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Although the future of ICD-10 in the United States is currently unclear, that certainly is not the case for many other countries around the globe.  Not only is ICD-10 being used in more than 100 countries, but many have been using it for more than a decade.

Even though many of these countries have very different healthcare systems from the United States, much can be learned from their respective transitions to ICD-10. An overview of Australia’s and Canada’s experiences may shed some light on what to expect here in the United States.


Australia began using ICD-10 for capturing mortality data in 1994 – around the same time health officials in that country realized that the use of ICD-10 for collecting morbidity data was on the horizon.

The Australian National Centre for Classification in Health (NCCH) played the lead role in the transition to ICD-10 by planning nearly every aspect of it. One of the organization’s first and most demanding tasks was to determine if ICD-10 was a necessity for the future.

The NCCH performed an analysis on the sustainability of ICD-9 and examined whether ICD-10 was the best option if ICD-9 was found to be inadequate. Not surprisingly, the study resulted in a recommendation for the transition to ICD-10 as soon as possible.

Next, a feasibility study was carried out to ensure that ICD-10 codes could be used with the Australian diagnosis-related groups. Forward and backward mappings between ICD-9 and ICD-10 were created to determine where modifications needed to be made. Further changes to the tabular and alphabetic index resulted in the creation of ICD-10-AM (Australian Modification).

A procedure classification then was developed from the Australian fee schedule, the Medicare benefits schedule and traditional classification principles. This classification was considered part of ICD-10-AM and was named the Australian Classification of Health Interventions (ACHI).

Development of further coding standards was the NCCH’s next task. The organization collaborated with clinical coders and clinicians who were familiar with the problems surrounding how the new codes would be used.

The NCCH also appointed a national coordinator of ICD-10 implementation. This person met regularly with state and territory coordinators to ensure that implementation was going as smoothly as possible.

Educational and marketing materials were created by the ICD-10-AM Education Working Party, which was appointed by the NCCH in 1995. The organization also developed an ICD-10-AM implementation kit that gave users background about the decision to move to ICD-10-AM, information on the implementation process and an overview of the training and education program.

The ICD-10-AM Education Working Party also created booklets called Taste of Ten, with the texts focusing on topics of major change or common usage. When ICD-10-AM was implemented, an exercise book called Mastering Ten, which encouraged self-teaching, was published.

In addition, 81 courses were taught for 2,423 participants in all states of Australia and New Zealand. These courses involved face-to-face workshops with coders and “train the trainer” sessions.

Although the ICD-10-AM Education Working Party was developed nearly three years prior to implementation, it still was felt that insufficient time to provide adequate education was offered to providers.

Finally, in July 1998, ICD-10-AM was introduced in approximately half of Australia. By July 1999, the other half of Australia and New Zealand began using ICD-10-AM.

Surveys were distributed to coders soon after implementation to obtain feedback. The results of the survey were used to help clarify issues through further workshops.

An impact assessment was performed by the NCCH. It was found that the approximate costs to cover employment of additional coders, training, backlog and materials amounted to approximately $10.5 million.

Two years after implementation, reports showed that it took approximately 12 weeks for coders to adjust to the new classification. It took four to six months for a coder’s confidence level to return to normal.


Much also can be learned from our neighbor to the north, Canada, when it comes to ICD-10 implementation. That nation implemented the new coding set in a phased approach throughout its provinces and one territory from 2001 to 2006.

Canada, like several other countries, made modifications to ICD-10 in order to achieve greater specificity, titling its specific version ICD-10-CA. It also had to create a new companion interventional classification, which was titled The Canadian Classification of Health Interventions (CCI).

Development, testing and piloting of these new classifications lasted approximately 12 months. Once the content was approved, French and English versions needed to be created.

Canada faced many challenges when attempting to implement the new classification system. One of the most pressing issues was that it had decided to move its classifications to an electronic format (prior to ICD-10-CA, coding books came in hard copies only).

This required that coders receive training not only in how to use the new software, but how to use the hardware. Many of them never even had used a mouse. Unfortunately, those who were familiar with computers had to attempt to transition from DOS to Windows. Also, the majority of coding professionals were between the ages of 40 and 50 and had been coding for 20 or more years. This meant that many of them were coding from memory.



Some coders had to be re-taught to look up codes in the alphabetic index. They also had to try to forget all the codes they had memorized.

Another challenge the nation faced, an issue to which the United States definitely can relate was a shortage of coding professionals.

Education was provided in four modules. The first was a self-learning toolkit containing comparisons between ICD-9 and ICD-10, an explanation of the new structure of CCI, and an introduction to using the electronic format.

Next, because facilities could not have their coders out for more than two days at a time due to backlogs, a two-day workshop and online case studies for further practice were offered. Also offered was an optional one-day refresher course, held six months after the initial workshop.

Another tool Canada developed was an online coding query service. This was a website through which coders were able to ask questions, review responses from other queries and access resources.

The actual transition to ICD-10-CA and CCI was led by the Canadian Institute for Health Information, with the effort starting in 2001 and ending in 2006.

One of the first things the institute did when it was time to implement ICD-10-CA and CCI was to establish committees made up of key stakeholders. Provincial leaders or project coordinators responsible for overseeing implementation were named. These officials also were responsible for performing environmental scans identifying needs and resource requirements.

This also helped get the key stakeholders engaged. The buy-in from government agencies, colleges, professional associations, vendors and healthcare facilities was critical.

By 2005, all Canadian provinces and the country’s other territories were using ICD-10-CA and CCI for morbidity reporting. The average time it took for providers to return to pre-ICD-10-CA and pre-CCI productivity levels was about six months.


Although Australia and Canada are very different from the United States in many ways, much can be learned from their success stories. Their dedication to preparation, education and stakeholder buy-in was surely something we can use as a model.

How well we use the lessons learned by other countries likely will dictate our success. As mentioned earlier, we are unsure about the arrival date of ICD-10-CM in our country, but we do know that eventually it will be implemented. The more we prepare, the better.

About the Author

Brittney Kozlowski is the quality improvement coordinator at Lake Superior Community Health Center in Duluth, Minn. In May 2012 Brittney graduated summa cum laude from the College of St. Scholastica in Duluth, where she majored in health information management.

To comment on this article please go to editor@icd10monitor.com


Innes, K., Peasley, K., & Roberts, R. (2000). Ten down under: implementing ICD-10 in Australia. Retrieved June 11, 2012, from AHIMA: Body of Knowledge:             http://library.ahima.org/xpedio/groups/public/documents/ahima/bok3_004782.hcsp?dDocName=bok3_004782

Moskal, L. (2004, October). The implementation of ICD-10-CA and CCI in Canada. Retrieved June 10, 2012, from AHIMA: Body of Knowledge: http://library.ahima.org/xpedio/groups/public/documents/ahima/bok3_005526.hcsp?dDocName=bok3_005526

Roberts, R. (2004, October). ICD-10: An update on the worldwide implementation – the Australian experience. Retrieved June 11, 2012, from AHIMA: Body of Knowledge: http://library.ahima.org/xpedio/groups/public/documents/ahima/bok3_005527.hcsp?dDocName=bok3_005527

Roop, E. S. (2008, December 8). Look North- Canada’s slant on smooth ICD-10 strategies. Retrieved June 12, 2012, from For the Record: http://www.fortherecordmag.com/archives/ftr_120808p20.shtml


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