadian Institute of Health Information
Incorporating content from
ICD-11 Field Testing Training Manual_Final Draft_Version 3_270616
ICD-11 Reference Guide_Draft_20180318
Module 1: Introduction to ICD-11
• Objectives
• To understand why ICD-11 has been developed and its uses
• To develop an understanding of the potential benefits of using
ICD-11
• To develop a basic understanding of ICD-11 architecture and
key differences between ICD-11 and ICD-10
• To understand stem codes and extension codes

WHO and ICD
• Let’s first take a look at the WHO website and ICD-11
• https://www.youtube.com/watch?v=tZFcoYfnwiM&feature=youtu
.be
• http://www.who.int/classifications/icd/revision/en/
Uses and Potential Benefits of ICD-11:
 More comprehensive for use in broader
clinical settings, e.g. primary care
(responding to multiple user needs)
 Reflect current medical terminology

and information needs (up-to-date
scientific knowledge)
 Greater international comparability for morbidity
 Linkages with other classifications/terminologies:

• International Classifications of Disease for Oncology (ICD-O)
• International Classification of Functioning and Disability (ICF)
• Gene Ontology (GO)
• SNOMED-CT
Development to date
• Revision process occurred on an internet-based platform for

easier discussion and review
• Translatable into multiple languages
• International collaboration on content
• Disease specific Topic Advisory Groups (TAGs)
• Horizontal TAG groups- big picture – mortality, morbidity,
informatics, quality & safety, functioning
Reference Guide
The Reference Guide is an important resource document that provides
detail on the:
• Context of ICD-11 within the Family of International Classifications.
• Components of ICD-11.
• Content of ICD-11, including the new chapters.
• Uses of ICD-11.
• Differences between ICD-10 and ICD-11.
• ICD-11 for Mortality & Morbidity Statistics (MMS).
• Coding process for ICD-11 MMS, including chapter by chapter coding
guidelines.
• Comparison of changes to coding guidelines for mortality and morbidity.
• Overview of essential mortality and morbidity coding guidelines for
clinical coding and field testing; including a definition for ’main
diagnosis’.
ICD-11: What’s new
New terminology/methods:
 Stem codes and extension codes
 Pre and Post coordination
 Cluster coding
 Sanctioning rules
 Multiple parenting
 Tabular lists
Updated content and new

chapters:
 Disorders of the immune system
 Dis. Blood & blood forming organs
 Conditions related to sexual health
 Sleep-wake disorders
 Traditional medicine
 Extension codes
The Foundation
• A multidimensional collection of all ICD entities

• Diseases, disorders, injuries, external cause codes, signs, and symptoms
• Subsets of the foundation can be created - these are known as

Tabular Lists
• Instructions (sanctioning rules) on how to combine certain codes

in a Tabular List to achieve more detail in coding
Tabular Lists
• Subset of the Foundation
• Like Volume 1 of ICD-10 (Tabular)
• Multiple Tabular lists possible for multiple settings
Examples:
• ICD-11 MMS (mortality and morbidity statistics)*
• Used for coding illness and/or cause of death for international
comparison; like previous versions of ICD
• Primary Care Tabular Lists (Primary Care Low Resource Settings (PCL)
and Primary Care Intermediate Resource Setting (PCM))
• Verbal Autopsy (VA)
• Simple Mortality List (SMoL)
• Specialty Tabular Lists (i.e. Dermatology, Oncology, Mental Health)
ICD-11 MMS
• 27 chapters
• Very similar to ICD-10 for the most part in overall structure
• New chapters:
• Conditions related to sexual health
• Sleep-wake disorders
• Traditional medicine
• Extension codes
Code Structure
• An alphanumeric code with a letter in the second position and
number in the third character position to differentiate from the
codes of ICD-10.
• Alphanumeric codes cover the range from 1A00.00 to ZZ9Z.ZZ.
• Codes starting with an 'X' indicate an extension code

• (more on extension codes later in the presentation)
• The letters ‘O’ and ‘I’ have been omitted to prevent confusion
with the numbers ‘0’ and ‘1’.
Examples: GB60.0 Acute kidney failure, stage 1

3A71.Z Anaemia of chronic disease, unspecified
Definitions in ICD-11
Each entity in the classification will now include a (short)
definition.
With all entities having a definition, coders everywhere can
be consistent with the common understanding of a concept;
thus promoting the accuracy and reliability of coded
information ‘worldwide’.
Types of Codes in ICD-11
ICD-11 has 2 general types of codes:
1. Stem codes
2. Extension codes
Stem Codes
Stem codes are for clinical entities in a tabular list that can be
assigned alone.
Extension Codes
Extension codes allow the user to add more detail to

the entity (stem code) that is chosen.
An extension code can only be used with a stem code
as its prefix
(i.e. cannot be assigned alone).
Extension Codes
The Extension Codes chapter (X) uses 2 main types of extensions
codes to enhance coding possibilities.
• Type 1 refine the level of detail of a stem code
Examples:
• severity such as mild/moderate/severe,
• aetiology such as infectious agents,
• specific anatomical detail, or
• temporality such as acute or chronic.
• Type 2 identify the different uses of an ICD stem code
Examples:
• main condition, present on admission, or certainty of diagnosis
such as provisional diagnosis).
Pre and Post-Coordination
Pre-Coordination Post-Coordination
Pre-coordination refers to a stem Post-coordination refers to using a
code that has all pertinent stem code and an extension code(s)
information in a pre-combined or a stem code and further stem
fashion code(s) to achieve additional detail
Example: squamous cell carcinoma Example: squamous cell carcinoma
of bronchus and lung of left bronchus and lung
Post-coordination
Some users and settings are interested in reporting more
detail than that which is included in a single stem code.
This additional detail can be captured using post
coordination and cluster coding (a string of codes).
Stem
Stem / Stem
Stem & Extension
(or combinations of above)
Stem & Extension / Stem & Extension & Extension
Cluster Coding
Stem + Stem (joined with /)

5A10/GB61.5
Cluster Coding
Stem + Extension (joined with &)

CA23.31&XS25
Cluster Coding
Mixed (may use both & and /)

5A10/GB61.5&XY6M
Comparing ICD-10-CA to ICD-11
• Patient with CA of UOQ of L breast
ICD-10-CA ICD-11
C50.41 Malignant neoplasm of 2C6Z Malignant neoplasms of
upper-outer quadrant of left breast breast, unspecified (stem code)
XK8G Left (extension code)
XA2Q54 Upper outer quadrant of
breast (extension code)
String or Cluster:
2C6Z&XK8G&XA2Q54
Comparing ICD-10-CA to ICD-11
• Patient with Type 1 diabetes mellitus with diabetic retinopathy:
ICD-10-CA ICD-11
E10.30† Type 1 diabetes with 5A10 Type 1 diabetes mellitus
background retinopathy (stem code)
H36.0* Diabetic retinopathy 9B71.0Z Diabetic retinopathy
(stem code)
String or Cluster:
5A10/9B71.0Z = Type 1 DM with
diabetic retinopathy, unspecified
Retired Conventions
• Square brackets [ ]
• Colon :
• Brace { }
• And/or in code titles; in ICD-11 its one or the other not
‘both’
• Dot point/dash to indicate need for extra character ( ._).
Current conventions
The following also exist in ICD-11 and have the same meaning as
they do currently:
• Inclusions
• Exclusions
• ‘Code also’ (mandatory) or ‘Use additional code, if desired’
(optional)
• NEC and NOS
• Residual categories (‘other’ and ‘unspecified’)
• ‘Due to’ (causal relationship) or ‘with’ (no causal relationship)
• And
• Or
Other information
• Terms will be listed in their singular form
• Apostrophes have been removed

Example: ‘Hodgkin lymphoma’ (instead of ‘Hodgkin’s lymphoma’)
• Entities are described using natural language

Example: ‘myocardial infarction’ (instead of ‘infarction, myocardial’)
• Abbreviations use upper case letters, followed by the complete

title in full.
Example: ‘MI – myocardial infarction’
• Parentheses enclose the code to which an exclusion term refers.

Example: 9A01.3 Infectious blepharitis
Exclusions: blepharoconjunctivitis (9A60.4)
Sanctioning Rules
Sanctioning rules are a set of instructions to help coders
visualize the permitted code combinations when using a
Tabular List.
Sanctioning tables containing these rules are expected to be

embedded in ICD-11. They tell you what is:
• required
• allowed
• optional
• not applicable
Index
As the ICD-11 is envisaged to be a predominantly electronic
classification, the use of the coding tool provides an electronic
index through which to locate the appropriate codes.
Quick Quiz
What is a stem code?

What is an extension code?
What is meant by post-coordination?
What is a cluster in ICD-11?
What is a sanctioning rule?
Name 2 new chapters in ICD-11
Module 2: ICD-11 Tooling Environment
Learning objectives
• To develop an understanding of the ICD-11 tooling
environment
• To develop skill sets to master the use of the tools

Overview of ICD-11 Tools
• ICD-11 for Mortality and Morbidity Statistics (Draft for
quality assurance)
• ICD-11 Beta Draft

Using the ICD-11 Beta Draft Tool:
Searching for codes
Browser searching has three options:
• Browsing via hierarchy (Tabular Browsing)
• Quick Search
• Advanced Search
• ICD-11 Training videos - The Browser
Source: ICD-11 Field Trial Education Package – June 2016, p. 27

Browsing for Codes
Open the coding tool and search for the following:
• Anterior STEMI
• Acute kidney injury (AKI)
Source: ICD-11 Field Trial Education Package – June 2016, p. 31-34

Using the Coding Tool
• ICD-11 coding tool. ICD-11 Coding Tool

• Can search for all ICD-11 terms.
• The coding tool has a link to the ICD-11 Browser
Open the coding tool and try the following :

Congestive heart failure
Source: ICD-11 Field Trial Education Package – June 2016, p. 34

Summary – Questions?
Quick Quiz
How can you tell if you can post coordinate?

What if the option to post coordinate is not there?

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ICD-11

• To develop an understanding of the potential benefits of using

• To develop a basic understanding of ICD-11 architecture and

key differences between ICD-11 and ICD-10

• To understand stem codes and extension codes

• Let’s first take a look at the WHO website and ICD-11

 Reflect current medical terminology

 Greater international comparability for morbidity

 Linkages with other classifications/terminologies:

• Revision process occurred on an internet-based platform for

Updated content and new

• A multidimensional collection of all ICD entities

• Subsets of the foundation can be created - these are known as

• Instructions (sanctioning rules) on how to combine certain codes

• Alphanumeric codes cover the range from 1A00.00 to ZZ9Z.ZZ.

• Codes starting with an 'X' indicate an extension code

Examples: GB60.0 Acute kidney failure, stage 1

ICD-11 has 2 general types of codes:

Extension codes allow the user to add more detail to

• Type 2 identify the different uses of an ICD stem code

Stem + Stem (joined with /)

Stem + Extension (joined with &)

Mixed (may use both & and /)

• Patient with CA of UOQ of L breast

• Apostrophes have been removed

• Entities are described using natural language

• Abbreviations use upper case letters, followed by the complete

• Parentheses enclose the code to which an exclusion term refers.

Sanctioning tables containing these rules are expected to be

What is a stem code?

• To develop skill sets to master the use of the tools

• ICD-11 Beta Draft

• ICD-11 Training videos - The Browser

Source: ICD-11 Field Trial Education Package – June 2016, p. 27

Open the coding tool and search for the following:

Source: ICD-11 Field Trial Education Package – June 2016, p. 31-34

• ICD-11 coding tool. ICD-11 Coding Tool

Open the coding tool and try the following :

Source: ICD-11 Field Trial Education Package – June 2016, p. 34

How can you tell if you can post coordinate?

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