Case #434

Candida infections as complicating dx

Added by Martti Virtanen almost 5 years ago. Updated over 1 year ago.

Status:AcceptedStart date:2015-10-07
Priority:MinorSpent time:-
Target version:Expert Group 2016
Initiator:Nordic Casemix Centre Target year:2017
Case type: Owner / responsible:
MDC:MDC18 Old forum status:



Initiated: 2015-10-07
Initiator: Martti Virtanen, Nordic Casemix Centre
In ICD-10 candidal infection belong to group B37. Some of the problems are complicating secondary dx (with compl cat 18C04 'Candidiosis') and some (in the Swedish system) major complications (with compl cat 18G04). Local superficial infections are regarded as non complicating conditions and do not belong to any complication category. For 18C/G04 complication categories all B37 codes are excluded i.e. candida infections can not be complicated by other candida infections.
The noncomplicating dx are:
B3700 'Acute pseudomembraneous candidal stomatitis'
B3720 'Candidiasis of skin and nail'
B372A 'Candidal onychia'
B372B 'Candidal paronychia'
B372C 'Candidial intertrigo'
B372D 'Interdigital candidiasis'
B3720 'Candidiasis of vulva and vagina' - that can be combined with N77.1* 'Vaginitis, vulvitis and vulvovaginitis in infectious and parasitic diseases classified elsewhere'
B3790 'Candidiasis, unspecified'
The only Dx with 18C04 is:
K2380*B3780 'Candida esophagitis' (Swedish code B378D)
The codes with 18G04 are:
B3710 'Pulmonary candidiasis'
B3740 'Candidiasis of other urogenital sites'
B3750 'Candidal meningitis' - that can be combined with G02.1*
B3760 'Candidal endocarditis' - that can be combined with I39.8*
B3770 'Candidal septicaemia'
B3780 'Candidiasis of other sites'
B378A 'Candidial cheilitis'
B378B 'Candidial enteritis'
B378C 'Disseminated candidiasis'

The B3740 'Candidiasis of other urogenital sites' includes all ohther urogenital sites than vulva and vagina, among others all male genital candidiases. WHO notes
N5120*B3780 'Candidal balanitis'
N3700*B3780 'Candidal urethritis'

In addition B3740 should include
N2910*B3780 'Renal candidiasis'
that is an important clinical problem without specific code.

The question became obvious whne we started to wonder why K2380*B3780 does not belong to 18G04 but instead to 18C04. This is because the combination is specifically defined to have 18C04.
It seems obvious that Candidal cheilitis and balanitis are not (major) complications of anything but by correct coding they now belong to compl cat 18G04.
Urethritis and esophagitis are somewhat more severe and 18C04 level might be correct. These condition are anyway less severe the septic infections. Now esophagitis belongs to 18C04 and urethritis to 18G04.
It is very tempting to code B378C 'Disseminated candidiasis' instaed of B3790 'Unspecified candidiasis' or combination of sites that are not counted as severe.

The special property of K2380*B3780 could be removed and then 'Candida esophagitis' would belong to 18G04. The cheilitis B378A could be left without compl. cat.
The disseminated candida could be without compl. cat or with 18C04.

However, as noted for example in eMedicine "Disseminated candidiasis with end organ involvement requires an individualized approach. Thus, the manifestation of invasive candidiasis involving localized structures, such as in Candida osteomyelitis, arthritis, endocarditis, pericarditis, and meningitis, requires prolonged antifungal therapy for at least 4-6 weeks. The optimum dosage and duration of therapy for various types of deep candidal infection have not been definitively determined."

This is a fairly simple situation where some of the compl. categories are obviously not quite correct. To solve the question demanded one whole working day already now. The work that would be needed to check to whole ICD-10 is large.

Technical changes #434.xlsx (15.8 KB) Martti Virtanen, 2016-04-12 17:42

Candida infections as complicating, cost data file SWE to Forum.xlsm (533 KB) Ralph Dahlgren, 2018-03-06 16:27

Candida infections as complication 20180404 to Forum.xlsm (21.9 KB) Ralph Dahlgren, 2018-04-04 12:18

Suggestion for TC #434 C616 after the Expertmeeting 201803.xlsx (15.6 KB) Ralph Dahlgren, 2018-04-04 12:18

Technical changes case #434-2.xlsx (22.8 KB) Martti Virtanen, 2018-04-16 13:52


#1 Updated by Anonymous over 4 years ago

  • Target version set to Expert Group 2016

#2 Updated by Martti Virtanen about 4 years ago

2016-03-15 Expert group(MV)
The is no mention on the expert group notes on this case.
However, two simple corrections should be done.
Removing the specified complication category from the code pair K3280*B3780 inhibits that adding the etiological code would make the case less complicated
The Candida cheilitis B378A is obviously not a sever condition that should result in a CC DRG in any situation.

#3 Updated by Mats Fernström about 4 years ago

Mats Fernström, NPK, Sweden 2016-04-12
According to our memoranda from the Expert meeting, the case was postponed and there was no decision to change anything. Sweden has a case on this going on (ID C616) and in that work we will probably agree with Marttis comment. But we cannot change anything now. Everything has to wait, as we agreed on according to the issue #460. The case must be discussed at the next Expert spring meeting (2017) before we do any changes.

#4 Updated by Martti Virtanen about 4 years ago

  • Status changed from Active to Further active

2016-05-03 Martti Virtanen
Thus the case is postponed for analysis at least by Sweden.

#5 Updated by Martti Virtanen about 3 years ago

2017-03-13 Expert group
Postponed for another year.
See also case #550.

#6 Updated by Martti Virtanen over 2 years ago

2018-02-20 Martti Virtanen
This case has to be solved at the Expert group meeting in Reykjavik.
Clinically and economically this is a minor thing but the current structure is not logical.
I hope Sweden will be able to comment on it.

#7 Updated by Ralph Dahlgren over 2 years ago

2018-03-06 Ralph Dahlgren
Here I enclose an Excell-File for this case containing the Swedish Cost Data (KPP 2016).
The way the data has been sought out is by looking at each indivdual code. Finding out which DRG that has one of the involved codes. If the DRG has a case that has one of the codes as bi-diagnose the case will be shown in the tables that you can see in the Excell-file. If more than one case per DRG the cases will be put together.
The Excell-file contains alot of sheets but the summary I think will be sufficient if you do not wish to spend alot of time going through the data.
Read through the ”Read me” sheet and the ”Summary” at least. Hopefully the information there will be enough to understand.
Observe that the hits (positiv findings of cases) are not that many sometimes.
The way of counting and working with data has been cleared and approved with a Statistician at the Swedish Department of Health and Welfare Sweden.
At least we don´t need to discuss how the material is worked with.
There are suggestions for different CC-levels in the ”Summary” sheet, look at that in advance to make it easier during the meeting to make a decision what CC-levels the involved codes should have.

#8 Updated by Ralph Dahlgren over 2 years ago

2018-04-04 Ralph Dahlgren
At the Expertmeeting 2018-03-12 Sweden understood that the code B378 must not have any CC-level at all. The rest of the original Swedish suggestions were accepted.
Sweden has gone through the original suggsetion again because at some places it was not clear.
Here comes the final Swedish CC-level suggestions in one file and in Another file we have made suggestions for technical Changes.
Sweden would like to have the technical Changes examined by Martti, corrected wherever necessary.

#9 Updated by Martti Virtanen about 2 years ago

2018-03-12 Expert group
The expert group agreed that the Swedish proposals are OK but the B378W 'Candidiasis of other sites' cannot belong to any complication category, since it can be used together with banal local candida infections that are certainly not complicating at all.
If any specific combination must have CC property, it can be defined serapately to a defined pair of codes like K2380*B3780 'Candida esophagitis' and N2910*B3780 'Renal candidiasis'.
(See above Ralph Dahlgrens comment after the meeting)

#10 Updated by Martti Virtanen about 2 years ago

2018-04-16 Martti Virtanen
I write this separately since it is a separate issue.
In this process we have not discussed the exclusion of the complication categories.

The main point of the CC-exclusion system is to make it impossible to create a CC-case by repeating almost same information in two formats. For example using B378, B378A or B378W as principal dx with some othe B378 code as secondary dx must not result in CC-case. Obviously these codes should not be used as principal dx when a more severe format of candidiasis is present.
Thus B3780 (B378&B378W) and B378A must retain the CC 18C04 exlusion that inhibits this type of misuse. It also means that the addition of exclusion 18C04 to neither K2380*B3780 nor N2910*B3780 is needed.

B375 'Candidal meningitis' is a diffent case. B375 has CC-category 01C34 'Candidal meningitis' with G-level (01G34) and of course B375 is also on the exclusion list of 01C34. It has not been excluded for 18C04 'Candidiosis'. This can be questionable, since this now means that 'Candidal meningitis' may be complicated by f.ex. 'Candidal endocarditis' (B3760 with 18G04) or 'Disseminated candidiasis' (B378C also with 18G04). These are probably very rare combinations but might create a possibility for 'upcoding'.

The way to correct the last problem is to combine 01C34 with 18C04 (B3750 will have 18G04 instead of 01G34). B3750 is the only code with 01C34 and the only exclusion are B3750 and B3770 'Candidal sepsis'. 01C34 becomes obsolete and B3750 will need exclusion for 18C04. The listed pairs do not need any separate exclusions in any case.

I presume that the last change is also acceptable and we can perform it as part of this case, but I suggest all countries should accept it. It can also be postponed to next year. Thus I expect a reaction from all countries to this case.
See technical changes for (hopefully) all details.

#11 Updated by Kristiina Kahur about 2 years ago

Finnish National DRG-Centre 17-4-2018

The changes Martti suggests and asks for comments from national organisations are fine with Finland.

#12 Updated by Ralph Dahlgren about 2 years ago

2018-04-18 Ralph Dahlgren
The last part of this case concerning B375/B3750 and a change of compl from 01G34 to 18G04 is a good idea. Sweden support this idea but want it to be discussed and decided for the definitiontables for 2020. This is not only to avoid any type of late Changes in this years process but foremost this will give all the participants a possibility to once more get information/knowledge about compl. excl table.

#13 Updated by Martti Virtanen over 1 year ago

  • Status changed from Further active to Accepted

2019-03-11 Expert group
Even the additions were accepted for all countries (see Technical changes case #434-2.xlsx

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