Open Access Technical advance

Pediatric complex chronic conditions classification system version 2: updated for ICD-10 and complex medical technology dependence and transplantation

Chris Feudtner123*, James A Feinstein45, Wenjun Zhong1, Matt Hall6 and Dingwei Dai1

Author Affiliations

1 Pediatric Advanced Care Team and the Center for Pediatric Clinical Effectiveness, The Children’s Hospital of Philadelphia, CHOP North-Room 1523, 34th and Civic Center Blvd, Philadelphia, PA 10194, USA

2 Department of Pediatrics, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA

3 The Department of Medical Ethics and Health Policy and the Leonard Davis Institute, University of Pennsylvania, Philadelphia, PA, USA

4 Children’s Outcomes Research Program, Children’s Hospital Colorado, Aurora, CO, USA

5 Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA

6 Children’s Hospital Association, Overland Park, KS, USA

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BMC Pediatrics 2014, 14:199  doi:10.1186/1471-2431-14-199

Published: 8 August 2014



The pediatric complex chronic conditions (CCC) classification system, developed in 2000, requires revision to accommodate the International Classification of Disease 10th Revision (ICD-10). To update the CCC classification system, we incorporated ICD-9 diagnostic codes that had been either omitted or incorrectly specified in the original system, and then translated between ICD-9 and ICD-10 using General Equivalence Mappings (GEMs). We further reviewed all codes in the ICD-9 and ICD-10 systems to include both diagnostic and procedural codes indicative of technology dependence or organ transplantation. We applied the provisional CCC version 2 (v2) system to death certificate information and 2 databases of health utilization, reviewed the resulting CCC classifications, and corrected any misclassifications. Finally, we evaluated performance of the CCC v2 system by assessing: 1) the stability of the system between ICD-9 and ICD-10 codes using data which included both ICD-9 codes and ICD-10 codes; 2) the year-to-year stability before and after ICD-10 implementation; and 3) the proportions of patients classified as having a CCC in both the v1 and v2 systems.


The CCC v2 classification system consists of diagnostic and procedural codes that incorporate a new neonatal CCC category as well as domains of complexity arising from technology dependence or organ transplantation. CCC v2 demonstrated close comparability between ICD-9 and ICD-10 and did not detect significant discontinuity in temporal trends of death in the United States. Compared to the original system, CCC v2 resulted in a 1.0% absolute (10% relative) increase in the number of patients identified as having a CCC in national hospitalization dataset, and a 0.4% absolute (24% relative) increase in a national emergency department dataset.


The updated CCC v2 system is comprehensive and multidimensional, and provides a necessary update to accommodate widespread implementation of ICD-10.

Pediatrics; Complex chronic conditions; Chronic disease; Classification; International classification of disease codes; Comorbidity; Mortality; Health services research