Webinar: Highlights of ICD-11

Slide 1: Title page

Welcome to the Highlights of ICD-11 webinar. It will provide a high-level overview of new features in ICD-11 (International Classification of Diseases, Eleventh Revision) and highlight key changes between ICD-11 and ICD-10-CA, the Canadian modification of ICD-10.

Slide 2: Learning objectives

At the end of this webinar, you will be able to

• Distinguish between the ICD-11 Foundation and ICD-11 MMS
• Locate the ICD-11 browser, Coding Tool and ICD-11 maintenance platform on the web
• Explain the ICD-11 Foundation 
• Describe the new chapters and identify the new sections in ICD-11 MMS
• Outline the ICD-11 MMS coding scheme and summarize key features
• Describe the use of ICD-11 postcoordination 
• Navigate the ICD-11 electronic tools (that is, the Coding Tool and integrated browser)
• Understand the use of the ICD-11 maintenance platform, and
• Locate available resources

Slide 3: ICD-11

As you may know, the ICD-11 Foundation and the core tabular list for international use (that is, the International Classification of Diseases for Mortality and Morbidity Statistics, Eleventh Revision — known as ICD-11 MMS) has been released and is now available; it came into effect on February 11, 2022. There has been no decision yet about adoption and timing of implementation in Canada. If you want a high-level overview of ICD-11 MMS, we invite you to access our webinar Introduction to ICD-11 for Mortality and Morbidity Statistics. It’s available on our ICD-11 web page.

Slide 4: ICD-11 home page

You can access the official home page for ICD-11 from the World Health Organization’s ICD website. On the WHO’s home page, there are hyperlinks to the 2 main ICD-11 electronic tools: the ICD-11 browser and the Coding Tool. There are also direct links to the maintenance platform and ICD-11 Reference Guide, which we will talk about later on. You can also access ICD-11 fact sheets, the ICD-11 terms of use and license agreement, and the WHO’s online training material.

Slide 5: ICD-11 Foundation

A new component of ICD-11 is the Foundation. 

Slide 6: Novel architecture: Foundation

The WHO Family of International Classifications (or WHO-FIC) is a suite of classifications. One of its components — the WHO-FIC Foundation — in the context of ICD-11, is the overarching repository for all ICD entities, also referred to as distinct or unique clinical concepts — diseases, disorders, injuries, external causes, signs and symptoms, and extension entities. The ICD-11 Foundation is built on a content model. This content model provides structure for the Foundation and defines the parameters (or properties) for each entity type. This model ensures that entities are defined in a standardized way. The Foundation stores these entities with filled parameters and holds the operational knowledge to generate linearizations, such as ICD-11 MMS.

Slide 7: ICD-11 Foundation

All ICD entities can be viewed and accessed in the ICD-11 maintenance platform. The Coding Tool is able to draw content from the Foundation. Each entity has its own unique and unchanging Uniform Resource Identifier, or URI. The foundation URI is a non–human readable code that allows linkage with other products, such as external terminologies. Future webinars will go into more detail about the URI.

Slide 8: ICD-11 MMS (visual)

Slide 9: Chapters

We will now highlight differences between ICD-11 MMS and ICD-10-CA. The first key change we will highlight is the difference in chapters for ICD-11 and ICD-10-CA, as well as some concept movements.

Slide 10: Chapters

You can see from the examples here that ICD-11 uses Arabic numbering, whereas you are likely familiar with the Roman numeral numbering of the chapters in ICD-10-CA.

ICD-11 has 25 main chapters, 4 of which are new: 

• Chapter 3: Diseases of the blood or blood-forming organs
• Chapter 4: Diseases of the immune system 
• Chapter 7: Sleep–wake disorders
• Chapter 17: Conditions related to sexual health

The addition of these new chapters means that the chapter numbers are not the same in ICD-11 and ICD-10-CA.

ICD-11 also has a new supplementary chapter, 26: Traditional medicine conditions — Module 1. There are also 2 new supplementary sections, V: Functioning assessment and X: Extension codes. Chapter 26 and the supplementary sections are optional to use for international morbidity reporting.

Let’s look at the 4 new main chapters in ICD-11 and see how each one is structured, compared with ICD-10-CA.

Slide 11: Chapter 3: Diseases of the blood or blood-forming organs

Chapter 3: Diseases of the blood or blood-forming organs was previously part of Chapter 3 in ICD-10-CA. In ICD-10-CA, Chapter 3 includes both diseases of the blood and diseases involving the immune mechanism; however, these diseases are now in separate chapters in ICD-11. Most ICD-10-CA concepts have been redistributed into 3 main sections in ICD-11’s Chapter 3:

• Anaemias or other erythrocyte disorders
• Coagulation defects, purpura or other haemorrhagic or related conditions, and
• Diseases of spleen

As you can see, D80–D89 Certain disorders involving the immune mechanism in ICD-10-CA are now in Chapter 4 of ICD-11.

Slide 12: Chapter 4: Diseases of the immune system

Chapter 4: Diseases of the immune system includes most of the remaining diseases from Chapter 3 in ICD-10-CA. This chapter was created to better capture the complexity of the disease processes of the immune system. It includes sections for immunodeficiencies and nonorgan specific systemic disorders. Autoinflammatory disorders and allergic or hypersensitivity conditions are now grouped together in this chapter. In ICD-10-CA, these are currently in various body system chapters. 

Slide 13: Chapter 7: Sleep-wake disorders

Chapter 7: Sleep-wake disorders is another new chapter in ICD-11. Currently in ICD-10-CA, sleep-wake disorders mainly overlap mental health, neurological disorders and pulmonary conditions. A decision was made for ICD-11 to have a unique place for these concepts. The table on this slide highlights the concept movements to this new chapter. Sleep-related movement disorders are new in ICD-11; ICD-10-CA did not distinctly identify these.

Slide 14: Chapter 17: Conditions related to sexual health

Chapter 17: Conditions related to sexual health is the last new chapter we will highlight in this webinar. Most of the conditions in this new chapter are in the mental health and genitourinary categories in ICD-10-CA. For example, codes from mental health category F52 Sexual dysfunction in ICD-10-CA have moved to this new chapter. The other 2 major sections in this chapter are Sexual pain disorders and Gender incongruence.

Slide 15: ICD-11 code scheme

The next key change to highlight is the code scheme.

Slide 16: Code scheme

In ICD-11, the numbers 1 to 9 are used for the first character of codes in the first 9 chapters. For chapters 10 through 25, a letter is used for the first character of the code. For example, the letter A at the beginning of code AA00 correlates to Chapter 10: Diseases of the ear or mastoid process.

In ICD-10-CA, the first character of the code is a letter, but it has no relationship to the Roman numeral chapter numbering. For example, J18.9 is a code in Chapter X: Diseases of the respiratory system.

The ICD-11 stem codes are alphanumeric like in ICD-10-CA, except a letter is in the second position and a number is in the third position, whereas ICD-10-CA codes have a letter in the first character position and a number in the following positions. The ICD-11 code scheme omits the letters O and I to prevent confusion with the numbers zero and one.

In ICD-11, stem codes have a maximum of 6 characters and a minimum of 4. CA02.10 Pharyngitis due to Adenovirus is an example of a 6-character stem code. ICD-10-CA codes also have a maximum of 6 characters but a minimum of 3. T82.700 is an example of a 6-character Canadian enhancement code.

Extension codes are also new in ICD-11. They are available to use when it is desirable to add supplementary or additional detail that is not precoordinated in a stem code. Extension codes are identifiable by the letter X as the first character and they cannot appear in the first position. For more information on extension codes, we invite you to access CIHI’s webinar Introduction to ICD-11 for Mortality and Morbidity Statistics, which is available on CIHI’s ICD-11 web page.

Slide 17: ICD-11 code structure example

Here is an example demonstrating ICD-11’s code structure.

A diagnosis of acute ST elevation myocardial infarction, anterior wall is classified to BA41.0 Acute ST elevation myocardial infarction. We know that the code XA7RE3 is an extension code because it begins with the letter X. The anatomy site detail “anterior wall of heart” is not precoordinated in the stem code BA41.0 (unlike the ICD-10-CA code I21.0); therefore, if the anatomy site detail is desired for reporting purposes, the extension code XA7RE3 can be linked to the stem code using an ampersand. The linking — or what is referred to as postcoordination — of BA41.0 and XA7RE3 creates what is called a “cluster.” We will discuss postcoordination, another new feature in ICD-11, in greater detail later in this webinar.

Slide 18: Residual codes

The code scheme for a residual code in ICD-11 is different than in ICD-10-CA. In ICD-11, the terminal letter Y or decimal Y in a stem code represents the residual code “other specified.” 3A00.Y Other specified iron deficiency anaemia is an example of an “other specified” residual code.

In ICD-11, “unspecified” residual codes are represented by the terminal letter Z or decimal Z. 6B8Z Feeding or eating disorders, unspecified is an example of an unspecified residual code.

Slide 19: Postcoordination

As mentioned earlier, postcoordination is a new feature of ICD-11 where 2 or more codes can be linked together to create a cluster.

Slide 20: Postcoordination

Postcoordination is a functional feature of ICD-11 as opposed to a content feature, and it supports users to use and link multiple ICD-11 codes to fully describe a documented clinical concept. Some postcoordination instructions are optional for international reporting purposes while others (such as causing condition) are mandatory.

A forward slash is used when linking 2 or more stem codes together, and an ampersand is used when linking an extension code to a stem code or linking 2 or more extension codes together. These conventions help distinguish one code from the other in the cluster.

Slide 21: Postcoordination examples

The first example — Breast cancer, right breast, upper outer quadrant — demonstrates linking with an ampersand. The laterality and anatomy extension codes are linked to the stem code 2C6Z Malignant neoplasm of breast. The addition of the anatomy and laterality extension codes is optional for international reporting purposes.

The other example — Diabetic retinopathy in type 2 diabetes mellitus — demonstrates linking 2 stem codes together using the forward slash.

You can find more detailed information about postcoordination in CIHI’s webinar Using the ICD-11 Coding Tool.

Slide 22: Browser

Another new feature of ICD-11 is the availability of electronic applications.

Slide 23: ICD-11 MMS browser

(Demo) The ICD-11 MMS online browser allows access to the tabular list of ICD-11. There are navigation tabs, including an Info tab. Here you can access a User Guide, the ICD-11 Reference Guide, print versions and more. Clicking the Coding Tool tab will take you directly to the tool.

The ICD-11 hierarchy is displayed on the left side of the screen. Once you select a code, all the code’s associated information is displayed to the right of the hierarchy. In the top right corner of the screen, you can select different languages. Clicking a language with a single arrow beside it will display 2 languages side by side for comparison purposes. Or you can change the language for the entire browser and Coding Tool by selecting a language with no arrow. To go back to the original language, simply click the language that you want to access.

Slide 24: Coding Tool and integrated browser

Slide 25: ICD-11 MMS Coding Tool

Here is the ICD-11 MMS Coding Tool, an electronic index that can be searched to help find ICD-11 terms. You can tell that it is the released version by the blue-coloured bar. (The work-in-progress version has an orange bar.) ICD-11 uses a web-based search functionality to assist users in locating the correct codes for diagnoses. The diagnosis, as recorded in the chart, can be searched without having to establish a lead term or secondary term, as was common when using ICD-10-CA alphabetical index.

[Demo starts] For example, if we type “femur fracture” in the Search bar, all results are displayed and referred to as Destination Entities. The tool provides synonyms and cross-references to direct you to the appropriate code, and also has smart features such as word prediction to improve your search. The tool will show any matching terms that are available and, when appropriate, will also show any inclusions and exclusions for a selected code. If you click “See in hierarchy,” it will lead to a built-in integrated browser. Here you can see the code details along with postcoordination. You will also see an interactive code hierarchy to the left to ensure you have selected the most specific code available for the clinical term or phrase you are looking for. [Demo ends]

If you want to learn more about using the Coding Tool and integrated browser, we invite you to access CIHI’s webinar Using the ICD-11 Coding Tool, available on CIHI’s ICD-11 web page.

Slide 26: WHO-FIC maintenance platform

Earlier in this webinar, we showed you where to access the ICD-11 home page on the WHO’s ICD website, and we mentioned that there was a link to the maintenance platform.

Slide 27: WHO-FIC maintenance platform

As mentioned previously, the ICD-11 Foundation content is found on the WHO-FIC maintenance platform. The audience for the maintenance platform is those who maintain, contribute to and translate the classification. Anyone can contribute directly to ICD-11 by submitting a proposal for updates, but CIHI is determining a submission process specific to Canada.

As you can see here, the maintenance platform encompasses more than just ICD-11. Anyone wishing to view work-in-progress versions of the WHO-FIC Reference Classifications — ICD-11, ICF (International Classification of Functioning, Disability and Health) and ICHI (International Classification of Health Interventions) — can do so on the maintenance platform.

It is important to note that the classifications seen on this site are not the released version of the classifications. You may sometimes hear the maintenance platform referred to as the “orange browser.” Its orange colour makes it distinguishable from the released version, which is blue. 

Slide 28: Summary

We are nearing the end of the webinar. In summary, you have learned the following:

• The ICD-11 Foundation is a collection of all ICD entities and it is essentially an underlying database that holds content for the ICD-11 MMS.
• There are 25 main chapters in ICD-11, 4 of which are new. There’s also 1 new supplementary chapter, Traditional Medicine, and 2 new supplementary sections — section V (Functioning assessment) and section X (Extension codes). 
• ICD-11 uses Arabic chapter numbering. The first 9 chapters use the numbers 1 to 9 as the first character of the code; for chapters 10 through 25, a letter is used for the first character of the code, starting with the letter A for Chapter 10, the letter B for Chapter 11, etc. 
• As previously noted, the terminal letters Y or Z identify a residual stem code in ICD-11, and the letter X as the first character of a code identifies an extension code in ICD-11.
• Postcoordination is a functional feature of ICD-11 that enables multiple codes to be linked together, creating a cluster. The cluster represents a documented clinical concept.
• The ICD-11 online browser allows access to the tabular list, and the Coding Tool uses a web-based search functionality with an integrated browser embedded within it.
• The maintenance platform — sometimes referred to as the orange browser — is for the maintainers, contributors and translators of the classification.

Slide 29: Resources

There are various resources available to learn more about ICD-11. 

Slide 30: Reference Guide

The ICD-11 Reference Guide can be found at the link provided on this slide. We invite you to refer to the specific sections shown here for more in-depth information on the content we’ve covered in this webinar.

Slide 31: Useful links

As we come to the end of this webinar, we want to share the WHO links we’ve reviewed as well as a link to CIHI’s ICD-11 web page, where you can find the other ICD-11 webinars we mentioned — Introduction to ICD-11 for Mortality and Morbidity Statistics, and Using the ICD-11 Coding Tool.

Slide 32: Contact information

Thank you for taking the Highlights of ICD-11 webinar. We would like to hear from you! Which ICD-11 topic interests you the most? If you would like to learn more about specific ICD-11 features of different use cases, please contact the Classifications and Terminologies ICD-11 team at ICD-11@cihi.ca. You can also email us if you have any general questions or feedback.

Slide 33: End