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mort05_2

2005-09-06_01 Pneumonia obvious consequence of Cri du chat syndrome or Down's syndrome

(Rule 3)

[Question from Bridget Allison, Australia:]
 
I hope you are all enjoying your summer break.
I am a Health Information Manager working with Sue Walker at NCCH in Brisbane, Australia.

I have a query I'd like to put to the mortality forum, regarding the use of Rule 3 and whether chromosomal abnormalities can cause respiratory conditions such as pneumonia or lower respiratory tract infection.
For example:
 
Example 1  
1a) Pneumonia    J189
2 Cri du chat syndrome  Q934
UCOD - J189 or Q934
 
Example 2  
1a) Lower respiratory tract infection  J22
2 Down's Syndrome Q909
UCOD - J22 or Q909

We used the MMDS decision tables as a guide and in example 1 the Rule 3 tables stated that Cri du chat syndrome (Q934) could cause Pneumonia and therefore be the Underlying cause.  However, in the second example the Rule 3 tables stated that Down's syndrome in Part 2 could not cause a lower respiratory tract infection but if the Down's Syndrome was in a 'due to' position (in 1b)), it could be considered as the underlying cause of the lower respiratory tract infection.  What is the mortality forum's view on this ruling?
[Comments:]
 
2005-09-20:
 
USA /Julia Raynor/:
Just a comment:
 
A few years ago when pneumonia was added to the Modification Tables as a direct sequel of many conditions, lower respiratory tract infection, J22, was not included with pneumonia. This is an example of the dilemma of making decisions for the automated system. How many categories should be included, where to start and where to stop? Of course, even though J22 is not used as pneumonia now, it could be proposed as an addition in the future.
 
Sweden /Lars Age Johansson/:
Julia is right, of course. The Mortality Reference Group discussed under which circumstances Rule 3 would apply to certificates with pneumonia reported as the originating condition in Part I, and the decision that the MRG finally agreed on only mentioned pneumonia in J18.0 or J18.2-J18.9. ACME was then updated completely in accordance with the MRG decision. As Julia also says, it might make sense to handle other types of lower respiratory infections in the same way as pneumonia, and in fact the issue of adjustments to the instructions on Rule 3 and pneumonia is on the MRG's agenda.
 
2005-09-13:
 
Cuba /Ana C Mesa/:
Persons with chromosomal abnormalities, many times have an associated immunodeficiency processes, and are therefore susceptible to acquire infections. If the doctor writes in sequence in Part I accept it, if he writes it partly 2, I don't apply Rule 3.
 
Sweden /Lars Age Johansson/:
Opinions differ very much on when Rule 3 is to be applied, especially when the reported underlying cause in Part I is pneumonia. To achieve better international comparability, a few years ago the Mortality Reference Group compiled decision tables for pneumonia. According to these tables pneumonia should be considered an obvious consequence of both Cri-du-Chat syndrome and Down's syndrome. That is, Rule 3 applies, and the syndrome is selected as the underlying cause of death. Since pneumonia is a lower respiratory infection I would assume that these tables apply to J22 as well.
 
USA /Julia Raynor/:

Example 1
Part I Line a) J189  
Part II  Q934 Underlying Cause Q934
Select pneumonia, J189 by General Principle.  Using Rule 3, J189 is considered as a direct sequel of Q934.

Example 2
Part I  Line a) J22  
Part II Q909  Underlying Cause J22

Select J22 by General Principle.  J22 is not considered a direct consequence of Q909. It is correct that J22 could be due to Q909 but it is not reported due to Q909. The position of the conditions on the certificate is extremely important in applying the selection and modification rules.  It seems since both J189 and J22 are respiratory infections they should both be considered as a direct sequel of the same conditions. Pneumonia is treated differently though  and is coded as direct sequel of many, many conditions.

2005-09-06_02 Bronchiolitis in boy with mitochondropathy

(Rule 3)

[Question from Jozica Selb, Slovenia:]

We would like to submit you a question which we are not sure how to solve.
 
Six month old boy died as follows
 
I a) Cardiomyopathy dilated
  b)  Acute kidney failure
  c) Bronchiolitis due to RSV
 
II  Mitochondriopathy
 
Could you help us with coding this death?
[Comments:]
 
2005-10-04:
 
Canada /Patricia Wood/:
Like Julia, I would select J210 as the underlying cause of death because the ACME decision tables support an application of the General Principle to the causes on this certificate.  I don't doubt the clinical validity of what Lars Age says, but I am concerned that many mortality coders do not have the medical expertise to make this same assessment.  They might be more likely to rely on the automated system and/or a manual application of the rules with the support of the decision tables.  Of course this is not a new problem but coder experience and expertise can introduce another level of inconsistency to classification!
 
Sweden /Lars Age Johansson:/
Patricia makes a perfectly valid point, of course, and I wouldn't recommend this kind of "from case to case" evaluation of sequences in routine production of mortality statistics. For statistics, it is absolutely essential that the cases are always classified according to established procedures. However, coding procedures - including decision tables - have to be tested and improved, and discussing difficult cases in the Mortality Forum might be one way of doing that!

2005-09-20:
 
Cuba /Ana C. Mesa/:
I agree with their reasoning
 
WHO /Robert Jakob/:
I fully agree with Lars.
Apart from this, the certificate looks indeed as if the certifier had inverted the sequence, as Ana already mentioned.
 
2005-09-13:
 
Cuba /Ana C. Mesa/:
There are many varieties of Mitochondriopathy. Some can cause a death, but here it is not known which it is. Also, is the sequence acceptable? Could the dilated cardiomyopathy be due to the viral infection? Or, what did the doctor mean with dilated cardiomyopathy?
Is it an inverted sequence?  Could the mitochondriopathy affect the heart muscle? When I have so many doubts, I apply the general principle.
Therefore I code UC J21.0
 
Sweden /Lars Age Johansson/:
As Ana says, there are many questions here. However, I find it difficult to believe that an acute kidney failure could have caused a dilated cardiomyopathy, so I would apply Rule 2 and select dilated cardiomyopathy as the temporary underlying cause. The we have the question whether Rule 3 should also be applied, and the cardiomyopathy considered an obvious consequence of the mitochondriopathy. As far as I understand this is very likely. However, there is the difficulty that mitochondriopathy has no specific code in the current version of the ICD. I would suggest that this is a reason to apply Rule D, Specificity, and select I42.0 as the underlying cause of death - this code gives a better description of the underlying cause ("mitochondric" cardiomyopathy) than G71.3 (mitochondrial myoptahy, not elsewhere classified) or even E88.9 (metabolic disorder, unspecified).
 
USA /Julia Raynor/:
 
Line a) I420  
Line b) N179  
Line c) J210  
Part II E889  Underlying cause J210

Bronchiolitis is indexed as Bronchiolitis, due to, respiratory syncytial virus J210. Mitochondropathy is not indexed but we code Disease, mitochondrial E889

2005-09-13_01 Hemorrhagic pneumonia due to leptospirosis

(Chapter I)

[Question from Ana C Mesa, Cuba:]

a) Hemorrhagic pneumonia
b) Leptospirosis
 
How would you code this? A279 or A270
[Comments:]
 
2005-10-04:
 
Canada /Patricia Wood/:
I agree with Lars Age - I would code the leptospirosis as unspecified at A279.
 
2005-09-27:

Sweden /Lars Age Johansson/:
A27.0 is to be used for infections with a specific variety of Leptospira (L. interrogans serovar icterohaemorrhagiae), and as far as I understand a hemorrhagic pneumonia may develop even if the patient is infected with other varieties of Leptospira. In this case the certificate doesn't specify the exact type of Leptospira, so I would use A27.9.

2005-09-13_02 Electronic death certificate and automated coding

[Question forwarded by Roberto Becker, PAHO:]
I received this question from Colombia I would very much appreciate to have your comments:
 
Forum-CIE/C197/09/05
(from Colombia)

DANE (Colombian National Administrative Department of Statistics) is working jointly with the Ministry of Social Protection (Colombian Ministry of Health) in a project for technological improvement of the System of Vital Statistics, as one of the elements of the National Health Information System. The idea is to perform the certification of births and deaths using electronic forms, which implies the elimination of paper certificates.
 
With regard to the definition of causes of death, it is expected that the physician can select diagnosis using software, through anatomic systems, diseases or ICD-10 Chapter, to obtain the corresponding code(s). In addition, it is expected that the software would select automatically the underlying cause of death.
 
We would like to know the experience that other countries may have in this matter, especially related to the following:
1. How are ICD-10 codes assigned automatically to the diagnoses made by the doctors?
2. Are automated systems for selecting the underlying cause of death available?
3. Advantages and disadvantages of the elimination of paper forms for death and live births. What alternatives have been used as a source document?
4. How are failures of (electronic) system solved?
5. How can institutions located in rural areas without connection be incorporated?
6. How is the certification of events occurring outside hospitals managed?

We thank you for all the comments and suggestions that you may have for the improvement of this information system.
Estadísticas Vitales - DANE, Colombia
[Comments:]
 
2005-10-04:
 
USA /Donna Hoyert/:
In the U.S., more than 95% of births are certified electronically, and systems have existed for 15-20 years.  Various initiatives have attempted to establish systems for electronic certification of deaths; while we probably have about 20 of our 57 registration areas trying to develop something for death, we don't have much in place yet.  The latest reengineering initiative had the goal of continuing the evolution of the birth systems and continuing to try to develop death systems.  The initial birth systems were fat client systems in which the current software had to be installed on any pc used. The goals of the current efforts are to have thin client systems in which
participants log into a central Web-based system.  Pragmatism and security have always been important issues, and some of the security issues have gained even more importance in the last few years.

The physicians should not be using the software to select diagnoses to obtain a corresponding code, and it is not advisable for them to see the underlying cause for a specific record.  The changes introduced in URC 0106 "The medical practitioner or other qualified certifier should use his or her clinical judgement in completing the medical certificate of cause of death. Automated systems must not include lists or other prompts to guide the certifier as these necessarily limit the range of diagnoses and therefore have an adverse effect on the accuracy and usefulness of the report" emphasize this point.  We do have a number of individuals who are fixated on promoting forced lists; it's a frustrating task trying change their minds as they pretty much refuse to accept long established research findings.

1) The doctors should be entering text into the medical certification section of the electronic death registration system.  At the vital
registration office, this information is exported to be run through the MMDS software, so that codes are assigned.
 
2) Yes, MMDS is used to select the underlying cause, but it is separate from the electronic death registration system.
 
3) Advantages are improving timeliness of registration; opportunity to improve data by editing data as it is being entered; potential to adopt standards for electronic transmission and improve system to system communications; and potentially more flexibility to introduce new questions or short-lived questions. Disadvantages are costs of operation increase; vital registration offices need to hire different kinds of staff; potential access and control problems if information technology staff are centralized in the State and not employees within the vital registration office; potential problems with system to system communication to ensure that the data being imported from another source used the same question that the electronic birth registration, for example, would have asked directly.  With electronic death registration, we fear that the physicians might get more removed from the process if we can't get them to use the system directly.

With respect to alternative source documents, the birth side is assuming that a health information management specialist (birth clerk) is
going to be referring to common documents that are completed as women interact with the health care system during their pregnancy and on through delivery.  In the latest iteration of the electronic birth registration system development, the electronic system is set up with items grouped according to the external document that is likely to be the source.  There are also paper worksheets with the same order that can be used to collect the information before the clerk logs onto the system.  Whether they use the worksheet or enter data directly, additional guidelines have been developed to direct the clerk to the proper source document.  For demographic items, the intent is that the mother will provide information on the mother's paper worksheet.  On the death side, we want the physicians to be direct participants and complete the medical certification.  However, there is enormous skepticism that that will be achieved and there is also the problem that most physicians infrequently complete the death certificate (usability goals clash with security goals for the infrequent certifier).  The idea of having a paper worksheet that the physician actually completes and then allowing a third party transcribe the information is very appealing to our State vital statistics offices.  Yet, this eliminates a number of the advantages of an electronic system.

4) Failures like electrical outages? For the certifiers, the process reverts to a paper process.  At the State vital statistics office, it largely depends on how the information technology support is organized.  If they have a central server, then many of the States have redundant systems or sites so that they can switch over to the other system if the failure isn't resolved in x amount of time.  If the vital statistics office has a stand alone system, they aren't likely to have redundant systems.  In those cases, the processes revert to paper at the state office also.  Each office should have a disaster recovery plan, so that all the regular participants know what to do when problems arise.
 
5) This hasn't been too much of a concern.  The main approach has just been to encourage those without connection to get connected, and if they have telephone lines, it is fairly simple to take that step.  If the infrastructure isn't there or you have groups that are opposed to using technology (e.g., our Amish communities), again we would revert to a paper process.
 
6) For births, it's rare for the birth to occur outside of some kind of facility.  These rare events generally are completed using the paper
process.  For the deaths, implementation is targeted at institutions, funeral homes, and other high volume participants.
 
The expectation is that a paper process will continue.

2005-09-27_01 Coronary artery thrombosis and recent fracture of femur

(Rule 3)

[Question from Elaine Tower, England:]
 
We have a death which we would like some assistance with:
1a Acute Myocardial Infarction
1b Coronary artery thrombosis

Part II Recent internal fixation fractured neck of left femur
Verdict deceased died from natural causes
 
Codes allocated are I219; T818; Y834; S720; X599.
As a verdict is mentioned  we would usually stay with the natural causes and X599 would be the underlying cause, but the cause in 1b is post-operative so should we use Rule 3 and then we would come up with the accident of the fractured femur.
[Comments:]
 
2005-10-04:
 
Canada /Patricia Wood:/
As Elaine suggests, we would consider the coronary artery thrombosis to be a postoperative complication and we would apply Rule 3 to select the condition necessitating the surgery, the external cause of the fracture of the neck of the femur, as the underlying cause of death.

As an aside, we might use T84.8 and Y83.1 for the complication and the surgery as "internal fixation" of the fracture is specified.
 
Germany /Stefanie Weber/:
Dear Forum, I would recommend to code the MI with I21.9. Having a coronary artery thrombosis due to a fracture is not very likely and only possible if the patient had a persisting foramen ovale of the heart. Therefore I would not apply Rule 3.
 
Sweden /Lars Age Johansson/:
I would go by the instructions on Rule 3, according to which (among other things) thrombophlebitis, embolism, and thrombosis are to be considered direct consequences of surgery. In other words, I would select X59 as the underlying cause. I don't think it is necessary to assume that the blood clot has moved all the way from the leg to a coronary artery. I don't know if it would be a common or very likely scenario, but couldn't the workload resulting from the fracture and the surgery cause a cardiac arrhythmia (transient or permanent), which, in its turn, might bring about a coronary thrombosis?

2005-11-01_01 Allergic shock due to food

(Chapter XIX, XX)

[Question from Josiane Mornie, Belgium:]

How to code an allergic shock to food (in our case to fish)? We have T78.1 but what code to use from Chapter XX? We 're not happy with Y59.8 or X49 (only food poisoning).
[Comments:]
 
2005-11-22:
 
Cuba /Ana C Mesa/:
I agree with Martti.
 
Cyprus /Pavlos Pavlou/:
Since we have to use an external cause code I think the best available choice is X49. This is a rare cause of death but, I wonder if there should be a specific code outside the external causes chapter. I have difficulty in thinking of food anaphylaxis or shock (or allergy) as an accident. I think of it as an acute abnormal response of a human to the ingestion of a, normally harmless, nutrient. Preventive measures would be directed towards finding a diagnostic method and giving preventive treatment for this presumed abnormal systemic predisposition.
 
USA /Julia Raynor/:
Just a note about food allergy. The MRG recommended X58 for food allergy.
 
We added to 2006 Volume 3:
Allergy X59
- food (any) X58
- latex X58
- other specified substance X58
 
If we really want to identify food allergy, perhaps we could assign a fourth character X58.0 and use X58.9 for Exposure to other specified factors.

Sweden /Lars Age Johansson/:
Julia, thanks for reminding me of the recommendation we in the MRG finally arrived at. My memory isn't what it ought to be! You are quite right, of course, we settled for X58 because X49 is for chemicals and noxious substances, and that doesn't fit food very well.
 
Martti brings up several very interesting issues. He is right, of course, that if you use the code T78.0, a specific code for food allergy in Chapter XX wouldn't add much information. The problem is that quite a few countries do not use S and T codes in their mortality statistics. This is because according to the definition of underlying cause, S and T codes should not be used as underlying cause, but the external event that produced the injury or effect described by the S and T code. As Martti says, it would of course be possible to introduce exceptions for such S and T codes that do contain all necessary information on the death, but such exceptions always causes
difficulties in statistical tabulation and reporting. I would say that it would be practical to have a specific code in Chapter XX for food allergy, even if it doesn't add any information to the code T78.0.
 
In my experience deaths due to food allergy are still fairly rare, but since allergies are getting more common we might see more of such deaths in the future. At the moment we don't need very much detail in the Chapter XX code, but it might change in the future.
 
2005-11-15:
 
Nordic Centre/Martti Virtanen/:
Since this problem needs to be corrected during the ICD revision process, I would like the Mortality forum participants to consider following questions:
 
T78.0 stands for "Anaphylactic shock due to adverse food reaction". Since very many if not most consumed food products can potentially cause allergic reactions, an added external cause code of type "Food causing allergic reaction" would not add anything to the information on T78.0. Such code is therefore not necessary?
 
A rather philosophical question is, is food allergy an injury caused by external cause (food) or is it a disease (allergy) causing unusual reaction to normal food. If the latter is the case, the code is actually misplaced in chapter 19. However, in the case of other allergies the external cause might be more motivated. Maybe T78.0 should remain in chapter 19 but there should be an exception to the rule demanding external cause for all codes in chapter 19?
 
If external cause is demanded, the real additional information is what substance is causing the reaction. That is, we would need create codes for fish, tomato, chocolate etc?
 
This is obviously a minor question for mortality but it is obviously much more common as morbidity problem. For the revision process all comments are valuable.

2005-11-08:

 
Cuba /Ana C. Mesa/:
Volume 3
Shock
- food (anaphylactic) T78.0
Y40-Y84 Complications of medical and surgical care
Y40-Y59 Drugs, medicaments and biological substances causing adverse effect in therapeutic use
 
I think T78.0/X49.
X49 it is not good, but there is no other code now.
 
England /Elaine Tower/:
This is similar to the question I raised A 2005-03-01-Q1, Update 1; it was Mushroom allergy. Your reply was to place it on the MRG for discussion. We code at present to X49 for these types of deaths.
 
Sweden /Lars Age Johansson/:
I agree with Ana that there is no really satisfactory Chapter XX code for allergic shock caused by food, and I also agree that X49 is the least bad alternative. As Elaine says, we did discuss the matter in the MRG, but we found that because there isn't much free space in Chapter XX it would be difficult to add an external cause code for allergic reaction to food. We decided to wait and see how big the problem is - if this is a recurrent problem in mortality coding, we will get back to the matter. So please let me know if you often see deaths due to food allergy, and if you think that a specific code is needed.

2005-11-01_02 Anaphylactoid syndrome of pregnancy

 (Chapter XV)

[Question from Elaine Tower, England:]

Can you help on this death:
 
1a) Anaphylactoid syndrome of pregnancy
2)   Pre-eclamptic toxaemia
We have coded the Anaphylactoid syndrome of pregnancy to Amniotic Fluid Embolism O88.1.
Are other members in agreement?
This is the web address that we found information on:-
http://www.emedicine.com/med/byname/amniotic-fluid-embolism.htm
[Comments:]
 
2005-11-08:
 
Cuba /Ana C Mesa/:
Anafylactoid syndrome can be understood as Amniotic fluid embolism, but it can also be produced by medications. What does it mean in their country? Does it always signify Amniotic fluid embolism, and in all countries?
 
Sweden /Lars Age Johansson/:
On most of the web sites that I have looked at, the terms "anaphylactoid syndrome of pregnancy" and "amniotic fluid embolism" are treated as synonyms, or at least as very closely related entities. I would use O88.1 as well.

2005-11-01_03 Accidental rupture of hemodialysis graft

(Rule GP)

[Questions from Lars Age Johansson, Sweden:]
 
Would you code a case like this as an accident or as a complication of medical care?
 
1a) Massive hemorrhage
1b) Rupture of arteriovenous dialysis graft
1c) Chronic glomerulonephritis
Supplementary information: Patient under hemodialysis treatment, fell and tore the dialysis graft open, died from the blood loss.
Comments:]
 
2005-11-08:
 
Cuba /Ana C Mesa/:
There is no time intervals for the conditions, and that is very important.
If the rupture happened during the procedure the codes would be Y60.2/T83.8
If the rupture happened some time after the procedure it would be
Y84.1/T83.8.
UC: N03.9
 
England /Elaine Tower/:
We would have the underlying cause as W19.9 and Secondary cause as T14.5. We would code this using the W19.9 as the code for the fall there is no mention of complication of medical care stated so we will not assume this.
 
Malta /Kathleen England/:
I would code the fall as the underlying cause of death, as if he did not fall he might mot have torn his graft.

2005-11-01_04 BCG infection from BCG treatment of bladder cancer

(Rule GP)

[Questions from Lars Age Johansson, Sweden:]
 
And a similar case:

1a) Disseminated BCG infection
1b) BCG treatment for cancer of urinary bladder
 
How would you code the infection resulting from a treatment, and what would you select as the underlying cause?
[Comments:]
 
2005-11-08:
 
Australia /Margaret Cambell/:
T88.0 Complication vaccination, infection (general) (local)  - BCG vaccine is administered intravesically in the treatment of carcinoma of the bladder.
Y58.0 BCG vaccine
C67.9 Ca Bladder
I think the UC would be Ca Bladder, without which they would not have received the treatment; which caused their death
 
England /Elaine Tower/:
We would select the C67.9 as the underlying cause.
 
Malta /Kathleen England/:
The cancer of the urinary bladder required BCG treatment which resulted in complications, therefore I think the underlying cause of death would be the bladder cancer.
I am not sure about the disseminated BCG infection but A41.9 would cover the dissemination.

2005-12-06_01 Spongioform encephalopathy, progressive ataxia, and syphilis

(Rule C, Chapter I)

[Question from Monica Pace, Italy:]

 

Dear colleagues, could you please give me your suggestions on this certificate? The closest code we found for progressive ataxia is

"(syphilitic) spinal progressive ataxia" A521, but according to us there is no clear indication of syphilis despite the encephalopathy. On the other hand the C.J. disease is defined "subacute" and we do not have such an indication.

 

Ia) Cardio-circulatory collapse R579

Ib) Progressive ataxia; recurrent infections R270 R99

Ic) Spongiform encephalophaty A810

Id)

II) Hypertension I10

U.C. A810


[Comments:]

2005-12-20:

Sweden /Olafr Steinum/:
I am not at all an expert in the rules of mortality coding, but want nevertheless give an input in this case. For me (a clinician) in seems that C.J. is a reasonable choice. "Subacute" is probably covered by the term "progressive" ataxia, don't you think so?

2005-12-13:

Sao Paulo Centre /Ruy Laurenti and Heloisa Di Nubila /:
Spongiform encephalopathy (subacute), coded as A81.0, is an atypical viral infection of central nervous system, with the eponym "Creutzfeld-Jakob disease". This disease is shortly defined as a "spastic pseudosclerosis with corticostriatal-spinal degeneration; caused by one of the slow viruses", according Stedman´s Medical dictionary. So, you can find ataxia amongst symptoms, that manifests as a progressive feature regarding severity (you have coded correctly as a symptom - R27.0). This progressive ataxia has not any linkage with syphilis. In our opinion, your chosen underlying cause is correct (A81.0 - Creutzfeld-Jakob disease / subacute spongiform encephalopathy).

Norway /Gunvor F. Østevold/:
Hello from Norway! According to our medical advisor Ic) Spongiform encephalophaty is A81.0, Creutzfeldt-Jakobs disease, and the correct U.C. in this case.

WHO /Robert Jakob/:
A progressing ataxia is a symptom associated with subacute spongiform encephalopathy (and oter spongiform encephalopathies). The term subacute is missing. As far as I found, it's prion diseases that make a spongiform encephalopathy and the code in this case would be A81.9.

Though it is much more probable that the certifier used clinical jargon and meant the bovine|subacute spongiform encephalopathy, with a heavy heart I would select A81.9 as UC.


2005-12-12_01 Failure of ventilator due to power cut

 

(Rule GP, Chapter X, XX)

[Question from Elaine Tower, England:]

I wonder if the Forum could help us:
We have a death of a 77year old female who was at home on a ventilator when there was a power cut. The power cut thus stopped her ventilator and the lady died.

Death certificate is:-
1a Emphysema
Coroner's verdict is Accidental Death

We are wondering what code to use for the mechanical failure of this appliance. Is it Y848 or Y658 with T818? Also how have, or how will, the the USA approach similar deaths that occurred in the Hurricane Katrina?

2005-12-12_02 Code for inhalation of helium

 

(Chapter XX)

[Question from Mary Field-Smith, England:]

In the course of our research, we are encountering an increasing number of deaths (mainly suicides) resulting from asphyxiation after the inhalation of helium. This is frequently obtained from commercial sources such as party balloon shops and information on this method of suicide is freely available on the internet.

We have discovered that in the ICD10 coding rules, helium is to be entered as X440 or X640, whereas we would have expected these type of deaths to be coded as X470/670.

Has this issue been raised before and is there a case for altering this rule?

2005-12-12_03 Secondary neoplasm due to stomach polyp

 

(Rule GP)

 

[I am very happy to forward a couple of questions from Tadahiro Ootsu, Japan, to the Forum. Some members of the Forum have already seen them, and I include the replies we have received so far:]

This question is about Polyp of stomach and duodenam (K317), and Polyp of colon (K635). For example,

I(a) Secondary malignant neoplasm of lung (C780)
(b) Polyp of stomach (K317)

Can I code C169 (Stomach, unspecified) as the underlying cause of death? If I can not, I would like to know correct code of this example.

And, how about the relation between polyp and malignant neoplasm ? Is there a sequence?


[Comments:]

2005-12-13:

Canada /Patricia Wood/:
The Implication of Malignancy instruction in ICED-10 (2nd Edition), Volume 2, page 76 says that, "mention on the certificate that a neoplasm has produced metastases means that it must be coded as malignant, even though this neoplasm without mention of metastases would be classified to some other section of Chapter II." Polyps of stomach, duodenum and colon, not specified as adematous, are not classified as a neoplasms so malignancy is not implied when the polyp is certified as the cause of a secondary malignant neoplasm of the lung.

In the absence of further specification about the nature of the polyp by the certifier, I would apply Rule 2.

2005-12-12_04 Dementia due to vascular disease

 

(Rule C)

[Question from Tadahiro Ootsu, Japan:]

The next question is about the recommendation below.

I60-I69 Cerebrovascular diseases when reported as the originating antecedent cause of conditions in:

F01-F03, code F01

For example,

I(a) Unspecified dementia (F03)
(b) Other specified cerebrovascular diseases (I678)
Is the underlying cause of death Other vascular dementia (F018)? Is it correct? If not, I would like to know the correct code of this example.

And, I would like to know the linkages between I60-I69 and F012, F013 and F018. I can not understand how to use F010, F011, F019 or F012, F013, F018.


[Comments:]

2005-12-13:

Canada /Patricia Wood/:
The question asked involves the guideline, to be implemented in 2005, saying that when I60-I69 is reported as the cause of F01-F03, code F01. I would assign the underlying cause of death to F01.9 in the particular example mentioned, rather than F01.8 as there is no real specification of the vascular dementia.

Aren't the linkages between I60-I69 and F012, F013 and F018 all the same; if F012, F013 or F018 is specified as due to any condition in I60-I69, the specific F code is preferred? For example, subcortical vascular dementia

(F012) specified as due to a stroke (I64); the underlying cause of death will be F012.

2005-12-12_05 Electromechanical dissociation

 

(Chapter IX)

[Question from Tadahiro Ootsu, Japan:]

I am also asking about the following case:
I(a) Heart failure 60 minutes
(b) Electromechanical dissociation 60 minutes
II Schizophrenia 18 years

I have no information except the above.

Because electromechanical dissociation means cardiac arrest, I think that the underlying cause of death is I469 ( Cardiac arrest, unspecified ).

Is it correct? If not, should I code I509 ( Heart failure, unspecified ) or another code?


[Comments:]

2006-01-17:

Slovenia /Jozica Selb/:
As I know electromechanical dissociation means the heart "too good to die", as was also said here, pulse less heart in case of the rupture of the heart wall or hemorrhagic shock or so on. In this case no other information except heart failure has been done which is not in accordance with heart too good to die. Anyway in this case we would code I509 as an underlying cause of death.

2006-01-10:

WHO /Robert Jakob/:
Electromechanical dissociation means, as already mentioned, a lack of pulse though there is electric activity (ECG). This means, the conduction is working, but there is no reaction from the muscle. This occurs (usually) only when the heart is dying. Electromechanical dissociation is neither a conduction disorder nor an arrhythmia and should not be classified with these codes. It is an elegant term describing the combination of findings around the moment of the cardiac arrest (I46.9). It is an ill-defined condition. According to the coding rules already decribed below, the UC in Tadahiro's case would be "heart failure" I509.

I would suggest to propose an additional entry to the index accordingly and to agree whether one would prefer to code R943 or I469.

To be sure this term is used the same way in different regions the participants of the Mortality Forum may wish to ask for the clinical meaning clinicians in their respective countries.

2005-12-20:

Germany /Stefanie Weber/:
To my understanding electromechanical dissociation means the dysfunction of the electrical stimulus towards the mechanical function of the myocardial cells resulting in no or low output of blood as the cells contract "untuned". This could be due to damage of the cells (infarction, intoxication) but the reason for this malfunction is not contained in the word electromechanical dissociation itself. Basically the neural stimulus does not make the cells work. Therefore I would agree to the coding of I45.8.

2005-12-13:

England /Elaine Tower/:
Here in England we would use the following codes:
1a Heart Failure = I50.9,
1b Electromechanical dissociation = I45.8, Schizophrenia = F20.9.
The underlying cause would be the I45.8. We would not use the I46 codes as I46.1 excludes conduction disorder of which the electromechanical dissociation is included in. Also, the I46.9 is an ill-defined code.

PAHO /Roberto Becker/:
If electromecanical dissociation really means cardiac arrest, this one can not cause heart failure. In this case, there is no sequence. Rule 2 applies and the underlying cause of death is Hearth failure.

Even if you could select cardiac arrest as underlying cause, rule A would apply and you would reselect Hearth failure again, because for that purpose,

I46.9 is considered ill-defined.

However, as electromechanically dissociation is not in the index, if the meaning is any conduction or arrhythmia hearth disorder, (anything coded to

I44-I45 or I47-I49, but not I46) I would select that one as Underlying cause of death and not hearth failure.

[Following the replies from Elaine and Roberto:]
Japan /Tadahiro Ootsu/:
My literature on this subject, in Japanese, explains that Electromechanical dissociation has another name, which is Puseless electrical activity. We can see some waves in the EKG, but no pulse.

The literature defines Electromechanical dissociation as a condition of cardiac arrest. And the cause of Electromechanical dissociation is hypovolemia or malfunction of the myocardium.

From Roberto's and Elaine's answer, I would like to code I458. But, is Electromechanical dissociation really a conduction disorder? I think Electromechanical dissociation is a condition but not disease.

So I also would like to regard that the underlying cause of death is Heart failure. I understand, at least, I469 is incorrect.

Sweden /Lars Age Johansson/:
In Sweden, the term "electromechanical dissociation" would be used of the situation where the electrocardiogram shows myocardial complexes, but clinically there is no circulation of blood. There could be different reasons for this, for example heart rupture or other kinds of cardiac tamponade. Since this is a symptom rather than a disease, we in Sweden have decided to use the code R94.3 for electromechanical dissociation. I'm not sure if that is the best code, but we would not code it as a conduction disorder. In the example submitted by Tadahiro, we would select heart failure (I50.9) as the underlying cause of death.

2005-12-20_01 Linkage diabetes - autonomic dysreflexia

(Rule C, Chapter IV)

[Questions from Tadahiro Ootsu, Japan. Please see also see the attachment, File Q7-9.pdf:]

[Q7] Can I regard that the new code G904 (autonomic dysreflexia ) has linkages with Diabetes mellitus (E10-E14 )? In ACME, for example, G909 links with E149 (LMC), and becomes E144. How about G904?


[Comments:]

2006-02-28:

Canada /Patricia Wood/:
Robert's advice is reflected in the Table E (Modification) in the 2006 version of NCHS Instruction Manual Part 2c where G904 is not linked to, or modified by any subcategories in E10-E14.

2006-01-17:

WHO /Robert Jakob/:
Autonomic dysreflexia is defined as "wrong" autonomic reactivity following spinal chord injury (source: e.g. PubMed ) . Starting from this definition I can't see any relationship to diabetes mellitus. Some other autonomic diseases can be caused by diabetes mellitus.

2005-12-20_02 Linkage HIV - D50-D89

(Rule C, Chapter I)

[Questions from Tadahiro Ootsu, Japan. Please see also see the attachment, File Q7-9.pdf:]

[Q8] Due to the recommendation, can I regard that B20-B24 have linkages with D50-D89? Now in Japan, like ACME, B24 links with D500-D899 (BDSC), and becomes B232. Is it correct that there is a new linkage BMP between B20-B24 and D500-D899?

2005-12-20_03 Non-rheumatic and rheumatic valvular conditions on the same certificate

(Chapter IX)

[Questions from Tadahiro Ootsu, Japan. Please see also see the attachment, File Q7-9.pdf:]

[Q9] Case 1:
1(a) Nonrheumatic tricuspid (valve) insufficiency (I361)
1(b) Disorders of both mitral and aoretic valves (I080) In Japan, regarding LMC between I361 and I080, I have coded I083 (Combined disorders of mitral, aortic and tricuspid valves) until now. But hereafter, should I code I38 (Endocarditis, valve unspecified), because I361 is nonrheumatic? Is this correct? If not, I would like to know correct code of Case 1.


[Comments:]

2006-02-28:

Canada /Patricia Wood/:
For Tadahiro's first case I would code line a) as I361 because the tricuspid insufficiency is specified as nonrheumatic. I would code line b) as I059 and I069 because the mitral and aortic valve diseases are jointly reported.

Then applying Rule 2 I would select I361 as the tentative underlying cause of death. I would not link (Rule C) the nonrheumatic and rheumatic valvular heart diseases. I would keep I361 as the underlying cause of death.

I am not sure about the second one as the pulmonary valve insufficiency on line a) is not specified as nonrheumatic ... I am inclined to code line a) as I371 and line b) as I059 and I079. Applying Rule 2, I would select I371 as the tentative underlying cause of death, Again, I would not link (Rule

C) nonrheumatic and rheumatic heart diseases. That would leave me with I371 as the underlying cause of death, but I am tentative about this! I would probably see if I could get some clarification from the certifier.

2006-01-17:

Japan /Tadahiro Ootsu:/
I have more questions related 2005-12-20-03 and 04. As a practical matter, we often see cases with no reference of rheumatic or nonrheumatic valve disorders.For no references of rheumatic or nonrheumatic cases, which should I code,

I05 - I07 or I34 - I37?
If there are many countries to be observed frequently no reference of rheumatic or nonrheumatic valve disorders like Japan, should we discuss major change of these codes?

Sweden /Lars Age Johansson/:
I think Tadahiro has a point that the assumptions in ICD-10 concerning the etiology of valvular disorders should be reviewed. For example, it is assumed that a mitral stenosis is due to rheumatic fever if nothing else is stated on the death certificate. That was probably quite correct 30 or 40 years ago, but may not be true quite as often and in quite as many countries today. Perhaps something to consider for ICD-11?

2006-01-10:

Sweden /Lars Age Johansson/:
If there is no mention of either "rheumatic" or any other cause of the valvular conditions, you can use I08. However, if there is a mention of a non-rheumatic cause of the valvular disease, you should select an underlying cause in the usual way:

1a Aortic stenosis
2 Mitral insufficiency
Select I08.0 (disorders of both mitral and aortic valves) as underlying cause but
1a Aortic stenosis
1b Atherosclerosis
2 Mitral insufficiency
Select I35.0 (aortic stenosis) as underlying cause

That is, I38 does not replace I08 in non-rheumatic cases.

If there is no information on the cause of the valvular disease, the ICD code depends both on which valve that has been affected, and on the type of the valvular disease. For example, mitral stenosis of unknown origin is coded to I05.0, but mitral insufficiency of unknown origin is coded to I34.0. The easiest way to find the correct code is to check the English alphabetical index (ICD Vol. 3) under "Stenosis", "Insufficiency", and "Endocarditis" (for cases where the type of valvular disease is unspecified as well). There you will find the correct code for each combination of valve, type of disease, and etiology.

2005-12-20_04 Pulmonary, mitral, and tricuspid valvular conditions on the same certificate

(Chapter IX)

[Questions from Tadahiro Ootsu, Japan. Please see also see the attachment, File Q7-9.pdf:]

Case 2:
1(a) Pulmonary valve insufficiency (I371)
1(b) Disorders of both mitral and tricuspid valves (I081) In Japan, regarding LMC between I371 and I081, I have coded I088 (Other multiple valve diseases) until now. But hereafter, should I code I38 (Endocarditis, valve unspecified) because I371 is nonrheumatic? Is this correct ? If not, I would like to know correct code of Case 2.


[Comments:]

2006-01-17:

Japan /Tadahiro Ootsu:/
I have more questions related 2005-12-20-03 and 04. As a practical matter, we often see cases with no reference of rheumatic or nonrheumatic valve disorders. For no references of rheumatic or nonrheumatic cases, which should I code,

I05 - I07 or I34 - I37?

If there are many countries to be observed frequently no reference of rheumatic or nonrheumatic valve disorders like Japan, should we discuss major change of these codes?

Sweden /Lars Age Johansson/:
I think Tadahiro has a point that the assumptions in ICD-10 concerning the etiology of valvular disorders should be reviewed. For example, it is assumed that a mitral stenosis is due to rheumatic fever if nothing else is stated on the death certificate. That was probably quite correct 30 or 40 years ago, but may not be true quite as often and in quite as many countries today. Perhaps something to consider for ICD-11?

2006-01-10:

Sweden /Lars Age Johansson/:
If there is no mention of either "rheumatic" or any other cause of the valvular conditions, you can use I08. However, if there is a mention of a non-rheumatic cause of the valvular disease, you should select an underlying cause in the usual way:

1a Aortic stenosis
2 Mitral insufficiency
Select I08.0 (disorders of both mitral and aortic valves) as underlying cause but
1a Aortic stenosis
1b Atherosclerosis
2 Mitral insufficiency
Select I35.0 (aortic stenosis) as underlying cause

That is, I38 does not replace I08 in non-rheumatic cases.

If there is no information on the cause of the valvular disease, the ICD code depends both on which valve that has been affected, and on the type of the valvular disease. For example, mitral stenosis of unknown origin is coded to I05.0, but mitral insufficiency of unknown origin is coded to I34.0. The easiest way to find the correct code is to check the English alphabetical index (ICD Vol. 3) under "Stenosis", "Insufficiency", and "Endocarditis" (for cases where the type of valvular disease is unspecified as well). There you will find the correct code for each combination of valve, type of disease, and etiology.

2005-12-20_05 End stage renal disease and congenital anomalies in infant

(Rule 3, Chapter XVI, XVII)

[Question from Stefanie Weber, Germany:]

While coding certificates for death under the age of two years we came upon a couple of cases with multiple congenital anomalies mentioned in part 2.

Example:
Age 4 month
1a Hypoxymia
1b Lung oedema
1c End stage renal disease
II Prematurity, Multiple congenital anomalies

My colleague and I differ in choosing the underlying cause. He would code the renal disease as underlying cause as ACME does. I would use rule three and combine/specify the renal disease with the other anomalies and code to Q89.7. What would you recommend?


[Comments:]

2006-02-07:

Brazil /Ruy Laurenti and Heloisa Di Nubila/:
In Brazil, we use ACME system since 1983. We think that, before using ACME, a well-trained codifier has to choose the underlying cause manually. After this, the codifier can judge if ACME, as a tool, could reach his/her logic on choosing the underlying cause. We agree with Lars' reasoning, U.C. Q89.7.

2006-01-31:

Canada /Patricia Wood/:
Like Stefanie's colleague, I would assign the underlying cause of death to the end stage renal disease (ICD-10 code N180). I think that to apply Rule 3, which is to say that the renal disease is obviously a direct consequence of the multiple congenital anomalies, would require some clarification from the certifier.

2006-01-17:

Norway/Gunvor Ostevold/:
We think and do like Belgium. We are not using ACME yet, but we will start using ACME coding the data from 2005. Then we have to code cases like this manually, I guess? How do you cope with this, Sweden?

Slovenia /Jozica Selb/:
As I understand this particular death certificate, the renal anomaly was the main cause out of the multiple anomalies contributing to death. So we would code congenital renal disease Q649. It is also possible to code Q899 - congenital malformation unspecified.

Sweden /Lars Age Johansson/:
To reply to Gunvor's question first - yes, here in Sweden we code all perinatal deaths both with ACME and manually. In this case we would first have tried to get more information on the death. For example, what kind of anomalies were there, was there some kind of malformation syndrome present, and so on. If there is no further information to get we would use Rule 3 and select the multiple anomalies. It is highly unlikely that a child of four months with multiple anomalies would have developed an end stage renal disease that was not due to the anomalies, I would think.

2006-01-10:

Belgium /Josiane Mornie/:
We take Q89.7 = the multiple congenital anomalies.

2005-12-20_06 Commotio cordis and selection of underlying cause

(Chapter XIX, XX)

[Question from Tadahiro Ootsu, Japan. I submit this question separately because Tadahiro had already got a couple of comments before the question reached the Mortality Forum. /Lars Age]

I have two cases of "commotio cordis". My literature, in Japanese, explains that "commotio cordis" is cardiac arrest due to injury of thorax. Commotio cordis is a cause of sudden cardiac death of child, and there were 128 reported cases in USA. Which code should I choose for commotio cordis? I think S268 ( other injuries of heart ) is suitable. Is it correct ? How about in USA?


[Comments:]

2005-12-12:

Japan /Tadahiro Ootsu/:
Thank you for your advice. The cases are the following.

Case 1
1(a) Commotio cordis
1(b) Bruise of the back
From autopsy: Bleeding of heart

I think that 1(a) and the autopsy result give S260. And 1(b) gives S202 ( or S204). The underlying cause of death for Case 1 is S202 because of the General principle. But should I code S299?

Case 2
1(a) Unknown
Diagnosis from autopsy: Possibility of commotio cordis The situation: Injury of thorax due to judo (Japanese traditional combative sport)
I think that the underlying cause of death for Case 2 is S202. But should I code S299?

Because my literature explains that commotio cordis is caused by a slight injury, it would be suitable to choose S20. But should I rather choose S29? And what about the following case?

Case 3
1(a) Commotio cordis

Should I code S299 when there is only a mention of commotio cordis? Or should I code S268? Please see Robert's suggestion, and please advise me again.

2005-12-11:

USA /Julia Raynor/:
In the US, we code Commotio cordis to S299, Unspecified injury of thorax. The underlying cause for the certificate would be the code for the external information.

2005-12-08:

WHO /Robert Jakob/:
S26.8 (0) is suitable. The external cause should in any case be recorded.

 

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