ICD-11

Source: Wikipedia, the free encyclopedia.

The ICD-11 is the eleventh revision of the

beta draft in May 2012, a stable version of the ICD-11 was released on 18 June 2018,[6] and officially endorsed by all WHO members during the 72nd World Health Assembly on 25 May 2019.[7]

The ICD-11 is a large taxonomy consisting of about 85,000 entities, also called classes or nodes. An entity can be anything that is relevant to health care. It usually represents a disease or a

ICD-O is a derivative classification optimized for use in oncology. The primary derivative of the Foundation is called the ICD-11 MMS, and it is this system that is commonly referred to as simply "the ICD-11".[8] MMS stands for Mortality and Morbidity Statistics. The ICD-11 is distributed under a Creative Commons BY-ND license.[9]

The ICD-11 officially came into effect on 1 January 2022.[10] In February 2022, the WHO stated that 35 countries were actively using the ICD-11.[11] On 14 February 2023, they reported that 64 countries were "in different stages of ICD-11 implementation".[12] In the United States, an expected launch year of 2025 has been given, but if a clinical modification is determined to be needed (similar to the ICD-10-CM), ICD-11 implementation might not begin until 2027.[13]

The ICD-11 MMS can be viewed online on the WHO's website. Aside from this, the site offers two maintenance platforms: the ICD-11 Maintenance Platform, and the WHO-FIC Foundation Maintenance Platform. Users can submit evidence-based suggestions for the improvement of the WHO-FIC, i.e. the ICD-11, the

ICHI
.

Structure

WHO-FIC

See also: Medical classification § WHO Family of International Classifications

The WHO Family of International Classifications (

WHO-FIC), also called the WHO Family,[14] is a suit of classifications used to describe various aspects of the health care system in a consistent manner, with a standardised terminology.[15] The abbreviation is variously written with or without a hyphen ("WHO-FIC" or "WHOFIC"). The WHO-FIC consists of four components: the WHO-FIC Foundation, the Reference Classifications, the Derived Classifications, and the Related Classifications.[15] The WHO-FIC Foundation,[16] also called the Foundation Component,[17] represents the entire WHO-FIC universe.[18] It is a collection of over hundred thousand entities, also called classes or nodes.[18] Entities are anything relevant to health care. They are used to describe diseases, disorders, body parts, bodily functions, reasons for visit, medical procedures, microbes, causes of death, social circumstances of the patient, and much more.[15]

The Foundation Component is a multidimensional collection of entities.

viral infection (i.e. by site or by etiology). Thus, the node Pneumonia (entity id: 142052508) has two parents: Lung infections (entity id: 915779102) and Certain infectious or parasitic diseases (entity id: 1435254666). The Pneumonia node in turn has various children, including Bacterial pneumonia (entity id: 1323682030) and Viral pneumonia (entity id: 1024154490
).

The Foundation Component is the common core on which all Reference and Derived Classifications are based.

ICD-O is a Derived Classification used in oncology. Each node of the Foundation has a unique entity id, which remains the same in all Reference and Derived Classifications, guaranteeing consistency. Related Classifications are complementary, and cover specialty areas not covered elsewhere in the WHO-FIC. For example, the International Classification of Nursing Practice (ICNP), draws on terms from the Foundation Component, but also uses terms specific for nursing not found in the Foundation.[15]

A classification can be represented as a tabular list, which is a "flat" hierarchical tree of categories. In this tree, all entities can only have a single parent, and therefore must be mutually exclusive of each other.[20] Such a classification is also called a linearization.

ICD-11 MMS

The ICD-11 MMS is the main Reference Classification of the WHO-FIC, and the primary linearization of the Foundation Component. The ICD-11 MMS is commonly referred to as simply "the ICD-11".[8] The "MMS" was added to differentiate the ICD-11 entities in the Foundation from those in the Classification. The ICD-11 MMS does not contain all classes from the Foundation ICD-11, and also adds some classes from the ICF. MMS stands for Mortality and Morbidity Statistics. The abbreviation is variously written with or without a hyphen between 11 and MMS ("ICD-11 MMS" or "ICD-11-MMS").

The ICD-11 MMS consists of approximately 85,000 entities. Entities can be chapters, blocks or categories. A chapter is a top level entity of the hierarchy; the MMS contains 28 of them (see Chapters section below). A block is used to group related categories or blocks together. A category can be anything that is relevant to health care. Every category has a unique, alphanumeric code called an ICD-11 code, or just ICD code. Chapters and blocks never have ICD-11 codes, and therefore cannot be diagnosed. An ICD-11 code is not the same as an entity id.

The ICD-11 MMS takes the form of a "flat" hierarchical tree. As aforementioned, the entities in this linearization can only have a single parent, and therefore must be mutually exclusive of each other.

blood cancers, including all forms of leukemia
, are in the "Neoplasms" chapter, but they are also displayed as gray nodes in the chapter "Diseases of the blood or blood-forming organs".

The ICD-11 MMS also contains residual categories, or residual nodes. These are the "Other specified" and "Unspecified" categories. The former can be used to code conditions that do not fit with any of the more specific MMS entities, the latter can be used when necessary information may not be available in the source documentation. The ICD-11 Reference Guide advises that health care workers always aim to include the most specific level of detail possible, either with one code or multiple codes.[22] In the ICD-11 Browser, residual nodes are displayed in a maroon color.[23] Residual categories are not in the Foundation, and therefore don't have an entity ID. Thus, in the MMS, they are the only categories with derivative entity IDs: their IDs are the same as their parent nodes, with "/other" or "/unspecified" tagged at the end. Their ICD codes always end with Y for "Other specified" categories, or Z for "Unspecified" categories (e.g. 1C4Y and 1C4Z).

Health informatics

The ICD-11, both the ICD-11 Foundation and the MMS, can be accessed using a multilingual

REST API. Documentation on the ICD API and some additional tools for integration into third-party applications can be found at the ICD API home page.[24]

The WHO has released spreadsheets that can be used to link and convert

SNOMED International announced plans to release a SNOMED CT to ICD-11 MMS map.[26]

The ICD-11 Foundation, and consequently the MMS, are updated annually, similarly to the ICD-10. Following the initial release of a stable version on 18 June 2018,[6] the Foundation and the MMS have received six updates as of February 2024.[27][28]

Chapters

Below is a table of all chapters of the ICD-11 MMS, the primary linearization of the Foundation Component.[16]

# Range Chapter # Range Chapter
1 1A00–1H0Z Certain infectious or parasitic diseases 15 FA00–FC0Z Diseases of the musculoskeletal system or connective tissue
2 2A00–2F9Z Neoplasms 16 GA00–GC8Z Diseases of the genitourinary system
3 3A00–3C0Z Diseases of the blood or blood-forming organs 17 HA00–HA8Z Conditions related to sexual health
4 4A00–4B4Z Diseases of the immune system 18 JA00–JB6Z Pregnancy, childbirth or the puerperium
5 5A00–5D46 Endocrine, nutritional or metabolic diseases 19 KA00–KD5Z Certain conditions originating in the perinatal period
6 6A00–6E8Z Mental, behavioural or neurodevelopmental disorders 20 LA00–LD9Z Developmental anomalies
7 7A00–7B2Z Sleep-wake disorders 21 MA00–MH2Y Symptoms, signs or clinical findings, not elsewhere classified
8 8A00–8E7Z Diseases of the nervous system 22 NA00–NF2Z Injury, poisoning or certain other consequences of external causes
9 9A00–9E1Z Diseases of the visual system 23 PA00–PL2Z External causes of morbidity or mortality
10 AA00–AC0Z Diseases of the ear or mastoid process 24 QA00–QF4Z Factors influencing health status or contact with health services
11 BA00–BE2Z Diseases of the circulatory system 25 RA00–RA26 Codes for special purposes
12 CA00–CB7Z Diseases of the respiratory system 26 SA00–SJ3Z Supplementary Chapter Traditional Medicine Conditions - Module I
13 DA00–DE2Z Diseases of the digestive system 27 VA00–VC50 Supplementary section for functioning assessment
14 EA00–EM0Z Diseases of the skin 28 XA0060–XY9U Extension Codes

Unlike the ICD-10 codes, the ICD-11 MMS codes never contain the letters I or O, to prevent confusion with the numbers 1 and 0.[29]

Changes

Below is a summary of notable changes in the ICD-11 MMS compared to the ICD-10.

General

The ICD-11 MMS features a more flexible coding structure. In the ICD-10; every code starts with a letter, followed by a two digit number (e.g. P35)—creating 99 slots, excluding subcategories and blocks. This proved enough for most chapters, but four are so voluminous that their categories span multiple letters: Chapter I (A00–B99), Chapter II (C00.0–D48.9), Chapter XIX (S00–T98), and Chapter XX (V01–Y98). In the ICD-11 MMS, there is a single first character for every chapter. The codes of the first nine chapters begin with the numbers 1 to 9, while the next nineteen chapters start with the letters A to X. The letters I and O are not used, to prevent confusion with the numbers 1 and 0. The chapter character is then followed by a letter, a number, and a fourth character that starts as a number (0–9, e.g. KA80) and may then continue as a letter (A–Z, e.g. KA8A). The WHO opted for a forced number as the third character to prevent the spelling of "undesirable words".[29] In the ICD-10, each entity within a chapter either has a code (e.g. P35) or a code range (e.g. P35–P39). The latter is a block. In the ICD-11 MMS, blocks never have codes, and not every entity necessarily has a code, although each entity does have a unique id.[29]

In the ICD-10, the next level of the hierarchy is indicated in the code by a dot and a single number (e.g. P35.2). This is the lowest available level in the ICD-10 hierarchy, causing an artificial limitation of 10 subcategories per code (.0 to .9).[30] In the ICD-11 MMS, this limitation no longer exists: after 0–9, the list may continue with A–Z (e.g. KA62.0 – KA62.A). Then, following the first character after the dot, a second character may be used in the next level of the hierarchy (e.g. KA40.00 – KA40.08). This level is currently the lowest appearing in the MMS. The large amount of unused coding space in the MMS allows for updates to be made without having to change the other categories, ensuring that codes remain stable.[29]

The ICD-11 features five new chapters. The third chapter of the ICD-10, "Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism", has been split in two: "Diseases of the blood or blood-forming organs" (chapter 3) and "Diseases of the immune system" (chapter 4). The other new chapters are "Sleep-wake disorders" (chapter 7), "Conditions related to sexual health" (chapter 17, see section), and "Supplementary Chapter Traditional Medicine Conditions - Module I" (chapter 26, see section).

Mental disorders

Overview

The following mental disorders have been newly added to the ICD-11, but were already included in the American

Frotteuristic disorder (ICD-11: 6D34; ICD-10-CM: F65.81), Hoarding disorder (ICD-11: 6B24; ICD-10-CM: F42.3), and Intermittent explosive disorder (ICD-11: 6C73; ICD-10-CM: F63.81).[30]

The following mental disorders have been newly added to the ICD-11, and are not in the ICD-10-CM:

Olfactory reference disorder (6B22), and Prolonged grief disorder (6B42).[30]

Other notable changes include:[30]

Personality disorder

The

Dissociality (6D11.2), (4) Disinhibition (6D11.3), and (5) Anankastia (6D11.4). Listed directly underneath is Borderline pattern (6D11.5), a category similar to Borderline personality disorder
. This is not a trait in itself, but a combination of the five traits in certain severity.

Described as a clinical equivalent to the Big Five model,[32] the five-trait system addresses several problems of the old category-based system. Of the ten PDs in the ICD-10, two were used with a disproportionate high frequency: Emotionally unstable personality disorder, borderline type (F60.3) and Dissocial (antisocial) personality disorder (F60.2).[a] Many categories overlapped, and individuals with severe disorders often met the requirements for multiple PDs, which Reed et al. (2019) described as "artificial comorbidity".[30] PD was therefore reconceptualized in terms of a general dimension of severity, focusing on five negative personality traits which a person can have to various degrees.[33]

There was considerable debate regarding this new dimensional model, with many believing that categorical diagnosing should not be abandoned. In particular, there was disagreement about the status of Borderline personality disorder. Reed (2018) wrote: "Some research suggests that borderline PD is not an independently valid category, but rather a heterogeneous marker for PD severity. Other researchers view borderline PD as a valid and distinct clinical entity, and claim that 50 years of research support the validity of the category. Many – though by no means all – clinicians appear to be aligned with the latter position. In the absence of more definitive data, there seemed to be little hope of accommodating these opposing views. However, the WHO took seriously the concerns being expressed that access to services for patients with borderline PD, which has increasingly been achieved in some countries based on arguments of treatment efficacy, might be seriously undermined."[33] Thus, the WHO believed the inclusion of a Borderline pattern category to be a "pragmatic compromise".[34]

The Alternative DSM-5 Model for Personality Disorders (AMPD) included near the end of the DSM-5 is similar to the PD-system of the ICD-11, although much larger and more comprehensive.[35] It was considered for inclusion in the ICD-11, but the WHO decided against it because it was considered "too complicated for implementation in most clinical settings around the world",[33] since an explicit aim of the WHO was to develop a simple and efficient method that could also be used in low-resource settings.[34]

Gaming disorder

Gambling disorder (6C50). The latter was called Pathological gambling (F63.0) in the ICD-10. Aside from Gaming disorder, the ICD-11 also features Hazardous gaming (QE22
), an ancillary category that can be used to identify problematic gaming which does not rise to the level of a disorder.

Although a majority

stigmatizing people who are simply engaging in a very immersive hobby.[38] Bean et al. (2017) wrote that the GD category caters to false stereotypes of gamers as physically unfit and socially awkward, and that most gamers have no problems balancing their expected social roles outside games with those inside.[39]

In support of the GD category, Lee et al. (2017) agreed that there were major limitations of the existing research, but that this actually necessitates a standardized set of criteria, which would benefit studies more than self-developed instruments for evaluating problematic gaming.

PTSD. In clinical practice, both disorders need to be diagnosed and treated. Rumpf et al. also warned that the lack of a GD category might jeopardize insurance reimbursement of treatments.[43]

The DSM-5 (2013) features a similar category called Internet Gaming Disorder (IGD).[44] However, due to the controversy over its definition and inclusion, it is not included in its main body of mental diagnoses, but in the additional chapter "Conditions for Further Study". Disorders in this chapter are meant to encourage research and are not intended to be officially diagnosed.[45]

Burn-out

In May 2019, a number of media incorrectly reported that

Anxiety or fear-related disorders (6B00–6B0Z
) have been ruled out.

As with the ICD-10, burn-out is not in the mental disorders chapter, but in the chapter "Factors influencing health status or contact with health services", where it is coded QD85. In response to media attention over its inclusion, the WHO emphasized that the ICD-11 does not define burn-out as a mental disorder or a disease, but as an occupational phenomenon that undermines a person's well-being in the workplace.[50][51]

Sexual health

Conditions related to sexual health is a new chapter in the ICD-11. The WHO decided to put the sexual disorders in a separate chapter due to "the outdated

Cartesian separation of "organic" (physical) and "non-organic" (mental) conditions. As such, the sexual dysfunctions that were considered non-organic were included in the mental disorder chapter, while those that were considered organic were for the most part listed in the chapter on diseases of the genitourinary system. In the ICD-11, the brain and the body are seen as an integrate whole, with sexual dysfunctions considered to involve an interaction between physical and psychological factors. Thus, the organic/non-organic distinction was abolished.[53][54]

Sexual dysfunctions

Regarding general sexual dysfunction, the ICD-10 has three main categories:

Male erectile dysfunction (HA01.1). The difference between Hypoactive sexual desire dysfunction and Sexual arousal dysfunction is that in the former, there is a reduced or absent desire for sexual activity. In the latter, there is insufficient physical and emotional response to sexual activity, even though there still is a desire to engage in satisfying sex. The WHO acknowledged that there is an overlap between desire and arousal, but they are not the same. Management should focus on their distinct features.[55]

The ICD-10 contains the categories Vaginismus (N94.2), Nonorganic vaginismus (F52.5), Dyspareunia (N94.1), and Nonorganic dyspareunia (F52.6). As the WHO aimed to steer away from the aforementioned "outdated mind/body split", the organic and nonorganic disorders were merged. Vaginismus has been reclassified as Sexual pain-penetration disorder (HA20). Dyspareunia (GA12) has been retained. A related condition is Vulvodynia, which is in the ICD-9 (625.7), but not in the ICD-10. It has been re-added to the ICD-11 (GA34.02).[53]

Sexual dysfunctions and Sexual pain-penetration disorder can be coded alongside a temporal qualifier, "lifelong" or "acquired", and a situational qualifier, "general" or "situational". Furthermore, the ICD-11 offers five aetiological qualifiers, or "Associated with..." categories, to further specify the diagnosis.[53] For example, a woman who experiences sexual problems due to adverse effects of an SSRI antidepressant may be diagnosed with "Female sexual arousal dysfunction, acquired, generalised" (HA01.02) combined with "Associated with use of psychoactive substance or medication" (HA40.2).

Compulsive sexual behaviour disorder

Excessive sexual drive (F52.7) from the ICD-10 has been reclassified as Compulsive sexual behaviour disorder (CSBD, 6C72) and listed under Impulse control disorders. The WHO was unwilling to overpathologize sexual behaviour, stating that having a high sexual drive is not necessarily a disorder, so long as these people do not exhibit impaired control over their behavior, significant distress, or impairment in functioning.[56] Kraus et al. (2018) noted that several people self-identify as "sex addicts", but on closer examination do not actually exhibit the clinical characteristics of a sexual disorder, although they may have other mental health problems, such as anxiety or depression. Experiencing shame and guilt about sex is not a reliable indicator of a sex disorder, Kraus et al. stated.[56]

There was debate on whether CSBD should be considered a (behavioral) addiction. It has been claimed that neuroimaging shows overlap between compulsive sexual behavior and substance-use disorder through common neurotransmitter systems.[57] Nonetheless, it was ultimately decided to place the disorder in the Impulse control disorders group. Kraus et al. wrote that, for the ICD-11, "a relatively conservative position has been recommended, recognizing that we do not yet have definitive information on whether the processes involved in the development and maintenance of [CSBD] are equivalent to those observed in substance use disorders, gambling and gaming".[56]

Paraphilic disorders

Frotteuristic disorder (6D34) has been newly added.[53]

Gender incongruence

Gender identity disorder of childhood (F64.2). In the ICD-11, Dual-role transvestism was deleted due to a lack of public health or clinical relevance.[53] Transsexualism was renamed Gender incongruence of adolescence or adulthood (HA60), and Gender identity disorder of childhood was renamed Gender incongruence of childhood (HA61
).

In the ICD-10, the Gender identity disorders were placed in the mental disorders chapter, following what was customary at the time. Throughout the 20th century, both the ICD and the

gender variant appearance and behavior.[61] Studies have shown transgender people to be at higher risk of developing mental health problems than other populations, but that health services aimed at transgender people are often insufficient or nonexistent. Since an official ICD code is usually needed to gain access to and reimbursement for therapy, the WHO found it ill-advised to remove transgender health from the ICD-11 altogether. It was therefore decided to transpose the concept from the mental disorders chapter to the new sexual health chapter.[53]

Antimicrobial resistance and GLASS

The group related to coding

fungi, and protozoa) against medication.[62]

Traditional medicine

"Supplementary Chapter Traditional Medicine Conditions - Module I" is an additional chapter in the ICD-11. It consists of concepts that are commonly referred to as

Traditional Medicine (TM). Many of the traditional therapies and medicines that originally came from China also have long histories of usage and development in Japan (Kampo), Korea (TKM), and Vietnam (TVM).[63] Medical procedures that can be labeled as "traditional" continue to be used all over the world, and are an integral part of health services in some countries. A 2008 survey by the WHO found that "[i]n some Asian and African countries, 80% of the population depend on traditional medicine for primary health care". Also, "[i]n many developed countries, 70% to 80% of the population has used some form of alternative or complementary medicine (e.g. acupuncture)".[64]

From approximately 2003 to 2007,[65] a group of experts from various countries developed the WHO International Standard Terminologies on Traditional Medicine in the Western Pacific Region, or simply IST.[b][66] In the following years, based on this nomenclature, the group created the International Classification of Traditional Medicine, or ICTM.[c][65][68] As of February 2023, Module I, also called TM1,[69][70] is the only module of the ICTM to have been released. Morris, Gomes, & Allen (2012) have stated that Module II will cover Ayurveda, that Module III will cover homeopathy, and that Module IV will cover "other TM systems with independent diagnostic conditions in a similar fashion".[65] However, these modules have yet to be made public, and Singh & Rastogi (2018) noted that this "keeps the speculations open for what actually is encompassing under the current domain [of the ICTM]".[71]

The decision to include T(C)M in the ICD-11 has been criticized, because it is often alleged to be

Western Medicine concepts of ICD-11 chapters 1-25.[70]

Other changes

Other notable changes in the ICD-11 include:

Footnotes

  1. Other specific personality disorders (ICD-9: 301.8; ICD-10: F60.8). Patients who might have NPD are sometimes also diagnosed with Dissocial/Antisocial personality disorder (ICD-9: 301.7; ICD-10: F60.2
    ).
  2. ^ The abbreviation "IST" is used in official WHO documentation.[66] Other abbreviations that have been used are "WHO-IST"[65] and "WHO ISTT".[63]
  3. ^ Morris, Gomes, & Allen (2012) also used the term "International Classification of Traditional Medicine-China, Japan, Korea" (ICTM-CJK).[65] This term does not appear in official WHO documentation, and has only limited use. Also, Choi (2020) have used the term "ICD-11-26" to refer to the TM-chapter.[67]

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  32. S2CID 85446539
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  33. ^
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  34. ^
    S2CID 163165767
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  36. PMID 30010410
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  41. PMID 28816494
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  42. PMID 28816495
    . Both diagnostic manuals (i.e., the DSM and the ICD) are regularly revised, thus characterized by permanent change. (...) Moral panics and stigmatization related to video games are mostly induced and maintained by media scaremongering and the differences in mentality of the younger and older generations (i.e., generation gap) and not the existence of a formal diagnosis.
  43. ^ Rumpf et al. (2018): "The argument of potential stigmatization is not specific to GD but relates to many other well-established mental disorders. (...) Health insurance companies and other financers of treatment may adopt the arguments raised by non-clinical researchers (e.g., "gaming is a normal lifestyle activity"); so that, those in need of treatment and with limited funds are unable to get professional help."
  44. ^ DSM-5, pp. 795-798.
  45. ^ DSM-5: "These proposed criteria sets are not intended for clinical use; only the criteria sets and disorders in Section II of DSM-5 are officially recognized and can be used for clinical purposes." (p. 783).
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  54. ^ a b Reed et al. (2019): "The classification of sleep disorders in the ICD-10 relied on the now obsolete separation between organic and non-organic disorders (...) The ICD-10 also embodied a dichotomy between organic and non-organic in the realm of sexual dysfunctions"
  55. ^ Reed et al. (2016): "Although there is significant comorbidity between desire and arousal dysfunction, the overlap of these conditions does not mean that they are one and the same; research suggests that management should be targeted toward their distinct features."
  56. ^
    PMID 29352554
    .
  57. PMID 26893127
    .
  58. S2CID 12805083
    . Until the middle of the 20th century, with rare exceptions, transgender presentations were usually classified as psychopathological.
  59. S2CID 16336939
    . The DSM has consistently approached gender problems from the position that a divergence between the assigned sex or "the" physical sex (assuming that "physical sex" is a one-dimensional construct) and "the" psychological sex (gender) per se signals a psychiatric disorder. Although the terminology and place of the gender identity disorders in the DSM have varied in the different versions, the distress about one's assigned sex has remained, since DSM-III, the core feature of the diagnosis.
  60. ISBN 978-1-119-38360-4
    . The World Professional Association for Transgender Health (WPATH), for example, defined GD as "discomfort or distress that is caused by a discrepancy between a person's gender identity and that person's sex assigned at birth (and the associated gender role and/or primary and secondary sex characteristics)"
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