Updates on status of ICD-11 and changes to other classification and terminology systems

Not sure about "unambiguous"...

All coded at the new sub-code, G93.32:

Myalgic encephalomyelitis/chronic fatigue syndrome
Chronic fatigue syndrome
ME/CFS
Myalgic encephalomyelitis

with Systemic exertion intolerance disease [SEID] (a term that has not been adopted by the CDC) now added and indexed to the G93.32 code.


What is going to happen to the thousands of US patients who are historically assigned code R53.82 Chronic fatigue syndrome NOS, now that this term has been Deleted from the R codes in ICD-10-CM? Are they destined to become collateral damage?

What mitigations and assurances has CDC put in place to ensure that all providers will undertake to re-assess and recode their existing patients with one of the categories now subsumed under this new, specific to ICD-10-CM, G93.32 sub-code?

 

When I said unambiguous, I meant that the clinical entity ME/CFS has a single correct code. Not that related problems would be immediately be fixed. You bring up a good point about older patients though. These people have R53.82 in their charts and it may not be changed for years or ever. This will make it harder to track healthcare costs or morbidity due to ME, because ME patients will be split between the old and new codes. I'm personally going to ask my doctors to update my coding, but most people probably never will.

 

Re: FY2023 ICD-10-CM Browser


I note that CDC has yet to amend the erroneous "Excludes1 chronic fatigue syndrome NOS (R53.82)" under G93.3


From the FY2023 ICD-10-CM Browser:

https://icd10cmtool.cdc.gov/?fy=FY2023





This error is now being reiterated by the commercial coding website: https://icd10data.com/ICD10CM/Codes.


There is no longer any listing for "Chronic fatigue syndrome NOS" under code R53.82 in ICD-10-CM because CDC deleted that term following approval of its proposals submitted at the September 2021 ICD-10-CM Coordination and Maintenance Committee Meeting: https://www.cdc.gov/nchs/icd/Sept2021-TopicPacket.pdf (Pages 169 - 172).

I and Mary Dimmock (and possibly some others) raised this anomaly with CDC shortly after the FY2023 files were first released on the CDC's website.

My understanding was that CDC eventually agreed with me and Mary that it was indeed an error and that they were going to be correcting this error.


However, the PDF for the FY2023 ICD-10-CM Tabular List continues to list:

G93.3 Postviral and related fatigue syndromes
Use additional code, if applicable, for post COVID-19 condition, unspecified (U09.9)

Excludes1: chronic fatigue syndrome NOS (R53.82)

neurasthenia (F48.8)​

G93.31 Postviral fatigue syndrome

G93.32 Myalgic encephalomyelitis/chronic fatigue syndrome

Chronic fatigue syndrome
ME/CFS
Myalgic encephalomyelitis​

G93.39 Other post infection and related fatigue syndromes


as does the CDC's ICD-10-CM Browser platform (as per the screenshot at the top of this post) and now the commercial website: https://www.icd10data.com/ICD10CM/Codes/G00-G99/G89-G99/G93-/G93.3 also reiterates the CDC's error.


I maintain that in order for a term and its associated code to be specified as an Excludes1 or Excludes2, it is an ICD-10 convention that the term needs to be listed elsewhere in the classification, either under a different parent within the same chapter, or under a different chapter.

If the term no longer exists within the classification because it has been Deleted or Retired there is no rationale for it being specified elsewhere in the system as an Excludes1 or an Excludes2; no jump link can be created for the term, either, which toggles between the location of its Exclusion and the term's location within the system.

 

Yes, you are correct that CDC has acknowledged it and I have followed up to request it be corrected. No response yet but I continue to ask. As an aside, I don't know if they have a mechanism to fix between their update cycle in October.

 

The last email I received from Traci Ramirez was dated 15 June 22. In this email, Ms Ramirez had said that she agreed it was an error; that it should be deleted and that she would add it to the September 2022 C&M Meeting addenda.

But, she quoted:

"Excludes1: ̶c̶h̶r̶o̶n̶i̶c̶ ̶f̶a̶t̶i̶g̶u̶e̶,̶ ̶u̶n̶s̶p̶e̶c̶i̶f̶i̶e̶d̶ ̶(̶R̶5̶3̶.̶8̶2̶)̶ ̶

Add neurasthenia (F48.8)"


which is how it had appeared in the proposals of September 2021, ie, not what actually appears in the FY2022 and FY2023 PDFs for the Tabular List. So I still felt she possibly hadn't fully grasped what the issue was. I wrote a couple more emails on 21 June 22 trying to explain again, but heard nothing further. (Unless Ms Ramirez was quoting what she was intending to request by way of correction in the September 2022 Meeting addenda.)

The Topic Packet for the September 2022 C&M Meeting is here:

https://www.cdc.gov/nchs/data/icd/Topic-packet-September-2022.pdf

The "TABULAR MODIFICATIONS PROPOSED ADDENDA All proposed effective October 1, 2024" starts on Page 138.

The "INDEX MODIFICATION PROPOSED ADDENDA All proposed effective October 1, 2024" starts on Page 146.

But I can't see any reference in either the Tabular or Index sections to any proposed amendment of the Excludes1 under G93.3. It didn't appear in the Topic Packet for the September 2022 C&M Meeting as an Agenda Topic for amendment, either.

If was omitted as an oversight and it doesn't now get added until the September 2023 Addenda, the amendment might presumably not become effective until October 1, 2025?

I suppose CDC might be planning to include it in the Addenda for the forthcoming March 2023 meeting - but I'm wondering whether it has been forgotten about.

 

If I were in the US and had an historical diagnosis of R53.82 Chronic fatigue syndrome NOS it would concern me that currently, according to the most recent release of ICD-10-CM, my existing R53.82 diagnosis is specified as Excluded from under the new G93.3 Postviral and related fatigue syndromes parent class.

I'd be interested to hear from those with an historical diagnosis of R53.82 Chronic fatigue syndrome NOS what revisions your clinician has made to your code since the proposals for restructuring of the ICD-10-CM R53.82 and G93.3 codes were approved and implemented.

 

Upcoming Meeting (US):

The next meeting of the NCHS/CDC ICD-10-CM Coordination and Maintenance Committee is scheduled for March 7 – 8, 2023.

The Tentative Agenda has been posted: https://cdc.gov/nchs/data/icd/Tentative-Agenda-March-2023.pdf

Register in advance for webinar: https://cms.zoomgov.com/webinar/register/WN__piUmNYaRjmkcYczb3ePIQ

Meeting ID: 160 600 6403
Passcode: 357110

After registering, you will receive a confirmation email containing information about joining the webinar.


(NB: Below is the Tentative Agenda. The Full Topic Packet with proposal rationale texts is usually posted a day or two before meeting Day One.)

Topics listed for discussion in the Tentative Agenda (which may increase in number when the full Topic Packet is published):

ICD-10-CM topics:

1. Anal Fistula
2. Bicuspid Aortic Valve
3. Childhood Obesity
4. Cholestasis Pruritus
5. Central Centrifugal Cicatricial Alopecia (CCCA)
6. Epileptic Seizures Related to External Causes, Intractable
7. Eating Disorders
8. Fanconi Anemia
9. Flank Anatomical Specificity
10. Frontal fibrosing alopecia (FFA)
11. Gulf War Illness
12. Injection Drug Use
13. Lymphoma in Remission
14. Personal History of Colonic Polyps
15. Post-exertional malaise/post-exertional symptom exacerbation
16. Primary Central Nervous System Lymphoma
17. Sepsis Aftercare
18. Addenda


Until the full Topic Packet is available (expected to be posted around March 5-6) I have no information on what changes to existing codes have been proposed for any of the topics listed for discussion above; what new codes have been requested or who has submitted these topics for discussion at the March virtual meeting.

 

NCHS/CDC now releases two updates to ICD-10-CM annually.

The release for April 1, 2023 was posted in January.

The FY2023 ICD-10-CM codes are to be used from April 1, 2023 through September 30, 2023.

The files can be downloaded from Zip files here:

https://www.cdc.gov/nchs/icd/Comprehensive-Listing-of-ICD-10-CM-Files.htm


As far as I can see, the error in the ICD-10-CM Tabular List (see posts #623, #624 and #625) under Excludes1 has not been corrected for this April 2023 release, which remains as:

G93.3 Postviral and related fatigue syndromes
Use additional code, if applicable, for post COVID-19 condition, unspecified (U09.9)​

Excludes1: chronic fatigue syndrome NOS (R53.82)

neurasthenia (F48.8)​

G93.31 Postviral fatigue syndrome​

G93.32 Myalgic encephalomyelitis/chronic fatigue syndrome

Chronic fatigue syndrome
ME/CFS
Myalgic encephalomyelitis​

G93.39 Other post infection and related fatigue syndromes

​

The next release (the October 2023 release) is expected to be posted in June-July.

 

ICD-11 and Australia:

The Australian Institute of Health and Welfare’s (AIHW) has released a third edition of its ICD-11 Stakeholder Update (January 2023).

The January 2023 update can be downloaded as a PDF here: https://www.aihw.gov.au/getmedia/94...911419/ICD-11-Newsletter-18-Jan-2023.pdf.aspx

"Welcome to the third edition of the Australian Institute of Health and Welfare’s (AIHW) ICD-11 Stakeholder Update.

"Since our last update, the AIHW has held several meetings of the Australian ICD-11 Task Force and members of our Collaborating Centre attended the annual meetings of the WHO-FIC Network’s Committees and Reference Groups either in person in Geneva, Switzerland or virtually. As one of those who attended in person, and it being my first in person WHO-FIC Network meeting, it was very valuable to meet our colleagues from other nations and the WHO in person and to have the richer opportunities to work out issues in corridor and tea break conversations that have been missing in recent years. Among other things, we were selected to host some of the mid-year Network meetings and there’s more details elsewhere in the newsletter on that.

"It was also great to see so many people attend the ICD-11 workshop at the HIMAA National Conference in Adelaide, in October. More information about these activities is contained in the Update. Please let us know if you have any feedback or questions about any of these activities. We hope you enjoy reading this edition of the Stakeholder Update.

Michael Frost Senior Executive, Data Governance Group and Head, WHO Collaborating Centre for the Family of International Classifications Australia..."​

ICD-11 Stakeholder Update no. 3 – January 2023

 

According to page 6 of the Australian Institute of Health and Welfare’s ICD-11 Stakeholder Update no. 3 – January 2023:

"WHO confirmed that the new release of ICD-11 is intended to be published in early 2023."


The current release of the ICD-11 for Mortality and Morbidity Statistics (Version: 02/22) was released last February, so I anticipate the latest release will likely be published at some point this month.


During the past 12 months, there have been no Proposal Mechanism submissions for changes to the ICD-11 8E49 code for Postviral fatigue syndrome and its inclusions: chronic fatigue syndrome; myalgic encephalomyelitis.


ICD-11 and POTS:

A submission for addition of the acronym "POTS", in the required convention for ICD-11 of:

POTS - [postural orthostatic tachycardia syndrome]​

under Synonyms to the existing ICD-11 code: 8D89.2 Postural orthostatic tachycardia syndrome was requested by me in June 2022.

This proposal was approved by the WHO and implemented in the Orange Maintenance Platform a few days later and should be incorporated into this year's release of the Blue ICD-11 for Mortality and Morbidity Statistics platform.

 

The Long Covid group "Patient-Led Research Collaborative", with support from #MEAction, Open Medicine Foundation, Solve ME/CFS Initiative, Massachusetts ME/CFS & FM Association, and Pandora Org has submitted a proposal to the March 7-8 ICD-10-CM Coordination and Maintenance Committee (C&M):


https://patientresearchcovid19.com/storage/2022/10/Post-exertional-malaise-ICD-10-Proposal.pdf

Patient-Led Research Collaborative

To: National Center for Health Statistics
From: Patient-Led Research Collaborative, with support from #MEAction, Open Medicine Foundation, Solve ME/CFS Initiative, Massachusetts ME/CFS & FM Association, and Pandora Org
Subject: ICD code for post-exertional malaise/post-exertional symptom exacerbation Date: June 10, 2022

The majority of Long COVID patients experience an exacerbation of some or all of their symptoms and a further reduction in functioning following physical or cognitive exertion or emotional, positional, sensory, or other stressors. 1-3 This symptom, referred to as post-exertional malaise (PEM) and post-exertional symptom exacerbation (PESE), is characterized by: 4-7

● Exacerbation of some or all of a patient’s symptoms or occurrence of new symptoms. Symptoms exacerbated can include physical fatigue, cognitive fatigue, exercise intolerance, problems thinking (e.g. slowed information processing speed, memory, concentration), unrefreshing sleep, muscle pain, joint pain, headaches, weakness/instability, light-headedness, flu-like symptoms, sore throat, nausea, orthostatic intolerance or other autonomic dysfunctions, sensory sensitivities, and other symptoms.
● Pathological loss of stamina and/or functional capacity that is not due to physical deconditioning 5,8
● An onset that can be immediate or delayed after the exertional stimulus by hours to days
● A prolonged, unpredictable time to return to baseline that is not easily relieved by rest or sleep and may last days, weeks, months, or longer
● Severity and duration of symptoms that is often out-of-proportion to the type, intensity, frequency, and/or duration of the exertion​

Even basic activities of daily living like toileting, bathing, dressing, communicating, and reading can trigger PEM/PESE. In some instances, the specific precipitant cannot be identified. The threshold for a precipitant to trigger PEM/PESE can vary between individuals as well as within the same individual, at different times during their illness.

This symptom has important implications for Long COVID diagnosis, treatment, disability assessment, morbidity tracking, and research using electronic health records. For instance:

● In its guidance on fatigue and recommendations for exercise, the American Academy of Physical Medicine and Rehabilitation discusses the importance of identifying PEM and cautions against exercise programs that provoke PEM. 9 The World Physiotherapy, a coalition of physical therapy associations from around the world, issued similar recommendations in its COVID briefing paper to prevent harm to patients. 10
● PEM/PESE needs to be evaluated and considered in recommendations for accommodations and in disability claims because of its significant impact over days or longer on a patient’s ability to work or attend school. 11,12
● Numerous Long COVID studies, including those in NIH’s RECOVER Initiative and by the CDC, are now using electronic health records to identify important sequelae of an acute SARS CoV-2 infection. 13,14 PEM/PESE is virtually invisible in these studies.
​

Currently, the ICD-10-CM does not have a code for the symptom of PEM/PESE as described for Long COVID and myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS).

As a result, this important symptom is not being identified or tracked in electronic health records or in morbidity tracking systems. A code for PEM/PESE is needed to rectify this issue. This would also facilitate education of physicians, improve communication between a patient and clinician and between the PCP and other healthcare providers, and improve the accuracy of Long COVID research using electronic health records.

It’s important to note that while PEM is included in a diagnosis of ME/CFS, 4 not all patients with Long COVID and PEM/PESE have been given an ME/CFS diagnosis, either because the patient has not yet met the 6 month diagnostic requirement of ME/CFS in adults 4 or because the patient does not meet the other ME/CFS criteria. Thus, a code for the symptom of PEM/PESE separate from a diagnosis of ME/CFS is required.

Further, while much of the existing literature on the symptom references PEM, we ask that PESE be included as an inclusion term, or be considered for the lead term, as PESE has started to be used by the patient and research community alike. 10,15 This is because it more accurately reflects patients’ experience of the symptom - an exacerbation of a host of symptoms as opposed to solely the experience of malaise. We ask that this new code be implemented no later than Spring of 2023. Expedited implementation is required because of the magnitude of the affected patient population and to ensure the accurate tracking of this important sequelae and the accuracy of current and ongoing research using electronic health records like in the RECOVER Initiative.

Please contact Lisa McCorkell (lisa@patientledresearch.com) with any questions or to discuss this or alternative approaches to achieving the objective of tracking the important symptom.

The following changes are recommended to capture the symptom of PEM/PESE:

TABULAR MODIFICATIONS

R68 Other general symptoms and signs

Add R68.4 Post-exertional malaise

Post-exertional symptom exacerbation
PEM
PESE
Post-exertional neuroimmune exhaustion​

Note:
Due to “malaise” being in the name of PEM, NCHS may be considering placing PEM under R53. However, PEM has been incorrectly conflated with fatigue. PEM is an exacerbation of some or all symptoms and a further reduction in functioning and should be categorized in another section to avoid reinforcing this misunderstanding.

References etc.

[Full document attached]

 

SEID should have been a separate diagnosis, see what I wrote in a previous discussion:

I feel the same way about the term ME. When you say "ME", patients think serious physical disease characterized by an adverse reaction to exertion but doctors hear delusional hypochondriac.

We need a new term, preferably one protected by law. The IOM could have gave us it with SEID but they screwed up by conflating it with CFS, the Wikipedia article for SEID was soon vandalized and made to redirect to CFS so we were back to hypochondria.

 

Just to note that once a proposal for ICD-10-CM has been submitted, it may be amended by NCHS/CDC before being placed on the agenda for discussion.

So the proposed code and terminology, as set out in the submitters' PDF, may have undergone revision since the submitters' initial submission and a compromise reached between the CDC and the submitters (Patient-Led Research Collaborative, with support from #MEAction, Open Medicine Foundation, Solve ME/CFS Initiative, Massachusetts ME/CFS & FM Association, and Pandora Org). Or NCHS/CDC may have decided to include an alternative coding structure for consideration alongside the submitters' original proposal.

Once the full Topic Packet has been posted, I will return to the thread with a copy of the proposal, as it appears for discussion at the March meeting.

 

we owe you a huge debt of thanks for continuing to keep up with this Suzy

 

I see there is inclusion of the term Post-exertional neuroimmune exhaustion. The meaning for this term is in the International Consensus Criteria

"Post- Exertional Neuroimmune Exhaustion (PENE pen׳-e)
Normal fatigue is proportional to the intensity and duration of activity, followed by a quick restoration of
energy. PENE is characterized by a pathological low threshold of physical and mental fatigability,
exhaustion, pain, and an abnormal exacerbation of symptoms in response to exertion. It is followed by a
prolonged recovery period.

Fatigue and pain are part of the body’s global protection response and are
indispensable bioalarms that alert patients to modify their activities in order to prevent further damage.
The underlying pathophysiology of PENE involves a profound dysfunction of the regulatory control network
within and between the nervous systems36, 37 This interacts with the immune and endocrine systems
affecting virtually all body systems, cellular metabolism and ion transport.38

The dysfunctional activity/rest control system and loss of homeostasis result in impaired aerobic energy production and an inability to
produce sufficient energy on demand. A test-retest cardiopulmonary exercise study revealed a drop of 22%
in peak VO2 and 27% in VO2 at AT on the second day evaluation.39 Both submaximal and self-paced exercise
resulted in PENE.40 These impairments and the loss of invigorating effects distinguish ME from depression."

"
A. Post-Exertional Neuroimmune Exhaustion (PENE pen׳-e) Compulsory
This cardinal feature is a pathological inability to produce sufficient energy on demand with prominent symptoms
primarily in the neuroimmune regions. Characteristics are:
1. Marked, rapid physical and/or cognitive fatigability in response to exertion, which may be minimal such as
activities of daily living or simple mental tasks, can be debilitating and cause a relapse.
2. Post-exertional symptom exacerbation: e.g. acute flu-like symptoms, pain and worsening of other symptoms
3. Post-exertional exhaustion may occur immediately after activity or be delayed by hours or days.
4. Recovery period is prolonged, usually taking 24 hours or longer. A relapse can last days, weeks or longer.
5. Low threshold of physical and mental fatigability (lack of stamina) results in a substantial reduction in pre-
illness activity level."

See here:

That is a much more specific description than what I have seen for PEM or PESE

 

Just adding my thanks to @Dx Revision Watch for the detailed and relentless pursuit of this.

I know that no other approach would work, even if I can’t follow all the details myself.

I think you are doing a huge service to the whole patient community.

 

I second that. Sincere thanks @Dx Revision Watch.

 

Thank you @JemPD, @Simon M and @Robert 1973 for your kind words.


A few points in relation to this ICD-10-CM proposal submission:

Firstly, I have no involvement in this proposal and was unaware that any request for a new Symptoms, signs chapter code had been submitted for discussion at the forthcoming March C & M meeting until I read the "Tentative Agenda", which does not give the names of the submitters or any other details beyond listing the topic for discussion.

The only copy of this proposal I have been able to find so far, on Google, is the document stored on the website of the Long Covid group "Patient-Led Research Collaborative". That document is here: https://patientresearchcovid19.com/storage/2022/10/Post-exertional-malaise-ICD-10-Proposal.pdf

I am happy to be corrected, but I can find no reference to this proposal on the sites of the ME/CFS groups that are supporting this submission: #MEAction, Open Medicine Foundation, Solve ME/CFS Initiative, Massachusetts ME/CFS & FM Association, and Pandora Org, nor on social media platforms.

If you are interested in who is behind the Patient-Led Research Collaborative for Long Covid their website is here: https://patientresearchcovid19.com. Their Leadership Team is listed here: https://patientresearchcovid19.com/covid19-patient-led-research-team/.

The proposal document states: "Please contact Lisa McCorkell (lisa@patientledresearch.com) with any questions or to discuss this or alternative approaches to achieving the objective of tracking the important symptom."


If you are interested in the mechanism for submitting requests for addition of new terms and new codes to ICD-10-CM, the process is set out here: https://www.cdc.gov/nchs/icd/icd10_maintenance.htm#Guidance


The Patient-Led Research Collaborative's proposal document was dated "June 10, 2022" and the submitters asked that ". . . this new code be implemented no later than Spring of 2023".

June 10, 2022 was the deadline for submission of requests for consideration for discussion at the September 13-14, 2022 meeting.

This suggests that the June 10, 2022 submission had been drafted with the intention of being considered for discussion last September, and if the proposal had been presented at that meeting and subsequently approved by the NCHS Director, that the addition be scheduled for fast track implementation for the April 2023 FY Release.

Evidently it was not accepted for discussion at the September 2022 meeting.

As mentioned in my earlier post, please bear in mind that when submitters put in a request for consideration of addition of a new term or a new code, NCHS/CDC may negotiate revisions to the proposed coding structure or proposed new terminology.

Sometimes NCHS/CDC may draft an alternative coding structure which will be presented instead of the original proposal or alongside the original proposal; so, for example, there may be a "Proposal A" and an alternative "Proposal B" presented for consideration (as happened with the proposals for changing the R53.82 and G93.3 coding structures).

Negotiations between submitters and NCHS/CDC (often with Ms Donna Pickett) are sometimes run down to the wire and remain in progress a day or two before meeting Day One. There has been at least one case where the addition of CFS to a Topic Packet agenda took place at the eleventh hour after the Topic Packet had already been finalised and posted on the CDC site and a revised PDF, which included the R53.82 and G93.3 proposals, was posted after the meeting had taken place.


So until the Topic Packet is available, please don't rely on the content of the proposal as it stood in June 2022 because it could feasibly have been revised since then to make it more acceptable to NCHS/CDC; or because NCHS/CDC has accepted the proposal for discussion in March, in principle, but has expressed preferences for an alternative coding structure or terminology, or has suggested a different parent class to the one under which the new term has been proposed to be located (which is R68.4).


Much of this uncertainty could have been avoided if the five ME/CFS groups supporting this proposal had been transparent about their support and involvement in this initiative from the outset.

It would also be interesting to learn whether this initiative came from the Long Covid group or had been instigated by one or more of the five ME/CFS groups and their external advisors, who then reached out to the Long Covid group.


As many of you know, I am in the UK where we use the WHO's international version of ICD-10 and NHS England will be migrating to ICD-11 at some point after 2026.

I more or less retired several years ago. I don't consider myself a stakeholder in the ICD-10-CM and I don't intend to express an opinion on whether I think addition of the terms:

Post-exertional malaise Post-exertional symptom exacerbation;
PEM;
PESE;
Post-exertional neuroimmune exhaustion

to the ICD-10-CM Symptoms, signs chapter could be a positive development for ME/CFS patients or could potentially result in unintended consequences.

But I am appalled at the apparent lack of transparency shown by the five groups supporting this proposal. The original submission appears to have been submitted 8 months ago and was presumably being put together in the weeks prior to that.

How come US patients and advocates only learned about this a few days ago? Why was it not put out for public consultation last year, ahead of submission?

Parts of Spain use an adaptation of ICD-10-CM - Spanish patient groups consider themselves to be stakeholders. My understanding is that Belgium and Luxembourg also use or are in the process of developing adaptations of ICD-10-CM; they are stakeholders, too.

So my question to #MEAction, Open Medicine Foundation, Solve ME/CFS Initiative, Massachusetts ME/CFS & FM Association and Pandora Org is - why have you all seemingly kept schtum about this proposal?

#MEAction styles itself as a grass roots organisation - why is it supporting potential changes to ICD-10-CM without first publicly consulting with patients and their carers, advocates, clinical and research allies and with a wider range of patient groups?

The changes to the structure of the R53.82 and G93.3 codes are still very new.

It's not yet known how well the new structure is being applied by clinicians/coders or what is happening to those patients who were historically assigned the R53.82 Chronic fatigue syndrome, NOS term (which now no longer exists in the classification).

The Tabular List Exludes1 error remains uncorrected.

SNOMED CT US Edition hasn't yet been updated to map the CFS and Synonyms 52702003 Concept Code to the new G93.32 code and under "Resets", still gives the option of selecting a map to either R53.82 or G93.3; yet here you are proposing yet more changes to ICD-10-CM without first informing and consulting your constituencies.

[Edited for clarity]

 

What does ICD-10-CM say about the use of codes from the Symptoms, signs chapter?

From the ICD-10-CM Official Guidelines for Coding and Reporting FY 2023 (October 1, 2022 - September 30, 2023):

[Extract p17]

18. Use of Sign/Symptom/Unspecified Codes

Sign/symptom and “unspecified” codes have acceptable, even necessary, uses. While specific diagnosis codes should be reported when they are supported by the available medical record documentation and clinical knowledge of the patient’s health condition, there are instances when signs/symptoms or unspecified codes are the best choices for accurately reflecting the healthcare encounter. Each healthcare encounter should be coded to the level of certainty known for that encounter.

As stated in the introductory section of these official coding guidelines, a joint effort between the healthcare provider and the coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures. The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation accurate coding cannot be achieved. The entire record should be reviewed to determine the specific reason for the encounter and the conditions treated.

If a definitive diagnosis has not been established by the end of the encounter, it is appropriate to report codes for sign(s) and/or symptom(s) in lieu of a definitive diagnosis. When sufficient clinical information isn’t known or available about a particular health condition to assign a more specific code, it is acceptable to report the appropriate “unspecified” code (e.g., a diagnosis of pneumonia has been determined, but not the specific type). Unspecified codes should be reported when they are the codes that most accurately reflect what is known about the patient’s condition at the time of that particular encounter. It would be inappropriate to select a specific code that is not supported by the medical record documentation or conduct medically unnecessary diagnostic testing in order to determine a more specific code.

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

From the April 2023 Tabular List:

ICD-10-CM Tabular List:

[Extract Preface to 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 medical care 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 signs and symptoms of breast (N63, N64.5)

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

 

Latest update of ICD-11 MMS:

The new release for ICD-11 for Mortality and Morbidity Statistics (ICD-11 MMS) was published yesterday.

Version : 01/2023 can be found here: https://icd.who.int/browse11/l-m/en

The Coding Tool which serves as ICD-11's equivalent to the index can be found here: https://icd.who.int/ct11/icd11_mms/en/release

Previous releases of ICD-11 MMS (back to the initial 2018 release) are archived at: https://icd.who.int/browse/releases/mms