The World Health Organization (WHO) released the new International Classification of Disease (ICD-11) which would come into effect in January 2022. This document takes a closer look at revisions made to the document and its possible impact on healthcare payers.

1. Sept 2019
ICD-11: Impact on
Payer Market
White Paper

2. 1. Introduction
The International Classification of Diseases and Related
Health Problems (ICD) is the international standard for
systematic recording, reporting, analysis, interpretation
and comparison of mortality and morbidity data. It
contains categories for diseases, health related
conditions, and external causes of illness or death. The
ICD is used to translate diagnoses of diseases and
other health problems into an alphanumeric code,
which allows storage, retrieval, and analysis of the
data.
The ICD has become the international standard
diagnostic classification for all general epidemiological
and many health management purposes. These
include analysis of general health situations of
population groups, monitoring of incidence and
prevalence of diseases, and other health problems in
relation to other variables, such as the characteristics
and circumstances of the affected individuals.
ICD is also suitable for studies of financial aspects of a
health system, such as billing or resource allocation.
About 70% of the world’s health expenditures use ICD
coding for reimbursement and resource allocation; 110
countries that collectively account for 60% of the
world’s population use ICD cause-of-death data for
health planning and monitoring in a systematic
fashion; and ICD10 alone is cited in more than 20,000
scientific articles. The usefulness of such critical data
can only be supported by a robust and correct
classification.
The 11th revision (ICD11) is the result of a
collaboration between clinicians, statisticians,
epidemiologists, coders, classification and IT experts
from around the world. ICD-11 is a scientifically
rigorous product which accurately reflects
contemporary health and medical practice and
represents a significant upgrade from earlier revisions.
All World Health Organization (WHO) Member States
are expected to use the latest version of the ICD for
reporting death and illness (according to an
international treaty, the ‘WHO Nomenclature
Regulations’, adopted by the World Health Assembly
in 1967). ICD - 10 has been translated into 43
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3. languages, and ICD - 11 has been available in all 6
official languages (English, French, Spanish, Russian,
Chinese, Arabic) since its publication. Most countries
(115 in 2017) use the system to report mortality data –
a primary indicator of health status.
1.1 Background and History
Initial attempts to systematically classify diseases were
made in the 1600s and 1700s, though the resulting
classifications were of little utility (largely as a result of
inconsistencies in nomenclature and poor statistical
data). During the 1800s, the importance of creating a
uniform system was realized, and several medical
statisticians were commissioned to complete this task.
The first international classification edition –
International List of Causes of Death, was adopted
by the International Statistical Institute in 1893. The
first 5 versions of the ICD system were each entirely
contained within a single volume which included an
alphabetic index and a tabular list.
WHO was entrusted with the ICD at its creation in
1948 and published the 6th version, ICD-6, that
incorporated morbidity for the first time and included
a section on psychiatric disorders. This sixth version
was known as the Manual of the International
Statistical Classification of Diseases, Injuries, and
Causes of Death. Revisions have continued
(approximately decade-by-decade basis) under the
WHO, and the seventh and eight revisions were
published in 1957 and 1968. In 1962, the United States
Public Health Service adapted the ICD to index
hospital records and classify surgical procedures
(ICDA) and published this system. The seventh edition
of the ICD, therefore, expanded to include materials
thought to be necessary for categorizing needs for
hospitals.
The Public Health Service later published an eighth
revision of the ICD, the ICDA-8, specifically for the
unique needs of the United States. It focused more on
morbidity and mortality reporting. The ICD has been
revised and published in a series of editions to reflect
advances in health and medical science over time.
The ICD-9 was published in 1977 by the Department of
Knowledge Management and Sharing of the World
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4. Health Organization. ICD-9 was an important transition
to increased granularity with 4-digit-level categories
and a variety of optional 5-digit subdivisions. It was
also pivotal in moving the system out of the WHO
after ICD became a part of the public domain. ICD-9-
Clinical Modification (CM) was the next expansion in
the United States. The intention was to allow
diagnostic coding of inpatient, outpatient, and
physician office (non-facility) use. It was developed by
the National Centre for Health Statistics.
The CM expansion provided an opportunity to capture
enhanced morbidity data and to update more
frequently. This system is updated on October 1 of
each year. ICD-9-CM was by now a 3-volume set with
the first 2 volumes pertaining to diagnostic codes and
the third containing procedural codes.
ICD-10 was endorsed in May 1990 by the Forty-third
World Health Assembly. It is cited in more than 20,000
scientific articles and used by more than 100 countries
around the world. ICD-10-CM is alphanumeric, with a
possible 7 digits of specificity as opposed to the 5
digits of the ICD-9.
▪ ICD-10 is printed in a three-volume set compared
with ICD-9’s two-volume set.
▪ ICD-10 has alphanumeric categories rather than
numeric categories.
▪ Few chapters have been rearranged, some titles
have changed, and conditions have been
regrouped.
▪ ICD-10 has up to twice as many categories as ICD-9.
▪ Minor changes have been made in the coding rules
for mortality.
A version of ICD-11 was released on 18 June 2018 to
allow Member States to prepare for implementation,
including translating ICD into their national languages.
ICD-11 will be submitted to the 144th Executive Board
Meeting in January 2019 and the Seventy-second
World Health Assembly in May 2019 and, following
endorsement, Member States will start reporting using
ICD-11 on 1 January 2022.
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5. 2. Timeline for ICD-11
3. Reasons for revision of ICD
3. Reasons for revision of ICD
▪ Substantial advancements in Medicine and in
Biological Sciences have occurred over the last 30
years - since ICD-10 was adopted -
• ICD-10 is now outdated, both clinically and from
a classification point of view.
• Crucial structural changes were needed for few
chapters.
• Changes could not be handled through the
normal updating mechanism.
• Changes needed well beyond the major update
cycle.
▪ Need to capture more information, especially for
morbidity use cases.
▪ In several areas, the use of individual categories of
the ICD was not completely clear and lacked
definitions, descriptions and additional information
to guide users.
▪ Technical conversion to electronic ontological
infrastructure for
4
Table1: ICD Revision History
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• Suitability for electronic documentation
• Improvement of the user guidance
• Improvement of the reproducibility of relevant
details
• Support for multilingual applications and
translations
• Simplifying the maintenance of the classification
• Connection to other terminology systems
4. Salient features of ICD 11
Updated for the 21st century and reflects critical
advances in science and medicine and covers a broad
range of uses including, clinical recording, the
collection and study of mortality and morbidity
statistics, epidemiological research, case-mix studies,
quality and safety interventions and planning, primary
care and more.
ICD is fully electronic, currently providing access to 17
000 diagnostic categories, with over 100 000 medical
diagnostic index terms. The index-based search
algorithm interprets more than 1.6 million terms. ICD–
11 is easy to install and use online or offline, using free
'container' software.
It offers more than disease diagnoses for statistical
purposes– it also allows for the coding of signs,
findings, causes of injury and harm, rare diseases,
medical devices, medicaments, anatomy, severity
scales, histopathology, work or sports activities, and
much more. It links clinical terminology with statistics.
The ICD11 has been developed to enhance the ease
and accuracy of coding from both classification and IT
perspective, via a range of features which include
implementation and assessment tool, web services for
full search and coding functionality in any software
and offline services which allows use of ICD offline,
mapping tool to view disease classification in ICD10
format, and to convert data for comparison with
ICD11.
ICD-11 will be free to download online for personal
use (and in print form for a fee) and is available in all 6
official languages since its publication (English, French,
Spanish, Russian, Chinese, Arabic).
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Facilitates cross-sectoral comparability where different
systems are used, for example, between family
medicine, primary care and secondary care hospital
activity.
The problems or reasons for meeting health services
cannot be categorized in any code can be classified
under headings such as ‘Diagnosis’, ‘Reason for
admission’, ‘Conditions treated’ and ‘Reason for
consultation’.
5. New additions to ICD 11
▪ Contains more than 55,000 unique entities, more
than 1,20,000 derived from the latest scientific
knowledge and reflecting current practices &
diagnostic concepts and these entities point to
more than 17,000 categories.
▪ ICD–11 has five new chapters -
1. Chapter 03: Diseases of the blood or blood-
forming organs
2. Chapter 04: Disorders of the immune system.
Conditions affecting the immune system and
conditions affecting the blood are now in two
separate chapters.
3. Chapter 07: Sleep-Wake disorders. Sleep wake
disorders have been regrouped in this new
chapter.
4. Chapter 17: Conditions related to sexual health
which includes gender incongruence that was
previously classed as a mental disorder.
5. Chapter 27: Traditional Medicine. A chapter for
traditional medicine has been added.
▪ Coding for Antimicrobial Resistance, which was
missing in ICD10 to enable data documentation and
analysis consistent with the WHO Global
Antimicrobial Resistance Surveillance System
(GLASS).
▪ Gaming disorder has been added to the section on
addictive disorders.
▪ New primary care concepts for application in
settings where simple diagnoses are made.
▪ Clinicians can search for diagnosis using natural or
preferred terminology, which then relates this to
correct technical code. Its integration with existing
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digital record systems combines recording with
coding, reducing the number of steps needed to
obtain complete documentation and increasing user
compliance.
▪ ICD–11 categories have short and long descriptions
labelled ‘additional information’. The short
description is a maximum of 100 words on the
entity that states things that are always true about a
disease or condition and necessary to understand
the scope of the rubric. It appears in the tabular list
of the classification. The long ‘additional
information’ is the full description, without length
restriction. Special tabulation lists continue to exist
in ICD-11, but there are three additional lists - the
Start-up Mortality List (SMoL), the list for verbal
autopsy, and the list for infectious diseases by
agent.
▪ ICD11 can capture levels of detail to satisfy the
varying needs of clinical practice and research:
documentation may be produced to the broadest or
most detailed level of specificity for epidemiological,
case mix or other management purposes.
▪ This is facilitated by combining codes of the core
classification ‘stem codes’ and adding optional
codes in the form of ‘extension codes’, as for
anatomy, histopathology, medicaments, severity, or
injury research.
▪ In ICD 11 for morbidity, the definition of main
condition has changed to be the condition that is
determined to be the reason for admission,
established at the end of the stay. This definition is
less prone to interpretation.
▪ ICD11 has incorporated all rare diseases although
only a few of these have an individual code, but all
have their own Uniform Resource Identifier (URI),
allowing rare disease Registries and researchers
access to detailed epidemiological data on
conditions of interest.
▪ A new Supplementary Chapter for Traditional
Medicine provides standardized descriptions for
data capture and allows for country-level
monitoring through dual documentation alongside
mainstream practice, as well as international
comparison.
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▪ Linkages with other classifications and
terminologies. ICD11 incorporates or links with the
following classifications and terminologies through
the ICD11 Foundation -
• International Classification of Disease for
Oncology – ICD-O
• International Classification of External Causes of
Injury – ICECI
• International Classification of Functioning,
Disability and Health – ICF
• International Classification of Primary Care – ICPC
• Other terminologies such as OrphaNet and
SNOMED-CT
▪ The in-built interoperability components of ICD11
enhance data retrievability and integration of other
functions, such as pharmacy and laboratory data. Its
integration with existing digital record systems
combines recording with coding, reducing the
number of steps needed to obtain complete
documentation and increasing user compliance.
6. ICD 11 coding structure
The codes of ICD–11 are alphanumeric and cover the
range from 1A00.00 to ZZ9Z.ZZ. Codes starting with ‘X’
indicate an extension code. The inclusion of a forced
number at the 3rd character position prevents spelling
undesirable words. The letters ‘O’ and ‘I’ are omitted to
prevent confusion with the numbers ‘0’ and ‘1’.
Technically, the coding scheme would be described as
below:
ED1E.EE
▪ E corresponds to a ‘base 34 number’ (0-9 and A-Z;
excluding O, I)
▪ D corresponds to ‘base 24 number’ (A-Z; excluding
O, I)
▪ 1 corresponds to the ‘base 10 integers’ (0-9)
▪ The first E starts with ‘1’ and is allocated for the
chapter. (i.e. 1 is for the first chapter, 2: chapter 2, …
A chapter 10, etc.)
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The terminal letter Y is reserved for the residual
category ‘other specified’ and the terminal letter ‘Z’ is
reserved for the residual category ‘unspecified’.
For the chapters that have more than 240 blocks, ‘F’
(‘other specified’) and ‘G’ (‘unspecified’) are also used
to indicate residual categories (due to problems with
the coding space).
6.1 Inclusions
Typical optional diagnostic terms included within
coded categories are known as Included terms. In
addition to the title, they are given as examples of the
diagnostic statements to be classified to that category.
They refer to different conditions or be synonyms and
are not a sub-classification of the category.
Many of the items listed relate to important or
common terms belonging to the category. Others are
borderline conditions or sites listed to distinguish the
boundary between one subcategory and another.
6.2 Exclusions
Lists of conditions preceded by the word ‘Exclusions’ in
certain categories. These are terms which are classified
elsewhere. Exclusions serve as a cross reference in ICD
and help to delimitate the boundaries of a category.
for e.g. 5A60 Hyperfunction of pituitary gland which
excludes Cushing syndrome.
Fig.2: Inclusion terms of Diabetes Mellitus
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6.3 Chapters
Chapters are indicated by the first character. For
example, 1A00 is a code in chapter 1, and BA00 is a
code in chapter 11.
6.4 Blocks
Blocks are not coded within this code structure – each
has its own. However, hierarchical relations are
retained in the 4-digit codes. There is unused coding
space allocated in all blocks to allow for later updates
and to keep the codes stable.
6.5 Extension Codes
ICD-11 allows for adding specific detail to coded
entities using the following mechanisms:
▪ The extension codes comprised of groups of codes
e.g. anatomy, agent, histopathology and other
aspects that may be used to add detail to a stem
code. Extension codes are not to be used alone but
must be added to a stem code. Not all extension
codes can be used with every stem code.
▪ ‘Code also’ instructions provide additional
etiological information which is mandatory to code
in conjunction with certain categories, because that
additional information is relevant for primary
tabulation. The ‘code also’ instruction marks the
categories that must be used in conjunction with
the indicated condition. In some instances, they may
be a reason for treatment, where etiology is
unknown.
▪ ICD-11 has an explicit way of marking codes that
are post-coordinated (combining) to describe one
Fig.3: Exclusions of Hyperfunction
of Pituitary Gland
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condition, called cluster coding. This feature in ICD-11
that creates an ability to link core diagnostic concepts
(i.e. stem code concepts) when desired, and/or to add
clinical concepts captured in extension codes to
primary stem code concepts.
For e.g. In post-coordination, the condition urinary
tract infection due to Extended spectrum beta-
lactamase producing Escherichia coli’ is expressed
through a combination of two linked or clustered stem
codes.
Condition: GC08.0 Urinary tract infection, site not
specified, due to Escherichia coli has manifestation
(use additional code, if desired): MG50.27 Extended-
spectrum beta-lactamase producing Escherichia coli.
Cluster code: GC08.0/MG50.27”
In ICD 11 entities can be correctly classified in two
different places in ICD, for e.g. Lung cancer can be
classified by site or by etiology → it can be classified as
a condition of the respiratory system and as a cancer
under malignant neoplasms. The Foundation
Component will incorporate the "includes" notes for
these situations mentioning both possible parents
(multiple parents) → although, for the tabulation of
statistical out from a tabular list, there can only be one
parent for primary tabulation.
In the foundation view, both parents will be displayed
the same way and in a tabular list the primary parent
place will show the entity and its parents in black, and
possibly the secondary parent place in grey.
Figure 4: Multiple parenting example - an 'Invasive
ductal carcinoma of breast' is a malignant neoplasm as
well as a disease of the genitourinary system.
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7. Chapter structure of the ICD-11
MMS
Core linearization is divided into 28 chapters, of which
25 refer to health conditions similar to past ICD
versions, one serves to identify external causes of
morbidity and mortality, and another includes
concepts of traditional medicine.
There are two additional sections for optional
additional use, one for extension codes to add more
details for different dimensions of a disease, such as
anatomy, mark a condition to be present on
admission, or a disease having been relevant in the
family history. The other section allows functioning
assessment to provide a set of codes for assessment
and scoring in the ICD using ICF functioning domains
of high explanatory power.
ICD–11 has five new chapters. As a result, the
numbering of the chapters has changed. ICD 11
contains the following chapters:
▪ Chapter 01 – Infectious diseases
▪ Chapter 02 – Neoplasms
▪ Chapter 03 – Diseases of the blood and blood
forming organs
▪ Chapter 04 – Disorders of the immune system
▪ Chapter 05 – Conditions related to sexual health
▪ Chapter 06 – Endocrine, nutritional and metabolic
diseases
▪ Chapter 07 – Mental and behavioral disorders
▪ Chapter 08 – Sleep - Wake disorders
▪ Chapter 09 – Diseases of the nervous system
▪ Chapter 10 – Diseases of the eye and adnexa
▪ Chapter 11 - Diseases of the ear and mastoid
process
▪ Chapter 12 – Diseases of the circulatory system
▪ Chapter 13 – Diseases of the respiratory system
▪ Chapter 14 – Diseases of the digestive system
▪ Chapter 15 – Diseases of the skin
▪ Chapter 16 – Diseases of the musculoskeletal
system and connective tissue
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▪ Chapter 17 – Diseases of the genitourinary system
▪ Chapter 18 – Pregnancy, childbirth and the
puerperium
▪ Chapter 19 – Certain conditions originating in the
perinatal period
▪ Chapter 20 – Developmental anomalies
▪ Chapter 21 – Symptoms, signs, clinical forms, and
abnormal clinical and laboratory findings, not
elsewhere classified
▪ Chapter 22 – Injury, poisoning and certain other
consequences of external causes
▪ Chapter 23 – External causes of morbidity and
mortality
▪ Chapter 24 – Factors influencing health status and
contact with health services
▪ Chapter 25 – Codes for special purposes
▪ Chapter 26 – Traditional Medicine
▪ Chapter 27 –Extension Codes
8. The ICD 11 package and
components
ICD 11 is in maintenance phase and full version will be
available in both electronic and in print formats by the
year 2022. In the print format, the information will be
divided into three volumes; the tabular list, the
reference guide, and the index and all three are
needed to use ICD-11 correctly. Digital format
comprises of various tools and software for using the
classification to generate accurate descriptions of
health event information. It is designed to integrate
with local health information systems rather than to
introduce an additional layer of administration.
It may be used either online or offline. For example,
where internet stability is less reliable. It is Digital
health or e-Health compatible and is interoperable
with Health Information Systems. By integrating with
local IT infrastructure, the classification also becomes a
data collection system, that is, rather than having
multiple steps of transcription from paper, using the
Browser to generate a correct code also enables that
code to be directly recorded.
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8.1 ICD 11 Browser
The web-based browser tool allows the user to retrieve
concepts by searching terms, anatomy or any other
element of the ICD11th Revision. The ICD11 Browser
application includes context sensitive help, which may
be accessed by clicking on the icon located in several
different locations within the application. The browser
also allows users to contribute to updates and
continuous improvement of ICD, via a proposal
platform. Input is reviewed for consideration for
inclusion on an annual basis.
8.2 Coding tool
Coding Tool works by searching ICD content as the
user types in a term, for example “neoplasm”. It
generates (and dynamically updates) three different
outputs: a word list; matched entities with a link to the
Browser; and, the chapters associated with the target
term.
Fig.5: ICD 11 Browser
Fig.6: ICD 11 browser with an example
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8.3 Foundation Component - Index,
Guidance
The Foundation Component is the underpinning
repository or database of all ICD entities. These entities
comprise diseases, disorders, injuries, external causes
of injury and signs and symptoms, and the
relationships among them. The Foundation represents
the entirety of the ICD universe, and it is from this
which the Tabular List and Alphabetic Index are
derived. The ICD11 Foundation content is structured in
a standardized manner to facilitate point-of-care data
capture. It does this by housing content and
terminology for diseases and related health conditions,
and the structures necessary for incorporation into
digital health information systems.
8.4 Linearization for Mortality and
Morbidity Statistics (MMS)
It is from the Foundation that the subsets which create
the reference tabulation lists for mortality and
morbidity statistics (MMS) are drawn, as are all
specialty purpose versions of the ICD (e.g., for use with
Fig.7: ICD 11 Coding tool help the users of ICD search
and find categories within the classification
Fig.8: ICD 11. The coding tools. A word list and a configurable
chapter filter allow a quick and correct finding of the desired
key number. The search for the word "arterial" automatically
produces a list of associated words, a hit list, and the number
of hits at the chapter level. The search for "arterial
hypertension" shows how, if the search term matches
correctly, the entry in the result column is highlighted
separately in light blue.
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Mental and Behavioral Disorders, and Infectious
Diseases). Linearization are analogous to the classical
print versions of the ICD Tabular List (e.g. Volume I of
ICD10 or other previous editions) and may be built to
different levels of granularity, use case or other
purposes such as for Primary Care, Clinical Care or
Research. Because linearization is always drawn from
the digital foundation component, consistent use of
the ICD is ensured.
8.5 Translation Tool
It allows for specific language users centers to build
their translations that are faithful to the original. The
tool also notifies other registered translators of
changes and provides the same set of outputs in
multiple languages. The provisions for the use of the
tool require registration of users with WHO HQ, so
work is transparent and verified. At the time of writing,
the most developed translation of ICD11 is into
Spanish, followed by Chinese, with several others
having commenced translation work.
8.6 Application Programming Interface (API
services)
API allows programmatic access to the International
Classification of Diseases (ICD). Users must first
register via the site and may then use it to access up-
to-date documentation on using the API as well as
managing the keys needed for using the API.
8.7 Reconciliations
A mapping platform is in a restricted area of the ICD-
11 Online browser. This platform supports the manual
creation of transition tables between ICD-10 and ICD-
11. The links are made between the corresponding
entries of ICD-10 and ICD-11. n ICD-11, the logical
hierarchical structure does not end with the level of
coding, but extends up to 12 levels of branching, such
as roots, from the chapter level to the depth.
From the manually created detailed connections, the
mapping platform then calculates the transfer at the
level of the key numbers separately for both directions
of the transfer. Also, a version for re-encryption is
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output, as well as a table with the detailed
correspondences. The completed transitions can be
downloaded in the online browser.
8.8 ICD-11 Maintenance Platform
The ICD maintenance process allows the updating of
the ICD following the evolution in the understanding
of diseases, treatments, and prevention. It also ensures
improvements and clarifications coming from daily use
of ICD, and requests by Member States of WHO.
Workflows ensure that proposed changes are
considered both from a medical and scientific
perspective and from their value and place in a
particular use case. As a result, the Foundation
Component and the related tabular list(s) will be
released in updated versions.
9. Impact on Payers, potential
challenges and solutions
9.1 Impact on Payers
9.1.1 Benefits for Payers
▪ Accurate payment for procedures as the new codes
will be more specific for the diseases which will help
create better mapping between procedures, services
and payments.
▪ Improved coding accuracy as ICD-11 code sets are
specific and detailed which will reduce
misinterpretation and in turn will help improve
coding.
▪ Accurate claims submissions as ICD-11 will improve
precision in documentation of clinical care which in
turn will improve the likelihood of submitting
accurate claims at the first time.
▪ Fewer rejected claims as More accurate codes will
mean less claim rejection rate and faster claim
settlement.
9.1.2 Impact on Health Plan Eligibility and
Underwriting processes
▪ Due to inclusion of new diagnosis and procedure
codes in ICD 11, there might be new proposals for
including these diseases and services to be covered
under existing policies.
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▪ Eligibility verification criteria of payee changes due
to new inclusions in the health plan as per the new
revision of ICD.
▪ Staff handling the health plans requires training for
changes in the eligibility and verification process in
the existing or new health plans as per the
inclusions from ICD 11.
▪ Pre-authorization requirement for certain existing
and new services needs to be updated in the health
plan as per the inclusions from ICD 11.
9.1.3 Impact on Provider network management
▪ List of categories of providers within in the Network
and out of network might increase due to addition
of new diseases and services. for e.g. Gaming
rehabilitation or deaddiction centers.
▪ Increase in cost and effort for training: ICD 11 claims
of reducing cost and efforts in training of clinicians
and coders as Clinicians can search for diagnosis
using natural or preferred terminology, which then
relates this to the correct technical code (without
requiring the clinician to memorize codes) but in
transition phase it requires additional cost and
effort.
▪ Manual review is required for conversions or
mapping because of the significant differences in
language and structure between ICD-10 and ICD-11
in the initial phase of transition.
▪ Preauthorization workflow is affected in the
transition phase due to addition of diagnoses and
services form ICD 11. There might be more chances
of denial of preauthorization request due to
multiple coding systems.
▪ Payments to the providers are severely affected in
the initial phases as the Risk Adjustment Models like
Hierarchical Condition Categories (HCC), Health &
Human Service’s Hierarchical Condition Categories
(HHS-HCC), Chronic Illness and Disability Payment
System (CDPS+Rx) are used for payment to
providers for Medicare and Medicaid services are
solely based on ICD categories.
9.1.4 Impact on Claims Processing
▪ Claims submission process is affected due to
changes in coding structure for diagnoses and
services in the transition phase.
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▪ Increase in revenue loss due to potential for double
billing if two systems (ICD-10 and ICD-11) remain in
use during transition period.
▪ Late processing of claims and payments to
providers in transition phase due to multiple coding
systems, affecting the cash flow between payers and
providers or customers.
▪ Increase in denial of claims due to various factors
such as too lenient/stringent pre-processing edits or
incorrect benefit configuration during initial phase
of transition from ICD 10 to ICD 11.
▪ Increase in disputes or appeals might increase in the
transition phase due to increased denials due to
double coding system, changed coding structure,
etc.
▪ Hierarchical Condition Category (“HCC”) grouping
logic used in the Medicare risk adjustment program
where payments by CMS to health plans and
providers for Medicare Advantage members is
adjusted based on risk is affected as the ICD codes
are the primary component of the risk score.
▪ Revenue workflow is affected as changes have to be
made in explanation of benefits, explanation of
payment or electronic remittance advice to include
the additions from ICD 11.
▪ New payment policies have to be developed by to
correspond to the new ICD-11 coding rules, which
will vastly increase the possible payment scenarios.
9.1.5 Impact on Healthcare IT systems and
Software
▪ Modification to health information software systems
is required to accommodate the new composition
of codes and the mechanisms within the ICD11.
Necessary changes include the adaptation to the
new code structure of ICD11, use of the coding API
(offline or online; it replaces the index), and features
for clustering in User interface, Workflow, Database,
System Interfaces and reports including clinical,
financial, analytical reporting systems of payer.
▪ Increase in cost for ICD 11 embedding in existing
software, testing, availability, and training to
support ICD 11.
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▪ System logic becomes invalid for eligibility,
underwriting, enrolment, preauthorization and
claims processing for the new diagnoses and
services included in the policy.
▪ Increased granularity and complexity of ICD-11
codes will impose stricter requirements on system
applications in aspects such as performance,
storage, configuration flexibility, usability, fields and
reports.
▪ Enterprise computing and data infrastructure will
need to be assessed to understand how increased
complexity will impact the core infrastructure. For
example, an application that runs in a single batch
window will need to be reviewed for performance
when increased processing using ICD-11 codes is
required.
9.2 Challenges
▪ Conversion of ICD-10 codes to ICD-11 codes is
extremely complicated. ICD-11 vastly increases the
number and complexity of disease and procedure
codes over ICD-10 as single code in ICD 10 might
be translated to multiple codes in ICD 11.
▪ There may be challenges in determining the
National coverage determinations, Local coverage
decisions, Pharmacy coverage policies,
Laboratory/Device/DME, DRG/ case mix cases.
▪ Risk of Providers taking advantage of the new ICD
11 codes for claiming multiple claims for single
diagnosis which results in more payments. For e.g.
D53.8 in ICD 10 is translated into eight codes in ICD
11, in this scenario there is possibility of fraud as
provider might submit multiple claims with different
codes of ICD 11 instead of single code as per ICD 10
which results in multiple payments leading to
revenue loss.
▪ To estimate the possible costs and revenue loss
from the transition from ICD-10 to ICD11 is a
potential challenge for payer due to complexity of
adoption process as it involves changes that are not
limited within the organization’s boundaries, but are
also to be expected from trading partners, vendors,
regulatory agencies and business partners.
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22. 21
▪ A short-term loss of productivity of staff
approximately three to six months is expected
during transition from ICD 10 to ICD 11.
▪ Possible loss of data during crosswalk as the
precision of ICD codes vary between Revisions,
depending on the evolution of scientific
understanding and the resulting classification
changes: data mapped from ICD10 to ICD11 will not
be exactly equivalent to data initially reported in
ICD10. For example, the code for “Malignant
neoplasm of breast" is classified in ICD10 only by
site, whereas in ICD11 it is organized by site and
histopathology. Therefore, caution should be
exercised when interpreting health data collection
after implementation of new Revision.
▪ One ICD-10 code might often translate to several
ICD-11 codes and there may be multiple
translations for a source system code, all of which
are equally plausible.
▪ ICD 10 to ICD 11 mapping is important not only for
claims processing but also for revenue analysis as
the assumptions of estimated revenue are at risk for
inaccuracies if the data upon which they are
predicated is flawed.
▪ Probability of losing customers for payers in initial
phases of transition due to confusion in eligibility
for claiming of certain new diseases. For e.g.
Gaming addiction is newly added to ICD 11 but
there isn’t much scientific evidence that it is a
serious addictive disorder to be included in the list.
So, some payers might not tend to pay for this
diagnosis might affect the customer base of the
payers.
Table no.2: Example of single ICD 10 code mapping to
multiple codes in ICD 11
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23. 22
9.3 Way Forward
▪ Detailed process plans must be made to include
specific diseases and services from ICD 11 in the
Health plans, that affect eligibility, underwriting
process, enrolment, pre-authorization,
empanelment & claims processing. Plans should
include the additional cost burden to company on
including new diagnosis and services based on local
and national data.
▪ Eligibility criteria for enrolment into health plan has
to be revised as per the new ICD 11 codes, revised
national and local coverage determination policies.
▪ Adapt changes from ICD 11 in crucial areas such as
quality reporting, preauthorization for services,
patient eligibility verification, and documentation of
patient visits.
▪ Underwriting process based on which the eligibility
of beneficiary and premium rate is decided has to
be revised to include the new ICD coding rules. For
e.g. classification of personality disorders has been
reorganized, and the classification of substance use
disorders has been expanded which are previously
not reimbursed. If the payer chooses to include
these in the benefits provided, then the criteria for
eligibility verification changes and the premium rate
is calculated based on risk of inclusion of new
benefits.
▪ Contracts with Providers must be revised, or new
contracts must be prepared to revise the terms of
new services in ICD 11 eligible for payment.
▪ Setting of new criteria or revision of existing criteria
for pre-authorization as per revised health plan is
required.
▪ Effective and efficient training of clinicians and
coders on revised codes, newly added codes and
services to decrease errors in claim submission in
order to reduce denials or approvals in the
transition period. Because ICD-11 is more granular
and detailed than ICD-10, professional coders and
billing specialists who are experts in ICD 10 will
require training to become proficient with the new
ICD 11 codes.
▪ During transition period effective monitoring and
evaluation is required to prevent financial loss due
ICD 11: IMPACT ON PAYER MARKET

24. 23
to increased inappropriate approvals or decrease in
reputation due to more denial of claims.
▪ Payers along with their IT vendors should be
prepared well in advance with the readiness plan for
software embedding of ICD 11 for accommodating
the new codes and services as well as system
changes to support utilization, case management,
customer and provider service, reporting, optical
scanning processes, and statistical accumulations
for trend reporting, rate calculation, actuarial
functions, etc., must be updated.
▪ Risk Adjustment Models which are used for
payment to providers are required to be updated as
per the new codes of ICD 11 to prevent delay in
payments to the providers.
ICD 11: IMPACT ON PAYER MARKET

25. 24
CONCLUSION (1/2)
ICD-11 is a scientifically rigorous product which
accurately reflects contemporary health and medical
practice and representing a significant upgrade
from earlier revisions. It offers more than disease
diagnoses for statistical purposes – it also allows for
the coding of signs, findings, causes of injury and
harm, rare diseases, medical devices, medicaments,
anatomy, severity scales, histopathology, work or
sports activities, and much more. It links clinical
terminology with statistics.
ICD-11 has an improved ability to code for the
quality and safety of health care and highlights the
role of external factors that directly and indirectly
contribute to people's health, such as insufficient
social welfare support. the revision of ICD is a huge
step forward for health worldwide. The fully
electronic nature of ICD-11 will assist
implementation, reduce errors in diagnosis, and
make it more adaptable for local country contexts.
The common language of health and medicine in
ICD 11 is more fit-for purpose than ICD 10 version.
Introduction to ICD 11 impacts payer’s business
processes such as benefits management, network
providers management, billing, claims management,
software process etc. Including the new diseases
and services from ICD 11 changes the eligibility,
underwriting process for health insurance policy as
there might be potential challenges in determining
the National coverage determinations, local
coverage decisions, Pharmacy coverage policies,
Laboratory/Device/DME, DRG/ case mix cases etc.
Pre-authorization workflow is affected as certain
existing and new services needs to be updated in
the health plan.
Change in coding structure leads to increased
approval or denial of claims affecting the claims
processing system. Duplication of claims, late
processing of claims and payments to providers in
transition phase might occur due to multiple coding
systems and there might be potential loss of data
during crosswalk. Providers might leverage the
more complete inventory of ICD-11 codes to
develop new reimbursement systems which results
in more payments. New payment policies must be
developed according to the new coding rules which
increases the possible payment scenarios.

26. 25
CONCLUSION (2/2)
System logic becomes invalid for eligibility,
underwriting, enrolment, preauthorization and
claims processing for the new diagnoses and
services from ICD 11 which affects User interface,
Workflow, Database, System Interfaces and reports
including clinical, financial, analytical reporting
systems of payer. Increase in cost for embedding
ICD 11 in existing software, testing, availability, and
training to support ICD 11.
Detailed process plans must be made to include
specific diseases and services from ICD 11 in the
Health plans, that affect eligibility, underwriting
process, enrolment, pre-authorization,
empanelment & claims processing. Payers must
develop and implement readiness plans and
timelines for product embedding in existing
software, testing, availability, and training to staff
changes to support utilization, case management,
customer and provider service, reporting, optical
scanning processes, and statistical accumulations
for trend reporting, rate calculation, actuarial
functions, etc. Effective monitoring and evaluation
are required to prevent financial loss due to
increased inappropriate approvals or decrease in
reputation due to more denial of claims.
Payers should have detailed understanding of how
and why ICD-11 affects the eligibility, billing and
claims processes and be prepared with the
readiness plans and work on all the factors
impacting them. The decisions originating from
proper planning and deliberation will impact the
way payers look at clinical and business processes,
as well as their budgeting, staffing, systems and
governance structure.

27. 26
REFERENCES
▪ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3692324/
▪ ICD-11 Implementation or Transition Guide, WHO (2019)
▪ ICD-11 International Classification of Diseases for Mortality
and Morbidity Statistics, eleventh revision. WHO, 2019
▪ Laxmaiah Manchikanti, MD, Frank J.E. Falco, MD, and
Joshua A. Hirsch, MD. 2011. Necessity and Implications of
ICD-10: Facts and Fallacies. Pain Physician 2011; 14: E405-
E425 • ISSN 2150-1149
▪ Linda A. Winters-Miner et. al. 2015. Informatics Accuracy
and Cost-Effectiveness for Healthcare Administration and
Delivery Including Medical Research, 2015, Pages 106-115
▪ Tekla B. Sanders et.al. 2012. The Road to ICD-10-CM/PCS
Implementation: Forecasting the Transition for Providers,
Payers, and Other Healthcare Organizations. Perspectives in
Health Information Management, Winter 2012. Pages 1-15

28. 27
ANNEXURE
ICD 11 Terminology
▪ Foundation component: Underlying data base content
that holds all necessary information to generate print
versions of the tabular list and the alphabetical index, as
well as additional information that is needed to generate
specialty linearization of ICD-11 and country specific
modifications.
▪ Stem code: Stem codes are codes that can be used alone.
They are found in the tabular list of ICD-11 for Mortality
and Morbidity Statistics. Stem codes may be entities or
groupings of high relevance, or clinical conditions that
should always be described as one single category. The
design of stem codes makes sure that in use cases that
require only one code per case, a meaningful minimum of
information is collected.
▪ Extension code: Extension codes are designed to
standardize the way additional information is added to a
stem code when users and settings are interested in
reporting more detail than is included in a stem code.
Extension codes can never be used without a stem code
and can never appear in the first position in a cluster.
▪ Pre-coordination: Stem codes may contain all pertinent
information about a clinical concept in a pre-combined
fashion. This is referred to as ‘pre-coordination’. Example:
BD50.40 Abdominal aortic aneurysm with perforation.
▪ Post-coordination: Post-coordination refers to linking
(through cluster coding) multiple codes (i.e. stem codes
and/or extension codes) together, to fully describe a
documented clinical concept.
▪ Cluster coding: Cluster coding refers to a convention used
(either forward slash (/) or ampersand (&)) to show more
than one code used together (e.g. stem code/stem
code(s)&extension code(s)) to describe a documented
clinical concept. Example: Diagnosis: Duodenal ulcer with
acute hemorrhage, Cluster: DA63.Z/ME24.90; Condition -
DA63 Duodenal ulcer, unspecified; Has manifestation (use
additional code, if desired) - ME24.90 Acute gastrointestinal
bleeding, not elsewhere classified.
▪ Primary and secondary parents: The hierarchy of ICD-11
is defined the same as it was in previous versions of ICD.
The possibility to connect specific diseases and concepts
within the classification to another parent code was
introduced to enable specific extracts of the Tabular list for
medical specialties or for specific use cases. Example: A
code for a malignant neoplasm of the skin is in the chapter
for malignant neoplasms. The primary parent for this code
is a code or a block from this chapter. However, a medical
doctor treating only skin diseases might want to see only
codes from the classification that are relevant for his or her
specific clinical purpose. Therefore, a secondary parent was
defined in the skin chapter which will only show the code in
this chapter if the specific extract of code for his or her use
case is selected.

29. 28
ABOUT THE AUTHORS
Shobhit Saran
Consulting Lead, CitiusTech
shobhit.saran@citiustech.com
Shobhit has 14+ years of experience in the US healthcare industry. He has considerable experience in the provider
and payer area and has worked numerous product and IT services implementations. He has also managed
multiple IT delivery teams for healthcare projects in the payer and provider domain and leads the payer
consulting team for CitiusTech. He is a certified FHIR professional and SAFe Agilist.
Dr. Anil Kumar Mola
Healthcare Business Analyst, CitiusTech
anilkumar.mola@citiustech.com
Anil 4+ years of experience in the healthcare industry. He has clinical experience and has worked on healthcare
payer business. He holds a Masters degree in health administration and Bachelors degree in dental surgery.

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