Welcome to the fifth edition of our Classifications and Terminologies e-newsletter. It aims to promote Classifications and Terminologies activities, upcoming education courses, coding questions, topical data quality initiatives and more!

Classifications and Terminologies highlights

How a study of breast cancer surgery in Canada influenced the enhancement of v2015 ICD-10-CA/CCI and the Canadian Coding Standards

The Discharge Abstract Database (DAD) and the National Ambulatory Care Reporting System (NACRS) are a rich source of health care data in Canada. Compiling, analyzing and reporting this data, and that of other databases, is the primary vision of the Canadian Institute for Health Information (CIHI): "Better data. Better decisions. Healthier Canadians."

By mining the databases' wealth of information, CIHI analysts published findings of the experience of patients receiving their primary surgical intervention for the treatment of breast cancer. The study, which provided valuable information and highlighted regional variation in breast cancer surgery practice across Canada, is beginning to make a difference in the lives of Canadians diagnosed with breast cancer.

Limitations encountered in the encoded data provided the impetus for determining where the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Canada (ICD-10-CA), the Canadian Classification of Health Interventions (CCI) and the Canadian Coding Standards for ICD-10-CA and CCI could be enhanced or clarified. These enhancements will eliminate or reduce the data limitations for future follow-up studies. Classifications specialists (HIM professionals) on the study team collaborated with CIHI's Research and Analytic Products team and surgical oncologists to determine the ICD-10-CA/CCI code parameters and relevant coding standards that would be integral to the study.

To determine compliance with the surgical gold standard for diagnosis and staging of breast cancer, analysts must calculate the percentage of breast cancer surgery patients receiving an axillary sentinel lymph node biopsy (SLNB) prior to or during the same operative episode of care as the primary lumpectomy or mastectomy. Prior to the release of version 2015, the capture of SLNB followed by axillary lymph node dissection in the same operative episode was optional. As coding was optional, it was not possible to do analysis or to report on the compliance with the gold standard. To address this important need, a new coding standard for Sentinel Lymph Node Biopsy was added to version 2015 of the Canadian Coding Standards with the following direction:

"Whenever a sentinel lymph node biopsy is performed, assign a code from 2.M^.71.^^ Biopsy, lymph node(s), any site with extent attribute of 'SN' (Sentinel node(s)), mandatory."
With this change in standard, which took effect April 1, 2015, data analysts will be able to report on regional practices in the surgical diagnosis and treatment of breast cancer in the DAD and NACRs. The first full fiscal year of data is 2015–2016.

In addition, the initial biopsy technique (open, excisional or core) for the primary breast cancer was analyzed. As a result of the findings of the study, enhancements to the CCI rubric 2.YM.71.^^ Biopsy, breast were madeby adding a new, unique code for the core needle aspiration technique and additional inclusion terms for clarity.

The study identified another data limitation: the inability to definitively identify laterality (which side) in a personal history of breast cancer. This made it impossible to determine whether a current episode of care for a lumpectomy or mastectomy was being performed on the same or contralateral side of a previous malignant neoplasm. To address this, new codes identifying laterality at D05 Carcinoma in situ of breast have been added, which are helpful in the event of a prophylactic mastectomy.

Version 2015 of ICD-10-CA has been expanded at code Z85.3– Personal history of malignant neoplasm of breast to include laterality and to facilitate future longitudinal studies across index and subsequent hospitalizations. In version 2015 of the Canadian Coding Standards, it is mandatory to capture personal history associated with primary malignant neoplasms of the breast, lung and prostate. This enhancement helps in the determination of re-excision rates. 

Tied closely to the personal history code enhancement is the new (version 2015) coding standard Acquired Absence of Breast and Lung Due to Primary Malignancy. The purpose of assigning acquired absence codes with personal history codes in these specific cases is to assist in identifying patients who have undergone previous total mastectomy or partial/total pneumonectomy for treatment of primary malignancy. The mandatory capture of this information is vital to be able to analyze and report on surgical treatment outcomes. With this new standard, another data limitation will now be eliminated.

This article helps to explain the rationale for these specific enhancements to version 2015 of ICD-10-CA/CCI and the Canadian Coding Standards. Translating research into action will definitely lead to Better data. Better decisions. Healthier Canadians!

2015–2016 DAD reabstraction study findings

CIHI recently conducted a reabstraction study on open-year 2015–2016 DAD data to evaluate the coding quality of the data used in key health system performance indicators (specifically in-hospital sepsis, infections , obstetrical trauma, obstetrical hemorrhage, low-risk deliveries and dates/times of patients admitted through the emergency department). We would like to thank all of the facilities that were randomly selected to participate for making time for the study. These facilities recently received their own results and a public report will be available in the fall. A recording of a recent web conference on the study findings is also accessible via the Coders' Resource Page. The recording is available in English only.

Zika virus

In December 2015, the World Health Organization issued an instruction that U06.9 Emergency use of U06.9 be implemented to facilitate global surveillance of the Zika virus.

In February 2016, Classifications and Terminologies issued a bulletin stating that confirmed cases of the Zika virus should be classified using the following code:

U06.9– Emergency use of U06.9

The bulletin can be found on the Coders' Resource Page. A Q & A on this coding topic has also been posted in the eQuery database.

Please note that until this code can be added to the Case Mix Group+ (CMG+) and Comprehensive Ambulatory Classification System (CACS) tables, Zika cases will group to CMG+ 999 and CACS Z999. The code will be added in 2017–2018; when the 2016 data is regrouped, the visits will be assigned properly in the historical data.

Coding in-stent (re)stenosis — change in direction

Effective April 1, 2016, for cases submitted to the DAD and NACRS, all cases of in-stent (re)stenosis are classified as a complication of the device, regardless of any documentation of the underlying cause of the stenosis and any timelines. Assign T82.8 Other specified complications of cardiac and vascular prosthetic devices, implants and grafts as the primary code and Y83.1 Surgical operation with implant of artificial internal device as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure and apply the diagnosis cluster to each of the codes. No additional codes (for specificity) are required.

Clinical input informed this change in direction. Clinicians advised that more often than not, the underlying cause of in-stent (re)stenosis is unknown, or it may not be documented. What is clinically relevant is the outcome of the endovascular stent. In-stent (re)stenosis means that the stent has failed to maintain dilation of the coronary artery and is classified as a complication of the implanted vascular device.

Education and related resources

Featured education

With more than 30 Classifications and Terminologies education products to choose from, there are plenty of education opportunities to take advantage of. From time to time, in this section of the e-newsletter, we will be highlighting one of our education products, and this month we are featuring our Coding for Diabetes collection. This collection consists of 7 individual courses and a final assessment.

  • Coding for Diabetes — Introduction
  • Coding for Diabetes — Basic Diabetes Mellitus Coding Principles
  • Coding for Diabetes — Acute Short-Term Complications of Diabetes Mellitus
  • Coding for Diabetes — Diabetic Angiopathy
  • Coding for Diabetes — Diabetic Nephropathy
  • Coding for Diabetes — Diabetic Neuropathy
  • Coding for Diabetes — Diabetic Retinopathy

You are welcome to take all the courses in the collection or you may be interested in only 1 course. However, the Introduction course, which contains the key messages and basic concepts needed for coding diabetes mellitus in ICD-10-CA, is a prerequisite for all the other courses in the collection. It is also recommended that you take Coding for Diabetes — Basic Diabetes Mellitus Coding Principles prior to any of the remaining courses in the collection. Each of the other 5 courses addresses a specific clinical aspect of diabetes coding.

To register for the Coding for Diabetes collection or any other Classifications and Terminologies education products, please visit our Learning Centre.

Coding standards: Obstructed Labor

Review of recent DAD data shows that assignment of 5.MD.16.LL Maternal position for delivery (assistance) hyperflexion of hips is inconsistent. Upon review of the direction in the coding standard Obstructed Labor, it was realized that the direction was not clear as to whether McRoberts maneuver (5.MD.16.LL), when performed to resolve shoulder dystocia, is optional or mandatory.

Note: If your facility has consistently been assigning 5.MD.16.LL, it is not wrong; this communication is to clarify that it is an optional code assignment. Coding question #61489 also addresses this topic. 

For version 2018 of the Canadian Coding Standards, the reference to McRoberts maneuver in the rationale of the first example on page 282 will be removed. You can use the Comment feature in the Canadian Coding Standards PDF to flag this clarification in the Obstructed Labor standard. (Direction on how to use the Comment feature can be found in the October 2015 edition of the Classifications and Terminologies e-newsletter.) 


In our last e-newsletter, we included a high-level overview of ICD-11, which will be published by the World Health Organization. In this edition, we'd like to share some information on the basic architecture and key features of ICD-11.

How ICD-11 differs from ICD-10

ICD-11 has many new features; most striking, perhaps, is the inclusion of several new chapters:

Chapter 3: Diseases of the Blood and Blood-Forming Organs
Chapter 4: Disorders of the Immune System
Chapter 5: Conditions Related to Sexual Health
Chapter 8: Sleep–Wake Disorders
Chapter 26: Extension Codes
Chapter 27: Traditional Medicine

New concepts

Foundation component
A major innovation in ICD-11
A multidimensional collection of all ICD entities
Includes the definitional components that are common between SNOMED CT and ICD-11
Each element in the Foundation
A subset of the Foundation component
Similar to Volume 1 (tabular) of ICD-10
Stem code
Codes in a linearization that can be used alone
Extension code
Can be used only with a stem code as its prefix
A stem code that has all the pertinent information in a pre-combined fashion
Using a stem code and an extension code(s) or a stem code and further stem code(s) to provide additional information

New coding scheme

ICD-11 has adopted a new coding scheme, which includes the following features:

  • Chapter numbering is now in Arabic numbers, not Roman numerals.
  • The coding scheme for categories is now a minimum of 4 characters and 2 levels of subcategories.
  • The letters O and I have been omitted to prevent confusion with the numbers 0 and 1.
  • The second character is a letter (which differentiates ICD-11 codes from ICD-10 codes).

Coding questions

Archiving of coding questions

We archive questions in CIHI's eQuery service in the following circumstances:

  • We undertake a mass archive each time a new version of the classifications (i.e., ICD-10-CA and CCI) and the Canadian Coding Standards for ICD-10-CA and CCI are released. This is done to reduce the number of invalid or irrelevant answers users of the eQuery have to filter through to find the answer to a question.
  • From time to time, we archive active answers that are no longer valid or relevant or that are inaccurate.
  • Occasionally feedback from clients results in a change in direction. In this situation, we archive related questions.

Because of this archiving process, sometimes when you search for an answer you knew previously existed, you may not find it. If you do not find the answer to your question after looking for information in the other resources available (e.g., new code, new alphabetical index look-up, coding standards, educational product), submit your question, along with a copy of the clinically relevant documentation, and we will answer your question based on the current version of the classifications and coding standards.

Updated coding questions

The Coding Question Service is used by health care facilities that submit their data to the DAD and NACRS.

On occasion, a coding question is reopened to update or revise the answer. This is done when an error is identified or when there is new information or a change of direction and there is value in revising and reposting the answer.

The following coding questions have been revised and updated since October 2015. Log in to eQuery now to review them.

Coding questions
English French
44215 45328 46505 48723 49439 50273 50636 60654
51659 53150 53415 53419 53830 60365 60764 61536
60719 60750 60824 60834 60882 61058 61686 61959
61120 61128 61280 61329 61355 61411 62013 62564
61434 61440 61489 61546 61779 61795 62565 62752
61866 61932 62351 62426 62540 62729 63290 63330
62967 62981 63349 63512 N/A N/A N/A N/A

Note: The tagline ******* Updated on YYYY.MM.DD ********* identifies the date the answer was revised; a brief description of the change, in square brackets, immediately follows the tagline.

Coders' Resource Page

The Coders' Resource Page was designed as a one-stop shop for Canada's HIM professionals. You will find resources that support your work in the coding and abstracting of data for the DAD and NACRS data holdings. These resources are intended to facilitate more effective data collection to enhance data quality.
The following tips for coders have been posted on the Coders' Resource Page since October 2015:

  • Where Do Soft-Tissue Injuries Fit in the Classification
  • O99 Use Additional Code
  • Section 5 Intervention Codes Applicable to Stillbirths, Missed Abortion and Termination of Pregnancy
  • Fetal Heart Rate Anomaly

Tips for coders are developed and posted every 2 months. The 2016–2017 schedule for new tips is as follows:

  • August 2016
  • October 2016
  • December 2016
  • February 2017

Please note that the tip Pneumonia: Using X-Ray Reports for Specificity has been archived, as the content in this tip has been incorporated into version 2015 of the coding standard Pneumonia.

Get in touch

For additional information or questions about any of the topics presented in this e-newsletter, please contact the Classifications and Terminologies team at We welcome hearing from you and encourage you to submit feedback about this publication.