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Dr. Bateman answers IOM questions from the community: Part 1

Discussion in 'Phoenix Rising Articles' started by ClarkEllis, Mar 31, 2015.

  1. Dx Revision Watch

    Dx Revision Watch Owner of Dx Revision Watch

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    Although the IOM panel recommended in the text of the prepublication version that a new code should be assigned that

    'is not linked to “chronic fatigue” or “neurasthenia”'

    the panel made no suggestions about which chapter a new code should potentially be located under and no suggestions (as far as I am aware) of what, if any, modifications should be made to the existing ICD-10-CM G93.3 and R53.82 hierarchies.

    My understanding is that making recommendations for potential new codes or modifications to the existing code set did not fall within the panel's remit.

    Although the panel did go as far as saying 'not linked to "chronic fatigue"' it did not specifically recommend against locating a new term elsewhere within the Symptoms and signs (R code) chapter.

    It is NCHS that makes decisions about additions and modifications to the ICD-10-CM code set, via formal proposals submitted through the public C & M Committee process.

    If NCHS or CDC were to prefer not to locate a new term under the Diseases of the nervous system chapter (the Neurology chapter) they would be faced with proposing an alternative chapter location.

    If no other body system chapter is considered appropriate and given that there is no Multisystem Disorder chapter in ICD-10-CM, NCHS and CDC may consider that the most appropriate course, for the time being, would be to locate a new code within the R code chapter, but under a different parent class than R53 Malaise and fatigue.

    NCHS and CDC might try to justify such a decision on the grounds that the new term needs a code for billing and health records but until WHO's ICD Revision has resolved how it intends to classify the G93.3 legacy terms for ICD-11, ICD-10-CM should use the R code chapter as a holding pen for the new term.

    Note that it is very unlikely that NCHS could insert a new code until the partial code freeze has lifted in October 2016.

    So I would not rule out the possibility of a new term being located as an interim measure, post October 2016, under a different parent class within the R codes, if NCHS/CDC is reluctant to locate under Diseases of the nervous system.


    Here is the introductory text for ICD-10-CM Chapter 18:

    Chapter 18

    Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99)


    Note:
    This chapter includes symptoms, signs, abnormal results of clinical or other investigative procedures, and ill-defined conditions regarding which no diagnosis classifiable elsewhere is recorded.

    Signs and symptoms that point rather definitely to a given diagnosis have been assigned to a category in other chapters of the classification. In general, categories in this chapter include the less well-defined conditions and symptoms that, without the necessary study of the case to establish a final diagnosis, point perhaps equally to two or more diseases or to two or more systems of the body. Practically all categories in the chapter could be designated' not otherwise specified', 'unknown etiology' or 'transient'. The Alphabetical Index should be consulted to determine which symptoms and signs are to be allocated here and which to other chapters. The residual subcategories, numbered .8, are generally provided for other relevant symptoms that cannot be allocated elsewhere in the classification.

    The conditions and signs or symptoms included in categories R00-R94 consist of:

    (a) cases for which no more specific diagnosis can be made even after all the facts bearing on the case have been investigated;
    (b) signs or symptoms existing at the time of initial encounter that proved to be transient and whose causes could not be determined;
    (c) provisional diagnosis in a patient who failed to return for further investigation or care;
    (d) cases referred elsewhere for investigation or treatment before the diagnosis was made;
    (e) cases in which a more precise diagnosis was not available for any other reason;
    (f) certain symptoms, for which supplementary information is provided, that represent important problems in medicalcare in their own right.

    Excludes2:
    abnormal findings on antenatal screening of mother (O28.-)
    certain conditions originating in the perinatal period (P04-P96)
    signs and symptoms classified in the body system chapters
     
    Last edited: Apr 1, 2015
  2. Dx Revision Watch

    Dx Revision Watch Owner of Dx Revision Watch

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    There are a small number of diseases that will be associated with two chapters for ICD-10-CM, including the dementia related disorders, which straddle the Neurology and the Mental and behavioural chapters. This applies to WHO's ICD-10, too, where some dementia terms are listed under Chapter V but cross linked to a G code with the dagger symbol.
     
    Last edited: Apr 1, 2015
  3. Nielk

    Nielk

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    The P2P were not tasked to create research criteria. They originally were, and then it was left off. HHS left this gap which is creating a lot of confusion. If the Fukuda are the research criteria that HHS accepts and no new research criteria were created, does that mean that the Fukuda remains as the research criteria?
     
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  4. halcyon

    halcyon Senior Member

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    R53 is fatigue and malaise so it could potentially fit there as described, since fatigue and post exertional malaise are the hallmarks of the SEID criteria. Regardless, with the way SEID is described, I still think it would have to be in R (symptoms, signs and abnormal clinical laboratory findings).
     
  5. Dx Revision Watch

    Dx Revision Watch Owner of Dx Revision Watch

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    In an earlier post in this thread, I referenced the respective hierarchies for PVFS; BME; CFS, postviral and CFS NOS for ICD-10-CM for the 2003 draft compared with the 2007 Release.

    For the history of PVFS, BME and CFS in ICD (ICD-9, ICD-9-CM, ICD-10, ICD-10-CM) to March 2001, see this archive CDC document:

    https://dxrevisionwatch.files.wordpress.com/2009/12/icd_code-cdc-march-2001.pdf

    A Summary of Chronic Fatigue Syndrome and Its Classification in the International Classification of Diseases
    Prepared by the Centers for Disease Control and Prevention, National Center for Health Statistics, Office of the Center Director, Data Policy and Standards, March 2001


    In March 2001, the intention had been to locate all three terms under G93.3 (as the Canadian ICD-10-CA has since done and as the German ICD-10-GM has since done). From the March 2001 document:

    "In keeping with the placement in the ICD-10, chronic fatigue syndrome (and its synonymous terms) will remain at G93.3 in ICD-10-CM."



    When the draft of ICD-10-CM was posted in 2003, this had been the proposal:

    [​IMG]



    Around 2004, the G93.3 "Chronic fatigue syndrome, postviral" inclusion term was deleted, leaving "Chronic fatigue syndrome NOS" in the R code chapter as the only CFS term within the ICD-10-CM Tabular List.

    This decision had been effected outside the public NCHS/CMS ICD-9-CM C & M Committee meeting process. Proposals for modifications to the ICD-10-CM code set did not become part of the public ICD-9-CM C & M Committee meeting process until 2010. So it was done behind closed doors.

    (If you want the background to this deletion, Mary Schweitzer was at the meeting where this change first came to light during a slide presentation by the late William Reeves)


    So when the 2007 ICD-10-CM Release was posted it had this arrangement, which is how it has stood for subsequent annual releases:

    Chapter 6

    [​IMG]

    Chapter 18


    [​IMG]
     
    Last edited: Apr 2, 2015
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  6. Dx Revision Watch

    Dx Revision Watch Owner of Dx Revision Watch

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    I have been equally confused about whether the panel envisages the new term replacing CFS, or replacing both CFS and (B)ME, or whether it intends that it should exist in tandem with the existing terms, and I can see this creating difficulties for NCHS/CDC's assigning of an ICD code and specifying its relationship to the existing ICD terms.
     
    Last edited: Apr 2, 2015
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  7. Ember

    Ember Senior Member

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    Was the Jason et al. (2013b) study considered to be of such high quality as to provide the basis for making unrefreshing sleep, but not "additional" symptoms, a core SEID requirement? Or were decisions also based on unpublished CDC data? Dr. Bateman suggests that the SEID criteria were “based on the symptoms reported by patients in multisite studies, backed by research demonstrating the biological basis of the presenting symptoms.”

    The Jason et al. (2013b) study tests a combined CFS (Fukuda) and ME/CFS (CCC) patient population using the DePaul Symptom Questionnaire (DSQ), a questionnaire that lacks independent validation. The study filters its findings using a frequency/severity standard that requires symptoms to be moderately severe at least half of the time. Although the presence of immune markers discriminates well between patients and healthy controls, these are found to be present in half the population or less when the frequency/severity filter is applied. Lymph node tenderness and pain are nevertheless found to track best with a high/low severity split (3:13:45) in a CFI cohort. Pain is reported by Jason et al. in more than half the population after the frequency/severity filter is applied, and as the authors acknowledge, “Pain is the major contributor to incapacity and self-reported symptoms; thus, some might challenge its relegation to a secondary role.” Commenting on the limitations of their study, Jason et al. point out, “Symptoms were not asked about in relation to activity; as some patients may only experience certain symptoms in response to activity, the prevalence of these symptoms may be underrepresented in this study’s results.”

    The Report Guide for Clinicians uses figures from Jason et al. (2013b) to validate its core symptoms.
     
    Last edited: Apr 5, 2015
  8. Nielk

    Nielk

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    Dr. Clayton stated that they did receive and consider information from the ongoing unpublished CDC multi-site study. Even though, dr. Clayton stated at the start of the IOM that once the IOM process starts, they will not get any input from any of the HHS sponsoring agencies-CDC being one of them.

    I don't know how this was legal to include information from an ongoing study that has not completed yet and emanating from an agency that is sponsoring the work.
     
  9. Ember

    Ember Senior Member

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    When the ICC was introduced at the IACFS/ME Conference in September 2011, it was opposed by two researchers, Dr. Jason and Dr. Unger. Their work seems to have had a significant impact on these IOM criteria.
     
    Last edited: Apr 2, 2015
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  10. Ember

    Ember Senior Member

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    ME (ICC) differs from ME/CFS (CCC) enough to have warranted the development of distinct criteria, a new primer and a change of name. The Snell et al. (2005) test-retest exercise study was key to the development of PENE; genetic, neuorological, immune, mitochondria and ion transport studies brought greater clarity:
    The differences between ME (ICC) and ME/CFS (CCC) matter more than you suggest.

    As for ME/CFS (SEID), not even its authors seem able to tell what manner of hybrid that they conceived. In Part 2, Dr. Bateman will be asked to address International Classification of Diseases (ICD) coding for SEID.
     
  11. Dx Revision Watch

    Dx Revision Watch Owner of Dx Revision Watch

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    And just to confirm, there were no proposals for additions or modifications to the ICD-10-CM code set of relevance to us presented at the March 18-19 NCHS/CMS ICD-10-CM C & M meeting.

    The next meeting is scheduled for September 22-23, 2015, then March 2016, September 2016, March 2017 and so on.

    Although the partial code freeze does not lift until October 1, 2016 (ie 12 months after ICD-10-CM's implementation date), it would be possible for proposals for additions/modifications to be submitted during 2015 and 2016 for consideration for deferred incorporation, once the partial code freeze has ended.

    So in theory, proposals could be submitted by one of the stakeholder agencies at this year's September meeting or in March 2016 or September 2016, for consideration for incorporation on or after October 1, 2016.

    As the 2003 draft and the 2007 Release are now difficult to find and as the FY 2015 Release is part of a very large zip file downloadable from the CDC site, I have posted PDFs of the Tabular Lists for all three iterations on my site. The FY 2016 Release is expected to be posted on the CDC site in June.


    ICD-10-CM 2003 draft Tabular List
    [9.4MB]

    https://dxrevisionwatch.files.wordpress.com/2015/03/icd-10-cm-draft-2003.pdf


    ICD-10-CM 2007 Release Tabular List
    [5.4 MB]

    https://dxrevisionwatch.files.wordpress.com/2015/03/2007-tabular-list-release.pdf


    ICD-10-CM FY 2015 Release Tabular List
    [8.0MB]

    https://dxrevisionwatch.files.wordpress.com/2015/03/fy15_tabular.pdf
     
    Last edited: Apr 2, 2015
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  12. taniaaust1

    taniaaust1 Senior Member

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    One really has to wonder if the IOM thing got done when it did due to knowing that was happening, otherwise ME may of become accepted there esp since we all not long ago (when considering how fast or I rather should say, not fast medicine stuff moves) got the International ME criteria.

    There was a strong possibility that more and more people may of started using that code.
    ....

    Thanks Dr Bateman for answering peoples questions.
     
    Last edited: Apr 2, 2015
  13. taniaaust1

    taniaaust1 Senior Member

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    Ive read something like it takes medicine around 15 years (it may of been 17 years) to catch up on what is going on in science etc. So maybe the CCC was about to just come into its own when the IOM happened (as we know we did get experts finally universally agree on it and sign that letter calling for it).

    Anyway, in things to do with medicine and change, there is usually a big time delay. This field moves slowly with change.
     
  14. Dx Revision Watch

    Dx Revision Watch Owner of Dx Revision Watch

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    Nielk said:

    "Starting October 2015 we will have an ICD code in the U.S. for ME; ICD-10-CM G93.3"



    But this was hardly a recent decision on the part of NCHS!

    CMS commissioned a draft adaptation of WHO's ICD-10 in 1995. The entire draft of the Tabular List of ICD-10-CM and the preliminary crosswalk between ICD-9-CM and ICD-10-CM were made available on the NCHS website for public comment between December 1997 through February 1998.

    The intention to retain BME under G93.3 was discussed in the March 2001 CDC document.

    Field tests for ICD-10-CM were held in the summer of 2003.

    A draft of ICD-10-CM was posted in 2003:

    https://dxrevisionwatch.files.wordpress.com/2015/03/icd-10-cm-draft-2003.pdf

    The issue of the coding of PVFS, BME and CFS NOS has been discussed at two ICD-9-CM C & M meetings (2010/11), when alternative proposals for the coding of CFS were presented by a patient advocacy group and by CDC, themselves.

    Since 2010, annual releases of ICD-10-CM have been posted on the CDC website.

    It's been apparent since 1997 that NCHS had chosen to retain the G93.3 codes inherited from ICD-10.

    There has been a code freeze in effect since 2011 which severely limits modifications to the code set.

    If HHS or CDC or any other agency were looking to rid ICD-10-CM of G93.3 BME, why wait until a code freeze is in effect to commission a potential code changing report?

    They could have gotten rid of G93.3 BME at any time between 1997 and the enforcement of the code freeze, in 2011.

    (The partial code freeze is intended to facilitate provider and payer preparations for transition from ICD-9-CM to ICD-10-CM by providing a more stable code set.)


    BTW, the original implementation date for ICD-10-CM was proposed for October 1, 2011.

    This was subsequently delayed until October 1, 2013 (to allow more time for provider and payer preparations). It was then delayed a further year, to October 1, 2014, then a further year, to October 1, 2015 (due to the signing into law of a piggyback clause in the HR 4302 PAM Act 2014).

    Had it not been for these delays, the U.S. would already be using a code set that includes BME as the codeable inclusion term under G93.3 PVFS.
     
    Last edited: Apr 2, 2015
  15. medfeb

    medfeb Senior Member

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    As I understand it, we have a code today in ICD-9-CM for ME (listed as benign myalgic encephalomyelitis) but doctors rarely use it.

    The index file of the 2011 ICD-9-CM on the NCHS website contains the following term, indexed to code 323.9
    Encephalomyelitis (chronic) (granulomatous) (myalgic, benign) (see also Encephalitis)

    the code 323.9 is indexed to this code in the tabular list of the ICD-9-CM
    323.9 Unspecified cause of encephalitis, myelitis, and encephalomyelitis
    which falls under the section
    Inflammatory diseases of the central nervous system (320-326)"

    The index file is Dindex12.zip and the tabular listing is Dtab12.zip - both are at this link
    ftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Publications/ICD9-CM/2011/
     
  16. Ember

    Ember Senior Member

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    Are these tests considered to be part of a routine medical work-up? ECG, MRIs and a mental health screen aren't mentioned in the Report Guide for Clinicians. Neither are lab tests.
     
    Last edited: Apr 3, 2015
  17. Ember

    Ember Senior Member

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    Reading section by section, I can't find that the summary of the cited literature supports the Committee's conclusions and recommendations. A critical analysis of the report doesn't seem to yield consistent criteria by which core symptoms are differentiated from symptoms not considered core.
     
    Last edited: Apr 3, 2015
  18. Ember

    Ember Senior Member

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    The Report Guide for Clinicians doesn't explicitly suggest that clinicians use the CCC list of exclusions, but the IOM report offers this advice with respect to comorbidies:
    The Report Guide fails to provide such guidance.
     
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  19. Ember

    Ember Senior Member

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    As the more restrictive of the two definitions, the ICC lists fewer exclusions than does the CCC:
    In her “New Clinical Definitions for ME/CFS” presentation, Dr. Bateman comments on the IOM Committee's decision not to list exclusions for SEID:
     
    Last edited: Apr 3, 2015
  20. Nielk

    Nielk

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    So why do they distinguish the IOM criteria by stating that this is not an exclusionary criteria. It is a diagnosis to be made?
    The only difference being that they don't list the specific exclusions?
     

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