Using ICD-11 codes in diagnosing for medical aesthetics

In his article for the Consulting Room, Mr Taimur Shoaib, Consultant Plastic Surgeon and Course Director Inspired Cosmetic Training discusses the use of ICD-11 codes in diagnosing for medical aesthetics and cosmetic injectables

Healthcare is all about the diagnosis. In just about all healthcare settings, a patient has a history, examination, a differential diagnosis, investigations as necessary to confirm the working diagnosis, a range of options presented to the patient, treatment and follow up. Aesthetic medicine is no different. By formulating a diagnosis and treating that diagnosis, we cement the process of aesthetic medical treatments, into a medical set up, and we medicalise the process of care that we deliver. 

Diagnosis and VAT 

According to European Law, from a judgement that was delivered on 21st March 2013, only a doctor, dentist, or nurse can formulate a diagnosis for healthcare purposes. The judgement was made in relation to a VAT investigation against the PFC clinic in Stockholm, Sweden. The clinic argued that it did not require to pay VAT for cases it was performing, and since VAT is a European Union tax, the judgement has implications for the all EU member states. In all EU states, only a doctor, dentist, or nurse can make a diagnosis for the purposes of medicalising a treatment. If such a diagnosis is made, and treated, then that treatment is VAT exempt and is considered a medical treatment. 

Technicalities of the Law 

(Skatteverket v PFC Clinic AB (Case C-91/12). [2013] BVC 117, European Court of Justice Third Chamber): supplies of medical services for the purpose of protecting, including maintaining or restoring, human health can be exempt under art. 132(1)(b) and (c) of Directive 2006/112. In deciding the purpose of a treatment, health problems may be psychological in nature. In its ruling, the ECJ said at para. 39: plastic surgery and other cosmetic treatments fall within medical care where those services are intended to diagnose, treat or cure diseases or health disorders or to protect, maintain or restore human health.

This law has positive aspects as well as negative points. It means that if a patient, who has acne, sees a doctor and is advised treatment such as a wet facial, then the cost of the treatment will not incur additional VAT on top. Conversely, it means that if a beauty therapist or aesthetician sees a person who has acne and performs blue light laser on that person, then the person will have to pay VAT on the cost of the treatment, if applicable to the financial turnover of the business involved. A business only needs to be VAT registered when VATable turnover is more than £85,000 a year. 

Diagnosis and lockdown 

When the European VAT law is coupled with the coronavirus lockdown, the importance of medicalising our treatments, by formulating a diagnosis, is even more important. During lockdown, all nonessential services and businesses were told or advised to close. In Scotland, Healthcare Improvement Scotland (HIS) made it clear that nonessential services were to close, and the Department of Health and Social Care (DHSC) in England gave similar advice on close-contact services. As lockdown eased, HIS and DHSC allowed providers of non-essential healthcare to reopen so long as they had completed sufficient risk assessments for the health and safety of their service users. Some documents stipulated that face-toface treatments were disallowed but specifically stated that healthcare was exempt from the restrictions. 

Some of us are now finding ourselves in a position where we question what defines healthcare. To many, making a diagnosis and treating that diagnosis forms a strong part of that definition. We must never forget, though, that the formulation of a diagnosis follows a medical process where we take a history, examine the patient, and perform investigations if indicated. If you, as a doctor, dentist, or nurse, see and treat a patient, for treatment of a diagnosis, then that is undoubtedly a medical process. On the other hand, if you see clients who want fillers and you provide that service, it is unlikely to be seen by your peers and by the government as a healthcare service. As regulated healthcare professionals, we also have to work to specific standards laid down by case law in the UK and by our regulators. 

The medical process 

The medical process can be summarised in the following way: 

• Take a history
•Examine the patient
• Formulate a diagnosis (ECJ ruling – PFC case)
• Consider options (Montgomery vs Lanarkshire Health Board)
• Refer a patient if the practitioner cannot perform the option preferred by the patient
• Give the patient time to consider the treatment (GMC, NMC, GDC principles)
 • Perform the treatment with the skill of an ordinarily competent practitioner (Hunter vs Hanley, Bolam vs Friern Hospital Management Committee)

ICD-11 codes 

There are many options when it comes to making a diagnosis for our patients. Of all the methods, using ICD-11 codes is one such option. The International Statistical Institution created the first International List of Causes of Death in 1893, and when the World Health Organisation (WHO) was formed in 1948, they took over the management of the list. It became known as the 6th version of the International Classification of Diseases in 1948 and at that point started to include causes of morbidity. ICD-10 was endorsed in 1990, and ICD-11 codes will be used from January 2022. The ICD codes evolve as medical science evolves with time. Since ICD-11 has now been published on the WHO website (https://icd.who.int/en), it seems reasonable to use ICD-11 codes for diagnostic purposes in the setting of aesthetic medicine. 

ICD-11 is a huge and complex document. It is organised according to different categories of the bodily system. Despite its complexity, a few doctors have recently gone through the list to filter out those diagnoses most relevant to our practice in aesthetic medicine (see table) and, separately, for those diagnoses most relevant to our practice in aesthetic surgery. 

Whilst there may be other relevant codes according to different practices and the variety of conditions we see in our clinics, (e.g., acne, suspicious skin lesions, etc.); these codes form the basis of a medicalised process to allow healthcare professionals to formulate a diagnosis. Starting with a diagnosis allows injectors to medicalise the process of seeing their patients, and allows differentiation between regulated healthcare professionals and any other group of people who also deliver injectable cosmetic treatments.

ICD -11 CODES.pdf