HEALTH DATA CLASSIFICATION

TEACHING MANUAL

BY

NAOMI CHEPKEMOI

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Table of Contents

INTRODUCTION TO ICD, ICPM AND ICHI ...........................................................................5

Definition of terms ..................................................................................................................5
Types of classification .............................................................................................................6
Principles of disease classification ...........................................................................................8
Historical development of ICD and ICPM ...............................................................................9
Structure of classification ...................................................................................................... 18
General arrangement of ICD-10, ICD-11 and ICPM operations and their application............. 23
Difference between tenth and eleventh revision ..................................................................... 29
ICD in the context of the WHO Family of International Classifications ................................. 33
Advantages of ICD-11 ........................................................................................................... 37
ICD-11 Package and Components ......................................................................................... 38
PURPOSES AND USES OF DISEASE CLASSIFICATION .................................................... 40
MAJOR CATEGORIES OF ICD-10, ICD-11, ICPM/ICHI AND CONVENTIONS ................. 43
Introduction to major chapters of ICD and ICPM/ICHI .......................................................... 43
Chapter Structure................................................................................................................... 48
Conventions .......................................................................................................................... 49
Code structure of ICD-10 and ICD-11 ................................................................................... 56
CODING AND INDEXING MORBIDITY DATA AND RELATED RULES .......................... 57
Definition of terms ................................................................................................................ 57
Introduction on use of reference guide ................................................................................... 61
Introduction to morbidity coding requirement ........................................................................ 62
Documentation guidelines for morbidity coding .................................................................... 62
Coding ................................................................................................................................... 65
Introduction to coding tool..................................................................................................... 67
Sources of Morbidity data ...................................................................................................... 71
Coder guidelines for selecting the main condition and other conditions for coding purposes .. 71
Coder rule for use of extension codes .................................................................................... 75
APPENDICES .......................................................................................................................... 75

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Module competency

By the end of the module, the learners should demonstrate an understanding of the concepts of
disease classification, ICD-10, ICD-11, ICPM, ICHI, WHO Concept of family of international
classification, structure of classification, purposes of disease classification, major categories of
ICD-10, ICD-11, ICPM/ICHI, related conventions and finally, code and index codes of health
conditions/ diseases and procedures manually and electronically

Course outline

1. Introduction to ICD-11, ICPM, ICHI and structure of ICD and ICPM

 Definition of ICD-11 and ICPM/ICHI and other terms used in both ICD-10 and ICD-11
 Types of classification
 Principles of classification
 Historical development of ICD, ICPM and ICHI
 Structure of the classification
 General arrangement of ICD-10, ICD-11 and ICPM
 Difference between tenth and eleventh revision and their application
 WHO Concept of family of international classification.
 Advantages of ICD-11and the ICD-11 package and the components

2. Purposes of disease classification

 Purposes and uses of ICD in healthcare

3. Major categories of ICD-10, ICD-11, ICPM/ICHI and conventions

 Introduction to ICD
 Chapters structure (ICD-10/11)
 Conventions used in ICD-10 and ICD-11
 Codes structure

4. Coding and indexing morbidity data and related rules

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 Definitions of terms used
 Introduction on use of reference guide
 Introduction to morbidity coding requirement
 Introduction to coding tool
 Sources of morbidity data
 Coder guidelines for selecting the main condition and other conditions for coding
purposes
 Coding special conditions
 Coding using post-coordination in morbidity coding
 Coder rule for use of extension codes

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INTRODUCTION TO ICD, ICPM AND ICHI

Definition of terms

ICD- International Classification of Diseases and other related health problems formerly referred
to as International Statistical Classification of Diseases.

It is a tool for recording, reporting and grouping conditions and factors that influence health. It
contains categories for diseases and disorders, health related conditions, external causes of illness
or death, anatomy, sites, activities, medicines, vaccines and more.

The ICD is:

Internationally: Produced by the WHO (World Health Organization) as the result of international
agreements.

Statistical classification of diseases: Used by the member countries so that comparative figures
produced in statistical tables of disease and injuries arranged in a meaningful way

ICPM- It means international classification of procedures in medicine. ICPM outline the

classification of therapeutic, diagnostic and prophylactic procedures in medicine. It covers surgery,
radiology, laboratory and other procedures.

ICHI- The International Classification of Health Interventions

Other commonly used terms

Health- A complete state of physical, mental and social wellbeing of an individual and not merely
the absence of disease or infirmity.

Disease classification- Disease classification according to WHO can be defined as a system of

categories to which morbid entities are assigned according to established criteria

Code- Refers to a specific system or number agreed upon in a given set up to offer a classification
or an arrangement order for that particular set up.

Coding- It is the process of establishing a specified number for a given disease or condition for a
patient statement of cause of admission into the hospital.

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Indexing- it is the process of writing down the patients’ particulars on to an identified material or
equipment once coding has been done.

Morbidity- A state of being diseased or having disease.

Mortality- refers t-o the number of deaths that have occurred due to a specific illness or condition.

Diagnosis- this refers to the patients’ disease or conditions or statements of cause of admission

Discharge summary- this is the patients’ document written by clinician at the time of discharge.

Types of classification

1. Reference classifications

These are the classifications that cover the main parameters of the health system, such as death,
and disease (ICD), disability, functioning and health (ICF) and health interventions (ICHI). WHO
reference classifications are a product of international agreements. They have achieved broad
acceptance and official agreement for use and are approved and recommended as guidelines for
international reporting on health.

Examples include:

1. International Classification of Diseases and Health Related Problems (ICD)- Used to capture
morbidity and mortality

2. International Classification of Functioning, Disability & Health (ICF)- Used to capture

information on various domains of human functioning and disability and health

3. International Classification Health Interventions (ICHI)- Replaces the former ICPM used to
classify procedures in medicine. ICHI is much broader than the ICPM as it includes interventions
across all functional sectors of the health system, covering acute care, primary care, rehabilitation,
assistance with functioning, prevention, public health, and ancillary services delivered by all types
of providers

2. Derived classifications

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 Derived classifications are often tailored for use at the national or international level or for use
in a particular specialty.
 They are based on reference classifications (i.e. ICD, ICF, ICHI).
 Derived classifications may be prepared by: adopting the reference classification structure and
classes, providing additional detail beyond that provided by the reference classification and the
rearrangement or by aggregation of items from one or more reference classifications.
 The classifications include:

 The International classification of diseases for oncology, 3rd edition (ICD-O-3)- published by
WHO in 2000, is intended for use in cancer registries, and in pathology and other departments
specializing in cancer.
 The international classification of diseases to dentistry and stomatology, 3rd edition (ICD-
DA). It brings together ICD categories for diseases or conditions that occur in, have
manifestations in, or have associations with the oral cavity and adjacent structures.
 The ICD-10 classification of mental and behavioural disorders (included in Chapter V of the
ICD-10)- The ICD-10 classification of mental and behavioural disorders: clinical descriptions
and diagnostic guidelines, published by WHO in 1992, provides a general description and
guidelines concerning the diagnosis, as well as comments about differential diagnosis and a
listing of synonyms and exclusion terms.
 The international classification of diseases to neurology, 2nd edition (ICD-10-NA)- which
retains the classification and coding systems of ICD-10 but is further subdivided at the fifth-
character level and beyond, to allow neurological diseases to be classified with greater
precision.

3. Related classifications

 Related classifications describe important aspects of health or the health system not covered
by reference or derived classifications.
 They include:
 International Classification of Primary Care (ICPC)
 International Classification of External Causes of Injury (ICECI)
 Technical aids for persons with disabilities (ISO9999)

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  The Anatomical Therapeutic Chemical Classification with Defined Daily Doses
(ATC/DDD)
 The International Classification for Nursing Practice (ICNP)
Principles of disease classification

The structure of ICD was proposed by William Farr who recommended that for all practical,
epidemiological purposes, statistical data on diseases and conditions and their causes should be
grouped in the following way:

 Epidemic diseases
 Constitutional or General Diseases that affect the whole body
 Local diseases arranged by site
 Developmental diseases
 Injuries

This pattern can be identified in the chapters of both ICD-10 and ICD-11. It has stood the test of
time and, though in some ways arbitrary, is still regarded as a more useful structure for general
epidemiological purposes than any of the alternatives tested.

The first two and the last two as listed above comprise special groups which bring together
conditions that would be conveniently arranged for epidemiological study were they to be
scattered. In a classification arranged primary by anatomical site, the remaining group, local
diseases arranged by site includes the ICD chapters for each of the main body systems.

The distinction between the ‘special groups’ chapters and the ‘body systems’ chapters has practical
implications for understanding the structure of the classification, for coding to it, and for
interpreting statistics based on it. It has to be remembered that, in general, conditions are primarily
classified to one of the ‘special groups’ chapters. Where there is any doubt as to where a condition
should be positioned, the ‘special groups’ chapters should take priority.

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Example of special group chapters

Historical development of ICD and ICPM

The classification of diseases dates back to 1600s, when a captain, John Graunt directed the
attention of the world to morbidity and mortality statistics. He is credited with a statistical study
of diseases. His publication was based on London Bills of Mortality in 1662. The kind of
classification is exemplified by his attempt to estimate the proportion of live born children who
died before reaching the age of six years, no records of age at death being available. He took
all deaths and classified as thrush, convulsions, rickets, teeth and worms, abortives, infants,
livegrown and overlaid and added to them deaths classed as smallpox, swinepox, measles and
worms without convulsions.

Between 1706-1777, Francois Bossier de Lacroix, better known as Sauvages, made his first
attempt to classify diseases systematically. Sauvages ‘comprehensive treatise was published under
the title Nosologia methodica. In 1707-1778, a contemporary of sauvages called Linnaeus also
published a classification entitled General Morborum, a catalogue of diseases

At the beginning of 19th century, the classification of disease in most general use was one by
William Cullen (1710-1790), of Edinburgh, which was published in 1785 under the title synopsis
nosologiae methodicae.

Fortunately for the progress of preventive medicine, the General Register Office of England and
Wales, at its inception in 1837, found in William Farr (1807–1883) – its first medical statistician
– a man who not only made the best possible use of the imperfect classifications of disease

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available at the time, but laboured to secure better classifications and international
uniformity in their use.

Farr found Cullen’s classification in use in the public services. It had not been revised to embody
the advances in medical science, nor was it deemed by him to be satisfactory for statistical
purposes. Farr realised that small numbers that would result from a detailed classification would
not permit statistical inferences to be made.

In the first Annual Report of the Registrar General, therefore, Farr discussed the principles that
should govern a statistical classification of disease and urged the adoption of a uniform statistical
classification.

Both nomenclature and statistical classification received constant study and consideration by Farr
in his annual ‘Letters’ to the Registrar General published in the Annual Reports of the Registrar
General. Farr did much to promote his classification but could not find general acceptance.

However, the utility of a uniform classification of causes of death was so strongly recognised at
the first International Statistical Congress, held in Brussels in 1853, that the Congress requested
William Farr and Genevan Marc d’Espine to prepare an internationally applicable, uniform
classification of causes of death

At the next Congress, in Paris in 1855, Farr and d’Espine submitted two separate lists which were
based on very different principles. Farr’s classification was arranged under five groups: epidemic
diseases, constitutional (general) diseases, local diseases arranged according to anatomical site,
developmental diseases, and diseases that are the direct result of violence. D’Espine classified
diseases according to their nature (gouty, herpetic, haematic, etc.). The Congress adopted a
compromise list of 139 rubrics.

In 1864, this classification was revised in Paris on the basis of Farr’s model and was subsequently
further revised in 1874, 1880, and 1886. Although this classification was never universally
accepted, the general arrangement proposed by Farr, including the principle of classifying diseases
by aetiology followed by anatomical site, survived as the basis of the International List of Causes
of Death.

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Importantly, the 1855 Congress also recommended that each country should ask for information
on causes of death from the doctor who had been attending the deceased, and that each country
should take measures to ensure that all deaths were verified by doctors

At the Fourth International Statistical Congress, held in London in 1860, FlorenceNightingale

urged the adoption of Farr’s classification of diseases for the tabulation of hospital morbidity in
the paper, ‘Proposals for a uniform plan of hospital statistics.’

At its 1891 meeting in Vienna, the International Statistical Institute, the successor to the
International Statistical Congress, charged a committee chaired by Jacques Bertillon (1851-1922),
Chief of Statistical Services of the City of Paris, with the preparation of a classification of causes
of death. The committee’s report was presented and adopted at the meeting of the International
Statistical Institute in Chicago in 1893.

For main headings, Bertillon adopted the anatomical site rather than the nature of disease,
according to Farr’s plan. Bertillon’s list included defined diseases most worthy of study by reason
of their transmissible nature or their frequency of occurrence. In accordance with the instructions
of the Vienna Congress, Bertillon included three classifications: an abridged classification of 44
titles; a classification of 99 titles; and a classification of 161 titles. Bertillon also prepared some
rules or guidelines on the resolution of problems; for example, how statistical clerks should classify
what is written without imputing what the doctor might have meant. The ‘Bertillon Classification
of Causes of Death’, as it was first called, received general approval and was adopted by several
countries, as well as by many cities. The classification was first used in North America by Jesus
E. Monjaras for the statistics of San Luis de Potosi, Mexico.

In 1898, the American Public Health Association, at its meeting in Ottawa, Canada, recommended
the adoption of the Bertillon Classification by registrars of Canada, Mexico, and the United States
of America. The Association further suggested that the classification should be revised every ten
years.

At the meeting of the International Statistical Institute at Christiania in 1899, Bertillon presented
a report on the progress of the classification, including the recommendations of the American
Public Health Association for decennial revisions.

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The French Government therefore assembled in Paris, in August 1900, the first International
Conference for the Revision of the Bertillon or International List of Causes of Death. Delegates
from 26 countries attended this Conference. A detailed classification of causes of death consisting
of 179 groups and an abridged classification of 35 groups was adopted on 21 August 1900. The
desire for decennial revisions was recognized, and the French Government was requested to call
the next meeting in 1910. In fact, the next conference was held in 1909, and the Government of
France called succeeding conferences in 1920, 1929, and 1938. Bertillon continued to be the
guiding force in the promotion of the International List of Causes of Death, and the revisions of
1900, 1910, and 1920 were carried out under his leadership.

As Secretary- General of the International Conference, he sent out the provisional revision for
1920 to more than 500 people, asking for comments. His death in 1922 left the International
Conference without a guiding hand.

At the 1923 session of the International Statistical Institute, Michel Huber, Bertillon’s successor
in France, recognized this lack of leadership and introduced a resolution for the International
Statistical Institute to renew its stand of 1893 in regard to the International Classification of Causes
of Death and to cooperate with other international organizations in preparation for subsequent
revisions.

The health organization of the League of Nations had also taken an active interest in vital statistics
and appointed a Commission of Statistical Experts to study the classification of diseases and causes
of death, as well as other problems in the field of medical statistics. E. Roesle, Chief of the Medical
Statistical Service of the German Health Bureau and a member of the Commission of Statistical
Experts, prepared a monograph that listed the expansion in the rubrics of the 1920 International
List of Causes of Death that would be required if the classification were to be used in the tabulation
of statistics of morbidity. This careful study was published by the health organization of the League
of Nations in 1928.

In order to coordinate the work of both agencies, an international ‘Mixed Commission’ was created
with an equal number of representatives from the International Statistical Institute and the Health
organization of the League of Nations. This Commission drafted the proposals for the Fourth
(1929) and the Fifth (1938) revisions of the International List of Causes of Death.

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The Fifth Decennial Revision Conference

The Fifth International Conference for the Revision of the International List of Causes of Death,
was convened by the Government of France and was held in Paris in October 1938. The
Conference approved three lists: a detailed list of 200 titles, an intermediate list of 87 titles
and an abridged list of 44 titles. Apart from bringing the lists up to date in accordance with the
progress of science, particularly in the chapter on infectious and parasitic diseases, and changes in
the chapters on puerperal conditions and on accidents, the Conference made as few changes as
possible in the contents, number, and even in the numbering of the items. A list of causes of
stillbirth was also drawn up and approved by the Conference.

As regards classification of diseases for morbidity statistics, the Conference recognized the
growing need for a corresponding list of diseases to meet the statistical requirements of widely
differing organizations, such as health insurance organizations, hospitals, military medical
services, health administrations, and similar bodies. The following resolutions were adopted

 International list of diseases

 Previous classifications of diseases for morbidity statistics
 United States Committee on Joint Causes of Death- the American Secretary of State in
1945 appointed the United States Committee on Joint Causes of Death under the
chairmanship of Lowell J. Reed, Professor of Biostatistics at Johns Hopkins University.

Sixth revision of the International List

The International Health Conference held in New York City in June and July 1946 entrusted the
Interim Commission of the World Health Organisation with the responsibility of ‘reviewing the
existing machinery and of undertaking such preparatory work as may be necessary in connection
with: (i) the next decennial revision of ‘The International Lists of Causes of Death’ (including the
lists adopted under the International Agreement of 1934, relating to Statistics of Causes of Death);
and (ii) the establishment of International Lists of Causes of Morbidity.’

To meet this responsibility, the Interim Commission appointed the Expert Committee for the
Preparation of the Sixth Decennial Revision of the International Lists of Diseases and Causes of
Death. This Committee, taking full account of prevailing opinion concerning morbidity and
mortality classification, reviewed and revised the above-mentioned proposed classification which

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had been prepared by the United States Committee on Joint Causes of Death. The resulting
classification was circulated to national governments preparing morbidity and mortality statistics
for comments and suggestions under the title, International Classification of Diseases, Injuries,
and Causes of Death.

The International Conference for the Sixth Revision of the International Lists of Diseases and
Causes of Death was convened in Paris from 26 to 30 April 1948 by the Government of France
under the terms of the agreement signed at the close of the Fifth Revision Conference in 1938. Its
secretariat was entrusted jointly to the competent French authorities and to the World Health
Organisation, which had carried out the preparatory work under the terms of the arrangement
concluded by the governments represented at the International Health Conference in 1946. The
Conference adopted the classification prepared by the Expert Committee as the Sixth Revision of
the International Lists. The Conference approved the International Form of Medical Certificate of
Cause of Death, accepted the underlying cause of death as the main cause to be tabulated, and
endorsed the rules for selecting the underlying cause of death as well as the special lists for
tabulation of morbidity and mortality data.

The International Classification, including the Tabular List of Inclusions defining the content of
the categories, was incorporated, together with the form of the medical certificate of cause of
death, the rules for classification and the special lists for tabulation, into the Manual of the
International Statistical Classification of Diseases, Injuries, and Causes of Death.

The Manual consisted of two volumes, Volume 2 being an alphabetical index of diagnostic terms
coded to the appropriate categories. In the Sixth Revision, morbid conditions resulting from
injuries, poisonings and other external causes were classified according to both the external
circumstances giving rise to the injury and to the kind of injury.

The Sixth Decennial Revision Conference marked the beginning of a new era in international vital
and health statistics.

The Seventh and eighth revision

The International Conference for the Seventh Revision of the International Classification of
Diseases was held in Paris under the auspices of the WHO in February 1955. In accordance with

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a recommendation of the WHO Expert Committee on Health Statistics, this revision was limited
to essential changes and amendments of errors and inconsistencies.

The Eighth Revision Conference was convened by the WHO met in Geneva, from 6 to 12 July
1965. This revision was more radical than the Seventh but left unchanged the basic structure of
the Classification and the general philosophy of classifying diseases, whenever possible, according
to their aetiology rather than a particular manifestation.

During the years that the Seventh and Eighth Revisions of the ICD were in force, the use of the
ICD for indexing hospital medical records increased rapidly and some countries prepared national
adaptations which provided the additional detail needed for this application of the ICD.

The Ninth revision

The International Conference for the Ninth Revision of the International Classification of Diseases,
convened by the WHO, met in Geneva from 30 September to 6 October 1975. In the discussions
leading up to the conference, it had originally been intended that there should be little change other
than updating of the classification. This was mainly because of the expense of adapting data
processing systems each time the classification was revised. There had been an enormous growth
of interest in the ICD and ways had to be found of responding to this, partly by modifying the
classification itself and partly by introducing special coding provisions.

A number of representations were made by specialist bodies which had become interested in using
the ICD for their own statistics. Some subject areas in the classification were regarded as
inappropriately arranged and there was considerable pressure for more detail and for adaptation of
the classification to make it more relevant for the evaluation of medical care, by classifying
conditions to the chapters concerned with the part of the body affected rather than to those dealing
with the underlying generalised disease.

At the other end of the scale, there were representations from countries and areas where a detailed
and sophisticated classification was irrelevant, but which nevertheless needed a classification
based on the ICD in order to assess their progress in health care and in the control of disease. The
final proposals presented to and accepted by the Conference retained the basic structure of the
ICD, although with much additional detail at the level of the four-digit subcategories, and some

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optional five-digit subdivisions. For the benefit of users not requiring such detail, care was taken
to ensure that the categories at the three-digit level were appropriate.

For the benefit of users wishing to produce statistics and indexes oriented towards medical care,
the Ninth Revision included an optional alternative method of classifying diagnostic statements,
including information about both an underlying general disease and a manifestation in a
particular organ or site. This system became known as the dagger and asterisk system.

The Twenty Ninth World Health Assembly, noting the recommendations of the International
Conference for the Ninth Revision of the International Classification of Diseases, approved the
publication, for trial purposes, of supplementary classifications of Impairments and Handicaps and
of Procedures in Medicine as supplements to, but not as integral parts of, the International
Classification of Diseases.

The Tenth Revision

Even before the Conference for the Ninth Revision, the WHO had been preparing for the Tenth
Revision. It recognized that the great expansion in the use of the ICD necessitated a thorough
rethinking of its structure and an effort to devise a stable and flexible classification, which should
not require fundamental revision for many years to come. The WHO Collaborating Centres for
Classification of Diseases were consequently called upon to experiment with models of alternative
structures for ICD–10. It had also become clear that the established ten-year interval between
revisions was too short. Work on the revision process had to start before the current version of the
ICD had been in use long enough to be thoroughly evaluated, mainly because the necessity to
consult so many countries and organisations made the process a very lengthy one.

The Director General of the WHO therefore wrote to the Member States and obtained their
agreement to postpone a 1985 Tenth Revision Conference until 1989, and to delay the introduction
of the Tenth Revision which would have been due in 1989. In addition to permitting
experimentation with alternative models for the structure of the ICD, this allowed time for the
evaluation of ICD-9, for example through meetings organised by some of the WHO Regional
Offices and through a survey organised at headquarters.

The International Conference for the Tenth Revision of the International Classification of
Diseases, attended by delegates from 43 Member States, was convened by the World Health

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organisation in Geneva from 26 September to 2 October 1989. The United Nations, the
International Labour Organisation, and the WHO Regional Offices sent representatives to
participate in the Conference, as did the Council for International organisations of Medical
Sciences. Twelve other non-governmental organisations concerned with cancer registration, the
deaf, epidemiology, family medicine, gynaecology and obstetrics, hypertension, health records,
preventive and social medicine, neurology, psychiatry, rehabilitation and sexually transmitted
diseases were also invited.

The main innovation in the Tenth Revision was the use of an alphanumeric coding scheme of
one letter followed by three numbers at the four-character level. This had the effect of more
than doubling the size of the coding frame in comparison with the Ninth Revision and enabled the
vast majority of chapters to be assigned a unique letter or group of letters, each capable of
providing 100 three-character categories. Of the 26 available letters, 25 had been used, the letter
U being left vacant for future additions and changes, and for possible interim classifications to
solve difficulties arising at the national and international level between revisions.

Another important innovation was the creation towards the end of certain chapters of categories
for postprocedural disorders. These identified important conditions that constituted a medical care
problem in their own right. Postprocedural conditions that were not specific to a particular body
system continued to be classified in the chapter on ‘Injury, poisoning and certain other
consequences of external causes’. The Revision included definitions, standards, and reporting
requirements related to maternal mortality and to fetal, perinatal, neonatal and infant mortality. It
was published in three volumes: one containing the Tabular List, a second containing all related
definitions, standards, rules and instructions, and a third containing the Alphabetical Index.

The tenth revision was adopted in 1990, published in 1992 and was first used by the member states
in 1994

Eleventh revision of ICD

The ICD-11 is the eleventh revision of the International Classification of Diseases, and will replace
the ICD-10 as the global standard for coding health information and causes of death. The ICD is
developed and annually updated by the World Health Organization (WHO). Development of the
ICD-11 started in 2007 and spanned over a decade of work, involving over 300 specialists from

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55 countries divided into 30 work groups, with an additional 10,000 proposals from people all over
the world.

A stable version of the ICD-11 was released on 18 June 2018, and officially endorsed by all WHO
members during the 72nd World Health Assembly on 25 May 2019. The ICD-11 officially came
into effect on 1 January 2022.

ICPM Brief History

When ICD-9 was published by WHO, the ICPM was also developed in 1975 and published in
1978 but it was not maintained. ICPM was published separately from the ICD disease
classification. ICHI was developed to replace the former ICPM because it is much broader which
includes a full range of interventions. ICHI development together with ICD-11 began in 2007 as a
joint effort of the WHO family of international classifications network.

Content development commenced in 2011, and a first version was available in late 2012, with
subsequent yearly updates. ICHI development was undertaken by a broad-based international team
of experts and was followed by a range of tests and field at country and international level. Initial
planning was not to attempt to match the level of granularity in existing national classifications.
To allow users to add more detail if they chose, extension codes were added to ICHI as the content
development and refinement continued. Extension codes were being included at the same time in
the development of ICD-11, and care was taken to avoid duplication and inconsistencies.

The initial electronic platform for ICHI was developed in 2016 by the University of Udine, Italy,
which made the ICHI development process transparent and served as a development platform.

In 2020, the Beta-3 version of ICHI was released. ICHI was incorporated on to the WHO’s
classifications platform, which includes all three WHO reference classifications. The platform
provides an updating mechanism which allows improvements in user guidance and scientific
updates without compromising the statistical use of the classification.

Structure of classification

a. ICD-10

a). ICD-10- consists of three volumes

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b). The classification is divided into 22 chapters

c). The classification chapters are subdivided into blocks of categories. -eg. A00-A99 in the chapter
title is called a block.

d). The blocks of categories comprise of three-character categories

Within each block, some of the three-character categories are for single conditions, selected
because of their frequency, severity or susceptibility to public health intervention, while others are
for groups of diseases with some common characteristic.

Examples include:

A00 Cholera

A01 Typhoid and paratyphoid fevers

A06 Amoebiasis

A09 Other gastroenteritis and colitis of infectious and unspecified origin

e). The chapters are further subdivided into four subcategories. The fourth character follows a
decimal point. Possible code numbers therefore range from A00.0 to Z99.9

The four-character subcategories are used in whatever way is most appropriate, identifying, for
example, different sites or varieties if the three-character category is for a single disease, or
individual diseases if the three-character category is for a group of conditions.

The fourth character .8 is generally used for ‘other’ identified conditions belonging to the three-
character category but not provided and .9 is mostly used for the unspecified field meaning
conditions whose names are no more specific than the three-character category title.

When the same fourth-character subdivisions apply to a range of three-character categories, they
are listed once only, at the start of the range. A note at each of the relevant categories indicates
where the details are to be found. For example, categories O03–O06, for different types of
abortion, have common fourth characters relating to associated complications (see Volume 1).

The following fourth-character subdivisions are for use with categories O03-O06:

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Incomplete abortion includes retained products of conception following abortion.

Incomplete, complicated by genital tract and pelvic infection

.0
With conditions in O08.0
Incomplete, complicated by delayed or excessive haemorrhage
.1
With conditions in O08.1
Incomplete, complicated by embolism
.2
With conditions in O08.2
Incomplete, with other and unspecified complications
.3
With conditions in O08.3-O08.9
.4 Incomplete, without complication
Complete or unspecified, complicated by genital tract and pelvic infection
.5
With conditions in O08.0
Complete or unspecified, complicated by delayed or excessive haemorrhage
.6
With conditions in O08.1
Complete or unspecified, complicated by embolism
.7
With conditions in O08.2
Complete or unspecified, with other and unspecified complications
.8
With conditions in O08.3-O08.9
.9 Complete or unspecified, without complication

f). The classification contains supplementary subdivisions for use at the level of the fifth or
subsequent character. Such classifications for use at the fifth and subsequent character levels are
found in:

Chapter XIII – subdivisions by anatomical site (Indicating site affected).

Page 628, Volume 1: States:
 The following sub classification to indicate the site of involvement is provided for
optional use with appropriate categories in chapter XIII

0- Multiple sites
1- Clavicle, Scapula
2- Upper arm
3- Forearm
4- Hand
5- Pelvic region and thigh
6- Lower leg
7- Ankle and foot

20
 8- Other (eg. Head, neck, ribs, skull, trunk, vertebral column)

Chapter XIX – subdivisions to indicate open and closed fractures where closed=0 and Open= 1,
as well as intracranial, intrathoracic and intra-abdominal injuries with and without open wound;
(VOLUME 1 Page 903, closed 0, open 1).
Chapter XX – former subdivisions to indicate the type of activity being undertaken at the time of
the event have now become optional additional information that is recorded in a separate field.
For Example:
ACTIVITY CODE
The following sub classification is provided for optional use in a supplementary character position
with categories V01 – Y34 to indicate the activity of the injured person at the time the event
occurred. This sub classification should not be confused with or be used instead of, the
recommended fourth character subdivisions provided to indicate the place of occurrence of events
classifiable to W00- Y34. The fifth digit sub classifications are as follows:

0- While engaged in sports activity (Golf, Jogging, Riding, School athletics, Skiing,
Swimming, Trekking, Water – skiing)
1- While engaged in leisure activity (Hobby activities, Leisure time activities with an element
such as going to cinema, to dance or party)
2- While working for income (Paid Work-Manual or professional, Transportation, (time) to
and from such activities, work for salaries,
3- While engaged in other types of work (Domestic duties such as caring for children and
relatives, cleaning, cooking, gardening, household maintenance, Duties for which one
would normally gain an income, learning activities, e.g. attending school sessions or
lesions)
4- While resting, sleeping, eating or engaging in other vital activities e.g. Personal hygiene

8- While engaged in other specified activities

9- During unspecified activity

21
g). The classification also contains U codes which are only used by WHO for the provisional
assignment of new diseases of uncertain etiology. 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, for example, when testing an alternative subclassification for a special project.

Structure of ICD-11

The classification was developed out of William Farr’s principles. The chapters are divided into
two namely: Special chapters and the body system chapters.

Examples of special chapters

22
It is built on a Foundation component from which the tabular lists (such as the classification for
morbidity and mortality statistics) is derived. The Foundation Component is a multidimensional
collection of all ICD entities. It is an underlying database that holds all necessary information to
generate print versions of the tabular list and the alphabetical index, as well as additional
information that is needed to generate specialty linearisations of ICD-11 and country-specific
modifications. The linearization component includes the ICD-11 for mortality and morbidity
statistics (ICD-11 -MMS). The Core tabular lists for international use includes: Mortality and
Morbidity Statistics (MMS), Primary care low resources settings (PCL), Verbal Autopsy (VA) and
Startup Mortality List (SMoL)

It has three volumes namely, the tabular list, qualifiers and modifiers, the index and the reference
guide

It has 26 chapters with two supplementary classifications eg.

o VA00–VC50 Supplementary section for functioning assessment

o XA0060–XY9U Extension Codes

Structure of ICPM

 Has nine chapters. The complete series of categories for the nine chapters are numbered from
1-100 to 9-823, the first digit denoting the chapter number.
 Has two volumes
 Each volume will contain a tabular list and an alphabetical index.

General arrangement of ICD-10, ICD-11 and ICPM operations and their application

ICD-10 has 3 volumes namely;

Volume 1 contains the main classifications. It is also known as the tabular list or confirmatory list.
It contains the following:

a. The list of the diseases, disease groups and health related problems arranged in alphanumeric
order as contained in alphabetical index divided across the 22 chapters.

23
b. The ‘List of three-character categories’ and the ‘Tabular list of inclusions and four-character
subcategories. It is divided into 22 chapters. The tabular list has a list of inclusions, exclusions
and glossary descriptions. The inclusion terms are given in addition to the title, as examples of
the diagnostic statements to be classified to that rubric. They may refer to different conditions
or be synonyms. Exclusion terms are terms that, although the rubric title might suggest that
they were to be classified there, are in fact classified elsewhere. Glossary descriptions are
used to indicate the content of rubrics eg. in the chapter of mental and behavioral disorders,
glossary descriptions are used because the terminology of mental disorders varies greatly,
particularly between different countries, and the same name may be used to describe quite
different conditions.
c. The classification of the morphology of neoplasms
The classification of morphology of neoplasms may be used, if desired, as an additional code
to classify the morphological type for neoplasms which, with a few exceptions, are classified
in chapter II only according to behavior and site (topography). The morphology codes are the
same as those used in the special adaptation of the ICD oncology (ICD-O). The morphology
axis provides five-digit codes ranging from M-8000/0 to M-9989/3.
The first four digits indicate the specific histological term. The fifth digit after the slash (/) is
the behaviour code, which indicates whether a tumour is malignant, benign, in situ or uncertain
(whether benign or malignant).

The one-digit behaviour code is as follows:

/0 Benign
/1 Uncertain whether benign or malignant
Borderline malignancy1
Low malignant potential1
/2 Intraepithelial
Noninfiltrating
Noninvasive
/3 Malignant, primary site
/6 Malignant, metastatic site
Malignant, secondary site

24
 /9 Malignant, uncertain whether primary or metastatic site

d. Special tabulation lists for mortality and morbidity

These are tabulation lists used in statistics that emphasizes certain single conditions and groups
others. These lists are designed so that international comparison of significant diseases and
groups of diseases is not frustrated by different groupings having been used in different
countries. The four special lists for the tabulation of mortality are an integral part of the ICD.
Lists 1 and 2 are for general mortality where it is a condensed list of 103 causes and selected
list of 80 causes respectively. Lists 3 and 4 are for infant and child mortality (ages 0–4 years)
where list 3 is a condensed list of 67 causes and list 4 is a selected list of 51 causes. There is
also a special tabulation list for morbidity which has a list of 298 causes. The morbidity list is
intended as a basis for national lists and for intercountry comparison.
e. Definitions- The definitions in Volume 1 have been adopted by the World Health Assembly
and are included to facilitate the international comparability of data.
f. Nomenclature regulations. The regulations adopted by the World Health Assembly set out
the formal responsibilities of WHO Member States regarding the classification of diseases and
causes of death, and the compilation and publication of statistics.

Volume 2 also known as instructional manual- which provides guidance to users of the ICD. It
has 6 sections: A general introduction to ICD, description of the International Statistical
Classification of Diseases and Related Health Problems, how to use ICD, rules and guidelines for
mortality and morbidity coding, Statistical presentation and the history of the development of ICD.

Volume 3- Also known as alphabetical index. It is divided into three sections:

 Section I-Alphabetical index to diseases and Nature of injury- lists all the terms classifiable
to Chapters I–XIX and Chapter XXI, except drugs and other chemicals;
 Section II- External causes of injury- the index of external causes of morbidity and
mortality and contains all the terms classifiable to Chapter XX, except drugs and other
chemicals;
 Section III- Table of drugs and chemicals, lists for each substance the codes for poisonings
and adverse effects of drugs classifiable to Chapter XIX, and the Chapter XX codes that

25
 indicate whether the poisoning was accidental, deliberate (self-harm), undetermined, or an
adverse effect of a correct substance properly administered

General arrangement of ICD-11

1. It is in three forms:
In a digital setting and with web services
 ICD-11 is used for coding of diagnoses, in electronic health records or with electronic death
certificates, or in other digital data collections.
In an Electronic version- use of blue and orange browser
• The WHO provides this version (BLUE BROWSER) for browsing ICD-11 in multiple
languages (linked from https://icd.Who.Int).
• This tool allows the user to retrieve concepts by searching for terms, anatomy or any other
element of the content model.
• With the orange browser, users can also contribute to the updating and continuous
improvement of ICD with comments and suggestions.
• Both the web services and the online browser allow access and searching of all tabular lists
of the ICD, including for mortality and morbidity statistics, primary care, or for specialty
linearisations for certain specific domains
In an analogue paper-based setting
 ICD-11 can be used as an analogue printed version, if needed. Information is reported on
hard copy documents and then coded manually with the ICD-11.
 In the print version, the information is divided into 3 volumes, the tabular list, the reference
guide, and the index. All three are needed to use the ICD correctly. The volumes include:
1) Tabular List, Special Tabulation Lists, Qualifiers, and Modifiers
The Tabular list is an alphanumeric listing of diseases and disease groups, inclusion and
exclusion notes, and some coding rules. Chapters 1 to 25 of the ICD contain approximately
15 000 entities at the four-, five- or six-character level.
In addition, there is a section on extension codes and one on Traditional medicine. The
Special tabulation lists are presented at the end of the Tabular list. Special tabulation lists
are not designed for coding but are for tabulation and reporting only. Examples of the core
tabular lists for international use in ICD-11 include:

26
 • Mortality and Morbidity Statistics (MMS)
• Primary care low resources settings (PCL)
• Primary care intermediate resources setting (PCM)
• Verbal Autopsy (VA)
• Simple Mortality List (SMoL)
2) Index
The Alphabetical Index is a list of more than 120 000 clinical terms (including synonyms
or phrases). The index is used to find the relevant ICD codes or code combinations for
clinical terms. The mention of a term in the index exclusively serves coding. Mention of a
term in the index does not mean approval or endorsement of a particular condition.
3) The Reference Guide
contains an introduction to the context, components, and intended use of the ICD. It
describes the diverse components of ICD-11, provides guidance for certification,
recording, rules for mortality coding (i.e. causes of death statistics) and morbidity coding
(e.g. hospital statistics) and lists for tabulation of statistical data.

ICPM

Volume 1 contains:
1. Procedures for Medical Diagnosis
2. Laboratory Procedures
4. Preventive Procedures
5. Surgical Procedures
8. Other Therapeutic Procedures
9. Ancillary Procedure

Volume 2 contains:
3.Radiology and certain other applications of physics in medicine
6 and 7. Drugs, medicaments and biological agents

Structure and the general arrangement of ICHI and its operational application

27
ICHI comprises a comprehensive set of interventions, referred to as stem codes. Each stem code
is represented by a title and a unique seven-character code denoting the axis categories for that
intervention: three characters for the Target, two characters for the Action and two characters for
the Means.
• Target - entity on which the Action is carried out
• Action - deed done by an actor to the Target
• Means - processes and methods by which the Action is carried out.
For example, Cholecystectomy is coded as KCF.JK.AA:
• Target KCF is ‘Gall bladder’,
• Action JK is ‘Excision, total’, and
• Means AA is ‘Open approach’.
Each axis consists of a coded list of descriptive categories.
Each ICHI stem code has a unique combination of categories from the three axes. Not every
possible combination of the three axes is represented as an ICHI code.
An ICHI stem code includes all necessary elements of the intervention (e.g. laparotomy as an
operative approach, suture of abdominal incision after surgery). Separate coding of components is
not required.
ICHI does not include information about the provider of an intervention or the setting where the
intervention is performed. The reason(s) for an intervention, and its outcome, should be classified
using ICD and ICF, and is not included in ICHI.
Additional information about an intervention may be added as needed using extension codes,
including codes for therapeutic and assistive products, medicaments, essential pathology tests and
telehealth, as well as information such as quantification, laterality, and a more detailed description
of anatomy. Where applicable, extension codes used in ICHI are the same as those in ICD-11.
ICF codes may be used as extension codes to provide a more detailed description of functioning
Targets. Codes from other classifications (such as LOINC, the International Standard Industrial
Classification and the Central Product Classification) may also be used as extension codes, notably
for public health interventions
In fields such as rehabilitation, mental health and public health, packages or programs of treatment
are provided which include several specific ICHI interventions. ICHI includes the capacity to link,
or cluster, interventions provided as part of a package or program.

28
ICHI contains more than 8,000 interventions. The number of interventions in ICHI, and
consequently the level of detail (granularity) across the classification, has been determined with
regard to the use cases for ICHI and the need for stability of the classification over time.
ICHI interventions are grouped into the following four sections, based on the Target of the
intervention:
• Interventions on Body Systems and Functions (Chapters 1-12)
• Interventions on Activities and Participation Domains (Chapters 13-21)
• Interventions on the Environment (Chapters 22-27)
• Interventions on Health-related Behaviours (Chapter 28)
Difference between tenth and eleventh revision

Characteristics of the tenth edition

Has three volumes- Vol I- Tabular list, Vol II- Instructional manual and Vol II- Alphabetical Index

Contain 22 chapters of the main categories.

Chapter numbering is in roman numerals

ICD-10 code sets are alphanumeric

Has 3 to 7 characters

Green in color

Characteristics of eleventh edition

 The chapter numbering is in Arabic numbers
 The coding scheme for categories has 4 characters, and there are 2 levels of subcategories.
 The coding scheme always has a letter in the second position to differentiate from the codes of
ICD–10.
 In ICD–11, the first character of the code always relates to the chapter number. It may be a
number or a letter. The code range of a single chapter always has the same character in the first
position.
 In order to describe a causal relationship between conditions in a code title the preferred term
is ‘due to’.

29
 In order to indicate the concurrence of two conditions in a code title the preferred term is
‘associated with
 ICD–11 categories have a short description and a long definition labelled ‘additional
information'. The description is a short characterisation (maximum of 100 words) of the entity
that states things that are always true about a disease or condition and necessary to understand
the scope of the rubric.
 Special tabulation lists continue to exist in ICD-11, but there are three additional ones- the
Startup Mortality List (SMoL), the list for verbal autopsy and infectious diseases by agent.
 ICD-11 concepts are language independent. All concepts have unique identifier (URI), and
have a specific place in a hierarchy of groups, categories and narrower terms. The maintenance
of the ICD-11 on an international level is handled in the English language but the content
model of the ICD–11 is language independent and allows binding of any desired language to
the elements of its foundation.

Differences between ICD 10 and ICD 11

30
31
32
ICD in the context of the WHO Family of International Classifications

The WHO Family of International Classifications (WHO-FIC) comprises classifications that have
been endorsed by the WHO to describe various aspects of health and the health system in a
consistent manner.

The WHO-FIC provides standardized building blocks for health information systems and consists
of three broad groups: Reference classifications, Derived classifications, and Related
classifications.

The Reference and the Derived classifications are based on the Foundation Component, which is
a large collection of concepts (with synonyms and preferred terms) and their relationships, which
describe health and health-related domains.

Terms and entities related to diseases and health-related problems are organized into the ICD,
those pertaining to functioning into the ICF, and those related to interventions into ICHI

33
(International Classification of Health Interventions). Terms from the Foundation Component may
be used in more than one Reference classification.

Derived Classifications draw on terms that may come from one or more of the Reference
Classifications. Within the WHO-FIC Family, Related classifications are regarded as
complementary to the Reference and Derived classifications. Related classifications have their
own sets of terms, but can also share terms as part of the WHO-FIC Family.

The purpose of the WHO-FIC is to assist the development of reliable statistical and other data
systems at local, national, and international levels, with the aim of improving health status and
health care. Health related information might sometimes require additional detail to that contained
in the ICD. A group or ‘family’ of health relevant classifications covers these needs both by
classification of domains different from those of the ICD and provision of more details for specific
uses, e.g. cancer registration. The WHO-FIC designates a suite of integrated classification products
that share similar features and can be used singularly or jointly to provide information on different
aspects of health and health care systems. For example, the ICD as a reference classification is
mainly used to capture mortality and morbidity information. Functioning is classified in the
International Classification of Functioning, Disability and Health (ICF) and health interventions
in the International Classification of Health Interventions (ICHI)

The WHO-FIC provides a conceptual framework of information dimensions which are related to
health and health management. In this way, it provides a common language that improves
communication and permits comparisons of data within countries, across countries, health care
disciplines, services, and time. The WHO and the WHO-FIC Network (including collaborating
centres, Non-governmental Organisations (NGOs), and selected experts) strive to build the Family
of International Classifications based on sound scientific and taxonomic principles, ensure that it
is up-to-date, culturally appropriate and internationally applicable, and meet the needs of its
different users by focusing on the multi-dimensional aspects of health.

34
WHO-FIC: Reference Classifications

Reference classifications cover the main parameters of the health system, such as death and disease
(ICD), disability, functioning, and health (ICF) and health interventions (ICHI). The three
Reference classifications are:

1. International Classification of Diseases and Health Related Problems (ICD)

2. International Classification of Functioning, Disability & Health (ICF)
3. International Classification Health Interventions (ICHI)

The Reference Classifications are based on the same Foundation Component and share sets of
Extension Codes.

International Classification of Functioning, Disability & Health (ICF)

The ICF is the WHO’s framework for measuring health and functioning/disability at both the
individual and population levels. While the ICD classifies diseases and causes of death, the ICF
classifies health and health-related domains. ICD and ICF together provide a framework to capture
the full picture of health. The ICF classifies health and health-related states in two parts. Part one
deals with functioning and disability, described from the perspectives of the body, the individual,
and society. It is composed of two components: Body functions and structures, and Activities and
participation. Part two covers contextual factors and also has two components: Environmental
factors and Personal factors, since an individual’s functioning occurs in a context.

Functioning is a generic term for body functions (e.g. memory), body structures (e.g. occipital
lobe), and activities and participation (e.g. walking, engaging in paid work). It denotes the positive
aspects of the interaction between an individual (related to the individual’s health) and that
individual’s contextual factors (environmental and personal factors).

Disability is an umbrella term for impairments, activity limitations and participation restrictions.
It denotes the negative aspects of the interaction between an individual (with a health condition)
and that individual’s contextual factors (environmental and personal factors). Disabilities are
envisioned as a continuum and therefore the ICF and the codes within it do not confer an

35
international binary status of disabled/not disabled. Levels of disability can be used descriptively
in clinical settings when formulating a case. Program and policy decision-makers can apply the
ICF and specify their own standards for the level of disability as eligibility criteria that are relevant
for specific purposes.

ICF includes codes for Body Functions (b), Body Structures (s), Activities and Participation (d),
and Environmental Factors (e). ICF codes are only complete with the presence of a qualifier, which
denotes the level of health (i.e. severity of the problem from ‘no problem’ to ‘complete problem’).
Without qualifiers, codes have no inherent meaning.

WHO-FIC: Derived classifications

Derived classifications are often tailored for use at the national or international level or for use in
a particular specialty. They are based on reference classifications (i.e. ICD, ICF, ICHI). Derived
classifications may be prepared by:

 adopting the reference classification structure and classes

 providing additional detail beyond that provided by the reference classification
 rearrangement or by aggregation of items from one or more reference classifications.

ICD-11 has specialty linearisations that are derived from the common foundation. These include
a version for dermatology, one for primary care and one for mental health. Others may follow.

WHO-FIC: Related classifications

Related classifications are included in the WHO Family of International Classifications to describe
important aspects of health or the health system not covered by reference or derived classifications.
Related classifications are:

• International Classification of Primary Care (ICPC)

• International Classification of External Causes of Injury (ICECI)
• Technical aids for persons with disabilities (ISO9999)
• The Anatomical Therapeutic Chemical Classification with Defined Daily Doses
(ATC/DDD)

36
 • The International Classification for Nursing Practice (ICNP)

Links with other Classifications and Terminologies

ICD coded entities or categories can be used in conjunction with other relevant health
classifications and terminologies to fully document an episode of care, or a case for research.
Terminologies and classifications should be considered complementary. The ICD-11 incorporates
or links with the following classifications and terminologies through the ICD11 Foundation:

 International Classification of Disease for Oncology – ICD-O

 International Classification of External Causes of Injury – ICECI
 International Classification of Functioning, Disability and Health – ICF
 International Classification of Primary Care – ICPC
 Other terminologies such as OrphaNet and SNOMED-CT

Advantages of ICD-11 and the ICD-11 package and the components

1. Up-to-date scientific knowledge- The 11th Revision contains more than 55 000 unique
entities, more than 120 000 derived from the latest scientific knowledge and reflecting
current practices and diagnostic concepts
2. Improvements and additions- Has new primary care concepts for application in settings
where simple diagnoses are made; a section on the documentation of patient safety events;
Coding for Antimicrobial Resistance; HIV coding has been updated with new subdivisions
and removal of outdated detail, as well as codes for differentiating ‘HIV with malaria or
tuberculosis'; New supplementary section for Functioning Assessment; ICD11 has
incorporated all rare diseases; use URI to link with other information interchange products
and terminologies; and finally, added a concept in Traditional Medicine.
3. Ease of use- Clinicians can search for diagnosis using natural or preferred terminology,
which then relates this to the correct technical code (without requiring the clinician to
memorise these).
4. Multiple applications to meet health system priorities- Apart from the use in both
mortality and morbidity statistics, ICD-11 is applicable for use in primary care reporting

37
 for all levels of resource settings, epidemiology and population health, research, health
system performance, patient safety and quality, and casemix or activity-based funding
5. The coding tools to be embedded into the local EHR and IT systems.
6. Multilingual support on translation and output
7. Linkage to relevant other classifications and terminologies
8. Better coding quality- Enable coding of all clinical detail
9. Reduced training time and cost

Main reasons for a new revision from ICD-10 to ICD-11

• Need for scientific update- Incorporating more definitions and 41000 more codes than the
previous version
• Need for structural change to electronic format due to the introduction of electronic
documentation in all areas of the health sector and in all work environments
• Convenience of connection with other terminological systems- family of international
classifications
• Imposition to improve the reproducibility of important clinical details of the conditions
thus obtaining better usability-more clinical details with less training
• Enhanced user guidance
• Need to capture more information, especially for morbidity purposes
• ICD-10 is outdated both clinically and from a classification perspective

ICD-11 Package and Components

• ICD11 Browser

The web-based browser tool allows the user to retrieve concepts by searching terms, anatomy
or any other element of the ICD11th Revision. The browser also allows users to contribute to
updates and continuous improvement of ICD, via a proposal platform. Such input is reviewed
for consideration for inclusion on an annual basis

• ICD11 Coding Tool

38
 The Coding Tool works by searching ICD content as the user types in a term. It generates (and
dynamically updates) three different outputs: a word list; matched entities with a link to the
Browser; and, the chapters associated with the target term

• Foundation Component - Index, Guidance

The Foundation Component is the underpinning repository or database of all ICD entities. The
Foundation represents the entirety of the ICD universe, and it is from this which the Tabular
List and Alphabetic Index are derived.

• Linearization for Mortality and Morbidity Statistics (MMS)

It is from the Foundation that the subsets which create the reference tabulation lists for
mortality and morbidity statistics (MMS) are drawn. Linearizations are analogous to the
classical print versions of the ICD Tabular List (e.g. Volume I of ICD10 or other previous
editions).

• The Translation Tool

Part of the ICD11 Maintenance Platform, the translation tool allows for specific language users
centres to build their translations that are faithful to the original.

• Application Programming Interface (API services)

ICD API allows programmatic access to the International Classification of Diseases (ICD).
Users must first register via the site and may then use it to access up-to-date documentation on
using the API as well as managing the keys needed for using the API.

• Digital health (eHealth) compatibility and interoperability with Health Information

Systems

The ICD11 Foundation allows for standardised ‘point-of-care’ data capture by housing content
that essentially forms what was the Tabular List and Alphabetic Index in ICD10, terminology

39
 for diseases and related health conditions, and the structures necessary for incorporation into
digital health information systems.

• Linkages with other classifications and terminologies

ICD coded entities or categories can be used in conjunction with other relevant health
classifications and terminologies to fully document an episode of care, or a case for research.

PURPOSES AND USES OF DISEASE CLASSIFICATION

1. ICD use for mortality and morbidity reporting and comparison purposes
ICD is used to permit systematic recording, analysis, interpretation and comparison of
mortality and morbidity data collected in different countries or areas (international) and at
different times.
2. Morbidity coding, Certification and reporting of causes of death
ICD was originally use to classify causes of mortality as recorded at the registration of death
but later, its scope was extended to include diagnoses in morbidity. ICD is also used to classify
diseases and other health problems recorded on many types of health and vital records
including death certificates and hospital records.
Information on what people die of is recorded on standard forms, analyzed and reported
following ICD standards.
3. ICD use for systematic arrangement of health information
ICD is used to translate diagnoses of diseases and other health problems from words into an
alphanumeric code, which permits easy storage, retrieval and analysis of the data.
4. ICD use for all general epidemiological and many health management purposes
ICD is regarded as the international standard diagnostic classification for all general
epidemiological and many health-management purposes which include: Analysis of the
general health situation of population groups and Monitoring of the incidence and prevalence
of diseases and other health problems in relation to other variables, such as the characteristics
and circumstances of the individuals affected. In addition, ICD coded data, either from
morbidity or mortality sources, contribute to the understanding of the health of a population.
5. Statistical purposes

40
 ICD provides for a wide variety of signs, symptoms, abnormal findings, complaints and social
circumstances that may stand in place of a diagnosis on health-related records. Such can then
be used to classify data recorded under headings such as ‘diagnosis’, ‘reason for admission’,
‘conditions treated’ and ‘reason for consultation’, which appear on a wide variety of health
records from which statistics and other health-situation information are derived.
6. Standardization purposes
ICD provides a common language for recording, reporting and monitoring diseases. ICD offers
a standardized reporting system for diseases and procedures in medicine. This allows the world
to compare and share data in a consistent and standard way – between hospitals, regions and
countries and over periods of time.
7. Reimbursement
ICD is suitable for studies of financial aspects of a health system, such as billing. ICD
information is used by health insurers in paying up of medical claims.
8. ICD use for research purposes
The morbidity use case for ICD includes a number of situations where the primary goal is to
work in an academic research paradigm to extract information from ICD coded data to study
burden of disease, clusters of disease, geographic distribution of diseases, and health impacts
associated with various diseases.
9. Teaching
Medical data classification provides tools necessary for teaching purposes to all health
professions
10. Resource allocation

ICD-coded information is used for resource allocation or lumpsum payments of statistically

equal groups.
11. Assessing and monitoring the safety, efficacy, and quality of care

Quality of care uses ICD-coded information to describe the situation of the patient, outcome
of treatment and incidents or near-incidents including mechanisms and involved objects such
as the failure of an infusion pump or the accidental wrong dosage of a medicament by the
patient in line with the WHO recommendations for patient safety incident reporting and
learning systems
12. Casemix and Diagnosis-Related Grouping (DRG)

41
 ICD provides with casemix classifications which provide the health care industry a means of
relating the type of patients a hospital treats (i.e., its case mix) to the costs incurred by the
hospital with mix of types of patients (range and type) treated by a hospital or other health care
facility. Prospective payment rates based on Diagnosis Related Groups (DRGs) have been
established as the basis of Medicare’s hospital reimbursement system. ICD-coded information
is used for resource allocation or lumpsum payments of statistically equal groups.
13. Health service planning

ICD coded information const itutes a very useful tool for healt h planners and
administrators to identify priorities for public health interventions, budgeting, future research
needs and preparation of guidelines.

Note: The Primary users of ICD include physicians, nurses, health workers, researchers, health
information managers, policy-makers, insurers and national health programme managers, among
others.

REVISION QUESTIONS

Discuss five reasons why a Health Record and Information management student should learn
Medical Data Classification

Discuss the concept of Specialty-Based Adaptations, giving four examples of specialties

included

Outline five major differences between ICD-11 and ICD-10

State five principles of disease classification

Discuss the concept of family of international classifications with relevant examples

Outline the basic structure of disease classification according to William Farr

42
MAJOR CATEGORIES OF ICD-10, ICD-11, ICPM/ICHI AND CONVENTIONS

 Introduction to ICD
 Chapters structure (ICD-10/11)
 Conventions used in ICD-10 and ICD-11
 Codes structure

Introduction to major chapters of ICD and ICPM/ICHI

ICD 10

Chapter Block Title

I A00–B99 Certain infectious and parasitic diseases

II C00–D48 Neoplasms
Diseases of the blood and blood-forming organs and
III D50–D89
certain disorders involving the immune mechanism
IV E00–E90 Endocrine, nutritional and metabolic diseases
V F00–F99 Mental and behavioral disorders
VI G00–G99 Diseases of the nervous system

VII H00–H59 Diseases of the eye and adnexa

VIII H60–H95 Diseases of the ear and mastoid process

IX I00–I99 Diseases of the circulatory system
X J00–J99 Diseases of the respiratory system
XI K00–K93 Diseases of the digestive system
XII L00–L99 Diseases of the skin and subcutaneous tissue
Diseases of the musculoskeletal system and connective
XIII M00–M99
tissue
XIV N00–N99 Diseases of the genitourinary system
XV O00–O99 Pregnancy, childbirth and the puerperium
XVI P00–P96 Certain conditions originating in the perinatal period
Congenital malformations, deformations and
XVII Q00–Q99
chromosomal abnormalities
Symptoms, signs and abnormal clinical and laboratory
XVIII R00–R99
findings, not elsewhere classified
Injury, poisoning and certain other consequences of
XIX S00–T98
external causes
XX V01–Y98 External causes of morbidity and mortality

43
 Factors influencing health status and contact with health
XXI Z00–Z99
services
XXII U00–U99 Codes for special purposes

ICD 11

01. 1A00–1H0Z Certain infectious or parasitic diseases

02. 2A00–2F9Z Neoplasms
03. 3A00–3C0Z Diseases of the blood or blood-forming organs
04. 4A00–4B4Z Diseases of the immune system
05. 5A00–5D46 Endocrine, nutritional or metabolic diseases
06. 6A00–6E8Z Mental, behavioural or neurodevelopmental disorders
07. 7A00–7B2Z Sleep-wake disorders
08. 8A00–8E7Z Diseases of the nervous system
09. 9A00–9E1Z Diseases of the visual system
10. AA00–AC0Z Diseases of the ear or mastoid process
11. BA00–BE2Z Diseases of the circulatory system
12. CA00–CB7Z Diseases of the respiratory system
13. DA00–DE2Z Diseases of the digestive system
14. EA00–EM0Z Diseases of the skin
15. FA00–FC0Z Diseases of the musculoskeletal system or connective tissue
16. GA00–GC8Z Diseases of the genitourinary system
17. HA00–HA8Z Conditions related to sexual health
18. JA00–JB6Z Pregnancy, childbirth or the puerperium
19. KA00–KD5Z Certain conditions originating in the perinatal period
20. LA00–LD9Z Developmental anomalies
21. MA00–MH2Y Symptoms, signs or clinical findings, not elsewhere classified
22. NA00–NF2Z Injury, poisoning or certain other consequences of external causes
23. PA00–PL2Z External causes of morbidity or mortality
24. QA00–QF4Z Factors influencing health status or contact with health services
25. RA00–RA26 Codes for special purposes
26. SA00–SJ3Z Supplementary Chapter Traditional Medicine Conditions - Module I

44
 2 Supplementary chapters
VA00–VC50 Supplementary section for functioning assessment
XA0060–XY9U Extension Codes

Major Chapters of ICPM

Has nine chapters
1. Procedures for Medical Diagnosis
2. Laboratory Procedures
3. Radiology and certain other applications of physics in medicine
4. Preventive Procedures
5. Surgical Procedures
6 and 7. Drugs, medicaments and biological agents
8. Other Therapeutic Procedures
9. Ancillary Procedure

ICHI Chapters- Chapters organized in 4 interventions

45
Brief description of chapter of ICD (Neoplasms)
Has four aspects namely: behaviour, broad sites or systems, specific sites and the morphological
type
The general hierarchy of Chapter 02 consists of the following:

1st level – Behaviour- Malignant, benign, in-situ and uncertain behaviour

2nd level - Broad sites or systems- anatomical site of the neoplasm

3rd level - Specific site- either the primary or the secondary site

4th level - Morphological (histological) type

a. Behavior of neoplasms

The four major types of behaviour are:

46
 • Malignant: the neoplasm invades surrounding tissue or disseminates from its point of origin
and begins to grow at another site eg. Cancers

• In situ: the neoplasm is malignant but still fully confined to the tissue in which it originated;

• Benign: the neoplasm grows in the place of origin without the potential for spread; eg.
fibroids, lipomas

• Uncertain or unknown behaviour: it is undetermined or unknown whether the neoplasm is

benign or malignant.

b). Specific site- Primary or secondary

The primary site is the anatomical location where the malignant neoplasm originated (Point of
origin). A malignant neoplasm may spread to other parts of the body, and these sites are referred
to as secondary or metastases. It is most important to determine the primary site

c). Anatomical site of the neoplasm (Lung, breast, colon etc). These are neoplasms classified
according to the broad site it invades.

d). Morphology- It refers to the form and structure of neoplastic cells or the histopathology of the
cells. The morphology code records the type of cell that has become neoplastic and its biologic
activity; in other words, it records the kind of tumor that has developed and how it behaves. There
are three parts to a complete morphology code:

 4 digits cell type (histology)

 1 digit behavior
 1 digit grade, differentiation or phenotype

Eg. M-8000/0 to M-9989/3.

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Chapter Structure
a. ICD-10

The first character of the ICD code is a letter, and each letter is associated with a particular chapter,
except for the letter D, which is used in both Chapter II, Neoplasms, and Chapter III, Diseases of
the blood and blood-forming organs and certain disorders involving the immune mechanism, and
the letter H, which is used in both Chapter VII, Diseases of the eye and adnexa and Chapter VIII,
Diseases of the ear and mastoid process.

Four chapters (Chapters I, II, XIX and XX) use more than one letter in the first position of their
codes. Each chapter contains sufficient three-character categories to cover its content; not all
available codes are used, allowing space for future revision and expansion.

Chapters I–XVII relate to diseases and other morbid conditions, and Chapter XIX relates to Injury,
poisoning and certain other consequences of external causes. The remaining chapters complete the
range of subject matter currently included in diagnostic data.

Chapter XVIII covers Symptoms, signs and abnormal clinical and laboratory findings, not
elsewhere classified.

Chapter XX, External causes of morbidity and mortality, was traditionally used to classify causes
of injury and poisoning, but, since the ninth revision, has also provided for any recorded external
cause of diseases and other morbid conditions.

Finally, Chapter XXI, Factors influencing health status and contact with health services, is
intended for the classification of data explaining the reason for contact with health-care services
of a person not currently sick, or the circumstances in which the patient is receiving care at that
particular time, or otherwise having some bearing on that person’s care.

b. ICD 11- Mortality and Morbidity statistics

Divided into 28 chapters, of which 25 refer to health conditions similar to past ICD versions, while
one serves to identify external causes of morbidity and mortality, and another includes concepts
of traditional medicine. Lastly, there are two additional sections for optional additional use, one
for extension codes to add more detail for different dimensions of a disease, such as anatomy, mark
a condition to be present on admission, or a disease having been relevant in the family history and

48
the other for functioning assessment to provide a set of codes for assessment and scoring in the
ICD using ICF functioning domains of high explanatory power.

Has five new chapters. As a result, the numbering of the chapters has changed. The new chapters
are:

 Chapter 03 ‘Diseases of the blood or blood-forming organs and Chapter 04 ‘Disorders of

the immune system’. Conditions affecting the immune system’ and conditions affecting
the blood are now in two separate chapters.
 Chapter 07 ‘Sleep-Wake disorders. Sleep wake disorders have been regrouped together in
this new chapter.
 Chapter 17 ‘Conditions related to sexual health’. Sexual conditions have been grouped
together in this new chapter.
 Chapter 26 ‘Supplementary Chapter Traditional Medicine Conditions - Module I’. A
chapter for traditional medicine has been added.

Conventions

 ICD–10 and ICD-11 has standard ways of presenting its content. Conventions describe textual

content and also apply to the coding structure. They are rules used in the classification

irrespective of the guidelines

Instructional terms

Inclusions- Used in both ICD-10 and 11

 Within the coded categories there are typically other optional diagnostic terms. These are
known as ‘inclusion terms’ and are given, in addition to the title, as examples of the diagnostic
statements to be classified to that category. They may refer to different conditions or
synonyms. They are not a subclassification of that category
 Inclusion terms are listed primarily as a guide to the content of the category, in addition to the
descriptions. Many of the items listed relate to important or common terms belonging to the
category. Others are borderline conditions or sites listed to distinguish the boundary between
one subcategory and another. The lists of inclusion terms are by no means exhaustive.

49
 Alternative names of diagnostic entities (synonyms) are included and shown in the electronic
coding tool and the Alphabetic Index which should be referred to first when coding a given
diagnostic statement
 It is sometimes necessary to read inclusion terms in conjunction with titles. This usually occurs
when the inclusion terms describe lists of sites or pharmaceutical products, where appropriate
words from the title (e.g. ‘malignant neoplasm of …’, ‘injury to …’, ‘toxic effects of …’) need
to be understood.
 General diagnostic descriptions common to a range of categories, or to all the subcategories in
a four-character category, are to be found in the notes headed ‘Inclusions’, immediately
following a chapter, group, or category title.
 Example in ICD-10
I07 Rheumatic tricuspid valve diseases
Incl.: whether specified as rheumatic or of unspecified origin
Exclusions
 Certain categories contain lists of conditions preceded by the word ‘Exclusions’. These are
terms which are classified elsewhere though the category title might suggest that they were
to be classified there. An example of this is 5A60 Hyperfunction of pituitary gland which
excludes Cushing syndrome.
 Exclusions serve as a cross reference in ICD and help to delineate the boundaries of a
category. The coder will see a category or subcategory in parentheses to which the excluded
term should be allocated. Eg. G93.1 Anoxic brain damage, not elsewhere classified Excl.:
complicating: neonatal anoxia (P21.9)
 General exclusions for a range of categories or for all subcategories are found in the notes
heading ‘Excludes’, immediately following a chapter, group or category title.
 Multiple parenting in ICD-11 shows categories in the context of siblings that are placed
elsewhere in the classification. This is also an indication of an exclusion and means ‘a
sibling is coded elsewhere’. In the print and the electronic version this is marked with the
label ‘code elsewhere’.

Cross-references
Cross references are used to avoid unnecessary duplication of terms in the Alphabetical index. The
word ‘see’ requires the coder to refer to the other term; ‘see also’ directs the coder to refer

50
elsewhere in the Alphabetical index if the statement being coded contains other information that
is not found indented under the term to which ‘see also’ is attached.

Code also and use additional code if desired instructions

‘Code also’ instructions inform the user about required additional aetiological information which
is mandatory to be coded in a cluster with certain categories because that additional information is
relevant for primary tabulation. The ‘code also’ statement marks the categories that must be used
in conjunction with the indicated second code(s). However, in some instances aetiology may be
unknown although the condition requires treatment in its own right. In this circumstance, the code
may be reported alone.

For example, the category Diabetic cataract indicates ‘code also’ type of diabetes. This means that
in conjunction with the code for ‘diabetic cataract’, the code for the type of diabetes should be
assigned. Both stem codes for the type of diabetes and the diabetic cataract are always reported in
a cluster.

‘Use additional code, if desired’ - instructions inform the user about optional additional detail that
can be coded.

‘NOS’

The letters NOS are an abbreviation for the term ‘not otherwise specified’, implying that the
documentation that is used for classifying does not provide more detail beyond the term provided.
It implies ‘unspecified’, ‘incompletely specified’ or ‘unqualified’. Sometimes an unqualified term
is nevertheless classified to a rubric for a more specific type of the condition. This is because, in
medical terminology, the most common form of a condition is often known by the generic name
of the condition itself and only the less common types are qualified. For example, ‘pharyngitis’ is
commonly used to mean ‘acute pharyngitis’. These inbuilt assumptions have been taken into
account in order to avoid incorrect classification.

Careful inspection of inclusion terms will reveal where an assumption of cause has been accounted
for. Coders should be careful not to code a term as unqualified unless it is quite clear that no
information is available that would permit a more specific assignment elsewhere. Similarly, in
interpreting statistics based on the ICD, some conditions assigned to an apparently specified

51
category will not have been so specified on the record that was coded. When comparing trends
over time and interpreting statistics, it is important to be aware that assumptions may change from
one revision of the ICD to another. For example, before the Eighth Revision, an unqualified aortic
aneurysm was assumed to be due to syphilis (this is no longer the case since the introduction of
ICD–10). In ICD-11 in most instances the ‘NOS’ terminology points to unspecified categories, so
that future data analysis can take care of assumptions regarding the linguistic meaning.

‘Not elsewhere classified’

The stem ‘not elsewhere classified’, when used in a category title, serve as a warning that certain
specified variants of the listed conditions may appear in other parts of the classification. For
example, NF09 Adverse effects, not elsewhere classified. Codes to which the NEC description is
appended should only be used if one of the other options available in the classification is not
suitable.

Additional terms permitted in ICD coding:

Use of ‘And’ and ‘Or’

The words ‘and’ and ‘or’ in ICD–11 are used in their meaning in formal logic. A term that includes
a statement of the kind ‘A and B’ means that both A and B, have to be present in order to use that
category. A term that includes a statement of the kind ‘A or B’ means that the category may be
used if either A or B are present. An example in ICD-11 cases of ‘tuberculosis of bones’,
‘tuberculosis of joints’. ‘Tuberculosis of bones and joints’ are to be classified in the category tittle
1B12.40. 1B12 refers to tuberculosis, 1B12.4- tuberculosis of the musculoskeletal system and
1B12.40- Tuberculosis of bones and joints’

Certain
The term ‘certain’ is used where certain entities that could be grouped in a specific location in the
classification are grouped somewhere else outside the current chapter or block. For example, 8B22
Certain specified cerebrovascular diseases means that only some specified cerebrovascular
diseases are coded here, whereas other specific types of cerebrovascular disease are located
elsewhere in the classification.

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Residual categories – ‘Other’ and ‘Unspecified’

ICD-11 coding should always be completed to include the most specific level of detail possible
with the use of one code or multiple codes as described above. There are, however, circumstances
when that is not possible and for that reason the ICD-11 includes categories titled ‘other’ and
‘unspecified’. In some instances, necessary information to select a specific category may not be
available in the source documentation. When this is the case, the residual category ‘unspecified’
is selected. Conversely, there are instances where the information in the source documentation is
very specific, but the tabular list does not include a specific category. In this case, users identify
the closest category match, and code to the residual category titled ‘other’.

‘Due to’ and ‘Associated with’

‘Due to’ is the preferred term for categories where two conditions are mentioned, and a causal
sequence exists between them. Other terms, such as ‘caused by’ or ‘attributed to’ are allowable
synonyms. The phrase ‘secondary to’ is equivalent and may also be included as a synonym.
‘Associated with’ is the preferred term for categories where two conditions are mentioned but there
is no causal sequence implied.

Spelling, parentheses, grammar and other conventions

• Spelling and grammar of ICD-11 follow the British rules with exceptions and amendments
conforming to WHO spelling rules. The detailed conventions are listed below. The ICD-11
terminology uses the following conventions:
• Terms are listed in their singular form. For example, ‘Superficial injury of scalp’ instead of
‘Superficial injuries of scalp’
• No use of apostrophes with eponyms. For example, ‘Hodgkin lymphoma’ (instead of
‘Hodgkin’s lymphoma’)
• Entities are described using natural language. For example, ‘myocardial infarction’ (instead of
‘infarction, myocardial’).
• Abbreviations are printed using upper case letters and followed by the complete title in full.
For example, ‘MI – [myocardial infarction]’. In this manner, square brackets are used for

53
 abbreviations which are displayed using upper case letters and followed by the complete title
in full. For example, ‘CPB – [Cardiopulmonary bypass]
• Parentheses are used in the tabular list to enclose the code to which an exclusion term refers.
For example, 9A01.3 Infectious blepharitis Exclusions: Blepharoconjunctivitis (9A60.4).
• Parentheses are used to enclose supplementary words that indicate elements that may be
present or absent in the intervention being classified. They are also used to enclose the ICHI
stem code to which an exclusion term refers.

Other conventions used in ICD 10

Parentheses ( )

Parentheses are used in Volume 1 of ICD-10 in four important situations.

• 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. For example, in I10, the inclusion term, ‘Hypertension
(arterial)(benign)(essential)(malignant) (primary)(systemic)’, implies that I10 is the code
number for the word ‘Hypertension’ alone or when qualified by any, or any combination, of
the words in parentheses.
• Parentheses are also used in the tabular list to enclose the code to which an exclusion term
refers. For example: H01.0 Blepharitis Excludes: blepharoconjunctivitis (H10.5).
• Another use of parentheses is in the block titles, to enclose the three-character codes of
categories included in that block.
• The last use of parentheses was incorporated in the ninth revision and is related to the dagger
and asterisk system. Parentheses are used to enclose the dagger code in an asterisk category or
the asterisk code following a dagger term.

Square brackets [ ]

Square brackets are used:

a) For enclosing synonyms, alternative words or explanatory phrases; for example:

A30 Leprosy [Hansen disease]

54
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 at the beginning of this
block 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. They require one or more of the modifying or
qualifying words indented under them before they can be assigned to the rubric. For example, 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. Any of the terms
before the brace should be qualified by one or more of the terms that follow it.

For example: O71.6 Obstetric damage to pelvic joints and ligaments

Avulsion of inner symphyseal cartilage

Damage to coccyx obstetric

Traumatic separation of symphysis (pubis)

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.-)
meningomyelitis (G04.-) This indicates to the coder that a fourth character exists and should be
sought in the appropriate category. This convention is used in both the Tabular list and the
Alphabetical index.

55
The ‘dagger and asterisk’ system

Dagger marked by (†) is the primary code for the underlying disease (aetiology) and an optional
additional code for the manifestation which is marked with an asterisk (*). This convention was
provided because coding to underlying disease alone was often unsatisfactory for compiling
statistics relating to particular specialties, where there was a desire to see the condition classified
to the relevant chapter for the manifestation when it was the reason for medical care.

While the dagger and asterisk system provide alternative classifications for the presentation of
statistics, 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 are the primary
focus of care.

Code structure of ICD-10 and ICD-11

ICD 10
 Has 14,400 codes
 Alphanumeric 3-5 characters- If the code has only three characters, it can be assumed that the
category has not been subdivided
 Character 1 is alpha (all letters are used)
 Character 2 and 3 are numeric
 There is use of decimal after 3 characters.
 The fourth character comes after the decimal point. This means the category has been
subdivided, the code number in the Alphabetical index will give the fourth character.
 Alpha characters are not case-sensitive
ICD-11
 Has 55,000 codes
 Alpha numeric and cover the range from 1A00.00 to ZZ9Z.ZZ. These are referred to as stem
codes.
 The structure of stem codes is described below:

 The first character of the code always relates to the chapter number. It may be a number or
a letter.

56
  Codes starting with ‘X’ indicate an extension code
 There is always a letter in the second position to differentiate ICD-11 codes from the codes
in ICD–10.
 The inclusion of a forced number at the third character position prevents spelling
‘undesirable words’.
 The letters ‘O’ and ‘I’ are omitted to prevent confusion with the numbers ‘0’ and ‘1’. For
example, 1A00 is a code in Chapter 01, and BA00 is a code in Chapter 11.
 The terminal letter Y is reserved for the residual category ‘other specified’ and the terminal
letter ‘Z’ is reserved for the residual category ‘unspecified’.
 For the chapters that have more than 240 blocks, ‘F’ (‘other specified’) and ‘G’
(‘unspecified’) are also used to indicate residual categories (due to limitations in the coding
space).

CODING AND INDEXING MORBIDITY DATA AND RELATED RULES

Definition of terms
Coding- It is the process of establishing a specified number for a given disease or condition for a
patient statement of cause of admission into the hospital. It is done so that it is easier to store,
retrieve and analyze health information. Clinical coding is usually done all over the world to assist
in collection of morbidity data and of course data about causes of death (Mortality).

Indexing- it is the process of writing down the patients’ particulars on to an identified material or
equipment once coding has been done.

Lead terms- usually nouns, sometimes adjectives contain to the far left of each column in bold.
They refer mainly to the names of diseases or conditions

Modifiers- they are contained at different levels of indentation. They usually referred to the
varieties of sites or circumstances that affect coding. Modifiers which do not affect code
assignment appear in parentheses () after the condition. All modifiers appear in alphabetical order
except “with” which always appear first. Eg

57
Eponyms are words or terms derived from people’s names. Medical eponyms have been used for
centuries for identification and scientific recognition (sometimes erroneously) of various medical
diseases, syndromes, methods, process, substances, organs, organ parts, signs and symptoms.
Example, Parkinson’s disease named after James Parkinson.

Sanctioning rules are a set of instructions to help coders visualize the permitted code
combinations when using a Tabular List.

Stem codes

ICD–11 stem codes are codes in a particular tabular list that can be used alone. Stem codes may
be entities or groupings of high relevance, or clinical entities that should always be described as
one entity. The design of stem codes makes sure that in use cases that require only one code per
case a meaningful minimum of information is collected.

The stem codes of the ICD-11 are organized in 26 chapters that follow the traditional pattern of
the ICD, relating to aetiology, relevant organ system, maternal status, perinatal status, external
causes, and factors influencing health status.

Extension codes

The extension codes are comprised of groups of codes e.g. anatomy, agent, histopathology and
other aspects that may be used to add detail to a stem code. Extension codes are not to be used
alone in the context of statistical classification but must be added to a stem code. Extension codes
may be used in another context, e.g. for device documentation. Not all extension codes can be used
with every stem code.

58
There are two main types of Extension codes:

• Type 1 extension codes allow the user to add detail to a stem code in terms of severity,
temporality, anatomy, histopathology of the condition or other dimensions like substances and
medical devices. For example, if the diagnostic statement reads ‘cervical disc prolapse C5-C6’
the anatomy extension code XA1X49 Cervical intervertebral disc or space C5-C6 can be added
to the stem code FA80.1 Intervertebral disc degeneration of cervical spine with prolapsed disc
in order to capture the detail of contained in the diagnostic statement.
• Type 2 extension codes represent diagnosis code descriptors which indicate how the diagnosis
is to be used and/or interpreted. The meaning of the code refers to the same condition, but the
use of type 2 – diagnosis code descriptor extension code alters its interpretation. For example,
for adverse event reporting it is important to code diagnosis timing in terms of XY6M Present
on admission, XY69 Developed after admission, or XY85 Uncertain timing of onset relative to
admission

Pre-coordination

Some stem codes contain all pertinent information about a clinical concept in a pre-combined
fashion. This is referred to as ‘precoordination’.

Post coordination

Linking of core diagnostic concepts (i.e. stem+stem code concepts) when desired, and/or adding
clinical concepts captured in extension codes to primary stem code concepts. A health condition
may be further described to any level of detail, by applying more than one code, or by ‘post-
coordinating’ (i.e. combining codes):

 two or more stem codes, (i.e. code1/code2)

 stem codes with one or more extension codes. (i.e. stem code&extension code1&extension
code2)

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Post-coordination axis has the following:

‘Has causing condition’ - this field is indicating the causing condition that must be coded when
known. The causing condition can be compared to the ‘dagger’ code in ICD-10. This option is
found at entities that are typically caused by a range of different conditions and is referred to as
mandatory post-coordination in the Coding tool. It is mandatory to code the causing condition for
primary tabulation when it is known. Represented by the red plus sign in the coding tool

‘Has manifestation’ - prompts the user to code any manifestations. Manifestations can be
compared to the ‘asterisk’ codes in ICD-10. This option is found at entities that can develop
manifestations. It is optional to code manifestations of a disease. It is represented by the grey plus

‘Associated with’ - when conditions are captured together for a full picture but do not necessarily
represent a cause-and-effect scenario. This field is used when multiple codes are required to fully
describe a condition.

Special cases for postcoordination:

1. External cause codes are ‘allowed’ to identify the cause of an injury and are ‘associated
with’ the injuries.
2. The external cause code to identify a specific drug is ‘allowed’ with entities beginning with
or including the phrase ‘Drug -induced’.
3. External cause codes for the mode and mechanism of health care related harm are
‘associated with’ the codes for the harm.

Clustering/ cluster

A group of codes that have been post-coordinated is called a ‘cluster’. A cluster describes one
clinical concept as described by the health care practitioner. A forward slash (/) or ampersand (&)
is used to show the linkage between postcoordinated codes. In this manner, the classification can
address many clinical concepts with a limited range of categories. The linked diagnostic concepts
are called a cluster. Eg. Stem Code: DA63 Duodenal ulcer, unspecified, Has manifestation (use
additional code, if desired): ME24.90 Acute gastrointestinal bleeding, not elsewhere classified
Cluster: DA63/ME24.90)

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Multiple parenting

An entity may be correctly classified in two different places, e.g. by site or by aetiology. For a
disease, such as esophageal cancer, this would mean that it could be classified to cancers
(malignant neoplasms) or to conditions of the digestive system. In the same way, cerebral ischemic
conditions could be classified to the vascular system or to the nervous system. A decision about
which place a condition is in depends on international agreement and legacy.

Hierarchy

Entities are organized in a hierarchical structure, also called a parent-child hierarchy. A child
entity is a more specialized concept than the parent entity. A child entity can have multiple
parents in the Foundation Component. A child can have a set of direct parents, i.e., the first-level
ancestors in the hierarchy. Indirect parents are the ancestors found by traversing up the hierarchy
starting with the direct parents. A parent is also referred to as a superclass in the Foundation. In a
linearization, an entity has precisely one parent.

Introduction on use of reference guide

ICD 11 Reference guide is divided into three parts. While each part will contain information
valuable for your understanding and use of ICD-11, each has been created to be relevant to your
primary purpose for coming to the Guide.

If you are looking to gain a general, broad understanding of ICD-11, with little or no prior
experience with ICD, we suggest you start with Part 1.

If you are looking to understand how codes are created, and the details of the organisation
behind ICD-11, we suggest you start with Part 2.

If you are already familiar with ICD, particularly if you have used ICD-10, we suggest you start
with Part 3 to see what is new (and what has not changed) in ICD-11.

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Introduction to morbidity coding requirement

 What is coded?

a. Patient conditions
Main condition- It is the description of an episode of hospital care. The HCP should record and
identify as the main condition the one condition that is determined to be the reason for admission,
established at the end of the episode of health care. This evaluation is supported through
evaluations and investigations that aim to establish the diagnosis responsible for the admission

Multiple conditions contributing to need for admission

Where an episode of health care includes more than one condition contributing to the need for
admission (e.g. congestive heart failure and pneumonia; acute cerebral haemorrhage and hip
fracture; multiple injuries - concussion, rib fracture, right femur fracture after MVA; or influenza
A and Type 1 diabetic ketoacidosis), the health care practitioner should record and identify the
main condition to be the one condition that is deemed to be the most clinically significant reason
for admission.

Other conditions

In addition to the main condition, the health care practitioner should, whenever possible, also list
separately all other conditions or problems dealt with during the episode of health care. Other
conditions (also known as additional diagnoses) are defined as those conditions that coexist at the
time of admission or develop during the episode of health care and affect the management of the
patient. Conditions related to an earlier episode that have no bearing on the current episode should
not be recorded as other conditions. It is recommended, where practicable, to carry out multiple-
condition coding and analysis to supplement the routine data.

Documentation guidelines for morbidity coding

a. Documentation guidelines involving the term ‘Multiple’-For Single condition reporting.

In cases involving, for example, ‘multiple fractures’, ‘multiple head injuries’ or ‘multiple

62
 valvular disease’, it is acceptable documentation practice to record the diagnoses using the
term ‘multiple’ and then list separately the specific conditions or injuries. For example,
Multiple fractures of pelvis: fracture of os pubis, sacrum, ilium.
b. Specificity and detail

Each diagnostic statement should be as informative as possible in order for the clinical coder
to classify the condition to condition to a code that best captures the specific detail provided in
the diagnostic statement. Examples of such diagnostic statements include:

 transitional cell carcinoma of trigone of bladder

 acute appendicitis with localised peritonitis
 meningococcal pericarditis
 pregnancy-induced hypertension

c. Unconfirmed diagnoses

If no definite diagnosis has been established at the end of an episode of health care, then the
health care practitioner should document the information that permits the greatest degree of
specificity and knowledge about the reason for admission that has been established at the end
of the episode of care. This could be a symptom, abnormal finding or problem. Rather than
qualifying a diagnosis as “possible”, or “suspected”, when a diagnosis has been considered but
not established, when applicable, record the symptom, abnormal finding or problem.

d. Documentation of a ruled-out condition

The health care practitioner should document as main condition a “ruled out” condition when
the episode of care involves a person who presents some symptoms or evidence of an abnormal
condition which requires study, but who, after examination and observation, show no need for
further treatment, follow-up or other medical care. The health care practitioner should not
document a ruled-out condition as a main condition if some treatment was provided for a
symptom or follow-up is required to determine the cause of the sign or symptom. In that
instance, the health care practitioner should document the presenting sign or symptom that was
treated as the main condition. Example 1

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  Admitted for suspected deep vein thrombosis of leg, which after investigation is ruled out
and no follow-up necessary.
 Main Condition: Ruled out deep vein thrombosis.

Example 2

 A child is found playing with an empty acetaminophen bottle. The mother is uncertain if
there were any tablets in the bottle. The child is brought to the hospital and following
investigation, it is determined that the child did not ingest any pills
 Main condition: Ruled out unintentional ingestion acetaminophen (paracetamol)

Example 3

 A patient had an elevated PSA and presented for biopsy of the prostate. Biopsy revealed
no evidence of malignancy. No further follow-up planned for the patient.
 Main condition: Ruled out prostate malignancy

e. Contact with health services for reasons other than illness

Episodes of health care or contact with health services are not restricted to identification,
treatment or investigation of current illness or injury. Episodes may also occur when someone
who may not currently be sick requires or receives limited care or services. In this case the
health care practitioner should document the details of the relevant circumstances as the ‘main
condition’. Examples include:

 Monitoring of previously treated conditions

 Immunisation
 contraceptive management, antenatal and postpartum care
 Surveillance of persons at risk because of personal or family history
 Examinations of healthy persons, e.g. for insurance or occupational reasons
 Seeking of health-related advice

f. Conditions due to external causes

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 When a condition such as an injury, poisoning or other effect of an external causes is recorded,
it is important to document fully both the nature of the condition and the circumstances that
gave rise to it. For example:

• ‘fracture of neck of femur caused by fall due to slipping on pavement’

• ‘cerebral contusion caused when patient lost control of car, which hit a tree’
• ‘unintentional poisoning, patient drank disinfectant in mistake for soft drink’
• ‘severe hypothermia, patient fell in her garden in cold weather’
g. Documentation of sequelae

Where an episode of care is for the treatment or investigation of a residual condition (sequela)
of a disease that is itself no longer present, the health care practitioner should document the
residual condition (sequela) and its origin, together with a clear indication that the original
disease is no longer present. For example:

• ‘deflected nasal septum– fracture of nose in childhood’

• ‘contracture of Achilles tendon – late effect of injury to tendon’
• ‘infertility due to tubal occlusion from old tuberculosis’.

Where multiple sequelae are present and treatment or investigation is not directed
predominantly at one of them, a documented statement such as ‘sequelae of cerebrovascular
accident’ or ‘sequelae of multiple fractures’ is acceptable.

Coding

ICD 10

When coding you must use alphabetical index as well as the tabular list. These guidelines should
be followed when coding using ICD 10

1. Identify the type of statement to be coded and refer to the appropriate section of the
Alphabetical index. (If the statement is a disease or injury or other condition classifiable to
Chapters I–XIX or XXI–XXII, consult Section I of the index. If the statement is the external
cause of an injury or other event classifiable to Chapter XX, consult Section II.)

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2. Locate the lead term. For diseases and injuries, this is usually a noun for the pathological
condition. However, some conditions expressed as adjectives or eponyms are included in the
Alphabetical index as lead terms.
3. Read and be guided by any note that appears under the lead term.
4. 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 Alphabetical index.
6. Refer to the Tabular list to verify the suitability of the code number selected. Note that a three-
character code in the Alphabetical 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.
7. Be guided by any inclusion or exclusion terms under the selected code, or under the chapter,
block or category heading.
8. Assign the code. Specific guidelines for the selection of the cause or condition to be coded,
and for coding the condition selected, are given in Section 4.

ICD-11 Coding step by step

66
Introduction to coding tool

• Used to search all ICD-11 terms

• Serves the function of an alphabetic index
• It is linked to the ICD-11 browser to access further information about a category or code
• Lists approximately 120000 clinical terms
• Terms are listed in singular form
• Apostrophes are not used with eponyms
• Entities are described using natural language
• Abbreviations are listed using upper case letters and followed by the complete title in full
• Synonymous terms are also included as index terms
• For consistency and accuracy, it is recommended that coding begins with the coding tool
• The Coding Tool works by searching as the user continues typing in the search box

• Coding tool generates and dynamically updates two different outputs as the search continues

Word list

• On the left side the Coding Tool shows a list of words.

• If you are in the middle of a word the system will try to guess the word that you are typing.

67
If you have completed a word (it means that you have typed a space at the end of a word, or you
have selected a word directly from the word list) the system will show you related keywords. The
relatedness is calculated by using the number of times the words appear together in the ICD
together with some other similar measures.

Destination Entities

• The middle output of the Coding Tool interface shows the matched entities of the search. This
output is sorted by how well the text entered matches the phrase in the ICD. The matched
words are highlighted in this list (e.g: the word "tuberculosis" in the screenshot below). The
mouse's focus or the keyboard's focus (you can scroll throw the entities list also with the
keyboard up and down keys) is showing by the red arrow on the left side of the entity and by
the light-grey background

• On the right side of the entities result list, the Coding Tool also shows small icons that provide
specific information about entities, as in the screenshot below

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• Every icon has a different meaning:
• Post-coordination is available for this entity:
• Post-coordination is mandatory for this entity
• Coding note is available for this entity:
• There is/ are related category/categories in perinatal chapter for this entity:
• There is/ are a related category/categories in maternal chapter for this entity:
• If the search result contains a perfect match, the matching entity is emphasized with a
blue background as in the screenshot below.

• You may change the sort order by using the dropdown box at the top of the list. We have
two options
• Sort by matching score (default)
• Sort by classification order
• The list shows only the codes and titles, except if the title is not a search result. e.g in the
screenshot below, the highlighted term is a matching term:

69
• If the word(s) that have been entered in the search are not precise enough and the system
finds more results than it could show, it gives the following warnings:
• If it finds results in more than 50 entities, it will show the best 50 matches and will place
the warning: The results shown are incomplete

Flexible Search

• Flexible search feature could be used in cases when the Coding Tool's regular search do
not return any results.

• For example, let's say the user is searching for primary steatorrhea and there is no phrase
in the ICD-11 index that contains these words together. The regular search of the Coding
Tool will not give you any results whereas the flexible search will give you results that
contain one of the words. The top result in this case will be steatorrhoea which is an index
term under Other specified symptoms related to the lower gastrointestinal tract or abdomen.

70
Sources of Morbidity data

• Hospital records
• School medical records
• Death certificates
• Armed services records
• Occupational medical records
• Health surveys
• Outpatient/ ambulatory care records
• Maternal and child health services records
• Disease surveillance records eg. vaccine preventable diseases
• Cancer and chronic disease registry records

Coder guidelines for selecting the main condition and other conditions for coding purposes

Rules for selection of the main condition

These rules are for use when it is unclear which recorded condition should be selected as the main
condition for reporting purposes.

1. Several conditions recorded as ‘main condition’

• If several different conditions (that cannot be classified to a single stem code) are recorded as
the ‘main condition’, and other details on the record point to one of them being the ‘main
condition’ (one condition determined to be the reason for admission established at the end of
the episode of care), select that condition; otherwise, select the condition first recorded.
• If there is the desire to also report other discharge diagnosis types i.e. main resource condition
or initial reason for encounter or admission, then the applicable extension code(s) from Chapter
X ‘Extension codes’, should be assigned to indicate the different types of discharge diagnosis
types that are reported.

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Example 1:

• A patient was admitted with complaints of fever, chills, severe headache and stiff neck.
Following investigation, a diagnosis of staphylococcal meningitis was confirmed. While in
hospital the patient developed pneumonia.
• Main condition: Staphylococcal meningitis. Pneumonia
• Two conditions have been recorded as the main condition and querying the health care
practitioner is not possible. The details in the example point to staphylococcal meningitis as
the one condition being the reason for admission established at the end of the episode of care,
therefore the coder should code staphylococcal meningitis as the ‘main condition’. Pneumonia
is coded as an ‘other condition’. It meets the definition of an ‘other condition’ as it is a
diagnosis that arose during the episode of care.

Example 2:

• A patient who has a history of COPD was admitted for a biopsy of the prostate. Patient was
evaluated for COPD. Biopsy was performed and the final diagnosis from pathology results was
benign prostatic hypertrophy.
• Main condition: Chronic obstructive pulmonary disease (COPD). Hypertrophy of prostate.
• Two conditions have been recorded as the main condition and querying the health care
practitioner is not possible. The details in the example point to benign prostatic hypertrophy as
the condition being the reason for admission established at the end of the episode of care;
therefore, the coder should code hypertrophy of prostate as the ‘main condition’. COPD is
coded as an ‘other condition’ as the physician documented it as co-existing at the time of
admission and affecting the management of the patient.

Example 3:

• A patient presents to hospital at 35 weeks gestation with spontaneous premature rupture of

membranes. She is not having any contractions. Examination reveals the baby is in breech
presentation; therefore, delivery by caesarean section is recommended. Mother delivers
healthy preterm infant by caesarean section.
• Main condition: Premature rupture of membranes. Breech presentation.

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• Procedure: Delivery by caesarean section
• Two conditions have been recorded as the main condition and querying the health care
practitioner is not possible. The details in the example point to premature rupture of membranes
as the condition being the reason for admission established at the end of the episode of care.
Therefore, the coder should code premature rupture of membranes as the ‘main condition’ and
breech presentation and preterm delivery as ‘other condition’.

2. Condition recorded as ‘main condition’ is presenting symptom of diagnosed, treated

condition

• If a symptom or sign (usually classifiable to Chapter 21 Symptoms, signs or clinical findings,

not elsewhere classified), or a problem classifiable to Chapter 24 Factors influencing health
status or contact with health services, is recorded as the ‘main condition’, and this is obviously
the presenting sign, symptom or problem of a diagnosed condition recorded elsewhere and care
was given for the latter, reselect the diagnosed condition as the ‘main condition’.

Example 1:

• The patient presents to hospital with complaint of haematuria. Investigations reveal a

papilloma in the posterior wall of the bladder as the cause of the haematuria. The papilloma
was excised by diathermy.
• Main condition: Haematuria
• Other conditions: Papilloma of posterior wall of bladder
• Haematuria (symptom) is recorded as the main condition; however, it was determined to be
caused by the papilloma of the bladder (diagnosed and treated condition). Therefore, the coder
should reselect and code papilloma of posterior wall of bladder as the ‘main condition’.

Example 2:

• The patient presents to hospital with abdominal pain. Investigations reveal acute appendicitis
and the patient undergoes an appendectomy.
• Main condition: Abdominal pain
• Other conditions: Acute appendicitis

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• The symptom ‘abdominal pain’ was recorded as the main condition; however, it was
determined to be caused by appendicitis. Therefore, the coder should reselect and code acute
appendicitis as the ‘main condition’.

3. Signs and symptoms recorded as ‘main condition’ with alternative conditions recorded as
the cause

• Where a symptom or sign is recorded as the ‘main condition’ with documentation that it may
be due to either one condition or another, select the symptom as the ‘main condition’.

Example 1:

• Main condition: Headache due to tension or acute sinusitis

• The symptom ‘headache’ is recorded as the main condition with two possible causes; therefore,
the coder should code headache as the ‘main condition’.

Coding using post-coordination in morbidity coding

• Information about the aetiology and the manifestation of the condition of interest should be
coded.
• In some instances, the ICD category refers to both (i.e. precoordinated), while in other
instances more than one stem code (and/or extension code) needs to be used in order to express
the relevant detail.
• This requires postcoordination.
• E.g. Acute bleeding duodenal ulcer
• Stem Code: DA63.Z Duodenal ulcer, unspecified Has manifestation (use additional code, if
desired): ME24.90 Acute gastrointestinal bleeding, not elsewhere classified Cluster:
DA63.Z/ME24.90

Example 1

• A patient is admitted to the hospital for laser treatment of their diabetic retinopathy due to Type
2 diabetes mellitus. During the admission the patient’s medication for arterial hypertension
required adjustment on a number of occasions before discharge. Code as main condition the

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 diabetic retinopathy, unspecified postcoordinated with the stem code type 2 diabetes mellitus
(9B71.0Z/5A11). Code the other condition, essential hypertension (BA00.Z).
• For morbidity coding, the order of the codes in the first cluster in Example 1 has the diabetic
retinopathy ordered first as it is the diabetic retinopathy that meets the definition of main
condition followed by the causing condition Type 2 diabetes. (Note: The classification instructs
to code also the type of diabetes.)
• Where an established causal relationship is not documented or cannot be inferred, the two stem
codes cannot be part of the same cluster.

Coder rule for use of extension codes

Adding detail to Stem codes using Extension Codes

• Type 2 extension codes (a new section of codes in ICD–11) provide distinct codes that
serve as concept modifying flags for marking how a diagnosis is to be used and/or
interpreted. Examples of these extension code modifiers include:
• Discharge diagnosis types (main condition; main resource condition; initial reason for
encounter or admission);
• Diagnosis certainty (Provisional diagnosis; Differential diagnosis)
• Diagnosis Timing (Present on admission; Developed after admission; Uncertain timing of
onset relative to admission)

APPENDICES

BLOCKS OF CATEGORY.

CHAPTER ONE, CERTAIN INFECTIOUS AND PARASITIC DISEASES, A00-B99

(21 BLOCKS)

1. A 00- A09 - Intestinal infectious diseases

2. A15-A19 - Tuberculosis
3. A20-A28 - Certain zoonotic bacterial diseases
4. A30-A49 - Other bacterial diseases
5. A50-A64 - Infections with predominantly sexual mode of transmission
6. A65-A69 - Other spirochaete diseases
7. A70-A74 - Other diseases caused by chlamydia

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8. A75-A79 - Rickettsioses
9. A80-A89 - Viral infections of the central nervous system
10. A90-A99 - Arthropod – borne viral fevers and viral hemorrhagic fevers
11. B00-B09 - Viral infections characterized by skin and mucous membrane lesions
12. B15-B19 - Viral hepatitis
13. B20-B24 - Human immunodeficiency virus (HIV) disease
14. B25-B34 - Other viral diseases
15. B35-B49 - Mycoses
16. B50-B64 - Protozoal diseases
17. B65-B83 - Helminthiases
18. B85-B89 - Pediculosis, acariasis and other infestations
19. B90-B94 - Sequelae of infectious and parasitic diseases
20. B95-B97 - Bacterial, viral and other infectious agents
21. B99 - Other infectious diseases

CHAPTER II, NEOPASMS, (C00-D48) 7 BLOCKS

1. C00- C75 - Malignant neoplasms, stated or presumed to be primary, of specified sites,

except of lymphoid, haematopoietic related tissue
2. C76-C80 - Malignant neoplasm of ill-defined secondary and unspecified sites
3. C81-C96 - Malignant neoplasms, stated or presumed to be primary of lymphoid,
haematopoietic and related tissue
4. C97 - Malignant neoplasms of independent (primary) multiple sites
5. D00-D09 - In situ neoplasms
6. D10-D36 - Benign neoplasms
7. D37-D48 - Neoplasms of uncertain or unknown behaviour

CHAPTER III, DISEASES OF BLOOD AND BLOOD FORMING ORGANS AND

CERTAIN DISORDERS INVOLVING THE IMMUNE MECHANISM, (D50-D89) 6
BLOCKS

1. D50-D53 - Nutritional anaemias

2. D55-D59 - Haemolytic anaemias
3. D60-D64 - Aplastic and other anaemias
4. D65-D69 - Coagulation defects, purpura and other haemorrhagic conditions
5. D70-D77 - Other diseases of blood and blood forming organs
6. D80-D89 - Certain disorders involving the immune mechanism

CHAPTER IV, ENDOCTRINE, NUTRITIONAL AND METABOLIC DISEASES (E00-

E90) 8 BLOCKS

1. E00-E07 - Dosorders of thyroid gland

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2. E10-E14 - Diabetic mellitus
3. E15-E16 - Other disorders of glucose regulation and pancreatic internal
4. E20-E35 - Disorders of other endocrine glands
5. E40-E46 - Malnutrition
6. E50-E64 - Other nutritional deficiency
7. E65-E68 - Obesity and other hyperalimentation
8. E70-E90 - Metabolic disorders

CHAPTER V, MENTAL AND BEHAVIORAL DISORDERS (F00-F99) 11 BLOCKS

1. F00-F09 - Organic including symptomatic mental disorders

2. F30-F19 - Mental and behavioral disorders due to psychoactive substance use
3. F20-F29 - Schizophrenia, schizotypal and delusional disorders
4. F30-F39 - Mood (affective) disorders
5. F40-F48 - Neurotic, stress related and somatoform disorders
6. F50-F59 - Behavioural syndromes associated with physiological disturbances and
physical factors
7. F60-F69 - Disorders of adult personality and behaviour
8. F70-F79 - Mental retardation
9. F80-F89 - Disorders of psychological development
10. F90-F98 - Behavioural and emotional disorders with onset usually occurring in
childhood and adolescence
11. F99 - Unspecified mental disorders

CHAPTER VI, DISEASES OF THE NERVOUS SYSTEM (G00-G99) 11 BLOCKS

1. G00-G09 - Inflammatory diseases of the CNS

2. G10-G13 - Systemic atrophies, primarily affecting the CNS
3. G20-G26 - Extrapyramidal and movement disorders
4. G30-G32 - Other degenerative diseases of the nervous system
5. G35-G37 - Demyelinating diseases of the CNS
6. G40-G47 - Episodic and paroxysmal disorders
7. G50-G59 - Nerve, nerve root and plexus disorders
8. G60-G64 - Polyneuropathies and other disorders of the peripheral nervous system
9. G70-G73 - Diseases of myoneural junction and muscle
10. G80-G83 - Cerebral palsy and other paralytic syndromes
11. G90-G99 - Other disorders of the nervous system

CHAPTER VII, DISEASES OF THE EYE AND ADNEXA, (H00-H59) 11 BLOCKS

1. H00-H06 - Disorders of eyelid, lacrimal system and orbit

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2. H10-H13 - Disorders of conjunctiva
3. H15-H22 - Disorders of sclera, cornea, iris and ciliary body
4. H25-H28 - Disorders of lens
5. H30-H36 - Disorders of choroid and retina
6. H40-H42 - Glaucoma
7. H43-H45 - Disorders of vitreous body and globe
8. H46-H48 - Disorders of optic nerve and visual pathways
9. H49-H52 - Disorders of ocular muscles, binocular movement, accommodation and
refraction
10. H53-H54 - Visual disturbances and blindness
11. H55-H59 - Other disorders of the eye and adnexa

CHAPTER VIII, DISEASES OF THE EAR AND MASTOID PROCESS (H60-H95) 4

BLOCKS

1. H60-H62 - Diseases of external ear

2. H65-H75 - Diseases of middle ear and mastoid
3. H80-H83 - Diseases of inner ear
4. H90-H95 - Other disorders of ear

CHAPTER IX (I 00-I 99), DISEASES OF CIRCULATORY SYSTEM, 10 BLOCKS

1. I 00- I 02 - Acute rheumatic fever

2. I 05-I09 - Chronic rheumatic heart diseases
3. I10-I15 - Hypertensive diseases
4. I20-I25 - Ischaemic heart disease
5. I26-I28 - Pulmonary heart disease and diseases of pulmonary circulation
6. I30-I52 - Other forms of heart diseases
7. I60-I69 - Cerebrovascular diseases
8. I70-I79 - Diseases of arteries, arterioles and capillaries
9. I80-I89 - Diseases of veins, lymphatic vessels and lymph nodes NEC
10. I95-I99 - Other and unspecified diseases of the circulatory system

CHAPTER X, DISEASE OF THE RESPIRATORY SYSTEM, (J00-J99), 10 BLOCKS

1. J00-J06 - Acute upper respiratory infections

2. J10-J18 - Influenza and pneumonia
3. J20-J22 - Other acute lower respiratory infections
4. J30-J39 - Other diseases of upper respiratory tract
5. J40-J47 - Chronic lower respiratory diseases
6. J60-J70 - Lung diseases due to external agents

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7. J80-J84 - Other respiratory diseases principally affecting the interstitium
8. J85-J86 - Suppurative and necrotic conditions of lower respiratory tract
9. J90-J94 - Other diseases of pleura
10. J95-J99 - Other diseases of respiratory system

CHAPTER XI, DISEASE OF THE DIGESTIVE SYSTEM, (K00-K93), 10 BLOCKS

1. K00-K14 - Disease of oral cavity, salivary glands and jaws

2. K20-K31 - Diseases of oesophagus, stomach and duodenum
3. K35-K38 - Diseases of appendix
4. K40-K46 - Hernia
5. K50-K52 - Noninfective enteritis and colitis
6. K55-K63 - Other diseases of intestines
7. K65-K67 - Diseases of peritoneum
8. K70-K77 - Diseases of liver
9. K80-K87 - Disorders of gallbladder, biliary tract and pancreas
10. K90-K93 - Other diseases of the digestive system

CHAPTER XII, DISEASE OF SKIN AND SUBCUTANEOUS TISSUE, (L00-L99), 8

BLOCKS

1. L00-L08 - Infections of the skin and subcutaneous tissue

2. L10-L14 - Bullous disorders
3. L20-L30 - Dermatitis and eczema
4. L40-L45 - Papulosquamous disorders
5. L50-L54 - Urticaria and erythema
6. L55-L59 - Radiation related disorders of the skin and subcutaneous tissue
7. L60-L75 - Disorders of skin appendages
8. L80-L99 - Other disorders of the skin and subcutaneous tissue

CHAPTER XIII, DISEASE OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE

TISSUE, (M00-M99), 6 BLOCKS

1. M00-M25 - Arthropathies
2. M30-M36 - Systematic connective tissue disorders
3. M40-M54 - Dorsopathies
4. M60-M79 - Soft tissue disorders
5. M80-M94 - Oesteopathies
6. M95-M99 - Other disorders of the musculoskeletal system and connective tissues

CHAPTER XIV, DISEASE OF THE GENITALURINARY SSTEM, (N00-N99), 11

BLOCKS

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1. N00-N08 - Glomerular diseases
2. N10.N16 - Renal tubulo interstitial diseases
3. N17-N19 - Renal failure
4. N20-N23 - Urolithiasis
5. N25-N29 - Other diseases of kidney and ureter
6. N30-N39 - Other diseases of urinary system
7. N40-N51 - Diseases of male genital organs
8. N60-N64 - Disorders of breast
9. N70-N77 - Inflammatory diseases of female pelvic organs
10. N80-N98 - Non inflammatory diseases of female pelvic organs
11. N99 - Other diseases of genital urinary system

CHAPTER XV, PREGNANCY, CHILDBIRTH AND PUERPERIUM, (O 00-O 99), 8

BLOCKS

1. O00-O08 - Pregnancy with abortive outcome

2. O10-O16 - Oedema, proteinuria and hypertensive disorders in pregnancy
3. O20-O29 - Other maternal disorders predominantly related to pregnancy
4. O30-O48 - Maternal care related to the fetus and amniotic cavity and possible delivery
problems
5. O60-O75 - Complications of labour and delivery
6. O80-O84 - Delivery
7. O85-O92 - Complications predominantly related to the peurperium
8. O95-O99 - Other obstetric conditions, NEC

CHAPTER XVI, CERTAIN CONDITIONS ORIGINATING IN THE PERINATAL

PERIOD, (P 00-P 96), 10 BLOCKS

1. P00-P04 - Fetus and newborn affected by maternal factors and by complications of

pregnancy, labour and delivery
2. P05-P08 - Disorders related to length of gestation and fetal growth
3. P10-P15 - Birth trauma
4. P20-P29 - Respiratory and cardiovascular disorders specific to the Perinatal period
5. P35-P39 - Infections specific to the Perinatal period
6. P50-P61 - Haemorrhagic and haematological disorders of fetus and newborn
7. P70-P74 - Transitory endocrine and metabolic disorders specific to fetus and newborn
8. P75-P78 - Digestive system disorders of fetus and newborn
9. P80-P83 - Conditions involving the integument and temperature regulation of
newborn
10. P90-P96 - Other disorders originating in the Perinatal period

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CHAPTER XVII, CONGENIATL MALFORMATIONS, DEFORMITIES AND
CHROMOSOMAL ABNORMALITIES, (Q00-Q99), 11 BLOCKS

1. Q00-Q07 - Congenital malformations of the nervous system

2. Q10-Q18 - Congenital malformations of eye, ear, face and neck
3. Q20-Q28 - Congenital malformations of the circulatory system
4. Q30-Q34 - Congenital malformations of the respiratory system
5. Q35-Q37 - Cleft lip and cleft palate
6. Q38-Q45 - Other congenital malformations of the digestive system
7. Q50-Q56 - Congenital malformations of the genital organs
8. Q60-Q64 - Congenital malformations of the urinary system
9. Q65-Q79 - Congenital malformations and deformations of the musculoskeletal system
10. Q80-Q89 - Other congenital malformations
11. Q90-Q99 - Chromosomal abnormalities, NEC

CHAPTER XVIII, SYMPTOMS, SIGNS AND ABNORMAL CLINICAL AND

LABORATORY FINDINGS, NEC, (R00-R99), 13 BLOCKS

1. R00-R09 - Symptoms and signs involving the circulatory and respiratory systems
2. R10-R19 - Symptoms and signs involving the digestive system and abdomen
3. R20-R23 - Symptoms and signs involving the skin and sub cutaneous tissue
4. R25-R29 - Symptoms and signs involving the
5. R30-R39 - Symptoms and signs involving the urinary system
6. R40-R46 - Symptoms and signs involving cognition, perception, emotional state and
behaviour
7. R47-R49 - Symptoms and signs involving speech and voice
8. R50-R69 - General symptoms and signs
9. R70-R79 - Abnormal findings on examination of blood, without diagnosis
10. R80-R82 - Abnormal findings on examination of urine, without diagnosis
11. R83-R89 - Abnormal findings on examination of other body fluids
12. R90-R94 - Abnormal findings on diagnostic imaging and in function studies without
diagnosis
13. R95-R99 - Ill-defined and unknown causes of mortality

CHAPTER XIX, INJURY, POISONING AND CERTAIN OTHER CONSEQUENCIES OF

EXTERNAL CAUSES, (S00-T98), 10 BLOCKS

1. S00-T14 - Injuries
2. T15-T19 - Effects of foreign body entering through natural orifice
3. T20-T32 - Burns and corrosions
4. T33-T35 - Frostbite

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5. T36-T50 Poisoning by drugs, medicaments and biological substances
6. T51-T65 - Toxic effects of substances chiefly nonmedicinal as to source
7. T66-T78 - Other and unspecified effects of external causes
8. T79 - Certain early complications of trauma
9. T80-T88 - Complications of surgical and medical care, NEC
10. T90-T98 - Sequelae of injuries, of poisoning and of other consequences of external
causes

CHAPTER XX, EXTERNAL CAUSES OF MORBIDITY AND MORTALITY (V01-Y98),

9 BLOCKS

1. V01-X59 - Accidents
2. W00-X59 - Other external causes of accidental injury
3. X60-X84 - Intentional self harm
4. X85-Y09 - Assault
5. Y10-Y34 - Event of undetermined intent
6. Y35-Y36 - Legal intervention and operations of war
7. Y40-Y84 - Complications of medical and surgical care
8. Y85-Y89 - Sequelae of external causes of morbidity and mortality
9. Y90-Y98 - Supplementary factors related to causes of morbidity and mortality
classified elsewhere

CHAPTER XXI, FACTORS INFLUENZING HEALTH STATUS AND CONTACT WITH

HEALTH SERVICES (Z00-Z99), 7 BLOCKS

1. Z00-Z13 - Persons encountering health services for examination and investigation

2. Z20-Z29 - Persons with potential health hazards related to communicable diseases
3. Z30-Z39 - Persons encountering health services in circumstances related to
reproduction
4. Z40-Z54 - Persons encountering health services for specific procedures and health care
5. Z55-Z65 - Persons with potential health hazards related to other social economic and
psychosocial circumstances
6. Z70-Z76 - Persons encountering health services in other circumstances
7. Z80-Z99 - Persons with potential health hazards related to family and personal history
and certain conditions influencing health status

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