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2005-01-11_01 Caesarean section with amniotic fluid embolism

(Chapter XV)

[Questions from Germany /Stefanie Weber/:]

I do have a problem with maternal mortality after caesarean section. As we hardly see those and the cases hit the newspapers we want to be extra careful in coding.
 
1a    circulatory shock
1b    amniotic fluid embolism  
1c    caesarean section
 
We would code this one to O88.0 but the question is if we can assign Y69 for external cause?
[Comments:]
 
2005-02-18:
 
Sao Paulo Classification Centre /Ruy Laurenti/:
In the first case the u.c. was the cause for which the cesarean section was performed. It is necessary to get information with the physician who fulfill the death certificate. However if we have not this clarification the u.c is 075.4. For multiple cause the external cause to be code is Y83.8

2005-01-25:

Canada /Patricia Wood/:
I understand Stefanie's dilemma - in Canada we have fewer than 20 maternal deaths a year but they attract a lot of attention and can be the most difficult cases to code!  I am not sure that I am right in the codes I suggest and I think that if I had these records to code I would have sent them to the forum also!
 
In the first case, assuming that the certifier has correctly represented the sequence of events leading to death, the shock is a complication of the amniotic fluid embolism which is a complication of the operative delivery. I would code the underlying cause of death as O75.4, Other complications of obstetric surgery and procedures.  If the amniotic fluid embolism is in fact the indication for the C-Section I would code the underlying cause of death as O88.1.  I think that Martii's suggestion to seek clarification is very good.  I would not assign Y69 to this case in the multiple causes codes as there is no indication of a misadventure, rather an abnormal reaction or later complication.  I think that much is included in the title of the code O74.5 so I would not code Y83 either.
 
In the second case there is no indication of a condition requiring the C-section so I would code the underlying cause of death to O75.1, Shock during or following labour and delivery as this may be a little more specific that O75.4.  I would not include an external cause code for this case either ...
 
Cuba /Ana C. Mesa/:
1. O881 
2. O751-Y838
I agree totally with the proposal of Lars 
 
USA /Julia Raynor/:
Question 1 from Stefanie Weber, Germany:
Line b)  Amniotic fluid embolism is reported due to the caesarean section and we would consider it as a complication of the caesarean, not the reason it was performed. Indexed in Volume 3 as Complication, obstetric, procedure (instrumental) (manual) (surgical) specified NEC O75.4.  Since we would code it as a complication instead of a misadventure, we would not also code Y69.
I agree with Martti's suggestion to query for more information. Underlying Cause O75.4
 
2005-01-18:

England /Elaine Tower/:
For the first death we would assume that the caesarian was done for the amniotic fluid embolism O88.1 We would not add another operation code. In the second death there is no reason so we would code to the complication of labour and delivery O75.1 as instructed on page 60 Vol 2.
 
Nordic Classification Centre /Martti Virtanen/:
O88.0 is wrong, amniotic embolism is O88.1.
 
However, as the cases are recorded both say that the underlying cause is Cesarean section. Because of Cesarean section the amniotic fluid embolism and circulatory shock can only occur if there has been a direct misadventure during the operation. In that case the underlying cause should be Y60.0 'Unintentional cut, puncture, perforation or haemorrhage during surgical and medical care - during surgical operation.
 
But! Amniotic embolism and haemorrhage causing shock may occur during delivery in the absence of cesarean section. If the indication of the operation was the acute emergency because of bleeding or embolism, the death certificates should have amniotic fluid embolism and bleeding as 1c and cesarean section as 1b.
 
As this is extremely sensitive matter I would consult the hospital and ask them to clarify the matter. At least here in Finland the way the matter is presented in the death certificate would make it a police matter.
 
Sweden /Lars Age Johansson/:
If I understand the ICD correctly, a section cannot be coded as the underlying cause. Either you code to the cause of the section, or, if you do not know the cause, you code to the complication (O88.1 and O75.1, as you coded your examples). Since O80-O84 are not intended for mortality, you will lose the fact that a caesarean section was performed. I wonder if a solution might be to lift the restriction on O80-O84 for mortality? Let's bring that to the MRG.
 
Since they have reported complications due to a surgical procedure, but have not said anything about mistakes or misadventures at the time of the procedure, I would use Y83.8 rather than Y69.

2005-01-11_02 Caesarean section with intraoperative circulatory shock

(Chapter XV)

[Questions from Germany /Stefanie Weber/:]

I do have a problem with maternal mortality after caesarean section. As we hardly see those and the cases hit the newspapers we want to be extra careful in coding.
 
1a    hypoxic brain damage (brain death)
1b    intraoperative circulatory shock
1c    caesarean section
 
We would go for O75.1 but again have the question if Y69 can be added as external cause?
[Comments:]
 
2005-02-18:
 
Sao Paulo Classification Centre /Ruy Laurenti/:
In the case nº 2 the u.c. is 075.1 and in the case of multiple codification Y83.8
 
2005-01-25:
 
Canada /Patricia Wood/:
I understand Stefanie's dilemma - in Canada we have fewer than 20 maternal deaths a year but they attract a lot of attention and can be the most difficult cases to code!  I am not sure that I am right in the codes I suggest and I think that if I had these records to code I would have sent them to the forum also!
 
In the first case, assuming that the certifier has correctly represented the sequence of events leading to death, the shock is a complication of the amniotic fluid embolism which is a complication of the operative delivery. I would code the underlying cause of death as O75.4, Other complications of obstetric surgery and procedures.  If the amniotic fluid embolism is in fact the indication for the C-Section I would code the underlying cause of death as O88.1.  I think that Martii's suggestion to seek clarification is very
good.  I would not assign Y69 to this case in the multiple causes codes as there is no indication of a misadventure, rather an abnormal reaction or later complication.  I think that much is included in the title of the code O74.5 so I would not code Y83 either.
 
In the second case there is no indication of a condition requiring the C-section so I would code the underlying cause of death to O75.1, Shock during or following labour and delivery as this may be a little more specific that O75.4.  I would not include an external cause code for this case either ...
 
Cuba /Ana C. Mesa/:
1. O881 
2. O751-Y838
I agree totally with the proposal of Lars 
 
USA /Julia Raynor/:
 
Question 2 from Stefanie Weber, Germany:
Line b) We would consider the intraoperative circulatory shock as the complication of the caesarean section and code O75.4 as indexed under Complication, obstetric, procedure. We would not code Y69. 
 
2005-01-18:

England /Elaine Tower/:
For the first death we would assume that the caesarian was done for the amniotic fluid embolism O88.1 We would not add another operation code. In the second death there is no reason so we would code to the complication of labour and delivery O75.1 as instructed on page 60 Vol 2.
 
Nordic Classification Centre /Martti Virtanen/:
O88.0 is wrong, amniotic embolism is O88.1.

However, as the cases are recorded both say that the underlying cause is Cesarean section. Because of Cesarean section the amniotic fluid embolism and circulatory shock can only occur if there has been a direct misadventure during the operation. In that case the underlying cause should be Y60.0 'Unintentional cut, puncture, perforation or haemorrhage during surgical and medical care - during surgical operation.
 
But! Amniotic embolism and haemorrhage causing shock may occur during delivery in the absence of cesarean section. If the indication of the operation was the acute emergency because of bleeding or embolism, the death certificates should have amniotic fluid embolism and bleeding as 1c and cesarean section as 1b.
 
As this is extremely sensitive matter I would consult the hospital and ask them to clarify the matter. At least here in Finland the way the matter is presented in the death certificate would make it a police matter.
 
Sweden /Lars Age Johansson/:
If I understand the ICD correctly, a section cannot be coded as the underlying cause. Either you code to the cause of the section, or, if you do not know the cause, you code to the complication (O88.1 and O75.1, as you coded your examples). Since O80-O84 are not intended for mortality, you will lose the fact that a caesarean section was performed. I wonder if a solution might be to lift the restriction on O80-O84 for mortality? Let's bring that to the MRG.
 
Since they have reported complications due to a surgical procedure, but have not said anything about mistakes or misadventures at the time of the procedure, I would use Y83.8 rather than Y69.

2005-01-18_01 Fall from ladder hit by tractor

(Chapter XX)

1. [Question from Cuba (C175/12/04), forwarded by Roberto Becker:]

We discussed the case below in Forum-CIE and could not reach a consensus.
 
We have the following case:
Picking citrus in a grange, mounted in a ladder, a tractor with a trailer touched in passing and threw down the ladder, falling, then died. How to code?
 
We got different interpretations, with the following codes suggested:
V09.0
V84.9
V89.0
W11.7

What do you say?
[Comments:]
 
2005-03-01:
 
PAHO /Roberto Becker/:
 
This is a very interesting case.
I circulated MF answers on the "ladder X tractor" case in Forum-CIE. I think that it would be interesting for the MF group to see the opinions I got in Forum-CIE. Below is a translation to English.
=============================================
According to what was announced, below we have more opinions and comments on the case. We still don't have a consensus and I think it will be difficult to get it. It seems to be one of those cases that do not fit perfectly in any rule, note or code. I maintain my opinion, which is at end of the text.
Roberto Becker
=============================================
Comments received from Margaret Hazlewood, HQ/PAHO:
 
I support using W11.7.
The rubric in V09 indicates a "pedestrian." The ICD's definition of pedestrian includes "users of a pedestrian conveyance," for example. The deceased was on a ladder. V89 relates to a person injured in an "unspecified" motor vehicle accident; the specified vehicle is a tractor.The title of V84 refers to an "unspecified" occupant.  He was not an occupant of the tractor.  Reviewing how the V codes are constructed is Insightful. (Page 576 in Vol.
3). I agree that from the public health point of view, the focus should be on the tractor trailer as the culprit.  Indeed, it did set in motion the train of events that led to death. But finding the correct code is quite another matter.  The use of the data is one criterion that can determine the most meaningful underlying cause of death. This is a very though-provoking case.
==============================================
Comments received from Forum-CIE participants, translated from its original version, Spanish to English:
 
R175/12/04
I consider V09.0 the appropriate code, when I see that:
 - the injured person was a pedestrian (was not driving any vehicle at the time of the accident and was mounted in a ladder). (See definition (e) Vol.1 CIE-10.
 - the vehicle was a tractor (special vehicle mainly used in agriculture) (definition u).
-  the accident begins when the tractor touch the ladder and knocks down the person, which means that the tractor was the underlying cause. The exclusion note on W00-W19 is why it should not be assigned to W11.  When the fall is in or from transport vehicle, it sends it to V01-V99. (Yolanda Pérez Marcano - Venezuela)
 
It is complicated indeed to code to any of the categories proposed by  Cuba.
 
I think, based on the definitions of transport accident, that the first, V09.0, is the correct:
- V09.0 (pedestrian injured in nontraffic accident involving other and unspecified vehicles). The victim is a pedestrian; see coding instruction 3 on Vol 1: "Were transport accident descriptions do not specify the victim as a vehicle occupant and the victim is described as: ... knocked down... by any vehicle including... tractor... classify the victim as pedestrian (categories V01-V09)"
- V89.0: in this case we lose the most important information, about the victim.
- W11.0: we lose the information about the vehicle and it is classified like a simple fall from ladder, when the true cause of the fall was the tractor.
(Jorge Lara Báez/CEMECE - Mexico)
 
We would code V09.0, because in spite the person is in a ladder, he/she should be considered a pedestrian involved in a nontraffic motor vehicle accident.
(Olga Araya Umaña - Costa Rica)
 
In this case, I would not code V09.0 because the victim is not a pedestrian, according to what is defined on Volume 1, definition e and not even appears in the inclusion terms. I would not codify either V89.0 because this subcategory is for unspecified vehicle and we know it was a tractor. It would be nontraffic if one consider transport accident. I would code W11.
(Velia Emperatriz - Nicaragua)
 
This case cannot be considered a transport accident (V01-V99). I think that the suitable code is W11.7, considering there was a fall from a ladder which caused the death.
(Sara Cerdeira Caramés - Galicia/España)
 
Surely it is not V09.0 nor V89.0. This is a fall from a ladder and the most appropriate code is W11.7 although are not very satisfactory.
(Ruy
Laurenti/CBCD - Brasil)
================================
Comments - Roberto Becker/PAHO
 
Very interesting case: 3 opinions for V09.0 (pedestrian, transport accident) and 3 for W11.7 (fall from ladder). But there are other possibilities. Obviously if we had a specific code for a person knocked down from a ladder by a tractor in a farm, we would need no discussion. But ICD would have perhaps about 100.000 codes. Therefore, it is important to define the most relevant information we can get from the case, to be coded as the underlying cause. The victim (pedestrian?), the vehicle (tractor) or the fall (ladder)?
Only multiple coding will offer the complete information. To me, it seems clear that we should consider as transport accident (nontraffic), since it was informed that the fall was caused by a tractor in movement. Thus, W11 should be only used as an additional code in multiple coding. Now, we need to define if the victim was a pedestrian or not. Although the definition offered in Vol. 1 can allow, more by exclusion than by inclusion, to consider the case as pedestrian, it does not seem very convincing. If we did not consider as pedestrian, we have the problem that the victim was not an occupant of the vehicle, which is not "no specified", but perfectly defined (thus, information is lost with V89.0). It is interesting to notice that categories V80-V86 (and their subcategories) include the word "occupant", but that does not happen with V87-V89, that mention "victim's mode of transportation unknown" and/or "injured person". That was an accident involving vehicle for use in agriculture; for what we have the category V84.-. Although the subcategories mention "occupants", by the index (Vol. 3) we can obtain the following: Accident
- transport
- - agricultural vehicle (nontraffic) V84.9
- vehicle
- - special
- - - agricultural NEC V84.9
 
As we can see, none of the 3 proposed codes initially, nor V84.9 seem ideal. Nevertheless, since I consider that in the case, the most important information is the one that it was an accident involving an agricultural vehicle, I would code the underlying cause V84.9, using V09.9 and W11.7 as additional codes. I am going to send the case to the Mortality Forum, circulating later the answers received. Once again, we have situations in which consensus is not reached, but at the same time we must use them to improve the Classification, with updates or in the preparation of the next revision.
 
2005-02-08:

Cyprus (Pavlos Pavlou/:
I think V09.0 is correct. This is an accident involving (as victim) a pedestrian in a collision involving a non-traffic motor vehicle. The
description of what the victim was doing at the time of injury conforms with the definition of "pedestrian" as given in ICD-10 (page 1019).
 
England /Elaine Tower/:
We agree with Lars, V09.0 &  W11.7 as a pedestrian in a non-traffic motor accident and a fall from a ladder.

2005-01-25:

 
Sweden /Lars Age Johansson/:
According to definition (a) on p 1018 in Vol 1 a transport accident is "any accident involving a device designed primarily for ... conveying persons or goods ...". Since the death certificate does not say otherwise, I would assume that the tractor was used to convey persons or goods at the time of the accident, and code the death as a transport accident. Further, I would see this as a nontraffic accident (definition (d) on p 1019), since it did not occur on a public highway. Also, "pedestrian" is defined as "any person
involved in an accident who was not at the time of the accident riding in or on a motor vehicle, railway train, streetcar or animal-drawn vehicle" (definition (e) on p 1019). With all this taken together, I would see this as a collision between a pedestrian and a "special vehicle mainly used in agriculture" (definition (u), p 1022). Pedestrian injured by special vehicle is an inclusion term under V09, so I would choose V09.0, pedestrian injured in nontraffic accident involving other and unspecified motor vehicles.

2005-01-18_02 Code for victims of tsunami

(Chapter XX)

[Question from Lars Age Johansson, Sweden]
 
Although most of the victims of the recent tsunami disaster were local residents, a substantial number were tourists, including many Swedes. The morbidity classification team at the National Board of Health and Welfare has received a number of questions from Swedish hospitals on how to code the external cause of the injuries, a problem that will soon concern us in mortality as well.
 
Several problems have been raised. First, are we to code the earthquake that caused the flood, or the tsunami? The disaster started with an earthquake, so you could argue that the earthquake is the originating cause, but on the other hand, those killed or injured were not victims of the earthquake itself but of the tsunami.

Second, if we decide to code to the tsunami rather than to the earthquake, which code should we use? X38 (Victim of flood) is one obvious option, but in X39 (Exposure to other and unspecified forces of nature) "tidal wave" is given as an inclusion term. On many internet sites you can see the tsunami referred to as a tidal wave, but there are also quite a few web pages where it is claimed that "tidal wave" is not a proper description of the tsunami, since it was caused by an earthquake and not by the tide. My English (British) dictionary is of the same opinion. What do our native English speakers think - X38 or X39?

[Suggested coding:]
 
Cuba   X34
England  X39
Germany       X34/X39
Malta   X39
Sao Paulo Ctr  X34
USA   ?

[Comments:]
 
2005-02-15:

Germany /Robert Jakob/:
Ana's proposal sounds very tempting.
 
2005-02-08:

Sao Paulo Classification Centre /Ruy Laurenti/:
Regarding the question "earthquake" and "Tsunami" I would code the earthquake, for mortality, as the underlying cause, because it was the originating cause. I think that when occurred a succession of accidents the u.c. is the first accident. The final codification for me is: X34 (uc) and X39 (a consequence of the u.c)
 
Cuba /Ana C. Mesa/:
The starting point was the earthquake. However not all the deaths are direct consequence of it, because as it seems to be, most occurred because the "ground swell". There is not a single code on the ICD that can fully express this situations. If those events are not rare, and occur many times the same way: Earthquake - Ground Swell - Mud avalanche, etc., why don't we think in creating specific subcategories for X34?
 
X34.0 Earthquake causing ground swell
X34.1 Earthquake causing avalanche, landslide and other earth movements
X34.2 Earthquake causing ....
X34.9 Earthquake, unspecified
(The professor Dr Becker gave me help in the translation )
 
Sweden /Lars Age Johansson/:
I wonder if X34 is the best code. It is true that the chain of events started with the earthquake, but we generally do not follow the chain of events longer back than to the first thing that happened to the injured person. For example, if someone slips on an icy sidewalk, we code that to the fall (W00) and not to effect of cold weather (X31). But I certainly agree that we would need a clarification in the ICD.

2005-01-25:

 
England /Elaine Tower/:
Regarding the Tsunami we would code to the X39 as tidal wave is an inclusion term.

Germany /Robert Jakob/:
According to Merriam-Webster's Online Dictionary "tidal wave" is "
1 a : an unusually high sea wave that sometimes follows an earthquake,
b : an unusual rise of water alongshore due to strong winds" and it is the same for my dictionary and for the use of "tidal wave" in German.
 
X39 includes "tidal wave NOS "
X38 Excludes:  ...tidal wave: · NOS ( X39.-)· caused by storm (X37.- )
 
Following the logic for the tidal wave caused by a storm - leading to X37 "Victim of cataclysmic storm " why should a tidal wave caused by an earthquake no be excluded the same way and be coded to the underlying cause, "X34   Victim of earthquake". “NOS” means “not otherwise specified”, implying “unspecified” or “unqualified”. A Tsunami is a tidal wave caused by an earthquake. It is very well specified. So the tabular list in my opinion would implicitely lead to X34 but without interpretation leads to X39.
 
The alphabetical index tells
"Tidal wave (any injury) NEC X39.-
¯ caused by storm X37.-".
As the tidal wave caused by an earthquake is not elsewere classified, the correct code for the tsunami according to the alphabetical index would be the X39.
 
As a result
"X39- Exposure to other and unspecified forces of nature
Includes: natural radiation NOS
              tidal wave NOS"
would be the code for the tsunami.
 
Malta /Kathleen England/:
I have looked up the exact definition of Tsunami, which is described as  a 'habour wave', so there is no exact code for this in ICD-10. Other internet sites describe it as a tidal wave which is probably less exact. In the case of Malta we had 1 death caused by the Tsunami, who died a few weeks later as a result of complicated fractures and due to having swallowed an amount of water. Personally I think I would prefer X39 "TIDAL WAVE' as X38 is more specific to storm. The exact definition would probably be a tidal or habour wave caused by an earthquake but this does not exist in ICD. One can code to the originating cause that is the earthquake, however this would not differentiate from deaths caused just by an earthquake.
 
USA /Julia Raynor/:
I agree it seems that X34, Victim of earthquake should be limited to victims at the site of the quake. X38 or X39 does not seem to be sufficient to record the event that occurred. I do not have the answer to the correct category assignment but I suggest it is necessary to add some Inclusions/Exclusions for clarification. 

2005-01-25_01 Caesarian section and breast cancer - maternal death?

(Chapter XV)

/Questions from Patricia Wood, Canada/:
 
1a) Cardiorespiratory failure 2 days
1b) Sepsis   2 days  
1c) Breast Cancer  
 C-Section 1 day prior to death noted in Other Medical Particulars
 
I would like to submit them to the Mortality Forum for discussion as we have had a few maternal deaths lately. 

[Suggested coding:]
 
  Underlying   Multiple
Sao Paulo Ctr O998     C509 A419
Cuba   C509       J960/A419/C509
Sweden     O998     R092/A419/C509

[Comments:]
 
2005-02-08:

Sao Paulo Classification Centre /Ruy Laurenti/:
We have a similar case here in São Paulo. The C-session (in our case) was performed in order to facilitate the delivery. We considered a case of Indirect Obstetric Death and code as u.c: 099.8 and for multiple codification it was also coded the "Breast Cancer" and "Sepsis".
                           
Cuba /Ana C Mesa/:
 
1a) Cardiorespiratory failure  2 days  J96.0
1b) Sepsis   2 days A41.9
1c) Breast Cancer       C50.9
C-Section 1 day prior to death noted in Other Medical Particulars
Underlying cause C50.9
Pregnancy- related death.
 
Sweden /Lars Age Johansson/:
In the Mortality Forum we have had a couple of similar cases, that is, deaths in pregnant women but where the cause of death apparently has little to do with the pregancy. People have suggested very different codings, and because of that we brought the issue to the Mortality Reference Group. After long discussions the MRG finally decided that all deaths in pregnant women, except from the causes listed on p 721 of Volume 1, should be classified to Chapter XV. The MRG also said that full detail should, if possible, be retained in the multiple cause codes. In Patricia's first case a pregant woman dies from breast cancer, and the underlying cause will be O99.8 (C00-D48 are included under O99.8, see p 764). In the second I would use O99.4, since the "normal" underlying cause would have been I60.8.

2005-01-25_02 AV-malformation brain and pregnant - maternal death?

(Chapter XV)

/Questions from Patricia Wood, Canada/:

1a) Intracerebral Hemorrhage
1b) Arterio-venous malformation Right Brain
Death occurred during pregnancy - indicated "yes" on the Pregnancy Particulars Field. Notation from coroner that the decedent was in her 3rd trimester of an uncomplicated pregnancy.

I would like to submit them to the Mortality Forum for discussion as we have had a few maternal deaths lately. 

[Suggested coding:]
 
  Underlying  Multiple
Sao Paulo Ctr O994 I619 or I608/Q282
Cuba    O994/O998  
Sweden    O994    I619/Q282

[Comments:]

2005-02-08:
 
Sao Paulo Classification Centre /Ruy Laurenti/:

This case, in my opinion, is also an Indirect Obstetric Death and the u.c is 099.4.

Cuba /Ana C Mesa/:
 .
1a) Intracerebral Hemorrhage   I61.9/I60.8 ?
1b) Arterio-venous malformation Right Brain Q28.2
Q28.2 Excludes:
          Ruptured:
          . cerebral arteriovenous malformation I608 Q28.2........Chapter XV
O99.8 I60.8..........Chapter XV O99.4 Underlying cause O99.8 or O99.4 ?
When it is transferred to the Chapter XV? before or after applying the modification rules? Indirect obstetric death.
 
Sweden /Lars Age Johansson/:
In the Mortality Forum we have had a couple of similar cases, that is, deaths in pregnant women but where the cause of death apparently has little to do with the pregancy. People have suggested very different codings, and because of that we brought the issue to the Mortality Reference Group. After long discussions the MRG finally decided that all deaths in pregnant women, except from the causes listed on p 721 of Volume 1, should be classified to Chapter XV. The MRG also said that full detail should, if possible, be retained in the multiple cause codes. In Patricia's first case a pregant woman dies from breast cancer, and the underlying cause will be O99.8 (C00-D48 are included under O99.8, see p 764). In the second I would use O99.4, since the "normal" underlying cause would have been I60.8.

2005-02-08_01 Code for B-cell lymphoma of tonsil

(Chapter II)

[Question from Kathleen England, Malta:]
 
I have a death certificate of a 72 yr old female who died from B-cell lymphoma of the tonsil. What should be the underlying cause of death : C09.9 or C85.1?
[Comments:]
 
2005-02-22:

Sao Paulo Classification Centre /Ruy Laurenti/:
Related to the case from Kathleen England (Malta): For the Brazilian Center the better code is C85.1 because it is more specific (lymphoma). The code C09.9 give us only the localization and not the type.

2005-02-15:

Belgium /Josiane Mornie/:
C85.1.
 
Canada /Patricia Wood/:
When coding malignant neoplasms the morphological term, in this case "lymphoma", is the lead term to use looking in the index.  The modifiers listed under Lymphoma further qualify the type of lymphoma, in this case "B-cell", but they do not specify site.  There is no cross-reference to the Neoplasms table so B-cell lymphoma should be coded as C85.1
 
Cuba /Ana C. Mesa/:
"In Chapter II neoplasms are classified predominantly by site within broad groupings for behaviour. In a few *exceptional* cases morphology is indicated in the category and subcategory titles (Vol 1, p 182)." Underlying cause C851. Note this clarification for the coder when priority should be given to the codes C81-C96.
 
Germany /Robert Jakob/:
Malignant Lymphomas and Leukemias are to be coded according to their histology. Thus C85.1 would be the right code.
 
WHO /André L'Hours/:
Morphologies in C81-C96 are assigned to the morphologigal type and not to the site. For example, lymphosarcoma of the stomach is assigned to C85.0 not C16.9

2005-02-15_01-03 Code for malignant neoplasm of placenta

(Chapter II, XV)

[Question from Ana C. Mesa, Cuba:]

[In a comment on question 2005-01-25 Q1-2, Lars Age Johansson wrote:] "After long discussions the MRG finally decided that all deaths in pregnant women, except from the causes listed on p 721 of Volume 1, should be classified to Chapter XV." Also when the undelying case is Malignant neoplasm of placenta C58?
 
1) 20 years
Cause:
a) Hypostatic pneumonia J182 15 days
b) Malignant cachexia C80   2 months
c) Malignant neoplasm of placenta  C58 8 months
Underlying cause C58 or O998 ?  

2) 20 years
Cause:
a) Hypostatic pneumonia J182 15 days
b) Malignant cachexia C80  3 months
c) Malignant neoplasm of placenta  C58 2 years
Underlying cause C58 or O97 ?  

3) 65 years
Cause:
a) Hypostatic pneumonia J182 15 days
b) Malignant cachexia C80 3 months
c) Malignant neoplasm of placenta  C58 25 years
Underlying cause C58 or O97 ?  

[Comments:]
 
2005-03-01:
 
Ruy Laurenti /Sao Paulo Classification Centre/:
More or less two years ago I presented to the MRG some comments and proposals related to Maternal Mortality based on the preliminary results of an investigation about Mortality of women 10 -49 years old with emphasis in the Maternal Mortality.
 
Now we have just finished the majority of the analysis of the results (final results). There are very interesting things and it is our intention to present other proposals to MRG.
 
Today I only will present some results about pregnancy and external causes of death (summarized).
 
It was investigated 7.332 deaths of women 10 to 49 years old residents in the 26 capitals of states of Brazil and in the Federal District (Brasilia), occurred in the first semester of 2002. For each death it was done a household interview with the family of the deceased woman in order to fill a form with the complete identification, demographic data, family composition, history of all the pregnancies, it she was pregnant when she died or if she had been pregnant in the 12 months preceding the death; pre-natal care, medical, hospital and other medical care and other data.
 
After the family interview, physicians who assisted the woman were interviewed and all the documentation like medical records, results of exams, autopsy reports, and other information were collected.
 
From the total of 7,332 females deaths (10-49 years old), 6,869 hadn't been pregnant or give birth within a year before the death (group 1). Among the women that were at the expanded pregnancy-puerperal-cycle (till one year after the delivery or abortion), 239 died of obstetric causes and 224 of non-obstetric (group 2).
 
Excluding the deaths due to maternal causes, it was compared the causes of deaths of the groups 1 and 2. (group 1 had not a pregnancy or delivery in the past 12 months prior the death and group 2, that had a pregnancy).
 
Our attention was called to the difference in the percentage of deaths due to external causes: 15,5% in the group 1 (without delivery) and 33,5% in the group 2 (with delivery in the preceding 12 months).
 
The following was observed according the type of external causes in the two groups
 
  Group 1  Group 2
Accidents    7,1%  7,2%
Homicides  5,8%  19,2%
Suicides   2,6%   7,1%
External Causes 15,5%  33,5%
Note: % of deaths related to the total death in each group.

In the deaths due to Malignant neoplasms and cardiovascular diseases occurred the reversal:
 
Malignant neoplasm     25,5% 17,9%
Cardiovascular diseases   20,5% 11,6%
 
In these two cases on possible explanation is that the women with those diseases prevented the pregnancy.
 
The Brazilian Center has the intention to follow a sample of women during a 12 months period after the delivery or abortion in order to describe the cases and causes of death (excluding maternal causes) with special attention to external causes. The sample will be selected in Maternity hospitals.

2005-02-22:

Sweden /Lars Age Johansson/:
The understanding of the MRG is that if a woman dies from a malignant neoplam of the placenta, and more than 42 days has elapsed since the termination of her last pregancy, the death is to be classified to C58. The neoplasm would not have developed, of course, if the woman had not been pregnant, but it is strictly speaking not a complication of childbirth. According to the information we got in the MRG, the vast majority of placenta neoplasms develop after childbirth.

2005-02-15_04 Code for Staphylococcus aureus

(Chapter I)

[Question from Pavlos Pavlou, Cyprus:]

Dear mortality forum. Can you please help with this certificate?
90 year old woman. Resident in long-stay institution.
 
Ia) Cardiac arrest
Ib) Pulmonary oedema
Ic) Staphylococcus aureus
II    --------------
 
We would code this as UC: A48.8, Other specified bacterial diseases. Any other views?
[Comments:]
 
2005-03-01:
 
Cuba /Ana C. Mesa/:
OK! A490

2005-02-22:

Cuba /Ana C. Mesa/:
 
Ia) Cardiac arrest   I469
Ib) Pulmonary oedema J81   CUBA I501
Ic) Staphylococcus aureus A498/B956
II    --------------  
UC A498, the disease is not specified.
                 
Sweden /Lars Age Johansson/:
I agree with Ana that the entry on line 1c should be read as "unspecified disease caused by infection by Staphylococcus aureus". However, I would use A49.0 (Staphylococcal infection, unspecified) rather than A49.8 (Other bacterial infection of unspecified site).

2005-02-15_05 Code for Li-Fraumeini syndrome

(Chapter IV)

[Question from Grethe Westby, Norway:]
 
How would you code Li-Fraumeini-syndrome? This is a hereditary condition in chromosome 17, a mutation in the gene for p53 that reduces the resistance against malignancy of this proteine. The death certificate we have got is for a woman of 37 years with a malignant neoplasm of pancreas, and with Li-Fraumeni syndrome stated as underlying cause of death.
[Comments:]
 
2005-02-22:

Cuba /Ana C Mesa/:
Li-Fraumeni syndrome=Peutz-Jeghers syndrome Volume 2 Q858
UC C259
Cause antecedent Q858
 
Similar example:
Liver cell carcinoma    C220
Cirrhosis postnecrotic K746
Hepatitis B acute        B169
 
Rule 2                        C220
Cause antecedent       B169

 
Sweden /Lars Age Johansson/: According to a couple of websites I have checked, Li-Fraumeni and Peutz-Jegher are not identical syndromes, although both are associated with an increased risk of cancer. I'm not at all sure which code to use for the syndrome, very tentatively I would suggest Q99.8 (Other specified chromosome abnormalities). I agree with Ana that the underlying cause would still be C25.9 (malignant neoplasm of pancreas), since according to Vol 2 p 68 (b) a malignant neoplasm should not be considered as caused by any other condition, except HIV. Similarly, Rule 2 gives C22.0 as the underlying cause in Ana's second example.

2005-02-22_01 Code for Schimke syndrome

(Chapter XVI)

[Question from Josie Mornie, Belgium:]

Dear Forum,
We have a little girl ° 2001 with "Schimke Syndrome" = immuno-osseous-dysplasia. As advised by a professor of genetics, it is not chromosomal but a defect on one specific gene. How to code this?
Thanks!
[Comments:]
 
2005-03-01:
 
Cuba /Ana C Mesa/:
Consulted in ORPHANET: synonymous Spondyloepiphyseal dysplasia Q777?
 
Germany /Stefanie Weber/:
Dear Josie, as the disorder results in multisystem disorder (mainly bone dysplasia, nephropathy and T-cell deficiency) with changing severeness of the different disorders, I would go for Q87.8. As the genetic testing is only experimental and the diagnosis is based on clinical criteria, I would not use the Q99.8.

2005-03-01_01 External cause code for food allergy

(Chapter XX)

[Question from Elaine Tower, England:]

We have a death we would like some help on
 
1a Aspiration pneumonia
1b Vomiting
 
This lady died whilst in respite care following an ileostomy. She was intolerant to certain foods including mushrooms. She also suffered from Multi Infarct Dementia. She ate mushrooms and she vomited on taking to hospital and being admitted she died 3 days later of aspiration pneumonia caused by the vomiting. The risks associated with her eating mushrooms had not been fully recognised.
 
Food allergy  = T78.1. Would the external code be X49? Although we do not like this as it is a poisoning code and not an intolerance to food type of code.
 
How would others code this?
[Comments:]
 
2005-05-17:
 
Sao Paulo Classification Centre /Ruy Laurenti/:
For us the code X49 is not a good code for the case of  vomiting (1b) and aspiration pneumonia (1a). Why not the code W78 (Inhalation of gastric contents)? In the alphabetic index (pag. 318) there is: "Intolerance - food K90.4". In volume 1 (tabular list) K90.4: malabsorption due to intolerance, not elsewhere classified". We think that K90.4 is not for this case. The final resolution for the Brazilian Center is W78.
 
2005-03-08:
 
Cuba /Ana C. Mesa/:
The death certification says
 
a) Aspiration pneumonia  J690 (It is complication)
b) Vomiting  R11

Answer 1:
General Principle R11
Rule A J69.0
UC: J69.0
 
Considering the additional information:
Answer 2:
UC X58/T781 (There is not poisoning)
Additional code: Z91.0/F01.1/J69.0/R11/Z43.2
 
Answer 3:
UC J69.0
Additional code: T78.1/Z91.0/F01.1//R11/Z43.2
 
Answer 4:
UC F01.1
Additional code J69.0/T78.1/Z91.0/R11/Z43.2
A person with dementia doesn't possess control of if same

I think
UC J69.0  because, the risk associated with her eating mushrooms had not been fully recognised Additional codes: R11/T78.1/Z91.0/Z43.2/F01.1

Sweden /Lars Age Johansson/:
As is clear from Ana's four different solutions to Elaine's question, food allergies are extremely difficult to code in ICD-10. It won't help Elaine much right now, but we have just placed the issue of food allergy and anaphylactic shock due to food on the agenda of the Mortality Reference Group.

2005-03-01_02 Tabulation of cardiac arrest

(Chapter IX)

[Question from David Lidsky, Israel:]
 
There has been extensive discussion on the Mortality Forum of the possibility of taking cardiac arrest as the underlying cause of death (coded as I46.9) when it appears alone in Part 1 of the certificate (see our posting of 2002, 2002-03-04_01).
 
To a large degree (in those cases where other diagnoses appear in part 2) this problem has been solved by the decision of  the Heads of the Collaborating Centres to classify cardiac arrest as an ill-defined cause. However, in our experience, there still remain those cases in which cardiac arrest appears in part 1 as the sole diagnosis on the certificate, and they cause us disquiet.
 
We present our mortality statistics to WHO classified according to Mortality tabulation list 2. If cardiac arrest is the only diagnosis, taking I46.9 as underlying cause might artificially inflate the category of  "Other heart diseases". However, giving these cases a different code (for example R99) might have the opposite effect. We suspect that in many cases in which cardiac arrest is the only cause of death mentioned the certifier really means "sudden cardiac death". We cannot prove that, but if it is true there might be a significant loss of cardiac deaths in our final statistics if we do not use I46.9 in such cases.
 
Perhaps the solution is for the Mortality tabulation lists to be modified so that I46.9 no longer goes into the category of "Other heart diseases".
 
Do other countries encounter this problem?
[Comments:]
 
2005-05-17:

Sao Paulo Classification Centre /Ruy Laurenti/:
In Brazil our recommendation in the case of cardiac arrest is to ask the certified what was the cause of the cardiac arrest. If the certified does not answer we always code R99 (ill defined), when appear as the only cause in the death certificate.

2005-03-08:
 
PAHO /Roberto Becker/:
When we prepared the Spanish version of ICD-10, I introduced a note under Paro (the translation of "arrest")
- cardíaco I46.9 ("cardiac")
Here is the translation of the note:
"The code I46.9 should not be used for primary basic coding when the only information available in a death certificate is "cardiac arrest", unless there are clear evidences (from clinical or epidemiological investigation) that in this specific case it is probably a terminal manifestation of cardiac disease. If not, code R99 or R98 (for unattended death)"
 
As a consequence, some of South American countries that used to have 4-5% of general mortality "due to" cardiac arrest using ICD-9, now don't have any case. Of course the proportion of ill-defined causes increased, but when tabulating the data for analysis they can redistribute those ill-defined. This way, the part (probably in the same or in a very close proportion) of those "cardiac arrest", being really heart diseases, can "go back" to the correct place. With that we avoid the "inflation" of any category or group related to heart diseases. The large majority of the times that "cardiac arrest" appears alone in a death certificate, the physician simply mean "I
don't know the cause of the death"... It is possible that we are loosing some information, but I am quite sure that we are much more close to reality doing that, than coding the underlying cause I46.9. At the end, this is only one more "assumption" among hundreds of assumptions made by ICD rules, guidelines and notes. Some of them very questionable, indeed.
 
You may want to maintain the code I46.9 in the database for further investigation, so my suggestion is to use R99 as underlying cause and I46.9 as additional code (multiple coding) With regard to the Mortality tabulation list 2, as far as I know there are only few countries really using any of the short lists proposed in ICD-10 Vol. 1. My suggestion is to exclude I46.9 from any "cardiac" category in general tabulation lists. There are many other "ill-defined" codes outside Chapter XVIII ("R" codes) that in my opinion should go there. At least in ICD-11.

2005-03-29_01 Legal intervention and car crash

(Chapter XX)

[Question from Margaret Campbell, Australia:]

I've got a query about legal intervention deaths, specifically those involved in police car chases. The best code I could find was Y356 but then you lose the info about the transport accident. What do others think?


[Comments:]
 
2005-04-19:

Cuba /Ana C Mesa/:
I agree with Y356.

2005-04-12:
 
England /Elaine Tower/:
As you are aware we are governed by the verdicts and the manner of deaths given at the Coroners Inquests. We do not have set codes inplace, as such, for police chases. As for car chases - if the car crashed we would code to the transport accident codes V00 - V99
 
New Zealand /Claire Nicoll/:
We have discussed the issue of assigning legal intervention codes to accidents following police car chases and feel we would be guided in each case by the coroner's finding. If the coroner attributes the death as directly due to the actions of the police then we would code to Y356, otherwise we would code to the motor vehicle accident. In New Zealand the police generally only chase cars that are already speeding to such an extent that the driver is deemed to be endangering not only themselves but also other road users. We would therefore be reluctant to attribute any resulting accident as due to the legal intervention by police - the driver has made
the choice to continue driving unsafely rather than stop and give themself up to the police.  We can, however, see a case for coding to legal intervention if death results as a direct consequence of police actions - for example they ram the suspect's car and cause death, or road spikes are used to stop a car and this results in a fatal accident occurring. You can draw comparisons to other like situations that would not be coded to legal intervention - we recently had a case of a person jumping into a river to avoid arrest and they subsequently drowned. The deceased made an informed decision to leap into the water, they were not forced to, so we assigned the
death to drowning, not to legal intervention.  Similarly an inmate who commits suicide due to their distress at their incarceration, or imminent incarceration, would not be considered a victim of legal intervention.
 
2005-04-05:
 
Canada /Patricia Wood/:
Margaret is quite right, ICD-10 code Y356 does not allow us to capture the "car chase" part of the incident, but I think that it is the right code to use.  If we were to assign deaths resulting from police car chases to V01-V99 Transport accidents, we would lose the "police" part of the story. From a policy and prevention point of view it is probably the more important part to capture.  Is this an issue for ICD-11?
 
Sao Paulo Classification Centre /Ruy Laurenti/:
Relating the case from Margaret (Australia) for Brazilian Center the code is Y35.6. In this case the police car chases is more important than a transport accident.
 
Sweden /Lars Age Johansson/:
I agree with Ruy. The first thing we have to do when classifying a death due to external causes is to determine in which broad category it belongs - accident, intentional self-harm, assault, event of undetermined intent, legal intervention and operations of war, and so on. In ICD-9 there was an "includes" note on the block of legal intervention (E970-E978) that is not present in the 1992 version of ICD-10, but which the Update Reference Committee decided in 2003 to restore. It says that "legal intervention" includes "injuries inflicted by the police or other law-enforcing agents, including military on duty, in the course of arresting or attempting to arrest lawbreakers, suppressing disturbances, maintaining order, and other legal action." Since this clearly covers police car chases Y35.6 is the correct code. Of course I also agree that it is a pity to lose information on the collision or what else might have happened. Another issue is which code we would use if the injured person was one of the police and not the one the police tried to catch.

2005-03-29_02 Code for chronic bronchitis due to tobacco

(Chapter V, X)

[Question from Augusto Hasiak Santo, Brazil:]

How should "Tobacco chronic bronchitis" be coded?
(In Portuguese, "tobacco" becomes an adjective and the diagnosis is "bronquite crônica tabágica). This condition does not appear as such in the ICD-10 Index. Therefore, the first suggested code was J68.0. But "tobacco chronic bronchitis" is a composed word that may be considered as a "multiple-one-term entity". If we accept this way of classifying it, we should code both conditons, giving preference to tobacco as the first mentioned one (F17.2 J42). At last, the ICD-10 Index provides code for "smokers' (chronic) bronchitis", coded as J41.0. Which code is the more adequate?


[Comments:]
 
2005-04-19:
 
Cuba /Ana C Mesa/:
Volume 3, Portuguese Bronquite
- fumantes, dos J410
 
2005-04-12:
 
Germany /Stefanie Weber/:
In the German Index we code the paraneoplastic syndrome to C80 which I think is the correct code. This Syndrome is only diagnosed when a patient does have a diagnosed neoplasm of whatever origin. So the symptoms like thrombosis or prolonged bleeding, hormone deregulation etc. can only be called a secondary complex of symptoms for a neoplastic disease. The Code
E34.8 does not specify the malignancy that the expression indicates, so I would not agree with Lars Age. The Carcinoid-syndrome is for neoplasms that produce serotonin and E34.1 is only specified for intestinal neoplasms.Therefore I would code paraneoplastic syndrome to C80.
 
Sweden /Lars Age Johansson/:
Stefanie is right, of course, that C80 is the underlying cause code for the condition (unless, of course, you know the primary site - in that case you would use the appropriate code for the site in question). I was suggesting E34.8 as an additional code to denote the symptoms. Obviously the code E34.1 should be used for carcinoid syndrome only.
 
2005-04-12:
 
England /Elaine Tower/:
 
If we saw that the Chronic Bronchitis was due to the tobacco and this was stated on the certificate we would use the codes J42 as being due to F179. U/C would be J42 We would only come up with J410 if it stated 'Smoker's Bronchitis'.

2005-04-05:
 
Canada /Patricia Wood/:
I would consider "tobacco" and "smoker's" as synonymous adjectives to bronchitis and I would assign chronic tobacco bronchitis and chronic smoker's bronchitis to the same code (i.e. J41.0 as indexed under Bronchitis, smoker's).
 
Sweden /Lars Age Johansson/:
Again I agree with Patricia. In addition, the Notes for use in underlying cause mortality coding (Vol 2, p 52) say that chronic lower respiratory disease (J40-J47) reported as caused by use of tobacco should be coded to J40-J47.

2005-03-29_03 Paraneoplastic syndrome

(Chapter II)

[Question from Augusto Hasiak Santo, Brazil:]

The next question is about the following death certificate:

Female, 65 years of age
I (a) Pulmonary thromboembolism
I (b) Pulmonary artery thrombosis
I (c) Paraneoplastic syndrome
II Adenocarcinoid tumor of appendix Non-Hodgkin lymphoma

The question I have received was about the code to be used for "paraneoplastic syndrome". This cause is not found in WHO ICD-10 Index (I may have missed an eventual update). Also I think the question was not discussed before at the Mortality Forum.

Dictionaires mention paraneoplastic syndrome as follows:

"A collection of symptoms or clinical signs that are found in patients that have malignant disease. By definition, the signs and symptoms are not produced by a direct effect of a tumour or its metastasis nor due to direct invasion, compression, metastasis, infection, nutritional deficiency or treatment of the underlying neoplasm. Paraneoplastic syndromes can arise from tumour produced biologically active polypeptides or proteins, autoimmunity or immune complex production and immune suppression, blockade of the normal effect of a hormone, the release of substances from tumour associated endothelium which are not normally released and finally unknown causes." (On-Line Medical Dictionary)

"A syndrome directly resulting from a malingnant neoplasm, but not resulting from the presence of tumor cells in the affected parts." (Stedman's)

I have found in the current (2005) Index received from the National Center for Health Statistics that "paraneoplastic syndrome" is coded as L53.9, corresponding to "Erythematous condition, unspecified", that becomes the underlying cause of death when processed by our automatic coding software.

Considering that paraneoplastic syndrome results from a malignant neoplasm, we suppose that the ones mentioned in Part II of the above death certificate should be identified as the underlying cause and be coded as C97 (malignant neoplasms of independent (primary) multiple sites). (By the way, this figure was not found on the current (2005) Table E of the ICD-10 ACME Decision Tables also received from the NCHS).

We would appreciate the participants' comments on:
a) how to code paraneoplastic syndrome?
b) should paraneoplastic syndrome be considered a direct consequence of malignant neoplasms (Rule 3)?
c) how to code the underlying cause of death?


Comments:]


2005-04-05:
 
Canada /Patricia Wood/:
I am not sure how best to code paraneoplastic syndrome, but in light of the information Augusto has shared with us, it seems that there should probably be a causal relationship and a direct sequel relationship between paraneoplastic syndrome and all malignant neoplasms.  For the particular case that Augusto describes I think that the underlying cause would be assigned to C97, unless of course clarification could be sought from the certifier.
 
Sweden /Lars Age Johansson/:
Carcinoid syndrome, which of course is a much more specific term than paraneoplastic syndrome, is coded to E34.0, so perhaps E34.8 would be another possibility (L53.9 seems to be too much focussed on skin problems). I agree with both Augusto and Patricia that Rule 3 applies and that consequently C97 is the underlying cause of death.

2005-04-05_01 Viagra and coronary heart disease

(Chapter IX, XX)

[Question from Elaine Tower, England:]
 
We have a death that we would like the forum's advice on
 
Male 46 yrs old
 
1a Bronchopneumonia
1b Irreversible cerebral anoxia
1c Coronary Artery Disease
Part II Amphetamine and Viagra
Verdict given is accidental overdose
 
We have used the code T46.4 Angiotensin-converting-enzyme inhibitors for the Viagra. How have other countries coded deaths where Viagra is mentioned? What is the best code to use? It is not listed in the table of drugs and chemicals.
[Comments:]
 
2005-04-19:
 
Sao Paulo Classification Centre /Ruy Laurenti/:
We have not till now a death certificate with VIAGRA declaration. VIAGRA is "citrato de Sildenafil" (Sildenafil citrate) and this substance is a inhibitor of the fosfodiesterase-5 (PDE-5). Is this a synonym of "Angiotensin-converting-enzyme"? If yes, then a more appropriate code, in my opinion, is really T46.4.

2005-04-12:
 
Canada /Patricia Wood/:
To the best of my knowledge we have not had any Canadian deaths certified as due to Viagra, but I do notice that NCHS has included it in the Table of Drugs and Chemicals in Instruction Manual Part 2e, Volume 3 (ICD-10 index). The codes are: T46.7, X44, X64, Y14, and Y52.7.  The nature of injury code is T46 Poisoning by agents primarily affecting the cardiovascular system, .7, Peripheral vasodilators.

2005-04-12_01 Malformation of heart in Di George's syndrome

(Chapter III, XVII)

[Question from Monique Differding, Luxemburg:]

I need the help from the forum, please could you give me your helpful advice:
 
Newborn child from 27 weeks of gestation lived for 1 hour
1: malformation of heart within Di George syndrome
 
This includes more malformations and I don't know if Q259 would be the rigth one.
[Comments:]
 
2005-05-17:

Sao Paulo Classification Centre /Ruy Laurenti/:
Is the malformation of  heart within the Di George Syndrome? The translation of these two words has differents meaning in Portuguese. The code of  Di George Syndrome is D82.1. The code for "malformation of heart" (NOS) is Q24.9. The code Q25.9 is "Congenital malformation of great arteries, unspecified". We do not understand why Monique use code Q25.9.
 
2005-04-19:
 
Cuba /Ana C Mesa/:
I don't understand the question, but the Di George's Syndrome D821, (volume 3, page 157).
 
Sweden /Lars Age Johansson/:
As Ana says, the alphabetical index gives D82.1 for Di Geroge's syndrome. It seems strange that a heart anomaly should be coded to D82.1, which is in the block of disorders involving the immune system. However, the matter was discussed at a meeting of the Heads of Classification Centres some years ago. People agreed that since one of the most common features of the Di George syndrome is an immune defect it should be classified to D82.1, even when a heart anomaly seemed to be the patient's greatest problem.

2005-04-12_02 Coroner's verdict or autopsy report

(Rule GP)

[Question from Claire Nicoll, New Zealand:]
 
We have an issue in New Zealand when the coroner states that death is due to "Undetermined natural causes", but the pathologist has documented a suggestion re mechanism of death - e.g. "probable cardiac arrhythmia" before writing 'Undetermined natural causes' as the final summary of cause of death. Do we accept post mortem speculative causes as "probables" as we do for medical certificates of causes of death? We would be interested in hearing how other countries handle this type of situation.
 
In addition we get deaths where the coroner has delivered a finding that the death was due to "Undetermined natural causes", and this equates to the cause of death summary at the end of the postmortem report. However, on reading the body of the postmortem report a number of medical conditions may have been documented but the pathologist stated that he/she did not consider any of these would have caused the death. Recently we received coroners' findings for two deaths of young children where the autopsies revealed both
had been suffering from infections (Rotavirus and lower respiratory infection respectively). In each case the pathologist surmised that the infection was unlikely to have caused the death and stated that the death was due to "Unknown natural causes". In such cases should we apply Modification Rule A, as we would do if the death was certified on a medical certificate of causes of death, i.e.as "Undetermined natural causes is coded to R99 (an ill-defined condition) should we reselect the cause of death as if "Undetermined natural causes" had not been reported? (In these cases this would mean the Rotavirus infection and the lower respiratory infections
would be coded as the underlying causes of these two deaths.)
[Comments:]
 
2005-04-19:
 
Cuba /Ana C Mesa/:
Volume 2, page 88, 4.2.13 "Qualifyng expressions indicating some doubt as to the accuracy of the diagnosis, such as "apparently", "presumably", "possibly", etc should be ignored, since entries without such qualification differ only in the degree of certainty of the diagnosis". The alone autopsy, is not enough to determine the causes of death. The sick person's clinical evolution is very important. It is a topic to discuss, but I am not able to in English.
 
Sweden /Lars Age Johansson/:
The situation in Sweden is different since we do not have coroners. In cases like these we would get a death certificate filled out by the pathologist and we would code them in the same way (and according to the same rules) as other death certificates. Sometimes, however, we get both death certificates and autopsy reports, and in that situation we also have to evaluate the information in the report and decide on how to use it.
 
On the "probable" issue, we would apply the instruction Ana mentions to an autopsy report as well and use a diagnosis that the pathologist describes as "probable". However, we would only do it for conditions that cause changes to organs and tissues, so that the diagnosis the pathologist considers "probable" is based on something s/he noticed at the autopsy. A statement like "cardiac arrhythmia" probably just means "I don't know why this person died", and we wouldn't use it as a cause of death unless there is further
evidence of cardiac disease, like a clinical history of cardiac disease or the pathologist noted changes to the heart tissue.
 
In the second situation, we would not code a condition that according to the pathologist did not cause the death. A condition that didn't cause or hastened the death should not be entered on the death certificate, and should not be selected as the cause of death. After all, Rule A only applies to conditions that in some way or another caused or contributed to the death.

2005-04-19_01 Pharyngeal pouch in elderly

(Chapter III, XI, XVII)

[Question from Elaine Tower, England:]
 
We have deaths where there is a mention of Pharyngeal Pouch. All are in their 80's or 90's. What we would like to know is what code is acceptable.
In the Index - Pouch - Pharyngeal goes to Q38.7
If you go Syndrome - Pharyngeal Pouch = D82.1.
If you go to Pouch - Oesophagus acquired = K22.5
 
Should these be considered as Congenital?
Or should we consider that they are acquired as the person advances in age?
Thank you.
[Comments:]
 
2005-04-25:
 
Cuba /Ana C. Mesa/:
In advanced ages, bigger than...... years, if there is not another information that indicates that it is congenital, I agree K225.
 
Cyprus /Pavlos Pavlou/:
For these age groups, I would use K22.5.
 
Germany /Stefanie Weber/:
Pharyngeal pouches are quite common in older males. The muscular layers of the oesophagus weaken and form a diverticulum where food gets stuck. Therefore I would code to K22.5

2005-04-19_02 CVA due to atrial fibrillation and hypertension

(Rule GP)

[Question from Kathleen England, Malta:]
 
Part I: a) Cerebrovascular accident
          b) Atrial Fibrillation
          c) Hypertension
 
Part II: Ischaemic heart disease
 
When I saw this death certificate I first coded the cerebrovascular accident as the underlying cause of death, as both atrial fibrillation and hypertension predispose to CVA. However I am not sure and would like your opinion. When a death certificate states that a person died of CVA secondary to AF we should code the AF. However when CVA is caused by hypertension we should code CVA I think. This in my opinion causes problems with statistics regarding deaths due to stroke as in one instance we are coding the risk factor while in the other we are coding the disease. Any comments would be appreciated. Thanks.
[Comments:]
 
2005-04-25:
 
Cuba /Ana C Mesa/:
GP: I10
I10 with I64: code I64
I10 with I259: code I259
Rule C: "...Where a conflict in linkages occurs, link with the condition that would would have been selected if the cause initially selected had not been reported. Make any further linkage that is applicable" Thus, I64. But atrial Fibrillation,  it is a functional dysfunction, is a direct consequence of Ischaemic heart disease (Rule 3). I ask, is it correct the solution of the CIE I64? In my country the sequence Fibrillation dur to Hypertension is frequent, and if the ischemic cardiopatia is not mentioned, the underlying cause is I10.
 
Cyprus /Pavlos Pavlou/:
As hypertension is not a highly improbable cause of atrial fibrillation, we accept the certifier's statement (that atrial fibrillation was due to hypertension) and apply the General Principle. Therefore, the provisionally selected UC is hypertension - I10. Since this is present with mention of cerebrovascular accident - I64, we code to I64 as the UC (p. 50, 4.1.11 notes....)
 
The reason for not selecting atrial fibrillation, is because, the acceptable sequence of causes, does not end at atrial fibrillation as the provisionally selected UC. It goes further, to hypertension.
 
If there was no mention of hypertension on line Ic then, the UC would be atrial fibrillation.
 
In conclusion, the rules give a clear outcome. However, I agree with Kathleen's view that there is a difference between how the rules deal, statistically, with strokes reported as caused by hypertension and strokes reported as caused by atrial fibrillation.

2005-04-25_01 Kidney transplant in Part I, cirrhosis of liver in Part II

(Rule V)

[Question from Pavlos Pavlou /Cyprus/:]
 
Dear Mortality Forum,
 
We have difficulty in selecting the underlying cause of this certificate.
 
41 year old male.
Ia          Pulmonary tuberculosis
Ib          Haematemesis
Ic          Renal failure; Transplantation kidney
Id          .......
II           Cirrhosis of liver
 
How would you code this?
[Comments:]
 
2005-06-21:
 
WHO /Robert Jakob/:
If we wanted a different UC we would have to fill out the certificate in a different way or ask the certifier to do so. The mechanisms for selecting the underlying cause have been explained very clearly by Lars. The underlying cause in this certificate as it is and according to the rules would be the renal failure N19. From a medical point of view this might not be satisfactory. With the additional information provided and the certificate corrected as Pavlos proposes the UC would be B18.2

 

2005-06-14:
 
Cuba /Ana C Mesa/:
As I believe to understand, everything began with the Syndrome of Alport Q87.8 Here I don't agree with the CIE that forces me to code B18.2 (iatrogenia ). I code these cases Q87.8 (this problem has outlined it to the Dr Becker Roberto Forum CIE). For that you cannot accept the viral Hepatitis B, C like complication in exposed patients to this risk?
UC Q87.8
Others code: Y64.-/ B18.2/K920/N18.9/K74.6
 
2005-06-07:

Cyprus /Pavlos Pavlou/:
Following your comments we did ask for further information. It transpires that, this patient had developed cirrhosis of the liver from
chronic hepatitis C. The terminal event was haemorrhage due to oesophageal varices. In the physician's opinion, he would have survived for a little longer, if he had not had the haematemesis. He also had chronic renal failure due to Alport's syndrome for which he had a renal transplantation. He was on immunosuppressives and this caused pulmonary TB. He had recently been transferred from a renal unit to a TB ward for care. Assuming that the death certificate is modified so as to show the sequence terminating in death (hepatitis C etc) in Part I and the other conditions (renal failure etc) in Part II, I guess this points towards B18.2, Chronic viral hepatitis
C as the underlying cause of death.

2005-05-17:

Cuba /Ana . Mesa/:
Volume 2, page 67, 4.2.2
a).......any infectious disease may be accepted as "due to" disorders of the immune mechanism such as human immunodeficiency virus [HIV] disease or AIDS; immunosuppression by chemicals (chemotherapy) and radiation; and ....... GP N19 ( In Cuba N189). What is the cause of the chronicle renal failure? It is possible that the originating cause is the cirrhosis of liver. Treatments for cirrhosis of liver may be the cause of the chronic renal failure, but it is necessary to wait for the answer of the doctor to apply rule 3.
 
Israel /David Lidsky/:
We should determine the underlying cause for this certificate, submitted by Pavlos Pavlou in Cyprus, as follows:
Is there only one cause of death in line Ic? We should say that there is more than one, though there is room for disagreement.
Multiple diagnoses in Ic make the General principle inapplicable. Is there a sequence terminating in Pulmonary tuberculosis?  Pulmonary TB is not likely to be caused by haematemesis, and so rule 1 does not apply. That makes Pulmonary tuberculosis the underlying cause according to Rule 2.
 
Thus our coding would be:
Ia A16.2
Ib K92.0
Ic N19
Id
II K74.6
Underlying cause A16.2
 
We would not code Kidney transplant status, as we do not usually use Z codes, though our policy is to even so take account of such a diagnosis (if relevant) in determining the underlying cause. If one were to decide that there is only one diagnosis in line Ic, the
question arises as to whether pulmonary TB may be caused by Renal failure, by the presence of a kidney transplant, or by immunosuppressive medication. There is probably a statistical correlation, but we think it unlikely to be large enough to justify changing the coding (and the Acme Decision Tables agree with regard to renal failure).

Sweden /Lars Age Johansson/:
From the purely formal point of view I tend to agree with Ana. I would say that there is one diagnosis (renal failure) on the lowest used line in Part I, since "transplantation" isn't a disease but a procedure. We would then try the General Principle. The General Principle just requires that all conditions reported above the single condition entered on the lowest used line can all be due to this single condition. There is no requirement that the conditions entered above should form a sequence. Here, I think that both the hematemesis and the TB should be accepted as due to renal failure, since you would assume that the renal transplantation also involved treatment with immunosuppressive drugs. Thus, renal failure is the originating cause according to the General Principle.
But I must confess that I do not much like renal failure as the underlying cause in this case. The mention of hematemesis gives me the impression that the surgery was fairly recent and there would probably not have been time enough for the TB to develop. Perhaps the patient had TB before the transplantation. But would they have performed a renal transplantation on a patient with pulmonary TB? There are many difficulties here and I really do think that more information is needed. Failing that, I would stick to my interpretation of the rules and select the renal failure.

2005-04-25_02 Code for intranuclear inclusion body disease

(Chapter IV)

[Question from Claire Nicoll /New Zealand/:]

Members of the Forum,
 
Which code should I use for "intranuclear inclusion body disease". The deceased was 24 years old and had suffered from this for more than 7 years.
[Comments:]
 
2005-05-17:
 
Cuba /Ana C Mesa/:
It is very difficult to answer, it has diverse interpretations. It is present in a diversity of diseases and I don't know enough English to
explain it.

Sweden /Lars Age Johansson/:
Do you have any other details on the case? Most of the mentions of intranuclear inclusion body disease I have found are in the context of degenerative cerebral diseases, but I have also found descriptions of intranuclear inclusion bodies in other organs. As far as I can see it would be very difficult to code the condition unless more information is available.

2005-05-26_01 Chronic cerebral ischemia due to coronary heart disease

(Chapter IX)

[Question from Stefanie Weber, Germany:]
 
Dear Forum,
in our last training session we came upon a certificate that we could not finally decide on and would appreciate the Forum's advice on:
 
1a   Hypostatic congestion of the lung    (hours)
1b   Chronic cerebral ischaemia             (years)
1c   Coronary heart disease                   (years)
 
The question to us was if a coronary heart disease could be the underlying cause of chronic cerebral ischaemia if both have been existing for years? Isn't this two sequels of arteriosclerosis and would therefore not be accepted as a sequence and be coded to I67.8? ACME gives us I25.9 as underlying cause which some of our coder would choose, too, but it seems wrong to me.
[Comments:]
 
2005-06-07:
 
Cuba /Ana C Mesa/:
GP: I70.9
Rule C: Where a conflict in linkages occurs, link with the condition that would  have been selected if the cause initially selected had not been reported..... UC:I25.9.
 
Sweden /Lars Age Johansson/:
The "head and heart" issue (which cardiac diseases can cause which cerebral ones, and vice versa) is an old one, and countries have arrived at very different solutions. The Mortality Reference Group has recently discussed the matter, and the decision we arrived at is that conditions in I67.8-I67.9 should be accepted as due to conditions in I21-I22 and I25. I suppose some intervening  mechanism on the lines of coronary heart disease - arrhythmia - multiple minor embolisms would be possible, even if it certainly makes more sense to think of both the cerebral ischaemia and the coronary heart disease as manifestations of generalised atherosclerosis. However, in cases like this where countries apply the rules very differently, I would say that the most important thing is that we all code in the same way. And here, if we go by the MRG decision, the underlying cause will be I25.9, as Ana says.

2005-05-26_02 Heart rupture when removing pacemaker

(Rule GP)

[Question from Claire Nicoll, New Zealand:]
 
Members of the Forum, please could we have some guidance on selecting the underlying cause of death for the following scenario:
 
71 year old man:
1a  Exsanguination
1b  Ruptured apex of right ventricle during removal of faulty and fibrosed pacemaker
1c  Cardiac arrhythmia
[Comments:]
 
2005-06-07:
 
Cuba /Ana C Mesa/:
UC: I49.9
Other causes: T82.1/Y60.0/Y71.2 and T81.0 or T82.8  (I don't understand the question well). In ICD-10, Rule 12 it was eliminated.
 
Sweden /Lars Age Johansson/:
I fully agree with Ana. Since the pacemaker was implanted because of the cardiac arrhythmia, the sequence is correct and the General Principle applies. Rule 12 in ICD-9 said that if the sequence leading to death contained a medical misadventure, the death should be coded to the misadventure. When the classification rules were revised for ICD-10, that rule was removed because those responsible for the revision felt that the reporting of medical misadventures varies very much both between countries, hospitals and even individual doctors. That Rule 12 was removed means that in ICD-10 the ordinary selection rules apply also to sequences involving medical misadventures: if the sequence is acceptable, select the condition that started the train of events leading to death. In this case it is the
cardiac arrhythmia.

2005-06-07_01 Code for ventilator assisted pneumonia

(Chapter X, XIX)

[Question from Patricia Wood, Canada:]
 
We have been seeing a few deaths with "ventilator assisted pneumonia".  Any suggestions for a code?   On the internet it says that it complicates 47% of people with a ventilator.

[Comments:]
 
2005-06-14:
 
Australia /Margaret Campbell/:
I suppose in lieu of no specific code for this situation I would code to:
Complication of ventilation therapy NEC T81.8 + J18.9. The choice of the pneumonia code may depend on other information available e.g. causative organism.
 
Cuba /Ana C. Mesa/:
We code Y84.8. It is possible to also consider Y82.1.
 
WHO /Robert Jakob/:
A good definition can be found under
http://www.chestjournal.org/cgi/reprint/117/4_suppl_2/177S.pdf in the paragraph "Epidemiology". The pneumonia occurs during the ventilation. So in my opinion it is not to be considered "postprocedural" and does not fit in the organ chapter. The only place plausible in the context seems to be T81.8. As it is an infection one could consider T81.4 but the inclusion list suggests a different kind of infections and the title tells "following a procedure".

2005-06-21_01 Proteus syndrome and renal failure

(Rule GP)

[Question from Monika Bene, Hungary:]

Please, give your suggestions for the following case:
 
Female, 11 years
Ia) Chronic renal failure   1 yr
Ib) Renovascular hypertension   1 yr
Ic) Proteus-syndrome 11 yrs
II   Renal anaemia        1 yr

Thank you.


[Comments:]
 
2005-09-13:

Denmark /Klaus Brasso/:
My suggestion would be Q87.8.

2005-09-06:

Cuba /Ana C. Mesa/:
Syndrome of Proteus (Cohen y Hayden): The syndrome of Proteus is a congenital diseases that causes exaggerated and pathological growth of the skin with subcutaneous tumors, and atypical development of the bones with macrodactília and hemipertrofia. Was described for the first time in 1979 by the doctors Micahel Cohen and Hayden. It is an extremely rare disease, there have been described in the entire world around 100 cases.
Categories: Genetic disease
I think Q74.8 or Q82.8 or Q87.8
I like Q87.8
 
Germany /Stefanie Weber/:
As the overgrowth of tissue seems to be the main problem of Proteus disease I would code to Q87.3.
 
WHO /Robert Jakob/:
The Proteus Syndrome can affect the kidneys, too
(http://www.thefetus.net/page.php?id=436). So I would select the Proteus Syndrome as UC. As it is a congenital malformation affecting multiple systems and apparently with no dominance of a specific system, I would code it to Q87.8.
Comments