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Article: Coalition4ME/CFS Pushes For CFS Be Classified as Neurological Disorder Before Governmental

Discussion in 'Phoenix Rising Articles' started by Phoenix Rising Team, Sep 18, 2011.

  1. Bob

    Bob

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    Yes you are right Suzy, and I agree that that is a mistake/oversight on their part.

    They don't say to delete "Excludes1: postviral fatigue syndrome (G93)", so I think I am right to include that, even though the 'G93' reference is now incorrect.

    I think that their intention is to include:

    Excludes1: postviral fatigue syndrome (G93.32)
    Excludes2: chronic fatigue syndrome (G93.33)

    But, as you say, they have overlooked the fact that they have recategorised both postviral fatigue syndrome and Chronic fatigue syndrome.

    I'll leave my previous post as it is for now, until any mistakes have been corrected by IMEA.


    There is also a mistake under G93.33 where it says:
    "Excludes2: chronic fatigue, unspecified (R53.82)"
    I think it should be
    "Excludes1: chronic fatigue, unspecified (R53.82)"
  2. Dx Revision Watch

    Dx Revision Watch dxrevisionwatch.com

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    It looks as though the IMEA followed the NCHS, there, as the NCHS have "Excludes2" (or at least are reported thus).
  3. Bob

    Bob

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    Oh yes, if my text is correct, then they've both done it.
    It should be "Excludes1", shouldn't it, if there's no other "Excludes1" in place preceding it?

    I'm assuming that your notes, and my text is correct.
    I'm going to give my own text a quick check again now.
  4. Dx Revision Watch

    Dx Revision Watch dxrevisionwatch.com

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    It should be noted that in international ICD-10:

    http://www.who.int/classifications/apps/icd/icd10online/?gf40.htm f480

    F48 Other neurotic disorders

    F48.0 Neurasthenia

    has

    "Fatigue syndrome" classified under it and the Excludes:


    Excludes: asthenia NOS ( R53 )

    burn-out ( Z73.0 )

    malaise and fatigue ( R53 )

    postviral fatigue syndrome ( G93.3 )

    psychasthenia ( F48.8 )



    As I've already mentioned, in the draft of ICD-10-CM for 2011, this section of Chapter 5 is arranged differently than in ICD-10 and has Neurasthenia coded at F48.8, not at F48.0, with no specific Exclude that I can see for postviral fatigue syndrome (G93.3).


    It should also be noted that for ICD-11 (from pages of the draft not currently displayed in the public version of the draft but archived on my site here)

    Postviral fatigue syndrome "Reference G93.3 -> Gj92 Chronic fatigue syndrome" is specified as an Exclusion to Neurasthenia and also specified as an Exclusion to R53 Malaise and fatigue. ("Gj92" was a temporary "Sorting label" assigned to Chronic fatigue syndrome in the early ICD-11 alpha drafting process.)
  5. Bob

    Bob

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    I've checked it over again, and I had made one mistake...

    On option 1, I had:

    R53 Malaise and fatigue

    R53.8 Other Malaise and fatigue

    R53.82 Chronic fatigue, unspecified

    Excludes1: chronic fatigue syndrome (G93.3)​



    But it should be:

    R53 Malaise and fatigue

    R53.8 Other Malaise and fatigue

    R53.82 Chronic fatigue, unspecified

    Excludes1: postviral fatigue syndrome (G93.3)
    Excludes1: chronic fatigue syndrome (G93.3)​



    Is this a mistake on the part of the coalition? Or have I made a mistake?

    Should it be as follows?:

    R53.82 Chronic fatigue, unspecified

    Excludes1: postviral fatigue syndrome (G93.3)
    Excludes2: chronic fatigue syndrome (G93.3)​
  6. Dx Revision Watch

    Dx Revision Watch dxrevisionwatch.com

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    If you look at the PDF of

    ICD-10-CM TABULAR LIST of DISEASES and INJURIES 2011

    at any chapter, for example, Chapter 18, you will see that Excludes are listed, variously, as

    Exclude1 or

    Exclude2

    irrespective of whether more that one Exclusion term is listed. Sometimes Exclude2 lists only one exclusion term.

    So no, I don't think it is the case that a single Exclude would automatically be listed as Exclude1. Also, you will see perhaps eight or ten terms listed against "Exclude1" under some terms.

    I think it may refer to a class of Exclude but without doing some research, I cannot clarify under what circumstances "Exclude1" and "Exclude2" are used or why Exclude2 has been used in this specific case.
  7. Dx Revision Watch

    Dx Revision Watch dxrevisionwatch.com

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    ICD: Use of Excludes1 or Excludes2

    ICD: Use of Excludes1 or Excludes2


    https://www.cms.gov/ICD10/Downloads/6_I10tab2010.pdf


    ICD-10-CM TABULAR LIST of DISEASES and INJURIES

    Instructional Notations



    Includes:

    The word "Includes" appears immediately under certain categories to further define, or give examples of, the content of the category.

    Excludes Notes

    The ICD-10-CM has two types of excludes notes. Each note has a different definition for use but they are both similar in that they indicate that codes excluded from each other are independent of each other.

    Excludes1

    A type 1 Excludes note is a pure excludes. 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 for used for 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 it is excluded from 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.

    etc
  8. Bob

    Bob

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    Thanks Suzy. That's clarifies the situation.
  9. Dx Revision Watch

    Dx Revision Watch dxrevisionwatch.com

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    So, the ICD-10-CM draft as it currently stands has Excludes1 class excludes in both of the relevant sections of Chapter 6 and Chapter 18.

    The proposals of the Coalition also have Excludes1.

    The suggestion from the NCHS (as reported) has introduced Exclude2 class excludes.

    The IMEA have mirrored the NCHS's Exclude2 class excludes.


    Question: Does the Coalition and does IMEA understand the difference between Excludes1 and Excludes2 and what might the implications be for Excludes2 class excludes and was it explained at the meeting why Excludes2 class excludes were being suggested?

    From the ICD-10-CM document:

    "Excludes2

    A type 2 excludes note represents "Not included here". An excludes2 note indicates that the condition excluded is not part of the condition it is excluded from 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."
  10. Bob

    Bob

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    I've checked for any mistakes that I might have made, based on the information that Suzy kindly provided, and I did find one mistake, as discussed above, which I've now corrected.

    So I'm reposting my corrected list here.
    I think this list is now correct, based on Suzy's info.

    There are some mistakes, in the IMEA section, that are as a result of the IMEA's proposals themselves, which have inconsistencies.

    I think the following is how each proposal would look in it's final form (including the inconsistencies)...

    ------------------------------------------------------------------
    ------------------------------------------------------------------

    Existing latest ICD-10-CM draft:

    G93 Other disorders of brain

    G93.3 Postviral fatigue syndrome
    Benign myalgic encephalomyelitis

    Excludes1: chronic fatigue syndrome NOS (R53.82)​




    R53 Malaise and fatigue

    R53.8 Other malaise and fatigue

    R53.82 Chronic fatigue, unspecified
    Chronic fatigue syndrome NOS

    Excludes1: postviral fatigue syndrome (G93.3)​


    --------------------------------------------------------------------
    --------------------------------------------------------------------


    Option 1 (proposed by Coalition 4 ME/CFS):

    G93 Other disorders of brain

    G93.3 Postviral fatigue syndrome
    Benign myalgic encephalomyelitis
    Chronic fatigue syndrome​




    R53 Malaise and fatigue

    R53.8 Other Malaise and fatigue

    R53.82 Chronic fatigue, unspecified


    Excludes1: postviral fatigue syndrome (G93.3)
    Excludes1: chronic fatigue syndrome (G93.3)​


    ---------------------------------------------------------------


    Option 2 (proposed by NCHS):

    G93 Other disorders of brain

    G93.3 Postviral and other chronic fatigue syndromes

    G93.31 Postviral fatigue syndrome
    Benign myalgic encephalomyelitis​


    G93.32 Chronic fatigue syndrome
    Chronic fatigue syndrome NOS

    Excludes2: chronic fatigue, unspecified (R53.82)​




    R53 Malaise and fatigue

    R53.8 Other malaise and fatigue

    R53.82 Chronic fatigue, unspecified


    Excludes1: postviral fatigue syndrome (G93.31)
    Excludes2: chronic fatigue syndrome (G93.32)​


    ----------------------------------------------------------------------


    ICD-10-CM TABULAR PROPOSED CHANGES - from the International ME Association:

    G93 Other disorders of brain

    G93.3 Viral and infectious and post-infectious diseases of the nervous system with post-exertion symptoms.

    G93.31 Myalgic encephalomyelitis

    G93.32 Postviral fatigue syndrome

    G93.33 Chronic fatigue syndrome
    Chronic fatigue syndrome NOS

    Excludes2: chronic fatigue, unspecified (R53.82)​




    R53 Malaise and fatigue

    R53.8 Other malaise and fatigue

    R53.82 Chronic fatigue, unspecified


    Excludes1: postviral fatigue syndrome (G93.3)
    Excludes2: chronic fatigue syndrome (G93.32)​


    --------------------------------------------------------------------
  11. Dx Revision Watch

    Dx Revision Watch dxrevisionwatch.com

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    If I have time over the weekend, I'll go through the Coalition materials again and listen to the audio to see what, if any, explanation was given by NCHS for the use of Excludes2 class excludes rather than Excludes1, and the rationale for deleting "Chronic fatigue syndrome NOS" from the R code chapter but adding it into Chapter 6 under "Chronic fatigue syndrome".

    Again, I ask why on earth would IMEA want "Chronic fatigue syndrome NOS" in the G codes and under what circumstances does it envisage clinicians specifying a Chapter 6 coded "Chronic fatigue syndrome NOS"?

    And what is IMEA's rationale for using the Excludes2 class for excludes where the draft as it stands for 2011, uses Excludes1 class excludes?

    This is not the Pic 'n Mix counter at Woolworths.
  12. madietodd

    madietodd Senior Member

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    Thanks, Bob, for putting this information into a form I can understand. Now I can clearly see what all the shouting is about.
  13. Bob

    Bob

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    Thanks madie. Glad you found it useful. Actually, it's all down to Suzy's hard work. Suzy provided all of the info, and I wouldn't have had a clue about any of it without her. So it's all Suzy's work really.
  14. madietodd

    madietodd Senior Member

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    Thanks, Suzy!
  15. SOC

    SOC Moderator and Senior Member

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    Thanks to Suzy and Bob from me, too. That was a lot of work, but it clears up most of the confusion. Marvelous work!
  16. Dx Revision Watch

    Dx Revision Watch dxrevisionwatch.com

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    You're welcome.

    I'm pleased we've been able to establish the difference between Excludes1 and Excludes2 classes in ICD-10-CM.

    Someone has asked me about the proposed Multisytem Chapter for ICD-11 (ICD-11 is scheduled for pilot implementation in 2015). A Multisystem chapter does not exist in ICD-10 or ICD-10-CM, but has been proposed for ICD-11.

    I've posted the following in earlier threads on ICD-11, but there is an ICD-11 Discussion document available from this page on the ICD Revision site:

    http://sites.google.com/site/icd11revision/home/face-to-face-meetings/icamp2-2010/documents

    or archived on my site, here: http://dxrevisionwatch.files.wordpr...tions20on20multisystem_diseases_201008181.doc

    Multisystem Chapter [12 pp Word doc; Discussion document: Multisystem Chapter, authors: Aym, Chalmers, Chute, Jakob.]

    ICD has traditionally grouped diseases by aetiology and by affected organ system. For ICD11 the creation of a new chapter for multisystem disorders has been proposed. The following text sets out the rationale for and the possible scope of a multisystem disorders chapter.

    Contains Literature search reference at 119 to the Maes and Twisk paper, Treatment of myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), a multisystem disease, should target the pathophysiological aberrations (inflammatory and oxidative and nitrosative stress pathways), not the psychosocial barriers for a new equilibrium. 2010: Ireland. p. 148-9.

    Contains Literature search reference at 118 to published response to Maes and Twisk paper by Luyten, P. and B. Van Houdenhove, Treatment of myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), a multisystem disease, should target the pathophysiological aberrations (inflammatory and oxidative and nitrosative stress pathways), not the psychosocial barriers for a new equilibrium Response to Maes and Twisk. 2010, ELSEVIER IRELAND LTD, ELSEVIER HOUSE, BROOKVALE PLAZA, EAST PARK SHANNON, CO, CLARE, 00000, IRELAND. p. 147-147.

    ----------

    One of the conditions proposed to be placed under a projected Multisystem Diseases chapter for ICD-11 (currently listed as Chapter 24) is Behet disease.

    There is also another ICD-11 Discussion document (which again, I've flagged up in the past, and which is quite interesting) titled, "Signs and Symptoms" which sets out some of the history of the use of the "Signs and Symptoms" chapter and how diseases, conditions and disorders have been moved of this chapter into other chapters.

    Signs and Symptoms [4 pp Word doc; Discussion document: Considerations for handling categories and concepts currently found in chapter 18 of ICD-10, SYMPTOMS, SIGNS AND ABNORMAL CLINICAL AND?LABORATORY FINDINGS NOT ELSEWHERE CLASSIFIED, (R-codes), authors: Aym, Chalmers, Chute, Jakob.]

    Download here on the ICD Revision site:

    http://sites.google.com/site/icd11r...ningtochapter18ofICD110810.doc?attredirects=0

    Or open from here on my site: Discussion: Signs and Symptoms (Chapter 18):

    http://dxrevisionwatch.files.wordpr...aining20to20chapter201820of20icd201108101.doc
  17. Dx Revision Watch

    Dx Revision Watch dxrevisionwatch.com

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    There is a page on my Dx Revision Watch site, here:

    http://dxrevisionwatch.wordpress.com/icd-11-me-cfs/

    that collates information published by WHO ICD on the relationship between Index terms and terms classified within the Tabular List:

    Current codings in ICD-10 for Postviral fatigue syndrome; [Benign] myalgic encephalomyelitis and Chronic fatigue syndrome

    Information in Part One refers specifically to ICD-10 version for 2007

    Extract from Page 1


    The indexing of Chronic fatigue syndrome

    In ICD-10 Chronic fatigue syndrome is not included in Volume 1: The Tabular List.

    Chronic fatigue syndrome is included in Volume 3: The Alphabetical Index and is indexed to G93.3 (the same code as for Postviral fatigue syndrome and Benign myalgic encephalomyelitis).

    This is how Chronic fatigue syndrome is listed in the Index:

    Syndrome continued

    [...]

    - fatigue F48.0

    - chronic G93.3

    - postviral G93.3]



    There's an image of the page here:

    http://www.meactionuk.org.uk/G93-3-ICD-10-index-closeup.jpg (close up)

    The Index is an income generator for the WHO and is published only as a copyright print edition or paid for CD Rom. Unlike the Tabular List and Volume 2: The Instruction Manual (which is available in PDF format here), the Index in not available online.

    An unauthorised copy of Volume 3: The Alphabetical Index Version for 2006, here: (See Page 528) http://www.scribd.com/doc/7350978/ICD10-2006-Alphabetical-Index-Volume-3

    ----------

    Extracts from my site:

    How does ICD-10 view the relationship between Chronic fatigue syndrome, Postviral fatigue syndrome and Benign myalgic encephalomyelitis?

    The Introduction to ICD-10 Volume 3: The Alphabetical Index Version for 2006 lists several possible relationships between a term included in the Alphabetical Index and a term included in the Tabular List to which it is indexed:

    The terms included in the category of the Tabular List are not exhaustive; they serve as examples of the content of the category or as indicators of its extent and limits. The Index, on the other hand, is intended to include most of the diagnostic terms currently in use. Nevertheless, reference should always be made back to the Tabular List and its notes, as well as the guidelines provided in Volume 2, to ensure that the code given by the Index fits with the information provided by a particular record.

    Because of its exhaustive nature, the Index inevitably includes many imprecise and undesirable terms. Since these terms are still occasionally encountered on medical records, coders need an indication of their assignment in the classification, even if this is to a rubric for residual or ill-defined conditions. The presence of a term in this volume, therefore, should not be taken as implying approval of its usage.



    and, according to a February 2009 response from WHO HQ Classifications, Terminology and Standards Team, terms that are listed in the Index may be:


    a synonym to the label (title) of a category of ICD;

    a sub-entity to the disease in the title of a category;

    or a best coding guess.​



    ICD-10 does not specify whether, in indexing Chronic fatigue syndrome to G93.3, it views the term as a synonym to Postviral fatigue syndrome or to Benign myalgic encephalomyelitis, subclass, sub-entity or other relationship. Nor does ICD-10 specify how it views the relationship between Postviral fatigue syndrome and Benign myalgic encephalomyelitis. (In ICD-11, the relationship between ICD-11 Title categories and their Inclusion terms will be specified. See Terms: Synonyms, Inclusions, Exclusions iCAT Glossary of ICD-11 Terms)


    What has the Classifications, Terminology and Standards Team, WHO, Geneva, said?

    1] In a letter dated 16 October 2001, Dr B Saraceno, WHO HQ, Geneva, provided the following:

    I wish to clarify the situation regarding the classification of neurasthenia, fatigue syndrome, post viral fatigue syndrome and benign myalgic encephalomyelitis. Let me state clearly that the World Health Organisation (WHO) has not changed its position on these disorders since the publication of the International Classification of Diseases, 10th Edition in 1992 and versions of it during later years.

    Post viral fatigue syndrome remains under the diseases of the nervous system as G93.3. Benign myalgic encephalomyelitis is included within this category. Neurasthenia remains under mental and behavioural disorders as F48.0 and fatigue syndrome is included within this category. However, post viral fatigue syndrome is explicitly excluded from F48.0.

    The WHO ICD-10 Diagnostic and Management Guidelines for Mental Disorders in Primary Care, 1996, includes fatigue syndrome under neurasthenia (F48.0) but does not state or imply that conditions belonging to G93.3 should be included here.


    I would also like to state that the WHOs position concerning this is reflected in its publications and electronic material, including websites. It is possible that one of the several WHO Collaborating Centres in the United Kingdom presented a view that is at variance with WHOs position. Collaborating Centres are not obliged to seek approval from WHO for the material they publish. I understand that the Collaborating Centre concerned has now made changes to the information on their website after speaking with WHO. Source: ME/CFS: TERMINOLOGY: M Williams, 27 April 2009



    2] In a response dated 23 January 2004, Andre lHours, WHO HQ, Geneva, provided the following:

    This is to confirm that according to the taxonomic principles governing the Tenth Revision of the World Health Organizations International Statistical Classification of Diseases and Related Health Problems (ICD-10), it is not permitted for the same condition to be classified to more than one rubric as this would mean that the individual categories and subcategories were no longer mutually exclusive.

    This confirmation related to a contemporaneous issue concerning the WHO Collaborating Centre, Institute of Psychiatry, but the principle has significance for the DSM-ICD Harmonization issue.


    3] In responses from early 2009, Dr Robert Jakob, WHO Classifications, Terminology and Standards Team, reaffirmed that statements made in the past by Dr Saraceno and Mr lHours regarding coding and classification are still valid, adding that:

    there is no evidence that any change should be made to this in ICD-11;

    the same principles will apply to ICD-11.


    Note that none of these responses specifies ICD-10?s view of the relationship between Chronic fatigue syndrome, Postviral fatigue syndrome and Benign myalgic encephalomyelitis.
  18. Dx Revision Watch

    Dx Revision Watch dxrevisionwatch.com

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    ICD-10-CM Tabular List document

    The ICD-10-CM Tabular List draft version for 2011 is a whopping 7.8 MB PDF and needs extracting from a zipped file; this also includes the PDF for Volume 3: The Alphabetical Index (which is 4.7MB), but I can send these as PDFs on emails, if anyone would like copies. There used to be a page where the latest versions of draft ICD-10-CM could be downloaded as PDFs without the need for unzipping.

    The ICD-10-CM document I found yesterday, that contained the definitions for Includes1 and Includes2, also contains a Tabular List, and is a smaller file size (4.7MB). Caveat: for some categories the listings in this document may not be up-to-date with the draft version for 2011 released in late 2010, but the listings for PVFS, (B)ME and CFS NOS do appear the same:

    https://www.cms.gov/ICD10/Downloads/6_I10tab2010.pdf

    ICD-10-CM TABULAR LIST of DISEASES and INJURIES

    Instructional Notations



    On Page 325 you'll find the G93 codes, set out thus:

    Chapter 6


    G93.3 Postviral fatigue syndrome
    Benign myalgic encephalomyelitis​
    Excludes1:chronic fatigue syndrome NOS (R53.82)​



    And on Page 1165 is the listing for CFS NOS under the R53 Malaise and fatigue codes:

    Chapter 18


    ---------

    The Index for ICD-10 and the Index for ICD-10-CM are not easy documents to navigate.

    This is how "Chronic fatigue syndrome" is included in the draft ICD-10-CM Volume 3: The Alphabetical Index:


    Under Index term Syndromes

    [​IMG]


    but if you put "Chronic fatigue syndrome" into the PDF search function, it doesn't return an entry, because of the hierarchical system for the laying out of Index listings.


    You can find "Fatigue -chronic", via a search on "Fatigue":

    Fatigue R53.83
    - auditory deafness see Deafness
    - chronic R53.82
    - combat F43.0
    - general R53.83
    - - psychogenic F48.8
    - heat (transient) T67.6
    - muscle M62.89
    - myocardium see Failure, heart
    - neoplasm-related R53.0
    - nervous, neurosis F48.8
    - operational F48.8
    - psychogenic (general) F48.8
    - senile R54
    - voice R49.8


    Search for "R53.82" and you'll be offered:

    - fatigue
    - - chronic R53.82
    - - psychogenic F48.8


    also listed under under Syndromes:

    - postviral NEC G93.3
    - - fatigue G93.3


    Under Index heading Encephalomyelitis:

    Encephalomyelitis (see also Encephalitis) G04.90
    - acute disseminated (postinfectious) G04.00
    - - infectious G04.00
    - - noninfectious G04.81
    - - postimmunization G04.01
    - acute necrotizing hemorrhagic (postinfectious) G04.30
    - - postimmunization G04.31
    - benign myalgic G93.3


    A search for "Postviral" also returns under the Syndromes section the entry:

    - postviral NEC G93.3
    - - fatigue G93.3
  19. Dx Revision Watch

    Dx Revision Watch dxrevisionwatch.com

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    ICD-10-CM Official Guidelines for Coding and Reporting

    This PDF ICD-10-CM document on the CDC site may also be of interest:

    http://www.cdc.gov/nchs/icd/icd10cm.htm#10update

    http://www.cdc.gov/nchs/data/icd9/10cmguidelines2011_FINAL.pdf

    ICD-10-CM Official Guidelines for Coding and Reporting
    2011


    Which has sections on Conventions and structure of the Index and Tabular List.

    Also the following on Page 9, on Includes, Inclusion terms and Excludes:

    10. Includes Notes
    This note appears immediately under a three character code title to further define, or give examples of, the content of the category.

    11. Inclusion terms
    List of terms is included under some codes. These terms are the conditions for which that code 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 the various conditions assigned to that code. The inclusion terms are not necessarily exhaustive. Additional terms found only in the Alphabetic Index may also be assigned to a code.

    12. Excludes Notes
    The ICD-10-CM has two types of excludes notes. Each type of note has a different definition for use but they are all similar in that they indicate that codes excluded from each other are independent of each other.

    a. 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.

    b. 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.


    and on Page 12...

    4. Signs and symptoms
    Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider. Chapter 18 of ICD-10-CM, Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified (codes R00.0 - R99) contains many, but not all codes for symptoms.

    ------

    No more from me, today, I promise :eek:)

    Suzy
  20. medfeb

    medfeb Senior Member

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    Bob and Suzy
    Thanks so much for laying all that out.

    I wanted to give a little additional information on each of the options in terms of what was in the proposal, what I presented at the meeting on Sept 14, and the followup discussions since. There are basically 4 options for pointing CFS to G93.3 - 3 are essentially what Bob has listed and the fourth was the counterproposal that I presented at the meeting in response to Option 2. All 4 options were presented and discussed at the IACFSME meeting.

    A few points that go across options
    • Regarding Excludes - it should be Excludes1 for each option. This choice was actually recommended by a participant at the meeting in response to the NCHS proposal to use an Excludes2.
    • Regarding dropping benign from ME - based on meeting feedback, I think the most that can be done is rename to ME (benign). if this is allowed, it should be done in each option
    • Regarding changing the heading of G93.3 in option 2,3, and 4 once subcodes are created - need to understand what latitude is allowed here by WHO rules.
    • Regarding the use of NOS - there may be some coding conventions for that to be used under certain circumstances. See Option 2 where this is mentioned. I need to follow up with NCHS to understand the usage.

    Bob - I tried to get Option 3 and the revised option 4 into your nice format but couldnt figure it out so its not very pretty.

    I apologize for not providing this information sooner but I am away from home for a month with very limited access to email. Please PM me if you have any questions or if I seem to have misstated something and I will try to respond as soon as I can

    Mary Dimmock


    Option 1 was the option that the coalition actually proposed. This option is also included in the NCHS materials for the meeting

    • The Coalition proposal only specified 'Excludes', not 'Excludes1'. The NCHS defined this as 'Excludes1' in their meeting material
    • Technically, I don't know if an 'Excludes' is required for both PVFS and CFS since CFS points to the PVFS category which has an excludes. If both are required, then presumably an 'excludes' for ME is also required. In the proposal, I specified an excludes for CFS only since the proposal only focused on that term.



    Option 2 was developed by the NCHS and included in their meeting materials. They proposed this because they have years of data on CFS and PVFS that they do not want to lose by having one code. ME as a code is only rarely used. The intent in this proposal from the PVFS is that the term PVFS be used for those patients with a viral trigger and CFS be used for all other cases. There are three issues with that proposal:

    • both the ME/CFS Canadian Consensus Criteria and the ME-ICC include viral and bacterial triggers and the ME/CFS CCC explicitly include other triggers like environmental. Splitting out ME-ICC patients with a bacterial trigger and giving them a different diagnosis of CFS would be inappropriate.
    • Today, U.S. patients who have a known viral trigger have been diagnosed as having CFS
    • PVFS is an ill-defined term but there is evidence that some think of it as the diagnosis to be given initially, followed by the CFS diagnosis once either more evidence has been acquired or 6 months has passed
    Two other comments

    • In developing option 2, NCHS specified the Excludes2 for CFS on the R code. One of the participants in the meeting on Sept 14 stated that she felt the Excludes1 should be used because it wasnt appropriate to have both a G93.3 CFS and a R53.82 CF diagnosis at the same time.
    • Once PVFS was a subcode, NCHS needed to provide a new title for the category G93.3 which is where 'Postviral and other chonic fatigue syndromes' came from. This is addressed below in option 3.
    • As above, I dont know whether this has to be an Excludes for each term in category G93.3 or whether the excludes for G93.3 (the overall term) covers it.
    • Regarding the term CFS NOS under G93.3 I asked why the NOS was used there and believe I understand that it has to do with establishing a default term and because there is no term under the subcode. But I am not clear still and need to follow up on this further. From my perspective, its extraneous and inappropriate to have both a CFS and a CFS, NOS NOS from what?

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    Option 3 . To address the issued laid out above in Option 2, which I saw 2 days before the meeting, I presented a counterproposal during the meeting. THis counterproposal is not in the NCHS meeting materials.
    G93 Other disorders of brain
    G93.3 Postinfectious Fatigue Syndromes
    G93.31 Postviral fatigue syndrome
    Excludes1: chronic fatigue, unspecified (R53.82)
    G93.32 Benign myalgic encephalomyelitis
    Chronic fatigue syndrome
    Excludes1: chronic fatigue, unspecified (R53.82)

    R53 Malaise and fatigue
    R53.8 Other malaise and fatigue
    R53.82 Chronic fatigue, unspecified
    Excludes1: postviral fatigue syndrome (G93.31)
    Excludes1: Benign myalgic encephalomyelitis (G93.32)
    Excludes1: chronic fatigue syndrome (G93.32)

    Notes on this proposal
    • Addresses the issue of splitting ME-ICC cases with viral triggers from ME-ICC cases with bacterial triggers into two separate names
    • Counterproposed a different title to G93.3 that what NCHS proposed in Option 2. As Suzy points out, its not clear what latitude there is to change this although the NCHS had already proposed a modification here
    • I only specified the G93.3 codes in the presentation material with an 'Excludes' for CF. I believe this should be Excludes1 and that there should be Excludes1 on the R codes for G93.3. As stated above, I need to understand whether an Excludes can be provided at the G93.3 level or whether it is needed for each subcode
    • The counterproposal did not use the term NOS - need to follow up as stated above



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    Option 4 There is a fourth option - 1 code for each of the three terms. This is basically what IMEA have proposed and is basically what Bob laid out in a previous post.
    G93 Other disorders of brain
    G93.3 Postinfectious Fatigue Syndromes
    G93.31 Postviral fatigue syndrome
    Excludes1: chronic fatigue, unspecified (R53.82)
    G93.31 Benign Myalgic encephalomyelitis
    Excludes1: chronic fatigue, unspecified (R53.82)
    G93.33 Chronic fatigue syndrome
    Excludes1: chronic fatigue, unspecified (R53.82)
    R53 Malaise and fatigue
    R53.8 Other malaise and fatigue
    R53.82 Chronic fatigue, unspecified
    Excludes1: postviral fatigue syndrome (G93.31)
    Excludes1: Benign myalgic encephalomyelitis (G93.32)
    Excludes1: chronic fatigue syndrome (G93.33)
    A few notes

    • The IMEA proposal included a title of Viral and infectious and post-infectious diseases of the nervous system with post-exertion symptoms. I know a number of patients want to get the word Fatigue out of the title and expect that is why this title was proposed. But to Suzys point, I dont know what latitude there is but if it can be changed, it should be changed on option 2,3 and 4
    • The IMEA proposal also proposed dropping the term Benign from Benign ME. This was discussed at the meeting on Sept 14 and because of WHO rules, it can not be dropped. The audience suggested that it be renamed to ME (Benign). I left the word Benign on all options but if it can be moved to the end, that should happen on every option.
    • The IMEA proposal has ME first but I believe the discussion at the IACFSME used G93.31 for PVFS and G93.32 for ME.
    • I am not sure why they included the term CFS NOS but this relates to the issue listed in option 2 above
    • The Excludes should be an Excludes1. I dont know whether it technically needs to be listed for each term or for the category. Whatever decision is made, this should also be the same for all options.

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