Anticipating ICD-11 in the U.S. Health Scene

The World Health Organization (WHO) stopped supporting ICD-10 years ago. In the United States, the National Center for Health Statistics (NCHS) independently maintains ICD-10-CM for use in the U.S.  

The WHO has been developing and supporting ICD-11 for many years. It officially went into effect on January 1, 2022. Though the details and final decisions have yet to be made, it seems likely that the U.S. will be heading in the direction of ICD-11 adoption at some point. There are many stakeholders in the U.S. who will need to be consulted and involved in the formal decision-making. Included among these are health care providers, government agencies, and third-party payors as they all will bear various burdens associated with any changes. 

Compared to ICD-10, the WHO’s ICD-11 classification is completely restructured to take advantage of digital capabilities; to improve coordination with other classifications and terminologies; to provide flexibility to reduce the need for national clinical modifications and to improve the comparability of translations and support on-line services to reduce the cost of implementation. 

The National Committee on Vital and Health Statistics (NCVHS) ICD-11 Workgroup on Timely and Strategic Action to Inform ICD-11 Policy describes some of the unique features that ICD-11 might offer. These include: 

• Modern technology and user interfaces — Digital representation of health terms and classes, and relationships between terms and classes. 
• Changing to reflect medical knowledge — The ICD-11 foundation uses a comprehensive semantic model designed to be continuously updated, potentially reducing the need for major upgrades in the future. 
• Post-coordination — This is a feature of ICD-11 that allows clustering of codes with optional extensions to achieve necessary specificity. This provides flexibility without predefining every combination that may possibly be needed. 
• Linearizations — These are subsets of the ICD-11 foundation that are exposed to users for specific purposes. A linearization is used for international mortality reporting and another one is anticipated to be derived for U.S. morbidity coding. 
• Freely available online tools and services — ICD-11 is designed to ease translation and mapping between ICD-11 and other terminologies and coding systems. 

This same NCVHS workgroup describes some of the clinical content updates that ICD-11 includes: 

• Significant detail to classify rare diseases as well as social, community, and behavioral health. 
• Codes for antimicrobial resistance.  
• Codes for full documentation of patient safety. 
• Necessary detail for cancer registration fully-embedded. 
• Specific coding for clinical stages of HIV. 
• More clinically relevant coding for complications of diabetes. 
• Codes for common skin cancers basalioma, and melanoma subtypes. 
• Classification of heart valve disease and pulmonary hypertension, matching current diagnostic and treatment capacity. 
• New chapters for disease of the immune system, sleep-wake disorders, and conditions related to sexual health.
• Incorporation of traditional medicine diagnoses.
• Supplementary section for assessment of functioning. 

In anticipation of the U.S. adopting ICD-11, Dr. James A. Feinstein, MD, and colleagues have written about key preparations the U.S. healthcare system would need to make before adoption.¹  

Some of their suggestions include: 

• All potential end users and key stakeholders within the U.S. healthcare system should actively explore and become familiar with ICD-11. 
• Implementation will rely on the availability of transition tools, like crosswalk mapping files, translation software, and dual-coded data sets (including both ICD-10-CM and ICD-11 codes). These should be created and made publicly available well before the anticipated transition date. 
• Ensuring federal-state-industry partnerships, including substantial grant funding and project resources, to support the training, implementation, and evaluation of the transition to ICD-11 across all aspects of health care. 

Hospitals and their associations are also significant stakeholders. In January of 2024, the American Hospital Association (AHA) responded to the CDC/NCHS’s request for information about the potential adoption and use of ICD-11 within the United States. Overall, the AHA supports the transition to ICD-11 but did encourage the agency to: 

• Create and publish robust and meaningful case scenarios comparing side-by-side dual-coded acute care, post-acute care, outpatient, and physician office cases (ICD-10 versus ICD-11) for industry stakeholder review. 
• Provide an in-depth analysis that specifies the reporting differences, benefits, and challenges specific to these case scenarios when comparing ICD-11 to ICD-10. 
• Utilize these analyses to determine if the potential benefits of the ICD-11 transition outweigh the health care industry operational issues and factor its findings into its final recommendations on implementation to the secretary. 

They continue by suggesting the analysis of the potential benefits should at least include, among other things: 

• Provider documentation requirements noting similarities and differences. 
• Coding application and coding guideline similarities and differences. 
• Critical considerations for claim submissions (i.e., capture and reporting similarities and differences specific to the UB04 paper claim form, 837I electronic claim form, and the CMS 1500 claim form). 
• Key concerns related to quality reporting initiatives and anticipated differences in data output, meaning and reporting agency system capabilities. 

Future adoption of ICD-11 appears to be very likely. The “when” and “how” remains to be seen, but conscientious coders, auditors and compliance professionals should remain observant and anticipate these changes. Leaders in these spaces should be well versed on ICD-11 and be prepared to provide education, policy and any other necessary action to prepare their organizations for this future likelihood. 

¹ - JAMA Health Forum. 2023;4(7): e232253. doi:10.1001/jamahealthforum.2023.2253 

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