Guideline from Danish Health Authorities on coding Functional Disorders (also about ME)

[Kalliope]

The Danish Health Authorities has just published a guideline on how to code Functional Disorders.

ME has previously been included in the term Functional Disorders, but Danish politicians overruled this and decided WHO's definition of ME should be kept.

Here are the new codes on functional disorders and what is mentioned about ME in the guidelines:

An overview of diagnostic codes for functional disorders is shown below.

SKS Code Diagnosis
DR688A9 Functional disorder IKA
DR688A9A Functional disorder, multiorgan
DR688A9B Functional disorder, single organ
DR688A9B1 Functional disorder, general / fatigue
DR688A9B2 Functional disorder, gastrointestinal
DR688A9B3 Functional disorder, musculoskeletal
DR688A9B4 Functional disorder, cardiopulmonary
DR688A9B5 Functional disorder, neurological
DR688A9B6 Functional disorder, urogenital
DR688A9B9 Other functional disorder, single organ
DR688A9C Functional disorder, single symptom

.......


When the clinical assessment after completion of the assessment is that the patient has a functional disorder, it is generally recommended to use the new codes for functional disorders such as the primary codes (action diagnoses), as these in the vast majority cases will be more accurate and clinically meaningful than organ and / or special-specific syndrome diagnoses, such as chronic interstitial cystitis, iris profitable colon, health anxiety, fibromyalgia, myalgic encephalopmyelitis, etc. as these codes risk keeping both clinician and patient in either clean somatic or a purely psychiatric view of illness, which can be both equally inappropriate and stigmatizing for the patient.

The organ specific codes however, may, in a specific clinical judgment, be listed as supplemental or single standing codes where considered relevant. Regarding the specific code 'DG933A Benign myalgic encephalomyelitis', it is noted that it follows from Parliament's resolution V82 of 12 March 2019, that this Code Guide should separate this Code from the collective term functional disorders. This is accomplished by creating a new design in the neutral section DR68, while providing guidance below continued use of DG933A, which is located in another section, as however, at the same time it should be noted that codes from either or both paragraphs can out from specific clinical assessments be used to describe a symptom-image in a patient.
...

Case of chronic fatigue syndrome and ME
If a patient has chronic fatigue, which, after a thorough clinical assessment, may be probable as caused by a previous viral infection, the code DG933 Postviral fatigue syndrome may be relevant. If the assessment and the clinical assessment makes it more likely that there is an inflammatory state of the brain, the subcode DG933A Benign myalgic encephalomyelitis may be considered. Both codes are located below
area DG93 Other brain disorders.
If the above cannot be clinically supported and criteria as stated in section 3.1 is also fulfilled, then the new code for Functional Disorder, general/fatigue, is relevant.


SST: Kodning av funktionelle lidelser
google translation: Coding of functional disorders

 

[Invisible Woman]

If a patient has chronic fatigue, which, after a thorough clinical assessment, may be probable as caused by a previous viral infection, the code DG933 Postviral fatigue syndrome may be relevant. If the assessment and the clinical assessment makes it more likely that there is an inflammatory state of the brain, the subcode DG933A Benign myalgic encephalomyelitis may be considered. Both codes are located below
area DG93 Other brain disorders.

Bolding mine -

Ok, so PVFS no argument there, however whether or not there is inflammation in the brain is something that has been contested and is one of the arguments about the name, particularly the "encephalomyelitis" bit.

I should imagine most physicians will be reluctant to claim that there is a likelihood of such inflammation without substantial proof so it seems to me that this paragraph is actually making it more likely that a functional code will be slapped on patients who don't have a very clear post viral onset.

Or have I completely misread that?

 

[chrisb]

That was my interpretation too. It would seem to rule out, for example, Post Q Fever fatigue or Post Giardia fatigue

 

[spinoza577]

... however whether or not there is inflammation in the brain is something that has been contested and is one of the arguments about the name, particularly the "encephalomyelitis" bit.
...
Or have I completely misread that?

Thank you for clarifying, I knew that there is something not proper.

"Functional Disorder" though wouldn´t be bad at all, if only if not the all the world would like to add "of psychological cause", and, of course, "not of other causes".

 

[Dx Revision Watch]

Case of chronic fatigue syndrome and ME
If a patient has chronic fatigue, which, after a thorough clinical assessment, may be probable as caused by a previous viral infection, the code DG933 Postviral fatigue syndrome may be relevant. If the assessment and the clinical assessment makes it more likely that there is an inflammatory state of the brain, the subcode DG933A Benign myalgic encephalomyelitis may be considered. Both codes are located below
area DG93 Other brain disorders.
If the above cannot be clinically supported and criteria as stated in section 3.1 is also fulfilled, then the new code for Functional Disorder, general/fatigue, is relevant.

Worth noting in relation to the above, that the WHO provides no definitions, descriptions or any guidance on the application of codes or terminology within ICD-10 for either of the two terms coded at G93.3 [G933] (Postviral fatigue syndrome; Benign myalgic encephalomyelitis), or indexed to G93.3 [G933] (Chronic fatigue syndrome).

Nor does WHO provide any definitions, descriptions or any guidance on the application of codes or terminology within the forthcoming ICD-11 for any of the three terms coded at 8E49 (Postviral fatigue syndrome;Benign myalgic encephalomyelitis; Chronic fatigue syndrome).

 

[Dx Revision Watch]

Is there an English language version of this document please? The auto translation is a little iffy.

 

[Dx Revision Watch]

DR688A9A Functional disorder, multiorgan
DR688A9B Functional disorder, single organ

aka Fink's BDS criteria.

 

[Dx Revision Watch]

So, my reading of this (with the caveat that I am currently relying solely on an extract from the document that has been auto translated):

Probably viral onset: DG933 PVFS
Inflammatory state of the brain: DG933A subcode (good luck with providing supporting clinical evidence for that one)

Chronic fatigue/Chronic fatigue syndrome (ICD-10 G93.3, ICD-11 8E49): DR688A9B1 Functional disorder, general / fatigue



Bodily distress disorder (BDS) Single organ system type

Bodily distress disorder (BDS) Multi organ system type

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

From: Syndromes of bodily distress or functional somatic syndromes - where are we heading?
Lecture on occasion of receiving the Alison Creed Award 2017 Prof. Per Fink MD, PhD, Dr.Med.Sc.

Extracts from 87 slides presentation:

https://dxrevisionwatch.files.wordpress.com/2019/09/plenary_prof_fink.pdf

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

 

[spinoza577]

This might be pretty important (though I understand Danish not very well):

• udviklingen i forstâelsen af ârsager til funktionele lidelser

det er en öget anerkendelse og forsâelse af, at ârsager fra funktionele lidelser formentilg et multifaktoriel, og videnskabelige studier stötter op om denner forstâelse. Sâledes er det ikke blot en enkelt faktor, der ligger til grund for en funktionele lidelser.

• the development in understanding the causes of FD

There is increasing recognition and understanding, that the causes of FD are formally multi factorial, and scientific studies are pushing forward for understanding them. Sadly there is not only one single factor, underlying a FD.


(hope translation is right)

 

[rvallee]

Bolding mine -

Ok, so PVFS no argument there, however whether or not there is inflammation in the brain is something that has been contested and is one of the arguments about the name, particularly the "encephalomyelitis" bit.

I should imagine most physicians will be reluctant to claim that there is a likelihood of such inflammation without substantial proof so it seems to me that this paragraph is actually making it more likely that a functional code will be slapped on patients who don't have a very clear post viral onset.

Or have I completely misread that?

Eating their cake and having it too. I think you read it right. They follow the letter of the decision while crapping on its spirit and making eye contact the whole time.

So basically Danish medicine is now fully and operationally adopting an alternative belief system of medicine. What could possibly go wrong? No doubt complaints over those diagnoses, even when they are later found to be wrong, will be inadmissible. If a medical error happens and it is not written down, did it really happen? After all, the person making the complaint is functionally delusional, so does that person really exist?

Welp, that makes it official, medicine is incapable of self-regulating. What a disaster.

 

[Dx Revision Watch]

"The organ specific codes however, may, in a specific clinical judgment, be listed as supplemental or single standing codes where considered relevant. Regarding the specific code 'DG933A Benign myalgic encephalomyelitis', it is noted that it follows from Parliament's resolution V82 of 12 March 2019, that this Code Guide should separate this Code from the collective term functional disorders. This is accomplished by creating a new design in the neutral section DR68, while providing guidance below continued use of DG933A, which is located in another section, as however, at the same time it should be noted that codes from either or both paragraphs can out from specific clinical assessments be used to describe a symptom-image in a patient."



Note that in ICD-10, the R688 [R68.8] code is located under the ICD-10 XVIII Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified chapter, in the R68 category block:


https://icd.who.int/browse10/2016/en#/R68

R68 Other general symptoms and signs


under which sits R68.8:

https://icd.who.int/browse10/2016/en#/R68.8

R68.8 Other specified general symptoms and signs

 

[Dx Revision Watch]

So with the caveat I posted above, it appears they have created additional subcodes under the R68.8 rubric for the Danish extension in which to shoehorn these various Functional disorder codes:

DR688A9 Functional disorder IKA
DR688A9A Functional disorder, multiorgan
DR688A9B Functional disorder, single organ
DR688A9B1 Functional disorder, general / fatigue
DR688A9B2 Functional disorder, gastrointestinal
DR688A9B3 Functional disorder, musculoskeletal
DR688A9B4 Functional disorder, cardiopulmonary
DR688A9B5 Functional disorder, neurological
DR688A9B6 Functional disorder, urogenital
DR688A9B9 Other functional disorder, single organ
DR688A9C Functional disorder, single symptom

and these:

DR688A9A Functional disorder, multiorgan
DR688A9B Functional disorder, single organ

DR688A9B9 Other functional disorder, single organ
DR688A9C Functional disorder, single symptom

will likely be used for Fink's BDS.

 

[Dx Revision Watch]

Eating their cake and having it too. I think you read it right. They follow the letter of the decision while crapping on its spirit and making eye contact the whole time...

Having their cake, a couple of jam doughnuts and half a packet of chocolate chip cookies, too.

 

[Dx Revision Watch]

Though Fink was unsuccessful with his lobbying of ICD-11:

 

[Kalliope]

Is there an English language version of this document please? The auto translation is a little iffy.

Not that I'm aware of, but I'm glad you're looking into this and am happy to try to translate at least some sections.

ETA: In that case just let me know which sections you'd like to take a closer look at

 

[Kalliope]

This might be pretty important (though I understand Danish not very well):

• udviklingen i forstâelsen af ârsager til funktionele lidelser

det er en öget anerkendelse og forsâelse af, at ârsager fra funktionele lidelser formentilg et multifaktoriel, og videnskabelige studier stötter op om denner forstâelse. Sâledes er det ikke blot en enkelt faktor, der ligger til grund for en funktionele lidelser.

• the development in understanding the causes of FD

There is increasing recognition and understanding, that the causes of FD are formally multi factorial, and scientific studies are pushing forward for understanding them. Sadly there is not only one single factor, underlying a FD.


(hope translation is right)

This is good! Just a few suggestions to get it even more accurate:

• the development in understanding the causes of FD

There is increasing recognition and understanding that the causes of FD are probably multi factorial, and scientific studies supports this understanding. Thus there is not just one single factor, that underlies FD

 

[Dx Revision Watch]

Not that I'm aware of, but I'm glad you're looking into this and am happy to try to translate at least some sections.

ETA: In that case just let me know which sections you'd like to take a closer look at

Thank you, Kalliope, for that kind offer. I would not want to put you to a lot of trouble. I think one of the earlier Danish guidelines for the FDs was published in English, too, but that may not have been until some time after the Danish version was released.

I would be interested in a human translation of the extract in the original post.

What I will do over the weekend is skim the document searching specifically for any other references to classification/coding (eg ICD-11, ICPC-2). Then if there are any other extracts where it would be useful for me to have a human translation, I will come back to you. Thank you.

 

[spinoza577]

This is good! Just a few suggestions to get it even more accurate:

scientific studies supports this understanding.

This is even more reasonable, in a scientific surrounding - probably I am - as the most here - somehow sceptical about their ambitions ...

Thus there is not just one single factor,

Ha, due to the first inaccuracy (as you called it, very friendly) - sâ-ledes probabaly could directly translate into the English so-lead!!

 

[rvallee]

I assume that somewhere in this thing there must be discussion of which emotions target which organs? Or something like that. Someone must have made something like that, surely? Otherwise how does emotional disorder target specific organs? Is the left foot connected to derision? The left ventricule connected to anger about the weather? I wonder what emotions were tied to the appendice, probably all those repressed emotions that can be removed without much concern if they get too rowdy.

Conversion disorder of the liver? What are the emotions of the liver? What are the lungs thinking about? Are cauliflower ears caused by being too obsessed with professional boxing?

I'm frankly shocked at the mediocrity here of tying emotions to specific organs. This stuff belongs straight in the 19th century. Not surprised. Still shocking. This is basically thought crimes. You have been found guilty of flawed thinking. No evidence required, but your thoughts are clearly impure and must be cleansed in... uh... we'll call them re-education camps. Yes, that sounds good and proper. Emotional re-education camps, for the health of your liver and the proper functioning of your urinary tract.

How is anyone going to take these authorities seriously after this? Why no back straight to the humours, while they're at it? What's even the difference with this tripe?

 

[Dx Revision Watch]

@Kalliope

This extract here (on Page 6) regarding ICD-11:

WHOs nye ICD-11-klassifikation er endnu ikke er trådt i kraft i Danmark1 . Udover at en række koder er blevet ændret, så giver den bl.a. mulighed for at anvende multiple parenting som betyder, at nogle tilstande kan klassificeres to steder, og at begge placeringer kan være korrekte. Som eksempel kan nævnes lungecancer, der både kan klassificeres som en sygdom i det respiratoriske organsystem og som en cancersygdom. Ifm. implementeringen af ICD-11 vil nærværende kodevejledning derfor blive opdateret.​

I can manage with Google Translate, as I am familiar with the context:

Google Translation

WHO's new ICD-11 classification has not yet come into force in Denmark1. In addition to changing a number of codes, [there is the] possibility [of using] multiple parenting which means that some modes can be classified [in] two locations and that both locations may be correct. By way of example are mentioned lung cancer, which can be classified both as a disease of the respiratory organ system and as a cancer disease.

Ifm. [?] In connection with the implementation of ICD-11 the current code guide will therefore be updated.

[Edited to insert Kalliope's improved translation]​

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

Note that it specified within the ICD-11 classification whether any given category is secondary parented under another location (which may be a second parent within the same chapter or a second parent within a different chapter). It is not the user who determines or decides whether a category has multiple parents.

For ICD-11, multiple parenting is not relevant to the 8E49 PVFS; BME; CFS codes.

Nor is multiple parenting relevant to 6C20 Bodily distress disorder.

(The IASP Task Force for the development of the new Chronic primary pain disorders block has suggested that BDD should be secondary parented to the Chronic primary pain disorders. But so far, a formal proposal for this has not been submitted and BDD remains assigned under only one parent class.)