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

[Kalliope]

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. 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.

Yes, an English version may be underway. Seems the English section of the website to the Danish Health Authority is currently under construction, so who knows..

I'm so glad you're looking into this with your background knowledge and experience

Here's a translation of the extracts from the first post with a human touch:


When the clinical evaluation after the assessment is that the patient has a functional disorder, it recommended in general to use the new codes for functional disorders such as the primary codes (action diagnoses), as these in the vast majority of cases will be more accurate and clinically meaningful than organ and / or speciality-specific syndrome diagnoses, such as chronic interstitial cystitis, irritable bowel syndrome, health anxiety, fibromyalgia, myalgic encephalopmyelitis, etc. as these codes risk maintaining both the clinician and the patient in a purely somatic or a psychiatric illness perception, which can be both unsuitable and stigmatizing for the patient.

But the organ specific codes however may, according to a specific clinical judgment, be listed as supplemental or single standing codes where this is considered relevant.

Regarding the specific code 'DG933A Benign myalgic encephalomyelitis', it is noted that it according to the Parliament's resolution V82 of 12 March 2019, these coding guidelines must separate this code from the collective term functional disorders.

This is complied by making a new code unit in the neutral section DR68, while providing guidance below for 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 sections can from specific clinical assessments be used to describe a symptom display in a patient.
...

Case about chronic fatigue syndrome and ME

If a patient has chronic fatigue, which, after a thorough clinical evaluation, may likely be caused by a previous viral infection, the code DG933 Postviral fatigue syndrome might be relevant.

If the assessment and the clinical evaluation makes it more likely there is an inflammatory state in the brain, the sub code DG933A Benign myalgic encephalomyelitis may be considered.

Both codes are located below the 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, DR688A9B1 is relevant.

 

[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. [?] The implementation of ICD-11 will therefore be the current code guide up to date.

Yes, that's a fair translation, I think.

The last sentence is:
In connection with the implementation of ICD-11 the current code guide will therefore be updated.

 

[Dx Revision Watch]

I assume that somewhere in this thing there must be discussion of which emotions target which organs?...

In the context of the so-called, functional disorders, functional symptoms and functional syndromes, the terms "organ systems" or "body systems" are more often used than "organs".

Diseases in ICD are also ordered in chapters according to their aetiology or to the organ system affected, for example:

Diseases of the circulatory system
Diseases of the respiratory system
Diseases of the digestive system
Diseases of the musculoskeletal system or connective tissue


compare this with the "functional symptoms" below, arranged according to the organ or body system the "functional symptoms" manifest in:

So I might write, for example:

The DSM-5's Somatic symptom disorder and ICD-11's Bodily distress disorder are both characterised by "excessive" psychobehavioural responses to chronic, distressing symptoms or to a single symptom. The symptoms can be "medically unexplained" or they may be associated with, or exacerbated by a diagnosed general medical condition.

Whereas for the Fink et al (2007, 2010) Bodily distress syndrome diagnostic construct, "maladaptive" psychobehavioural responses are not required to meet the diagnosis (though they may be present). Physical symptoms are central and the diagnosis is made on the basis of chronicity, distress, degree of impairment and on specific symptom "clusters" from one or more body or organ systems.

If the symptoms are better explained by another disease, they cannot be labelled BDS. Symptoms associated with a diagnosed general medical disease or condition should be a differential diagnosis.​

I don't know which model the Danish document is using, but this is one of Fink's models:

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

[Edited to expand on earlier version]

 

[Dx Revision Watch]

Yes, that's a fair translation, I think.

The last sentence is:
In connection with the implementation of ICD-11 the current code guide will therefore be updated.

Thanks for this.

 

[Dx Revision Watch]

Yes, an English version may be underway. Seems the English section of the website to the Danish Health Authority is currently under construction, so who knows..

I'm so glad you're looking into this with your background knowledge and experience

Here's a translation of the extracts from the first post with a human touch:


When the clinical evaluation after the assessment is that the patient has a functional disorder, it recommended in general to use the new codes for functional disorders such as the primary codes (action diagnoses), as these in the vast majority of cases will be more accurate and clinically meaningful than organ and / or speciality-specific syndrome diagnoses, such as chronic interstitial cystitis, irritable bowel syndrome, health anxiety, fibromyalgia, myalgic encephalopmyelitis, etc. as these codes risk maintaining both the clinician and the patient in a purely somatic or a psychiatric illness perception, which can be both unsuitable and stigmatizing for the patient.

But the organ specific codes however may, according to a specific clinical judgment, be listed as supplemental or single standing codes where this is considered relevant.

Regarding the specific code 'DG933A Benign myalgic encephalomyelitis', it is noted that it according to the Parliament's resolution V82 of 12 March 2019, these coding guidelines must separate this code from the collective term functional disorders.

This is complied by making a new code unit in the neutral section DR68, while providing guidance below for 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 sections can from specific clinical assessments be used to describe a symptom display in a patient.
...

Case about chronic fatigue syndrome and ME

If a patient has chronic fatigue, which, after a thorough clinical evaluation, may likely be caused by a previous viral infection, the code DG933 Postviral fatigue syndrome might be relevant.

If the assessment and the clinical evaluation makes it more likely there is an inflammatory state in the brain, the sub code DG933A Benign myalgic encephalomyelitis may be considered.

Both codes are located below the 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, DR688A9B1 is relevant.

Thanks very much for this, Kalliope.

Today, time permitting (and if not, then over the weekend), I will skim a Google translation of the document for any other sections I would find useful to have a human translation for. Then I will collate those sections in one post, and post a copy in the
Updates on status of ICD-11 and changes to other classification and terminology systems thread.

 

[Dx Revision Watch]

@Kalliope


If it's not too much trouble, I would appreciate a human translation of this section here, on Page 6 of the Danish document:

Forventningen er, at en ny klassifikation af funktionelle lidelser vil fremme
kommunikationen mellem forskellige fagpersoner og bygge bro mellem funktionelle
lidelser i forskellige afsnit af den nuværende ICD-10 klassifikation (International
Classification of Diseases, WHO), som Danmark følger. Endvidere
vil det bidrage til en større ensartethed i epidemiologiske studier og studier
af sundhedsfaglig relevans.

----------

also from Page 12, Appendix 1

Bilag 1: Generelt om diagnosekoder

(...)


I Danmark har sundhedsfagligt personale pligt til at dokumentere sundhedsfaglig
virksomhed, både ved journalføring og ved kodning og indrapportering til registre
og databaser. Ejere af sygehuse, klinikker m.v. har pligt til at sikre indberetning
af oplysninger om sundhedsfaglig virksomhed til de centrale myndigheder. Til det
formål anvendes koder for kontaktårsag, herunder skadesmekanismer, symptomer
og diagnoser, udførte behandlinger m.v. som anført i Sundhedsvæsenets
Klassifikations System (SKS). SKS udvikles og vedligeholdes af Sundhedsdatastyrelsen
og bruges primært inden for sygehusvæsenet, bl.a. i forbindelse med
registrering af sundhedsfaglige ydelser i de patientadministrative systemer og efterfølgende
indberetning til Landspatientregistret (LPR).

SKS indeholder den danske version af WHO’s International Statistical Classifiation
of Diseases and Related Health Problems, ICD-10, med relevante tilføjelser
og afvigelser ud fra nationale hensyn. Diagnoseklassifikationen skal ikke betragtes
som en liste over ”godkendte sygdomme”, men derimod en struktureret overordnet
afspejling af sundhedsfaglig konsensus til statistiske formål.

Der er en løbende faglig udvikling på området, både generelt i forhold til det
fremtidige klassifikationssystem ICD-11, og specifikt i forhold til forståelse og
klassifikation af funktionelle lidelser. Til registrering af kontakter vedrørende udredning
og behandling af funktionelle lidelser kan anvendes en række forskellige
koder. Anvendelse eller undladelse af bestemte koder må ikke i sig selv være
bestemmende for, hvordan en tilstand opfattes hos den enkelte, og hvilken behandling,
der tilbydes.

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

I think I can probably manage the rest of the document from the Google Translation. No rush for this and thanks again for your time.

Suzy

 

[Kalliope]

@Kalliope


If it's not too much trouble, I would appreciate a human translation of this section here, on Page 6 of the Danish document:

Forventningen er, at en ny klassifikation af funktionelle lidelser vil fremme
kommunikationen mellem forskellige fagpersoner og bygge bro mellem funktionelle
lidelser i forskellige afsnit af den nuværende ICD-10 klassifikation (International
Classification of Diseases, WHO), som Danmark følger. Endvidere
vil det bidrage til en større ensartethed i epidemiologiske studier og studier
af sundhedsfaglig relevans.

----------

also from Page 12, Appendix 1

Bilag 1: Generelt om diagnosekoder

(...)


I Danmark har sundhedsfagligt personale pligt til at dokumentere sundhedsfaglig
virksomhed, både ved journalføring og ved kodning og indrapportering til registre
og databaser. Ejere af sygehuse, klinikker m.v. har pligt til at sikre indberetning
af oplysninger om sundhedsfaglig virksomhed til de centrale myndigheder. Til det
formål anvendes koder for kontaktårsag, herunder skadesmekanismer, symptomer
og diagnoser, udførte behandlinger m.v. som anført i Sundhedsvæsenets
Klassifikations System (SKS). SKS udvikles og vedligeholdes af Sundhedsdatastyrelsen
og bruges primært inden for sygehusvæsenet, bl.a. i forbindelse med
registrering af sundhedsfaglige ydelser i de patientadministrative systemer og efterfølgende
indberetning til Landspatientregistret (LPR).

SKS indeholder den danske version af WHO’s International Statistical Classifiation
of Diseases and Related Health Problems, ICD-10, med relevante tilføjelser
og afvigelser ud fra nationale hensyn. Diagnoseklassifikationen skal ikke betragtes
som en liste over ”godkendte sygdomme”, men derimod en struktureret overordnet
afspejling af sundhedsfaglig konsensus til statistiske formål.

Der er en løbende faglig udvikling på området, både generelt i forhold til det
fremtidige klassifikationssystem ICD-11, og specifikt i forhold til forståelse og
klassifikation af funktionelle lidelser. Til registrering af kontakter vedrørende udredning
og behandling af funktionelle lidelser kan anvendes en række forskellige
koder. Anvendelse eller undladelse af bestemte koder må ikke i sig selv være
bestemmende for, hvordan en tilstand opfattes hos den enkelte, og hvilken behandling,
der tilbydes.

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

I think I can probably manage the rest of the document from the Google Translation. No rush for this and thanks again for your time.

Suzy

You caught me in a moment of procrastination, looking for some distraction, so here you go I hope the text is a bit more accessible

It's expected that a new classification of functional disorders will advance the communication between different professionals and build bridges between functional disorders in different sections in the current ICD-10 classification (International Classification of Diseases, WHO) which Denmark is following.

Further it will contribute to a greater uniformity in epidemiological studies and studies of health professional relevance.

----------

also from Page 12, Appendix 1

Bilag 1: General about diagnostic codes

(...)

Healthcare professionals in Denmark are required to document health care activities, both with journal keeping and with coding and reporting to registers and databases.

Owners of hospitals, clinics etc have a duty to ensure reporting of information on health care activities to central authorities.
For this purpose codes for reason for contact, including injury mechanisms, symptoms and diagnoses, performed treatments etc are used as stated in the Health Care's Classification System (SKS)

SKS is developed and maintained by the Digital Health Strategy and is primarily used within the hospital system, among other in connection to registration of health care services in the patient administration systems and the following reporting to the National Patient Registry.

SKS contains the Danish version of WHO's International Statistical Classification of Diseases and Related health Problems, ICD-10, with relevant additions and deviations based on national considerations.

The diagnose classification should not be considered as a list of "approved illnesses", but rather a structured superior reflection of health professional consensus for statistical purposes.

There is an ongoing professional development in this area, both in general in relation to the future classification system ICD-11, and specifically in relation to understanding and classification of functional disorders.

For registering contacts when it comes to assessment and treatment of functional disorders, a variety of different codes may be used.

The use or omission of use of certain codes should not in itself determine how a condition is perceived by the individual and which treatment is offered.

 

[Dx Revision Watch]

As I've mentioned in the ICD-11 thread, the WHO would prefer to limit the number of modifications of ICD-11.

WHO would prefer all Member States adopted the same version (even if this means accommodating some additional country specific terms) rather than have multiple clinical modifications in use, globally.

WHO is still formulating its policies for the licensing of country specific adaptions.

Denmark is currently using a Danish extension of the WHO's ICD-10 with "relevant additions and deviations from national considerations".

As with other Member States that have been licensed by the WHO to develop national adaptions, for example, the U.S. and Germany, additional codes can be inserted; additional inclusion terms or exclusion terms can be added under existing codes; categories may be re-ordered; or relocated under new or different parent classes or relocated under different chapters; or removed from the classification altogether.


It's not known yet what the WHO's policies are going to be in regard to the development of national adaptations of ICD-11. But if Denmark is permitted to develop a DK adaptation, it will be interesting to see how it proposes to migrate these new ICD-10 additional sub codes.


The ICD-10 Symptoms, signs chapter code R68.8 Other specified general symptoms and signs category is the code under which these additional sub codes for Functional disorders have been created.

In the ICD-10 to ICD-11 Mapping Tables, ICD-10's R68.8 is forward mapped to ICD-11's Chapter 21: General symptoms block but with no specific corresponding code that I can see.

It is possible that a Danish adaptation of ICD-11 may create additional sub codes for these new DR688A9 to DR688A9C sub codes under the ICD-11 Chapter 21: General symptoms MGxx code block.

 

[Dx Revision Watch]

You caught me in a moment of procrastination, looking for some distraction, so here you go I hope the text is a bit more accessible

It's expected that a new classification of functional disorders will advance the communication between different professionals and build bridges between functional disorders in different sections in the current ICD-10 classification (International Classification of Diseases, WHO) which Denmark is following.

Further it will contribute to a greater uniformity in epidemiological studies and studies of health professional relevance.

----------

also from Page 12, Appendix 1

Bilag 1: General about diagnostic codes

(...)

Healthcare professionals in Denmark are required to document health care activities, both with journal keeping and with coding and reporting to registers and databases.

Owners of hospitals, clinics etc have a duty to ensure reporting of information on health care activities to central authorities.
For this purpose codes for reason for contact, including injury mechanisms, symptoms and diagnoses, performed treatments etc are used as stated in the Health Care's Classification System (SKS)

SKS is developed and maintained by the Digital Health Strategy and is primarily used within the hospital system, among other in connection to registration of health care services in the patient administration systems and the following reporting to the National Patient Registry.

SKS contains the Danish version of WHO's International Statistical Classification of Diseases and Related health Problems, ICD-10, with relevant additions and deviations based on national considerations.

The diagnose classification should not be considered as a list of "approved illnesses", but rather a structured superior reflection of health professional consensus for statistical purposes.

There is an ongoing professional development in this area, both in general in relation to the future classification system ICD-11, and specifically in relation to understanding and classification of functional disorders.

For registering contacts when it comes to assessment and treatment of functional disorders, a variety of different codes may be used.

The use or omission of use of certain codes should not in itself determine how a condition is perceived by the individual and which treatment is offered.

Gosh, that was quick. Many thanks, Kalliope.

 

[InfiniteRubix]

Sorry my head is exploding. Am I right to interpret that this is all good progress, no? Have I missed something that undermines it all?

(I don't want to demean the intricacies of proper coding...)

 

[Invisible Woman]

Forgive me if this is a stupid suggestion & I've got my timeline muddled.

This looks to me like the health authorities are simply ignoring or using the codes to carry on in their own merry way, despite the Danish politicians' (Health Minister?) undertaking that this should be considered a biomedical disease and treated as such.

Would a letter or email to the Danish Health Minister along with any other politicians who support the biomedical viewpoint be worthwhile. I think it would. Especially, if there's some public record of such a communication being sent.

 

[Kalliope]

The Danish medical journal Sundhedspolitisk Tidsskrift has an editorial about the Functional Disorder code guidelines.

The National Board of Health writes that the new codes should contribute to less stigma, more knowledge and to create a basis for more clear communication and better research.

On the social media, however, the diagnostic codes are not received favourably by some of the activist patients, as in debates on Facebook with several hundred posts among other calling the new guide a mess.

Læger vejledes: Funktionelle lidelser får nye diagnosekoder
google translation: Doctors are guided: Functional disorders are given new diagnostic codes

 

[Invisible Woman]

The National Board of Health writes that the new codes should contribute to less stigma, more knowledge and to create a basis for more clear communication and better research.

On which planet?

 

[rvallee]

The National Board of Health writes that the new codes should contribute to less stigma, more knowledge and to create a basis for more clear communication and better research.

On the social media, however, the diagnostic codes are not received favourably by some of the activist patients, as in debates on Facebook with several hundred posts among other calling the new guide a mess.

I mean. What is there to say about this? Good start to better and more clear communication to say "F those idiot patients, activists the lot of them", literally erasing the value of their input as being meaningless noise. Bad patient, shush, we're communicating with you, so listen, no, stop talking, WE are communicating with you.

Those guidelines were created with zero input or even consideration for the patients, are in fact hostile to patient well-being and explicitly insulting, and they expect that it will build trust and improve communication? Good grief. This is Marie Antoinette levels of delusional, and likely the worst interpretation of it, not the naive but possibly well-intentioned that is more likely true. Brioches but they're actually mud cakes.

There are circumstances where people will accept being lied to and even double down on those lies even after having been revealed to be lies. It requires people to buy into the lies, though, to accept them. When the lies are explicitly rejected at onset, you are literally destroying any possibility of trust of any kind. And from a position of authority in a total power imbalance relationship, you are being nothing but a massive, nay gigantic, douchebag.