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- 1. Proposal to ReclassifyChronic Fatigue Syndrome (CFS) in ICD10-CM (U.S.) by the Submitted to the NCHS on July 15, 2011 Presented to the CMC on Sep 14, 2011 Summary of Options for Discussionwww.coalition4MECFS.orgSept 23, 2011 - IACFS-ME Conference 2011
- 2. What is the ICD10-CM The ICD10-CM is the U.S. 10th Edition of the ICD10 (WHO) The CM stands for clinical modifications The ICD10-CM (U.S.) CFS classification differs from most others countries
- 3. Coalition4MECFS ICD9-CM Please note that the Coalition4MECFS proposal request for expedited review to reclassify CFS in the ICD9-CM was not accepted for Review Therefore this presentation will be only discussing the proposal to reclassify CFS in the ICD10-CM
- 4. CFS & ME Chapters CFS and ME are in the same chapter in the ICD10 published by the WHO In the U.S. CFS is in a different (R53) chapter (R53.82) in the ICD10-CM – “Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified”
- 5. CFS vs. ME We cannot continue have 1 disease with 2 names Multiple criteria Researchers need to answer this dilemma Will the most recent “International” New Criteria answer the dilemma? ME-ICC
- 8. When properly defined, CFS is the same as ME
- 9. Supported by today’s science, recent case definitions, recommendations of the government’s experts, classification in WHO, & the clinical modifications of other countries
- 15. According to attendees at the meeting and patient feedback, ME is rarely used in the U.S.
- 16. ME-ICC and CCC case definition doesn't discriminate based on viral versus bacterial – they include both
- 17. Patients with viral triggers have been given CFS diagnosis
- 19. Option Details (cont) Draft for review
- 20. Other Issues: Exclusion on Neurasthenia ICD10 includes exclusions listed against Neurasthenia F48.0Neurasthenia Fatigue syndrome Use additional code, if desired, to identify previous physical illness. Excludes: asthenia NOS ( R53 ) burn-out ( Z73.0 ) malaise and fatigue ( R53 ) postviral fatigue syndrome ( G93.3 ) (PVFS, ME and CFS listed here) psychasthenia ( F48.8 ) ICD10-CM does not have exclusions listed against Neurasthenia F48 Other non-psychotic mental disorders F48.1 Depersonalization-derealization syndrome F48.8 Other specified nonpsychotic mental disorders Dhat syndrome Neurasthenia Occupational neurosis, including writer's cramp Psychasthenia Psychasthenic neurosis Psychogenic syncope
- 21. Background: ICD10-CM terminology Inclusion terms Lists of terms are included under some codes. These terms are some of the conditions for which that code number is to be used. The terms may be synonyms of the code title, or, in the case of “other specified” codes, the terms are a list of some of the various conditions assigned to that code. The inclusion terms are not necessarily exhaustive. Additional terms found only in the Index may also be assigned to a code.(assume this refers to alphabetic index) Source: http://www.honorthenames.com/International_Classification_of/ICD%20guidelines%20.pdf Why care?– when two terms are against one code, one is on top. E.g. for option 3, G93.32 – is ME on top or CFS. If that option is chosen, I expect ME has to be on top, especially since there is an intent to retire. May need more feedback from NCHS official. Exclude 1 versus Exclude2 Excludes1: A type 1 Excludes note is a pure excludes note. It means “NOT CODED HERE!” An Excludes1 note indicates that the code excluded should never be used at the same time as the code above the Excludes1 note. An Excludes1 is used when two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition. Excludes2: A type 2 excludes note represents “Not included here”. An excludes2 note indicates that the condition excluded is not part of the condition represented by the code, but a patient may have both conditions at the same time. When an Excludes2 note appears under a code, it is acceptable to use both the code and the excluded code together, when appropriate. Source - http://www.cdc.gov/nchs/data/icd9/10cmguidelines2011_FINAL.pdf Why care?– the current NCHS proposal is using Excludes 2 but a speaker recommended that Excludes1 is more appropriate. We will need to decide which to use and which terms it should be applied to e.g. just CFS or also ME? What about PVFS? The entire category?
- 22. Background: ICD10-CM terminology (cont) NOS terminology .e “Unspecified” codes (NOS) Codes in the Tabular List with “Unspecified...” in the title (usually a code with a 4th or 6th character 9 and 5th character 0 ) are for use when the information in the medical record is insufficient to assign a more specific code. The abbreviation NOS, “Not otherwise specified”, in the Tabular List is the equivalent of unspecified. Source: http://www.honorthenames.com/International_Classification_of/ICD%20guidelines%20.pdf Why care?– the current proposal calls for the code Chronic Fatigue Syndrome NOS. It’s not clear why the term NOS is needed. When properly defined, does CFS warrant an NOS, especially if we are not splitting out viral from non-viral or other. Further discussion is needed with NCHS to understand when NOS is needed and why
- 23. Visit www.coalition4MECFS.org for complete proposal, update letter, and power point presentation dated Sep 14, 2011 Send your input to NCHS Nchsicd9CM@CDC.gov Observation: Please note that the e-mail address reads ICD9CM but you will be providing input for ICD10-CM, because ICD9-CM is locked down.
- 24. Steering Committee A word of appreciation to Mary Dimmock, who prepared the proposal and to Mike Munoz and Lori Chapo Kroger. Organization Members are: CFS/Fibromyalgia Organization of Georgia, Inc. CFS Knowledge Center CFS Solutions of West Michigan Chronic Fatigue Syndrome, Fibromyalgia, Chemical Sensitivity Coalition of Chicago PANDORA Inc. - Patient Alliance for NeuroendocrineimmuneDisorders Organization for Research & Advocacy, Inc. Phoenix Rising Rocky Mountain CFS/ME & FM Association (RMCFA) Vermont CFIDS Association Inc. Wisconsin ME/CFS Association, Inc.
Editor's Notes
- The bottom line:The ICD-10 published by WHO places CFS under neurological diseases. I looked at the German version with a translator and it appears to do the same. So does the Canadian. See belowThe U.S. is the ONLY country that does it differently in their clinical modification of ICD-10. I am not a WHO expert but I doubt the WHO will allow it to be left under Signs and Symptoms. England has used the position of CFS under G93.3 in ICD-10 to keep it from being pointed to Neurasthenia. (see below)Changing it to not be neurological is not something that can be done in the ICD-10-CM alone. This has to go back to the WHORegarding option 2 - people think they are splitting CFS from ME. But they are really splitting out ME-ICC cases that are triggered by bacteria or other pathogens and calling them CFS. Its important they understand the distinction. COuld you please stress
- ICD10C-Current: G00-G99 Diseases of the Nervous System G89-G99 Other disorders of the Nervous System G93 Other Disorders of brain G93.3 Postviral fatigue syndrome G93.3 Benign myalgic encephalomyelitis Excludes1: chronic fatigue syndrome NOS (R53.82) R00-R99 Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified R50-R69 General Symptoms and Signs R53 Malaise and Fatigue R53.8 Other Malaise and Fatigue R53.82 Chronic fatigue, unspecified R53.82 Chronic fatigue syndrome NOS Excludes1: postviral fatigue syndrome (G93.3)Change: Add G93.3 Chronic fatigue syndrome Delete R53.82 Chronic Fatigue Syndrome NOS Add at R53.82 - Excludes1: Chronic Fatigue Syndrome (G93.3) Delete from G93.3 - Excludes1: Chronic Fatigue Syndrome NOS (R53.82) Note: It is assumed that “Chronic Fatigue, unspecified” is needed as a symptom code but if the only purpose of this category is to provide a place for CFS, the committee may want to remove. Current: G00-G99 Diseases of the Nervous System G89-G99 Other disorders of the Nervous System G93 Other Disorders of brain G93.3 Postviral fatigue syndrome G93.3 Benign myalgic encephalomyelitis Excludes1: chronic fatigue syndrome NOS (R53.82) R00-R99 Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified R50-R69 General Symptoms and Signs R53 Malaise and Fatigue R53.8 Other Malaise and Fatigue R53.82 Chronic fatigue, unspecified R53.82 Chronic fatigue syndrome NOS Excludes1: postviral fatigue syndrome (G93.3)Change: Add G93.3 Chronic fatigue syndrome Delete R53.82 Chronic Fatigue Syndrome NOS Add at R53.82 - Excludes1: Chronic Fatigue Syndrome (G93.3) Delete from G93.3 - Excludes1: Chronic Fatigue Syndrome NOS (R53.82) Note: It is assumed that “Chronic Fatigue, unspecified” is needed as a symptom code but if the only purpose of this category is to provide a place for CFS, the committee may want to remove. ICD-9-CM - Current: 320-389 Diseases of the Nervous system and Sense organs 320-326 Inflammatory Diseases of the Central Nervous System 323 Encephalitis, Myelitis, and Encephalomyelitis 323.9 Unspecified causes of Encephalitis, Myelitis, and Encephalomyelitis 323.9 Encephalomyelitis (chronic) (granulomatous) (myalgic, benign) (see also Encephalitis) 780-789 Symptoms, Signs and Ill Defined Conditions 780-789 Symptoms 780 General Symptoms 780.7 Malaise and fatigue 780.71 Chronic Fatigue Syndrome 780.79 Other Malaise and Fatigue 780.79 Postviral (asthenic) syndrome 780.79 Postviral Neurasthenia Change Add 323.9 Chronic Fatigue Syndrome Add 323.9 Postviral Fatigue Syndrome Delete 780.71 Chronic Fatigue Syndrome Delete 780.79 Postviral (asthenic) Syndrome
- Researchers need to answer this dilemma – Patients deserve answers. The label “chronic fatigue syndrome” (CFS) has persisted for many years because of lack of knowledge of the etiological agents and of the disease process. In view of more recent research and clinical experience that strongly point to widespread inflammation and multisystemic neuropathology, it is more appropriate and correct to use the term “myalgic encephalomyelitis”(ME) because it indicates an underlying pathophysiology. It is also consistent with the neurological classification of ME in the World Health Organization’s International Classification of Diseases (ICD G93.3). Consequently, an International Consensus Panel consisting of clinicians, researchers, teaching faculty and an independent patient advocate was formed with the purpose of developing criteria based on current knowledge. Thirteen countries and a wide range of specialties were represented. Collectively, members have approximately 400 years of both clinical and teaching experience, authored hundreds of peer reviewed publications, diagnosed or treated approximately 50,000 ME patients, and several members coauthored previous criteria. The expertise and experience of the panel members as well as PubMed and other medical sources were utilized in a progression of suggestions/drafts/reviews/revisions. The authors, free of any sponsoring organization, achieved 100% consensus through a Delphi type process.
- Now to the proposal before you todayThe current draft of ICD-10-CM positions “CFS” in “Signs and Symptoms” under “Chronic Fatigue, unspecified” while ME and Postviral Fatigue Syndrome are at G93.3. The intent described to the CFSAC was to use the term PVFS for those cases that that are virally triggered and “CFS” for cases where the trigger is unknown or not viral. (Note from comments at the meeting – The attendees at the meeting were asked if anyone used the term ME today and everyone shook their hears no, they did not)This proposal is to reclassify “CFS” from “Chronic Fatigue, unspecified” to Nervous System Diseases at G93.3 where ME is prior to the implementation of ICD-10-CM in 2013. The second part of this proposal is to use the same code for both ME and CFS. As described on the previous slide, the ME/CFS case definition includes viral, bacterial and other pathogens and does not use a different name for those with viral triggers versus bacterial or other pathogenic triggersFinally, we are asking for expedited review to avoid the confusion that will result if the ICD-10-CM rolls out as currently drafted. The rest of this presentation will provide the rationale for this change and why we are asking for an expedited review and implementation.
- Discretion – I may not use it.