mort04_2

2004-09-07_01 Code for stenosis of the vertebral canal

(Chapter XIII)

[Question from Barbara Leitner, Austria:]

Dear colleagues, please help us with the following case:
75 year old woman with:
Pneumonia
Tetraplegia
Stenosis of the vertebra canal (cervical)

We did find only M43.8 for the underlying cause, which code would you take?
[Comments:]
 
2004-10-05:

Sao Paulo Classification Centre /Ruy Laurenti/:
For us it is very clear that the code for Stenosis of the vertebra canal is M48.0.

2004-09-21:

New Zealand /Claire Nicoll/:
We would code to M48.02 -which we reached via the index through stenosis, vertebral, cervical.

2004-09-14:


Canada /Patricia Wood/:
In ICD-10, Volume 3 (English) Stenosis, spinal is indexed to M48.0, a subcategory of M48, Other spondylopathies.  Would that be a suitable place to classify "stenosis of vertebral canal (cervical)"?  M48.0 is on the trivial cause list, but as the stenosis of vertebral canal is reported as the cause of the tetraplegia Rule B would not be applied.
 
Cuba /Ana C. Mesa/:
M500+G992*
 
Germany /Robert Jakob/:
UC would be "stenosis of the spinal channel". M48.0
 
USA /Julia Raynor/:
I think the term is referring to Stenosis, spinal, indexed to M480. In the 9th Revision there was a separate category for cervical spine stenosis but I have not found that in 10th Revision.

2004-09-07_02 External cause code for injuries following ejecting from a jet air

(Chapter XX)

[Question from Sue Walker, Australia:]

We have a death certificate which describes multiple injuries to the deceased as a result of striking the ground following ejecting from a Sabre jet aircraft. What is your opinion regarding the external cause code?
[Comments:]
 
2004-10-05:

Sao Paulo Classification Centre /Ruy Laurenti/:
In the case of multiple injuries as the result of the ejection from a jet aircraft the Brazilian Center code V97.0.
 
2004-09-21:

New Zealand /Claire Nicoll/:
As ejection from an aircraft only occurs when the aircrew have no other option for self-preservation, and assuming this it is neither a privately owned or commercial aircraft (we assume military) we would code to V95.8 -other aircraft accidents injuring occupant - as this captures the 'accident' to the aircraft which presumably would have resulted in death anyway had the aircrew not ejected!
 
2004-09-14:
 
Canada /Patricia Wood/:
This is an interesting case ... I wonder, why did the decedent eject from the aircraft, was there something wrong with it?  Did the decedent have a parachute, and if so, did it not work?  With the information that we do have I wonder if this death should be classified to V97.0, Occupant of aircraft injured in other specified air transport accidents? 
 
Germany /Robert Jakob/:
I would tend to V97.8 as striking the ground with these deathly injuries were caused in relation with leaving the aircraft and V97.1 surely was not intended for leaving the aircraft by ejecting.

2004-09-07_03 Code for mesenteric arterial occlusive disease

(Chapter IX)

[Question from Julia Raynor, USA:]

We are having a problem assigning a code for mesenteric arterial occlusive disease.  Occlusion, artery, mesenteric  is indexed to K550.  Disease, arterial, occlusive is indexed to I771.  Should we code Disease, arterial, occlusive with mesenteric not indexed, I771? Note that lead terms Occlusion, occluded does not include occlusive.  Does that make a difference in the code assignment?
[Comments:]

2004-11-03:

Sao Paulo Classification Centre /Ruy Laurenti/:
The Brazilian Center agrees with the comments from Patricia and Lars. For us the code is K55.1.

2004-10-05:

WHO /André L'Hours/:
Just to show that I do follow the Forum exchanges with great interest but only intervene when I think it is necessary or, in this case, where my name is mentioned.

K55.0 (Acute vascular disorders of intestine) includes ischaemia that is usually caused by thrombosis or embolism of the superior mesenteric artery and can result in partial or complete necrosis of the part of the intestine supplied by the artery. It is most often seen in elderly patients with cardiovascular disease. Onset of symptoms is usually acute with severe colicky abdominal pain that becomes diffuse and constant, abdominal distension, vomiting, anorexia and diarrhoea (usually with bloody stools). If intestinal necrosis is complete, approximately 24-72 hours after onset of symptoms, there is gangrene with peritonitis, sepsis and shock.

Synonyms: acute mesenteric ischaemia; acute small-intestinal ischaemia; haemorrhagic infarction of the intestine; mesenteric infarction; small intestinal infarction; transmural infarction of the intestine.

K55.1 (Chronic vascular disorders of intestine) relates to a form of ischaemia that is generally caused by partial mesenteric vascular occlusion and chronic arterial insufficiency. It is manifested by postprandial pain (15-60 minutes after eating) and weight loss due to decreased food intake because of fear of pain. The disorder may cause mucosal damage , fibrotic narrowing of the lumen, and malabsorption and may ultimately progress to infarction of the intestine.

On the basis of the above I would code "mesenteric arterial occlusive disease" to K55.1.

2004-09-28:

Germany /Robert Jakob/:
Maybe André may be able to clarify the original intention of K55?

2004-09-21:


New Zealand /Claire Nicoll/:
We feel that K55.0 would reflect the cause of death more accurately than I77.1, but we would agree that the terminology "occlusive" does not indicate an acute event in this case.
 
2004-09-14:
 
Canada /Patricia Wood/:
My logic may not actually line up properly with the intention of the classification but, here's what I'm thinking ... As many "mesenteric artery" problems are excluded from the block I70-I79, Diseases of arteries, arterioles and capillaries and included at K55, Vascular disorders of intestine, perhaps mesenteric arterial occlusive disease should be treated the same way.  As a bit of a compromise and in the absence of an indication that it is an acute condition I might consider K55.8, Other vascular disorders of intestine.

Germany /Robert Jakob/:
From a clinical point of view "occlusion" means complete obstruction, while "occlusive" means "on the way from free to occlusion", and you could only exclude that the vessel is completely free. The same would be valid for "occlusive disease". So at present the upper term does not indicate a complete obstruction and I would select "Disease, arterial, obstructive" loosing the information "mesenteric".
 
Sweden /Lars Age Johansson/:
Like Patricia, I get the impression that K55 is intended for vascular disorders of intestine in general, and not just for full occlusions. At K55.1 there is mesenteric atherosclerosis, which I think could be described as an occlusive disorder. I would choose K55.1, chronic vascular disorders of intestine.

2004-09-14_01 Identifying nosocomial infections

(Chapter I, XX)

[Question from Margaret Campbell, Australia:]
 
There appears to be an increasing demand for differentiating between hospital acquired and community acquired infections.  Australian morbidity coders are using Y95 Nosocomial condition as an additional following the infective condition to capture the hospital acquired  component when documented.  However, our mortality coders are unable to use this code because codes above Y899. are invalid codes for either UCOD's or MCOD'cods and therefore not used in MMDS [Medical Mortality Data System: the software pack developed at the National Center for Health Statistics, North Carolina, and which includes Micar, Acme, and Transax /Lars Age]. How are other countries dealing with this issue?
[Comments:]

2004-09-21:

Canada /Patricia Wood/:
I agree!  Here in Canada there are stories in the media regularly about the hundreds of people who are acquiring infections in the hospital and, in many cases, subsequently dying.  Clostridium difficile was featured just last week and blamed for over 100 deaths at just one hospital in the past year! In answer to Margaret's question, we aren't dealing with this yet but we have the same limitation on the use of Z codes because we use MMDS too.  Is this an situation that would justify the use of U code to indicate the specification of an infection as nosocomial?  I am also worried about the consistency (or lack of) in the certification of nosocomial infections as causes of death.  And then, if certified, how should the rules be applied to select the underlying cause of death?  Would the sequence of events leading to death be considered to have started with the nosocomial infection, or would we look (as with surgical complications and misadventures) at the condition that required the person to be hospitalized in the first place?  

2004-09-14_02 Syndromes: Cantrell, Kabuki, Pallister-Hall, Escobar

(Chapter XVII)

[Question from Monica Pace, Italy:]
 
Dear Mortality Forum participants, I have a general question about the inclusion of some congenital syndromes and malformation into code Q87.8; we are tentatively including into it the following:
 
Cantrell
Kabuki
Pallister-Hall
Escobar
 
Could you give a comment on this choice and possibly add other similar diseases you assigned to this code during your experience? Maybe we could come up with a shared list on this issue.
[On Escobar, please see MF question 2004-06-15 Q1 /Lars Age]
[Comments:]
 
2004-10-05:

Sao Paulo Classification Centre /Ruy Laurenti/:
The Brazilian Center agrees with the inclusion terms proposed by Monica Pace and with the comments made by Patricia Wood.

2004-09-21:

Canada /Patricia Wood/:
I would add Bowen-Conradi Syndrome and  Fryn's Syndrome to the list of terms to tentatively include at Q878, Other specified congenital malformation syndromes, not elsewhere classified.

Cuba /Ana C. Mesa/:
Cantrell Haller Ravitsch Q878 also known as:
Pentology of Cantrell
Pentology Syndrome
Thoracoabdominal Syndrome

Kabuki Q878 also known as:
Niikawa Kuroki Syndrome
 
Pallister-Hall Q878 also known as:
Hall-Pallister Syndrome
Hypothalamic Hamartoblastoma, Hypopituitarism, Imperforate Anus, Polidactyly
All these Syndromes affecting multiple systems

2004-09-28_01 Hepatocellular carcinoma due to hepatitis B

(Rule GP)

[Question from Kathleen England, Malta:]
Dear members of mortality forum, I have a query:

Part I of death certificate states
(a): Hepatocellular carcinoma
(b): with hepatits B virus infection
 
Part II: Hypertension

According to rules of ICD-10 only HIV can be reported as a cause of malignancy in the case of infections. However there is a causal relationship between hepatitis B and hepatocellular carcinoma. What in your opinion is the correct underlying cause of death in this case?

[Comments:]
 
2004-11-16:

Cyprus /Pavlos Pavlou/:
Having suggested that there is a need to update page 50 of vol 2, I am now making second thoughts following Lars Age's comments. The statistical arguments put forward are quite understandable. Also, from the prevention point of view, keeping the current rule, and coding such cases to C22.0 (not C22.9 as I had mistakenly suggested) would not, in my view, compromise appropriate prevention measures. For example, detecting, a high mortality rate from hepatocellular carcinoma in a community, would certainly, stimulate public health authorities to consider strengthening prevention measures against hepatitis B, which is known to be the originating cause of the problem in a large proportion of cases.

2004-11-03:

Sao Paulo Classification Centre /Ruy Laurenti/:
The Brazilian Center agrees with the considerations made by Pavlos Pavlou from Cyprus. The Mortality Reference Group has been discussing the update of "Notes for use....etc", in the item 4.2.2 volume 2.
 
Sweden /Lars Age Johansson/:
As Kathleen says, the ICD instructions tell us to accept that a malignant neoplasm may be caused by HIV, but not by other infectious diseases. As far as I understand, the reason is statistical rather than medical. Those who wrote the instructions felt it would be more useful to have as complete statistics on malignant neoplasms as possible than to register the causes, especially since the causes of many malignant neoplasms are not very well known and since most certificates in cancer deaths do not mention any particular cause of the cancer. This does not mean, of course, that the medical relationship is not recognised, only that the underlying cause statistics would be more useful if we select the malignant neoplasm rather than the infectious disease. For the same reason (usefulness of the statistics) the exception for HIV was introduced in ICD-10.

2004-10-05:

Cuba /Ana C. Mesa/:
In this case: B169 or B182 or B942 ?? Volume 2, 4.2.2 Interpretation of "highly improbable",b):  C220 See also A2002-04-22-Q6 Update 1. Bécker, Dr Robert,  FORUM-CIE have many questions about viral hepatitis I think, this is a grand problem not solved: viral hepatitis / Chronic viral hepatitis/Cirrhosis of liver/ (Hepatocellular carcinoma).
 
Cyprus /Pavlos Pavlou/:
I think Kathleen England is absolutely right about the causal relationship between hepatitis B and Hepatocellular carcinoma. However, my understanding is that coding is meant to follow strict rules. Until there is a change in the rules we should code UC: C22.9. Nevertheless, I would agree that there is a need to update page 50, "Notes for use in underlying cause mortality coding" to accommodate for this case and possibly other examples of infectious diseases that are now known to cause malignant neoplasms.

2004-10-19_01 Code for postpartum cardiomyopathy

(Chapter XV)

[Question from Saint Kitts & Nevis, translated from the Spanish-speaking ICD
Forum by Roberto Becker:]

I received the following question in ICD-Forum, from Saint Kitts & Nevis and would like to heve your opinion, because I also have doubts:

This patient in reference delivered a baby in December 2002. She had several admissions to hospital from April 2003, then subsequently died in May 2004. A certificate was issued with Postpartum Cardiomyopathy. Should it be coded O90.3 ?  O97 ? or other code?
[Comments:]
 
2004-11-03:

Cuba /Ana C. Mesa/:
O90.3 is for direct obstetric deaths, but here we have one year and five months. Code O97. Includes "Death from any direct obstetric cause ocurring one year or more after delivery"

Slovenia /Jozica Selb/:
I would code this death to O994 as a disease of the circulatory system complicating pregnancy, childbirth and the puerperium. For me it suits the most to the condition originating in pregnancy what cardiomyopathy connected with pregnancy usually should be.  I think it does not originate in puerperium. If it starts in puerperium, I would code to O903.
 
2004-10-19:

Canada /Patricia Wood/: Lars Age and I discussed a very similar certificate earlier this year:a) cardiac arrhythmia
b) cardiomyopathy-pregnancy induced (years)
c)
d)
       
II IDDM, renal failure (chronic), congestive heart failure

We concluded that we would classify the underlying cause of death as O97, Death from sequelae of direct obstetric causes.

2004-10-19_02 Fall in tub

(Chapter XX)

[Question from Canada /Patricia Wood/:]

My colleagues and I are reviewing the 2002 mortality file, verifying all kinds of variables prior to releasing it later this summer or early in the fall.  Naturally a big part of our review is to examine the causes of death on the file. Isn't it an eye opening experience to see some of the very creative ways that people will certify and then others will classify causes of death?
 
My problem is actually not all that complicated (I hope) - how would you code the external cause for fall in tub when the nature of injury is not drowning?
[Comments:]
 
2004-11-16:

Luxemburg /Monique Differding/:
I agree with Elaine, people can slip or strike, then fall into tub. But somebody can also have got a malaise and due to this can have fallen somewhere (in this case into the tub). We do not know the cause of the fall, so we would  use W 19.0.

2004-11-09:

Sao Paulo Classification Cente /Ruy Laurenti/:

Dear all, regarding the "fall in the tub" (independent of the nature of the injury) the underlying cause is W18.0.

2004-11-03:

Cuba /Ana C. Mesa/:
Fall in tub, is it possible to use:
W01 - Fall on same level from slipping, or
W18 - Other fall on same level?

Slovenia /Jozica Selb/:
For me it is hard to answer because of language difficulties. If in this example tub means bath I would prefer W01, because in my country falls in bath are in majority due to slipping.
 
Sweden /Lars Age Johansson/:
I assumed that Patricia's question was on someone falling in a bath-tub.
 
2004-06-24:

Australia /Sue Walker/:
If this had been fall into tub, we would suggest using W17 Other fall from one level to another - but given that it is fall in  tub, our preference is to use  W18 Fall on same level. We thought about W08 Fall involving other furniture - the question is a tub considered furniture or a fixture? We decided it was a fixture so we thought this probably wasn't right either.

What did others think??

England /Elaine Tower/:
Here in England we would use code W19.0 (the fourth digit would depend whether it happened at home (we are presuming this from the data supplied)).
 
Hope this helps.

Sweden /Lars Age Johansson/:
If there is no mention of slipping etc I would simply use W18, fall on same level. But as usual I have probably overlooked something?

2004-11-16_01 Maternal death after caesarian section

(Chapter XV)

[Questions from Augusto Hasiak Santo, Brazil:]

This time, I am submitting two death certificates to be discussed at the Mortality Forum. The death certificates are the following ones:
Female, 32 years,
I a) Acute anemia
I b) Hemoperitoneum
I c) Post-caesarean section surgery
I d) --
 
The code O82.- should not be used for mortality. We have a maternal death. How shall we code the underlying cause of death and the complications of the surgery mentioned on lines (a) and (b)? Multiple causes of death are very important in this death certificate.
[Comments:]
 
2004-11-30:

Cyprus /Pavlo Pavlou/:
I a) Acute anemia                              D62    Acute post-haemorrhagic anaemia
I b) Hemoperitoneum                        K66.1  Haemoperitoneum  (or S36.8 Injury of other intra-abdominal organs ?)
I c) Post-caesarean section surgery   O90.8  Other complications of the puerperium not elsewhere classified (via complications, caesarean section wound, in the index)
UC:  O90.8

2004-11-23:

Canada /Patricia Wood/:
Maternal deaths are really very challenging to code!  I may be wrong about this, but I think that the underlying cause of death is the hemoperitoneum complicating an operative delivery, and I would use ICD-10 code O75.4, Other complications of obstetric surgery and procedures.  For multiple causes, I would code the anemia on line a) to O99.0, Anemia complicating pregnancy, childbirth and the puerperium.
 
Cuba /Ana C. Mesa/:
There are several possibilities:
1.a) D62
   b) T810 (K661) (S368)
   c) O759
 
2. a) D62
    b) T810 (K661) (S368)
    c) O754
 
3. a) D62
    b) T810 (K661) (S368)
    c) O719
 
I would like
a) D62
b) T810 -O829
c) O719
 
CHAPTER XIX
Injury, poisoning and certain other consequences of external causes (S00-T98)
Excludes: Obstetric trauma (O70-O71)
O71 Other obstetric trauma
Includes: damage from instruments
 
England /Elaine Tower/:
The Acute anemia we will code to O99.0. As the Hemoperitoneum is in a due to sequence we will code to O75.4 as a mention with a mention of O82.9 and we would come up with the underlying cause as O75.4.

2004-11-16_02 Code for cancer of laryngopharynx

(Chapter II)

[Questions from Augusto Hasiak Santo, Brazil:]

This time, I am submitting two death certificates to be discussed at the Mortality Forum. The death certificates are the following ones:

Male, 79 years,
I a) Multiple organs failure
I b) Neoplastic cachexia
I c) Laryngopharynx cancer
I d) --
 
Code C14.1 was deleted from Volume I of ICD-10. Maybe some decision has already been taken about how to code Laryngopharynx cancer but I may have missed it. What code shall we use for underlying cause?
[Comments:]
 
2004-11-30:

Cyprus /Pavlo Pavlou/:
I a) Multiple organs failure        R99   Other ill-defined and unspecified causes of mortality ??
I b) Neoplastic cachexia          C80   Cahexia, cancerous (via index)
I c) Laryngopharynx cancer     C13.9 Malignant neoplasm of hypopharynx, unspecified (via index)
UC: C13.9

2004-11-23:

Canada /Patricia Wood/:
"Laryngopharynx" is a site included in the Neoplasm table (Volume 3 - English version) and it is indexed to C13.9, Malignant neoplasm of hypopharynx, unspecified.

Cuba /Ana C. Mesa/:
ICD-9 Spanish
148  Malignant neoplasm of Laryngopharynx
148.9 Laryngopharynx , unspecified
         Hypopharynx .........
 
ICD-9 English
148  Malignant neoplasm of hypopharynx
148.9 Hypopharynx, unspecified
         Laryngopharynx.......
 
ICD-10 English Volume 3
   Laryngopharynx C13.9
 
Now, ICD-10 English and Spanish:
 C13.9 Hypopharynx, unspecified
          Laryngopharynx....
 
England /Elaine Tower/:
1a = R68.8
1b = C80
1c = C13.9 This is indexed as Neoplasm - laryngopharynx and C13.9 selected as primary site. The Underlying cause then is the C13.9

2004-11-16_03 Post-operative pulmonary embolism - underlying cause

(Rule 4.2.6)

[Question from Kathleen England, Malta:]
Dear Mortality Forum,

I am a little confused about this type of death certificate:

Part I: Pulmonary embolism (4 days post-op)
        rt. total knee replacement

I spoke to the certifier who told me that the total knee replacement was performed for osteoarthritis. Should one code the underlying cause of death to Y83.1: Later complications of surgical operations or should one code the osteoarthritis. However the osteoarthritis was not the cause of death as any operation can result in this complication, ie pulmonary embolism. This problem sometimes also arises in other surgical operations done for other conditions, and the patient dies a few days post op. The osteoarthritis would have never killed the patient if she was not operated.

[Comments:]
 
2005-02-08:

Cyprus /Pavlos Pavlou/:
Following Augusto's comments I would also like to rectify our previously suggested code. I, initially, thought that the 5th digit ' 6' in the code M19.96 would adequately specify the localization of arthrosis to the knee joint. Now, I agree that M17.9 is the most appropriate and specific code. I wonder if it would be useful to add an exclusion note on page 639 of vol 1, at M19, as follows: "Excludes: gonarthrosis [arthrosis of knee] (M17.-)".

2005-01-18:

Brazil /Augusto Hasiak Santo/:
I would like to rectify the code I had assigned to osteoarthritis. After reading Elaine's comments, I realized that M17.9 is the most adequate code. The Index I used had a problem: looking at the lead term "Osteoarthritis" a cross-reference to "Osteoarthrosis" appears instead to "Arthrosis". Then I looked at the English and Spanish Indexes where the cross-reference is actually to "Arthrosis". The cross-reference to "Osteoarthitis" was found formerly in ICD-9 Index. The ICD-10 Index was prepared by inserting its codes over the ICD-9 old Index file. The indentation to "knee" is found only in the ICD-10 lead term "Arthrosis", giving the code M17.9.
 
2004-11-30:

Cyprus /Pavlos Pavlou/:
Our handling of this interesting case is as follows:
 
Part I: Pulmonary embolism (4 days post-op)                I26.9
          rt. total knee replacement (for osteroarthritis)      M19.96
          UC: M19.96
 
We have a clarification that the condition for which the operation was performed was osteoarthritis. There is no mention of misadventure but there is mention of a postoperative complication.
 
a) With reference to modification rule B, one may argue that osteroarthritis is a trivial condition unlikely to cause death and therefore we should choose the more serious condition, pulmonary embolism. However, we do not consider osteoarthritis (a condition that necessitated a major, risky operation) as trivial.

b) In many of the exisitng guidelines to physicians, (pulmonary) embolism following surgery is included in the list of imprecise conditions for which the condition necessitating surgery should be stated in the death certificate.
 
c) With reference to note 4.2.6, 'Operations',  which deals with certificates on which an operation is mentioned as the cause of death, our interpretation and structured use of the note is as follows:
 
We ask and answer the following sequential questions:
 
1   Is the condition for which it was performed mentioned?
Yes -> code to the condition, 
No -> go to question 2

2   Are the findings at operation mentioned?
Yes -> code to the findings,
No -> go to question 3
 
3   Does the alphbetical index provide a specific code for the operation?
Yes -> code to the specific code,   
No -> go to question 4

4   Does the name of the operation indicate an organ or site?
Yes -> code to the residual category...,        
No -> go to question 5
 
5   Is there mention of a therapeutic misadventure classifiable to Y60-Y84?
Yes -> code to Y60-Y84, 
No -> go to question 6

6   Is there mention of a postoperative complication?
Yes -> code to the complication, 
No -> code to R99
 
We answer 'yes' to question 1. Therefore, we code to the condition for which the operation was performed, osteoarthritis, and we do not proceed to ask the other questions. This is the way we see this. Please let us know if we have got it wrong.

Sao Paulo Classification Centre /Ruy Laurenti/:
The case from Kathleen England for us is very clear. The operation was made for a complication of  osteoarthritis (information from the certifier). Thus the u.c. is osteoarthritis. The code Y83.1 should be used only if the certifier did not mention the osteoarthritis in the investigation of the case.

2004-11-23:

Brazil /Augusto Hasiak Santo/:
Kathleen has had the correct decision when she spoke to the certifier physician. (In our automated processing cause of death system, when a surgery is mentioned alone, without its originating cause, a dialog box appear asking the coder about the disease that has given rise to the surgery). Taking into account the certifier's information, we may consider osteoarthritis as the underlying cause of death. On the other hand, osteoarthitis is not included in the list of trivial conditions unlikely to cause death. Assuming that pulmonary embolism is on line (a), right total knee replacement on line (b) and osteoarthititis on line (c), the multiple cause coding would be - T817/Y831/M199 - and M199 the underlying cause of death.
 
Canada /Patricia Wood/:
Death due to complications of surgery can be a confusing coding situation. When death is due to a complication(s) of medical and surgical care (Y40-Y84), the underlying cause of death should almost always be assigned to the condition necessitating the surgical or medical care.   If the condition necessitating surgical or medical care is a trivial condition, Rule B selects the adverse effect of treatment instead. There are some instructions on page 71 of Volume 2 that direct the selection of underlying cause when death is due to a complication(s) of medical or surgical care but the condition necessitating treatment is not stated.

In the case Kathleen presents the osteoarthritis is the condition necessitating the surgery which lead to the complication, so it should be selected as the underlying cause of death.

Cuba /Ana C. Mesa/:
Underlying cause M199
Other causes Y831
 
England /Elaine Tower/:
We would code this one as I26.9 for the Pulmonary embolism with a mention of T84.8 as a complication of internal orthopaedic prosthetic devices, implants and grafts. The right total knee replacement would be coded as Y83.1 with M17.9 Indexed as such - Osteoarthritis - see arthrosis - Arthrosis - Knee see Gonarthritis = M17.9
 
If, in the case, you did not know why the replacement was done we would have then coded to M25.9 - Joint disorder, unspecified with the mention of Y83.1

2004-11-30_01 Code for chronic venous leg ulcers

(Chapter IX, XII)

[Questions from Elaine Tower, England:]

I wonder if we could have some help on a couple of deaths that we are having a problem in coding:

Male of 77 years old
1a Multiple organ failure
1b Sepsis
1c Chronic venous leg ulcers
Pt II Chronic obstructive pulmonary disease, hypertension, ischaemic heart disease, peripheral vascular disease

We are trying to ascertain whether the 1c Chronic venous leg ulcers may be varicose? The Index sends us Ulcer - leg see lower limb (atrophic; chronic; neurogenic; perforating; pyogenic; trophic; tropical) and the code = L97

What do others think?
[Comments:]
 
2004-12-21:

Canada /Patricia Wood/:
I notice that the NCHS version of ICD-10 Volume 3 includes an index entry:

Ulcer
- vein, venous NEC (any site) I878  (Other specified disorders of veins)
 
This would suggest that users of MMDS and/or the NCHS ICD-10 index may code Elaine's case to I878.  If "venous" and "varicose" are synonymous perhaps this issue should be passed on to the MRG for consideration of a change to the index?
 
Cyprus /Pavlos Pavlou/:
I agree with Cuba /Ana C. Mesa/, I83.2.

Germany /Robert Jakob/:
Chronic venous insufficiency includes the deep veins of the leg as well as the superficial ones. The visible changes in the superficial venous system of the leg are summarized under varicosis. The chronic venous ulcers can be caused, due to the underying pathophysiologic mechanism of venous blood pooling in the leg, recirculation of blood in the leg and resulting edemas by both the varicosis and the insufficiency of the deep venous system of the leg. The manifestation of ulcerations usually requires a failure of the venous system at a certain level. At  this level there exists usually a visible varicosis. So in the given example I retain appropriate to code to I83.0 .
 
Sao Paulo Classification Centre /Ruy Laurenti/:
For us "chronic venous leg ulcers" is the u.c. and we assume that is varicous, thus the code is I83.0. Is it possible in this case to apply rule 3 and to select "peripheral vascular disease"? In this case "vascular" means only "arterial" or includes also "venous"?
 
2004-12-07:

Brazil /Augusto Hasiak Santo/:
The code assigned to chronic venous leg ulcers is I83.0. The argument of coding to the most frequent form linked to a given cause can be used to justify the assumption that as varicose a venous ulcer. This guidance is being applied by ICD in many revisions. Venous ulcer without varicose lesions is not so frequent as varicose ulcers.
 
Cuba / Ana C. Mesa/:
I think that it is correct. I would code I832, because there is sepsis mention in 1b).
 
Sweden /Lars Age Johansson/:
We have also used I83.0 for venous leg ulcers. I agree with Augusto that it is important to capture the cause of the ulcers, and if we were to use L97 we would lose the "venous" part of the statement on line 1c. It is true that "varicose" is an essential modifier here, but, again as Augusto says, since "varicose venous ulcer" essentially is the same disease as "venous ulcer" I would think a code in I83 is justified.

2004-11-30_02 Code for cerebrovascular hemorrhagic infarction

(Chapter IX)

[Questions from Elaine Tower, England:]

I wonder if we could have some help on a couple of deaths that we are having a problem in coding:
 
Male of 54 years old
1a Cerebrovascular Haemorrhagic Infarction

Should we have I61.9 and I63.9 with an underlying cause of I61.9?
[Comments:]
 
2005-01-11:

USA /Julia Raynor/:
I agree with Augusto that coding one-term and multiple one-term entities is a complex matter and has created confusion for us. In an effort to solve the problems associated with these entities when adjectival modifiers are reported, we have documented instructions in our instruction manuals for coding certain modifiers such as hemorrhagic that are not indexed under the lead term. For hemorrhagic cerebrovascular infarction, we  look in Volume 3 for the lead term, Infarction.  Infarction, cerebral does not have the adjectival modifier, hemorrhagic. Therefore, we code Infarction, cerebral, I639 only and consider the term as a one-term entity. Underlying cause would be I639.
 
2004-12-21:

Canada /Patricia Wood/:
In the absence of clinical support like Lars Age had, I would code cerebrovascular hemorrhagic infarction exactly as Elaine has suggested.

Cyprus /Pavlos Pavlou/:
I agree with Lars Age. The haemorrhage is a complication of the infrarction as described. UC: I63.9.
 
Germany /Robert Jakob/:
I completely agree with Lars. The meaning of hemorrhagic infarction is exactly the same in German, so I would follow his way of coding.
 
Sao Paulo Classification Centre /Ruy Laurenti/:
We accept I61.9 as the u.c.

2004-12-07:

Brazil /Augusto Hasiak Santo/:
The coding of one-term and multiple one-term entities are a complex matter. Regarding cerebrovascular haemorrhagic infarction it is not possible to assume which cause came first. We would follow Elaine's suggestion and code I61.9, I63.9 with I61.9 as the underlying cause of death.
 
Sweden /Lars Age Johansson/:
As we all know the same term sometimes have different meanings in different languages, and I don' t know if the term "hemorrhagic infarction" means the same in Sweden as in other countries. However, a Swedish specialist in cerebrovascular diseases once told me that in a hemorrhagic infarction the infarction comes first, and that the hemorrhage ensues because the walls of the arteries have been weakened by the infarction. Because of that we would code I63.- as the underlying cause and I61.- as a complication.

2004-11-30_03 Renal failure due to old age - apply Rule 3 to the renal failure?

(Rule 3)

[Questions from Elaine Tower, England:]

 
I wonder if we could have some help on a couple of deaths that we are having a problem in coding:
 
Female 99years old
1a Renal Failure
1b Old age
II Previous fracture Left neck of femur, on warfarin for previous DVT.
Treated with surgical fixation 29.9.4
 
Old age is causing the renal failure - should we stay with renal failure or because old age is ill-defined then the renal failure becomes post operative and then we would code for the reason for the operation?
[Comments:]
 
2005-01-11:

Cyprus /Pavlos Pavlou/:
I think, strict application of Rule 3, in this case, depends on the interval between the surgical fixation and death. If surgery "was carried out four weeks or more before death" (paragraph 3 of "Assumed direct consequences of another condition"), Rule 3 must not be applied. My interpretation is that we need to ask for the date of death before applying the rule.

2004-12-21:

Canada /Patricia Wood/:
I agree that Rule A should be applied to the tentative underlying cause R54. Coding the rest of the record as if the old age had not been reported would make one consider the renal failure to be a post procedural complication (N990), leading to the selection of fracture, cause unspecified (X59) as the underlying cause of death, with the femur fracture as the nature of injury (S720), and the hip fixation (Y831) as the surgical procedure causing abnormal reaction or later complication.
 
I do appreciate what Augusto has suggested though.  Would it be possible/practical to inform the certifier of what might happen in the classification of this certificate, giving him an opportunity to clarify his intention?
 
Sao Paulo Classification Centre /Ruy Laurenti/:
In part 1 "old age" is the u.c. but this diagnosis is ill-defined and we apply rule A and "renal failure" is the new u.c.. We linked renal failure with the post operative situation and now the u.c. is the reason for the surgery, this reason is not informed in the death certificate and according to the item 4.2.6/vol. 2, the new u.c.is Y83.8.
 
2004-12-07:

Brazil /Augusto Hasiak Santo/:
We accept renal failure as due to old age, the latter selected as a temporary underlying cause. Then, renal failure is reselected as the final underlying cause. Since renal failure was due to old age it is not logical to consider it as a post-procedural cause.
 
Cuba /Ana C Mesa/:
I would code underlying cause X59.- S72.0 ( In Cuba W19.- S72.0). Other codes Y831-N17.9 (acute) as operation complication
 
Sweden /Lars Age Johansson/:
We have had at least one similar case in the Mortality Forum before (1998-08-10 Q2, pneumonia due to old age), and people did not agree that time either. Consequently, the issue was brought to the Mortality Reference Group, which decided to apply the selection and modification rules strictly. That means, we would first select old age as the temporary underlying cause (General Principle), then re-select the underlying cause as if "old age" had not been mentioned (Rule A). That would bring us to the fracture as the underlying cause (Rule 3). There are, of course, perfectly valid reasons for both approaches - not applying Rule 3 to renal failure since it is reported as due to old age, or applying Rule 3 since Rule A tells us to disregard the ill-defined condition. The MRG went for the latter solution since we didn't want to introduce still another exception to the selection rules.

2004-11-30_04 Respiratory failure due to old age - what is underlying cause?

(Rule A)

[Question from Claire Nicoll, New Zealand:]

Please could we have some feedback on the following death certificate for a
 
95 year old :-
1a Respiratory failure               3 days
1b General organ failure           6 months
1c Debility of old age
 
I appreciate that earlier this year there was a question relating to senility as an acceptable underlying cause of death (2004-02-17). In the above example there is no code for the general organ failure,  and this has been stated as the antecedent cause of the respiratory failure which in reality is more of a mode of dying than an underlying cause of death.  So do we code the respiratory failure J960 as rule A instructs us to, or would it be acceptable to code senility (R54) which the certifying doctor has recorded as the underlying cause of death?  If R54 is considered to be a more specific code than vague medical terms such as "respiratory failure" and "cardiac arrest",  maybe we need an opinion from WHO as to which medical terms are the more statistically important, eg senility or modes of death such as "respiratory failure". I find it particularly interesting that in his reply to the previous "senility" question, Lars reported that he preferred doctors to certify death due to senility rather than "make something up".
[Comments:]
 
2004-12-21:

Canada /Patricia Wood/:
I agree with Lars Age and Augusto, there is no application of Rule A as all the conditions certified are ill-defined.  Old age (R54) is the underlying cause of death.
 
2004-12-07:

Brazil /Augusto Hasiak Santo/:
Respiratory failure, general organ failure and debility of old age are considered ill-defined conditions. Rule A does not apply and senile debility is the underlying cause of death.
 
Sweden /Lars Age Johansson/:
According to a decision by the Mortality Reference Group and the ICD-10 Update Reference Committee, acute respiratory failure is also considered an ill-defined condition. So as Augusto says, all conditions mentioned here are ill-defined. That being the case, old age, selected by the General Principle, should be the underlying cause. And yes, I don't think we should discourage physicians from certifying "old age" as the cause of death if the patient is very old (chronologically or biologically) and there is no other apparent explanation of the death.

2004-11-30_05 Congenital rubella syndrome and WHO health target

(Chapter XVI)

[Question from Monika Diebold, Switzerland:]

A person born in 1956 with
1a Cardiac insufficiency due to
1b Congenital rubella syndrome with multiple malformations
 
Our coding team agreed to code this case P35.0 as underlying cause. However, we received objections from partners outside our office who were afraid that this case would prevent Switzerland from reaching the aim of WHO to eliminate ccongenital rubella. We would be glad to know if others encounter similar problems and how you solve them. Thank you very much in advance.
[Comments:]
 
2005-01-18:

Cuba /Ana C. Mesa/:
P350 is correct. Codes don't exist for sequels of affections originating in the perinatal period

2005-01-11:

Sau Paulo Classification Centre /Ruy Laurenti/:
We completely agree with the comments from Lars. In this case the rubella occurred in 1956 and if one cross the diagnosis with the age of the deceased person it will be possible to verify that the disease occurred in the past!

2004-12-21:
 
Canada /Patricia Wood/:
I strongly agree with Lars Age that it would be detrimental to allow mortality classification to be influenced by political considerations such as the one described by Monika.  In this case the underlying cause of death originated in 1956!  I do not know the time line on the WHO initiative to eliminate congenital rubella but this particular case is clearly not a recent event.  I would not hesitate to code the underlying cause of death to P35.0!
 
Cyprus /Pavlos Pavlou/:
I think people in Switzerland should not worry about this case. I presume, the WHO, when confirming elimination of the disease, count new cases of, rather than deaths from congenital rubella. But, I also agree with Lars Age. Causes of death statistics are generated in order to influence policy. They should reflect the real situation. UC: P35.0

2004-12-07:

Sweden /Lars Age Johansson/:
I don't think our coding should be influenced by political considerations. If we were to avoid certain causes because they do not reflect well on the health state of our country, we would, in fact, make the mortality statistics useless as a source of information on the actual health situation and on its developments. In Sweden we had a similar problem in the early days of the HIV/AIDS epidemic, when a well-meaning official at the Ministry of Health advised doctors not to report AIDS on the death certificate, since that would stigmatise the patient. Once the official realised that the official numbers of deaths from AIDS/HIV were dependent on correct certification of death, the advise was withdrawn. Could a discussion on the uses of mortality statistics help in the rubella syndrome case as well?

2004-12-07_01 Dyspeptic syndrome obvious consequence of systemic lupus erythematosus

(Rule 3)

[Question from Brazil /Augusto Hasiak Santo/:]

Please consider the following death certificate that is being submitted to discussion:
 
Female, 30 years of age
I a) Hypovolemic shock
I b) Acute abdomen
I c) Dyspeptic syndrome
I d)
II   Systemic lupus erythematosus

We asked advice to a rheumatologist physician who informed that lupus does not attack usually the digestive system, but being possible the occurrence of abdominal vasculitis causing pancreatitis, mesenteric vasculitis, intestinal ischemia and even liver disease. Dyspepsia might be due to the use of medicaments. Should we consider dyspeptic syndrome a direct consequence lupus and apply Rule 3?
[Comments:]
 
2005-01-11:

Cyprus /Pavlos Pavlou/:
Having carefully read Rule 3 again, I do not feel justified in applying it to this case. I agree with Patricia Wood. Clarification would really be useful. I also suspect this is another example of physicians not being fully educated about the distinction between Part I and Part II, but one cannot be certain of the physician's intentions. If unable to obtain clarification I would (hesitantly) code K30 Dyspepsia as the UC. Dyspepsia is not in the "List of conditions unlikely to cause death".
 
2004-12-21:

Canada /Patricia Wood/:
This is the kind of case I always feel should be referred back to the certifier for clarification.  Perhaps he or she is just not aware of the fact that, as certified, the underlying cause of death for this record will be classified as K30, Dyspepsia.  I hesitate to speculate about the dyspepsia being an adverse effect of drug therapy without some more information from the certifier.  I realize that it is not always possible to get more information, but it would be really good in this case.
 
Cuba /Ana C. Mesa/:
Rule 3, M329 or M328?

2004-12-07_02 Code for hip infection

(Chapter XII)

[Question from England /Elaine Tower/:]

I am wondering if you can help on this death:

1a Old age
II Hip Infection
 
We have quite a few deaths where Hip Infection is mentioned, as in the above example, and we are wondering what would be the best code to use. There is no entry in the Index for Infection - Hip
[Comments:]
 
2005-01-11:

In relation to the question from Elaine Tower (old age and Hip infection) the Brazilian Center agrees with the comments from Lars. For us the u.c. is M00.9.
 
2004-12-21:

Canada /Patricia Wood/:
I notice that the NCHS ICD-10 index includes an entry:

Infection
- hip L089 (Local infection of skin and subcutaneous tissue, unspecified)
 
I wonder though if the infection is actually in the hip joint.  If that were the case, I like the entry (in both WHO and NCHS indices):
 
Infection
- joint - see Arthritis, infectious
 
Arthritis
- infectious or infective M009 (Pyogenic arthritis, unspecified)
 
Sweden /Lars Age Johansson/:
We have assumed that "hip infection" refers to the joint rather than to the skin, and our coding system assigns M009. If there is a mention of skin or ulcer we will not make this assumption, of course.
Comments