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mort07_1

2007-01-23_01 Definition of maternal death

(Chapter XVI)

[Question from Eduard Salakhov, Russia:]

Dear colleagues,

The following question came from our colleagues from Ukraine:

A death certificate submitted to the health statistics centre raised a discussion of experts on whether to code this case as a maternal death or not:

I a) Cerebral oedema
b) Intracerebral hemorrhage into left hemisphere
c) Congenital cerebral aneurysm
II Normal timely delivery, with one dead fetus, not in the maternity


[Comments:]

2007-02-06:

Cyprus /Pavlos Pavlou/:
Having read the previous comments and having found their logic quite reasonable, I was tempted to see what result ACME 2006.2 would give.

Using the following multiple cause codes (G936/I612/Q283*O994) ACME gives Q283 as the UCOD.

Alternatively, using the following multiple codes (G936/I612/I609*O994 - because the congenital aneurysm was ruptured), ACME gives I609 as the UCOD.

I think, there is a problem with the latter code in the sense that, it is specific for subarachnoid haemorrhage while the certificate specifies intracerebral haemorrhage.

If  I am using ACME correctly and if my multiple codes are correct, this is what ACME/TRANSAX codes as the UCOD. What we should be coding is a different matter. I agree, this is not an easy question. Whichever choice we make we shall lose significant information. This, I think, demonstrates the value of analysis and reporting of multiple causes of death. However, as we know, this is not so easy. I think we need further input and discussion on this example.

2007-01-30:

Canada /Patricia Wood/:
Well ... I think that we should have started our twelfth year with an easier question! Perhaps my logic is flawed, but here's what I would do in this case: If the decedent hadn't been pregnant less than 42 days before she died, I would code the underlying cause of death to I60.- because of the intracerebral hemorrhage (line b) due to a congenital cerebral aneurysm (line c). Therefore, since she was pregnant less than 42 days before she died, I would code the underlying cause of death to ICD-10 code O994, Diseases of the circulatory system complicating pregnancy, childbirth and the puerperium. Interestingly, in ICD-9 there was a specific code, 674.0 Cerebrovascular disorders in the puerperium, that I think would have applied in this case.

Jordan / Majed Asad/:
In Jordan I will consider this case a maternal death. The code will be O99.4.

Sao Paulo Classification Centre /Ruy Laurenti/:
Like Lars I am sending to all a "Happy new Mortality Forum Year".

Now to the question from Eduard Salaklov (Russia). The problem appointed by him is: is the case a maternal death or is it not? Taking in consideration only the Part I of the death certificate according the to General Principle the selected underlying cause of death is "Congenital cerebral aneurysm" in the category Q28.-. However, under the category Q28.- there is a Exclusion Note that excludes "ruptured cerebral arteriovenous malformation (I60.8)". In the category I60.- there is an "inclusion note" that "Includes ruptured cerebral aneurysm" and the code is I60.8. Thus, the selected cause by General Principle is Q28.3, but, in this case, we have a linkage and the final code is I60.8.

Now to the main question in this death certificate: is it or is it not a maternal death? I made consultations with physicians (clinicians and obstetricians) and several very good coders, and all agree with my point of view: This is a maternal death and, in this case, an obstetric indirect cause; and the code is O99.4.

It is O99.4 and not O99.8 because we make the linkage with I60.8 and not Q28.3. O99.4 includes I00-I99 and O99.8 includes Q00-Q99 (see pages 763-737, Volume I, ICD-10). It is an obstetric indirect cause because we have the cause "congenital cerebral aneurysm", that ruptured and produced an intracranial hemorrhage and death in the delivery. In our opinion the rupture of the aneurysm was caused by the struggle or effort during the delivery.

The death occurred one day after the delivery and it is very well know that there are cases in which the rupture of a cerebral aneurysm started and the total rupture occurs some days after. As a final comment: it is not easy in several cases of obstetric indirect causes to decide if it is or is not a maternal death.

2007-02-06_01 Liver tumour due to hepatitis B due to needle stick (occupational accident)

(Rule GP)

[Question from Elaine Tower, England:]

1a Hepatocellular Carcinoma
1b Liver Cirrhosis
Verdict: Industrial Disease B8

Coroners Inquest - Deceased was a General Practitioner who in 1978 contracted Hepatitis B owing to a needle stick accident, this subsequently leading to a tumour of the liver.Would this needle stick accident come under the "highly improbable" rules? Would the code be Y62.9 - During unspecified surgical and medical care? What would other countries do for this case?


[Comments:]

2007-02-20:

Canada /Patricia Wood/:
Like Lars Age and Dr. Laurenti, we would code the underlying cause of death to C220, Hepatocellular carcinoma. The bigger dilemma is how to code the multiple causes of death. I agree with Lars Age that Y60-Y69 is exclusive to misadventures to PATIENTS during surgical and medical care and therefore not suitable for the "needle stick" sustained by the decedent. While under discussion in the URC, the Australians suggested that the new code W46 (implemented in January 2006) have needle stick injury as an inclusion term.

Although the inclusion term was not part of the official update, I suppose that W46 would be a good way to represent the "external cause" in this case.

2007-02-13:

Sao Paulo Classification Centre /Ruy Laurenti/:
In this case, for us, the underlying cause of death is "Hepatocellular Carcinoma" according to the rules and guidelines in cases of malignant neoplasm. We do not take in consideration the hepatitis B or the needle stick accident.

Sweden /Lars Age Johansson/:
As Ruy says, the underlying cause is hepatocellular carcinoma. According to Vol 2 section 4.2.2 (Interpretation of "highly improbable"), a malignant neoplasm can't be due to anything else than HIV. The hepatitis B and needle stick could be coded as contributory causes, of course. I don't think that Y62.9 would be appropriate here, as Y60-Y69 are for misadventures to patients. There is an ICD update from 2004 and with implementation date 2006 that might do, "W46 Contact with hypodermic needle" - assuming, of course, that the needle in question was a hypodermic needle. If the data year is before 2006, W27 (Contact with nonpowered hand tool) seems to be the best code, and "needle" is one of the inclusions there.

2007-02-06_02 Primary pulmonary hypertension and caesarean section

(Chapter XV)

[Question from Elaine Tower, England:]

1a post Partum haemorrhage
1b Anterior abdominal wall bleeding following caesarean section 1c Primary pulmonary hypertension (caesarean section at 28 weeks performed)
II 3rd Trimester pregnancy
Verdict - Natural causes.

We would like to know how best to code the Primary pulmonary hypertension for a maternal death. We were thinking of the following codes. Which one would be the better one to use, O16 or O10.9 or O99.4?


[Comments:]

2007-02-27:

New Zealand [Sara Puaca-Stevanovic]:
There are many indications for caesarean section, and it is expected to solve the problem. The deceased would survive, having coexisting primary pulmonary hypertension and pregnancy, if there would not be the post-partal haemorrhage of the anterior abdominal wall, which has no link with primary pulmonary hypertension. Cause of death is directly obstetric, and it is not clear to me why was the verdict 'natural cause', as the mentioned haemorrhage was not of that category.

Sweden /Lars Age Johansson/:
As the certificate is written, I would presume that the pulmonary hypertension was the reason why the section was performed. Then the procedure was complicated by the hemorrhage, and the woman died. If this is a correct interpretation (and the ICD tells us to accept a stated sequence unless it is "highly improbable"), then the sequence of events started with the pulmonary hypertension. The coding instructions on deaths from complications of surgery (Vol 2, section 4.2.6) also apply, I believe, and they say that if the reason for a procedure is known, then that reason should be coded as the underlying cause of death. I would also code this case to O99.4.

2007-02-20:

Canada /Patricia Wood/:
I agree with Dr. Laurenti that the underlying cause of death should be assigned to ICD-10 code O994. I would not assign primary pulmonary hypertension complicating pregnancy to ICD-10 codes O16 or O109 because in Chapter IX, Primary pulmonary hypertension (I270) is not included in the block of codes for hypertensive diseases (I10-I15). The block of codes O10-O16 in Chapter XV includes hypertensive disorders in pregnancy, childbirth and the puerperium.

Examining these codes it seems that the "hypertensive disorders" are exclusive to diseases classified to I10-I15 in Chapter IX.

Also very helpful is the index entry:
Pregnancy
- complicated by
- - conditions in
- - - I00-I09, I20-I99, O99.4

New Zealand /Sara Puaca-Stevanovic/:
Direct cause of the death was post-procedural bleeding from anterior abdominal wall due to caesarean section. It is the complication of the puerperium, and one of the codes from O90 category [O90.0 Disruption of caesarean section wound, or O90.2 Haematoma of obstetric wound] would probably best describe the condition.

Primary pulmonary hypertension was not directly involved in the cause of death, being responsible only for the induction of the delivery.

2007-02-13:

Sao Paulo Classification Centre /Ruy Laurenti/:
This is a case of maternal death due to a obstetric indirect cause. The U.C is the primary pulmonary hypertension complicating the pregnancy. Code O99.4

2007-02-20_01 Aspiration pneumonia an obvious consequence of alcoholism?

(Rule R3)

[Questions from Gunvor Ostevold, Norway:]

In the first three examples I would like to use rule 3 (Direct Sequel), but ACME doesn't:

1a. Aspiration pneumonia, J690
II. Alcoholic hepatic failure with hepatic coma, K704

ACME uc J690, I will choose K704


[Comments:]

2007-02-27:

Canada /Patricia Wood/:
As Gunvor points out, in the first three cases ACME selects the tentative underlying cause of death from the lowest used line of Part I and does NOT make a direct sequel relationship with the condition in Part II.

In ICD-10, Volume 2, 4.1.6 Some considerations on selection rules state that Rule 3 "applies, however, only when there is no doubt about the causal relationship between the two conditions; it is not sufficient that a causal relationship between them would have been accepted if the certifier had reported it".
In each of these three cases, I notice that IF the certifier had reported the condition in Part II as part of the causal sequence in Part I, ACME would have selected it as the underlying cause of death. But, I wonder if the tentative underlying cause in each case is actually an "obvious consequence" of the condition in Part II? I don't have that kind of clinical expertise, but Rule 3 should only be applied if there is no doubt about the "obvious consequence" nature of these relationships. Lars Age, if that's the case, perhaps the MRG can propose that NCHS add them to the ACME decision tables?

Israel /Sam Rubin/:
Rule 3 is always a couse of lively debates among us, since it calls for the coder`s judgment. So here is my humble opinion: Rereading rule 3, we apply it when the condition selected by the general principle is the obvious and direct cause of another condition. On the first three questions the selected condition may or may not be the consequence of the condition stated on the second part, therefore rule 3 is not an option.

Sweden /Lars Age Johansson/:
The three conditions on the lowest used line in Part I (aspiration pneumonia, calculus of kidney, urinary tract infection) often appear as complications of other conditions, and there are special instructions on both aspiration pneumonia and urinary tract infection in Vol 2 already. I agree with Patricia that the MRG should review these instructions, and consider whether Rule 3 should apply in more cases, and to renal calculus as well. When doing so we must remember what Sam says, namely that Rule 3 applies only if there is no doubt about the relationship.

2007-02-20_02 Calculus of kidney an obvious consequence of multiple sclerosis?

(Rule R3)

[Questions from Gunvor Ostevold, Norway:]

1a. Urinary tract infection, N390
1b. Calculus of kidney, N200
II. Multiple sclerosis, G35

ACME uc N200, I will choose G35


[Comments:]

2007-02-27:

Canada /Patricia Wood/:
As Gunvor points out, in the first three cases ACME selects the tentative underlying cause of death from the lowest used line of Part I and does NOT make a direct sequel relationship with the condition in Part II.

In ICD-10, Volume 2, 4.1.6 Some considerations on selection rules state that Rule 3 "applies, however, only when there is no doubt about the causal relationship between the two conditions; it is not sufficient that a causal relationship between them would have been accepted if the certifier had reported it".

In each of these three cases, I notice that IF the certifier had reported the condition in Part II as part of the causal sequence in Part I, ACME would have selected it as the underlying cause of death. But, I wonder if the tentative underlying cause in each case is actually an "obvious consequence" of the condition in Part II? I don't have that kind of clinical expertise, but Rule 3 should only be applied if there is no doubt about the "obvious consequence" nature of these relationships. Lars Age, if that's the case, perhaps the MRG can propose that NCHS add them to the ACME decision tables?

Israel /Sam Rubin/:
Rule 3 is always a couse of lively debates among us, since it calls for the coder`s judgment. So here is my humble opinion: Rereading rule 3, we apply it when the condition selected by the general principle is the obvious and direct cause of another condition. On the first three questions the selected condition may or may not be the consequence of the condition stated on the second part, therefore rule 3 is not an option.

Sweden /Lars Age Johansson/:
The three conditions on the lowest used line in Part I (aspiration pneumonia, calculus of kidney, urinary tract infection) often appear as complications of other conditions, and there are special instructions on both aspiration pneumonia and urinary tract infection in Vol 2 already. I agree with Patricia that the MRG should review these instructions, and consider whether Rule 3 should apply in more cases, and to renal calculus as well. When doing so we must remember what Sam says, namely that Rule 3 applies only if there is no doubt about the relationship.

2007-02-20_03 Urinary tract infection an obvious consequence of osteogenesis imperfecta?

(Rule R3)

[Questions from Gunvor Ostevold, Norway:]

1a. E.coli septicaemia/endocarditis
1c. Urinary tract infection, N390
II. Osteogenesis Imperfecta, Q780

ACME uc N390, I will choose Q780


[Comments:]

2007-02-27:

Canada /Patricia Wood/:
As Gunvor points out, in the first three cases ACME selects the tentative underlying cause of death from the lowest used line of Part I and does NOT make a direct sequel relationship with the condition in Part II.

In ICD-10, Volume 2, 4.1.6 Some considerations on selection rules state that Rule 3 "applies, however, only when there is no doubt about the causal relationship between the two conditions; it is not sufficient that a causal relationship between them would have been accepted if the certifier had reported it".

In each of these three cases, I notice that IF the certifier had reported the condition in Part II as part of the causal sequence in Part I, ACME would have selected it as the underlying cause of death. But, I wonder if the tentative underlying cause in each case is actually an "obvious consequence" of the condition in Part II? I don't have that kind of clinical expertise, but Rule 3 should only be applied if there is no doubt about the "obvious consequence" nature of these relationships. Lars Age, if that's the case, perhaps the MRG can propose that NCHS add them to the ACME decision tables?

Israel /Sam Rubin/:
Rule 3 is always a couse of lively debates among us, since it calls for the coder`s judgment. So here is my humble opinion: Rereading rule 3, we apply it when the condition selected by the general principle is the obvious and direct cause of another condition. On the first three questions the selected condition may or may not be the consequence of the condition stated on the second part, therefore rule 3 is not an option.

Sweden /Lars Age Johansson/:
The three conditions on the lowest used line in Part I (aspiration pneumonia, calculus of kidney, urinary tract infection) often appear as complications of other conditions, and there are special instructions on both aspiration pneumonia and urinary tract infection in Vol 2 already. I agree with Patricia that the MRG should review these instructions, and consider whether Rule 3 should apply in more cases, and to renal calculus as well. When doing so we must remember what Sam says, namely that Rule 3 applies only if there is no doubt about the relationship.

2007-02-20_04 Treatment with lithium due to bipolar affective disorder

(Rule GP)

[Questions from Gunvor Ostevold, Norway:]

And what do you think about a certificate like this:
1a. Pulmonary embolism, I269
1b. Deep vein thrombosis, I802
1c. Nephrogenic diabetes insipidus due to treatment with Lithium, N251
1d. Bipolar affective disorder, F319

ACME uc N251 but from my point of view there is a sequence from 1d to 1c.


[Comments:]

2007-03-27:

Ruy Laurenti and Heloisa Di Nubila /Sao Paulo Classification Centre/:
For the Brazilian Center, the u.c. is F31.9. For us there is a logical sequence from Id to Ic, Ic to Ib, Ib to Ia.

2007-03-20:

Norway/Gunvor Ostevold/:
Thank you for all the comments to my questions about rule 3, DS, (2007-02-27). In the meantime while waiting for the MRG to decide we in Norway in some cases will code manually using rule 3.

2007-02-27:

Canada /Patricia Wood/:
On this certificate the nephrogenic diabetes insipidus is certified as an adverse effect of drug (Lithium) therapy administered for bipolar affective disorder. Reading the ACME input instructions (NCHS Manual 2b) I think that the record would be coded as:
I269/I802/N251/Y495/&F319

2007-02-27_01 Sinoatrial and atrioventricular nodal artery dysplasia

(Chapter IX)

[Question from Michelle J. White, USA:]

We have a few deaths listed as due to "sinoatrial and atrioventricular nodal artery dysplasia" and are not sure how to code the underlying cause. When we speak with the pathologists, they explain that the death is due to cardiac arrhythmia due to the dysplasia (abnormal growth & disordering of the cells) of the arteries to the sinoatrial and atrioventricular nodes, and that the dysplasia is not necessarily congenital.

I77.3, Arterial fibromuscular dysplasia, is the code we tentatively suggest.

However, we then lose the significance of the dysplasia being located in the cardiac vessels. Coding to I49.9, cardiac arrhythmia, is not satisfactory either, as the very specific cause of the arrhythmia is known. The pathologists note that this is a cardiac conduction system vasculopathy, so we wonder if I45.8, Other specified conduction disorders, would be more appropriate?

Any suggestions would be appreciated.


[Comments:]

2007-03-27:

Sao Paulo Classification Centre /Ruy Laurenti and Heloisa Di Nubila/:
For the Brazilian Centre, the code for the question from Michelle J. White is I45.8.

2007-03-20:

Sweden /Lars Age Johansson/:
Given the information Michelle provides, I would code this as a conduction disorder. Apparently the death certificates don't use the word "fibromuscular", which is required for the code I77.3. Of the two heart codes, it seems to me that I45.8 captures more information than I49.9.

2007-03-13_01 Sequence pancreatic cancer -> hip fracture?

(Rule GP)

[Question from John G. O'Connor, Ireland:]

1 a Myocardial Infarction    1 hour
1 b Hip Fracture                 1 week
1 c Pancreatic Cancer
2 -
Female Aged 79

Is there a reported sequence in the condition first entered in 1 a in this example? Supermicar/Acme suggests coding to the Cancer. What are you suggestions for coding?

Is there a highly improbable sequence here as there is no mention of epilepsy being the cause of the fracture. I welcome any comments.


[Comments:]

2007-04-03:

Canada /Patricia Wood/:
There is an instruction in NCHS Instruction Manual Part 2b, Section III - Intent of Certifier that is relevant to coding the ACME input for this record:
53. Fracture (any site) code M844 (Pathological fracture) when reported due to C00-C97 (page 143 of the 2007 manual)

This would make the ACME input for this record I219/M844/C259 from which ACME 2007.02 will select C259 as the underlying cause of death. Given the way the certifier reported these causes of death I think this is a valid application of the General Principle (assuming, as Dr. Laurenti points out, an intervening cause).

2007-03-27:

Sao Paulo Classification Centre /Ruy Laurenti and Heloisa Di Nubila/:
If we accept by assumption of an intervenient cause (item 4.2.1, vol II) that c leads to b (metastasis), we could apply General Principle, then u.c. is cancer pancreas.

2007-03-20:

Norway/Gunvor Ostevold/:
If the input to ACME is: I219/&X59 S720/C259 the UC will be X59, that is hip fracture and I think that make sense. If you do accept a sequence from 1c to 1b I think you have to use M907 which is Fracture of bone in neoplastic disease, but ACME version 2006.2 disregards asterisk codes. Anyway I have a feeling the doctor meant it to be a sequence since he put it like this in part one. How are the Forum dealing with asterisk codes? Have any of you started to use the newest version of ACME, 2007.02?

Sweden /Lars Age Johansson/:
I tried the asterisk code M907 in ACME 2007.02, but it still doesn't like asterisk codes and you get a message of "invalid code". But if we believe that the doctor really meant that the cancer caused the fracture, then the fracture should be coded as pathological, as Gunvor says. There are at least two possibilities to get that through ACME. First, we could start from the dagger-asterisk pair C259+ M907* that Gunvor suggests, but simply leave out the asterisk code because they aren't used in ACME. That would give us the multiple cause coding I219/C259, and ACME will select C259 as underlying cause. The second possibility is to code I219/M844/C259, that is, to code the hip fracture as an unspecified pathological fracture. I tried that in ACME 2007.02 and it works too.

In Sweden we use asterisk codes in the multiple cause coding, but we remove them from the code string that we send to ACME.

2007-03-20_01 Code(s) for frontal lobe syndrome and frontal lobe dementia

(Chapter V)

[Question from Gunvor Ostevold, Norway:]

Which code to use for Frontal lobe syndrome and Frontal lobe dementia? We use F070 for the syndrome and G310 for the dementia according to our medical advisor. Is it right to split into two different codes from different chapters?


[Comments:]

2007-04-03:

Canada /Patricia Wood/:
I can not comment on the clinical difference between Frontal Lobe Dementia and Frontal Lobe Syndrome but I do notice that the latter is indexed to F070 while the former is not indexed at all. I expect that this might lead many coders to assign Frontal Lobe Dementia to F03.

Japan /Tadahiro Ootsu/:
I searched about frontal lobe syndrome & frontal lobe dementia by PubMed, and found references below. Reference 1) probably indicates that frontal lobe dementia is a type of frontotemporal dementia (FTD).

Reference 2) shows that frontal lobe syndrome is included in the clinical diagnosis criterion of FTD. According to reference 3), it seems that FTD is a synonym of Pick's disease.

From the above, should we describe FTD clearly in G310 (F020) ? (However, I do not directly answer the question.)

1) Ideggyogy Sz. 2005 May 20;58(5-6):164-71. Frontotemporal dementia--Part I. History, prevalence, clinical forms.Galariotis V, Bodi N, Janka Z, Kalman J.

2) Ideggyogy Sz. 2005 Jul 20;58(7-8):220-4. Frontotemporal dementia--Part II. Differential diagnosis, genetics, molecular pathomechanism and pathology.Galariotis V, Bodi N, Janka Z, Kalman J.

3) Can J Neurol Sci. 2006 May;33(2):141-8. Progress in clinical neurosciences: Frontotemporal dementia-pick's disease.Kertesz A.

Sweden /Lars Age Johansson/:
In Swedish multiple cause coding we sometimes use more than one code for a condition. However, we distinguish between the main code for the condition and the supplementary code(s). According to the information Tadahiro supplies, this would be dementia in Pick's disease. ICD-10 has a dagger-asterisk pair for "dementia in Pick's disease", se we would use G31.0 as main code, and F02.0 as supplementary code.

2007-03-20_02 Cerebral haemorrhage an obvious consequence of ampehatamine poisoning?

(Rule R3)

[Question from Lars Age Johansson, Sweden:]

We recently had a death certificate like this:
1a) Cerebral haemorrhage
2 Acute poisoning by amphetamine

Would you consider the cerebral haemorrhage and obvious consequence (Rule 3) of the amphetamine poisoning?


[Comments:]

2007-04-24:

Norway/Gunvor Ostevold/:
It's such a relief for me as a simple coder to notice that a NCHS teacher also can do mistakes. It's not an easy task to keep track with all the rules, the exceptions, guidelines and instruction manuals! Besides that I cannot find Part 2b for 2007 under NCHS web sites/Instruction Manuals as Patricia refers to. Is this exception new in 2007? What about the exception if the acute poisoning was stated in part I of the certificate, would the code for 1a still be I619?

How do you think about this one:
1a) Intracerebral haemorrhage, 1 day
1b) Fractura colli femoris, surgery 1 day Do you consider 1a) as a complication to the surgery? Or do you use I619?
The underlying cause of death will differ.

2007-04-17:

Canada /Patricia Wood/:
Two things; first I must apologize for a mistake I made in my original answer to this issue! I notice that the instruction I refer to in Instruction Manual Part 2b has an exception which says not to apply this instruction is poisoning is reported!!! So, it would seem that I incorrectly suggested that the correct ACME input for this record would be

S062*T436 &X41 Now, I fear that I have to change my answer to say that the ACME input for this record would be I619*T436 &X41 (NCHS may not want me helping teach their courses anymore!)

The other thing; Lars Age asked is there any exceptions in Manual 2b, for example if the certificate states that the hemorrhage occurred before the trauma? Say that someone is driving a car and has a cerebral hemorrhage, and then collides with another car. Would the cerebral hemorrhage still be considered traumatic?

I believe that this situation is covered in an instruction in 2a saying that, "when a disease condition, such as cerebral hemorrhage ... Is indicated by the certifier to be the underlying cause of an accident, the assignment is made to the accidental cause unless there is evidence that the death occurred prior to the accident. Thus accidents are not generally accepted due to disease conditions."

2007-04-10:

[Unfortunately, last week I got the third reference in Tadahiro's comment wrong. It should be "BMJ. 2000 May 13;320(7245):1322-4. Lesson of the week: intracerebral haemorrhage in young adults: the emerging importance of drug misuse. McEwoy AW, Kitchen ND, Thomas DGT." and nothing else. I apologise for the confusion! /Lars Age]

2007-04-03:

Canada /Lars Age Johansson/:
Yes, I would consider the cerebral hemorrhage to be an obvious consequence of the amphetamine poisoning which would be the underlying cause of death.

For ACME input there is an instruction in Part 2b for just such a situation

- Section V, Part E. Conditions qualified as traumatic ... "Some conditions are indexed directly to a nontraumatic category but the Classification also provides a traumatic code. Consider these conditions to be traumatic and code as traumatic when they are reported on the certificate with an injury and/or external cause and/or a manner of death as Accident, ... etc." (page 230, 2b 2007)

So, the ACME input for this record would be: S062*T436 &X41 from which ACME will select X41 as the underlying cause of death

Japan /Tadahiro Ootsu/:
Japanese literature describes that hypertension is one of toxicity by amphetamine. So, it is probable that too much amphetamine causes cerebral hemorrhage. However, I have no confidence to regard this as an " obvious consequence ". According to references below, cerebral hemorrhage is rare complication of amphetamine poisoning. So, I think that Rule 3 should not applied in this case. Especially, please read the left column of 1323 p in reference 3, " The association between ..."

1: J Anal Toxicol. 2005 Sep;29(6):577-81. Intracerebral hemorrhage associated with amphetamine. Klys M, Konopka T, Rojek S.
2: Am J Med Sci. 1999 May;317(5):350-2. Massive intracerebral hemorrhage in an amphetamine addict. Chaudhuri C, Salahudeen AK.
3. McEwoy AW, Kitchen ND, Thomas DGT. Intracerebral haemorrhage in young adults: the emerging importance of drug misuse.

Sweden /Lars Age Johansson/:
According to Tadahiro's third reference the high blood pressure caused by the amphetamine causes a rupture in a pre-existing vascular anomaly.

Generally, the approach of the ICD to deaths from such "double" causes matters is to let the doctor decide: if the anomaly/hemorrhage is reported as the underlying cause then select the anomaly/hemorrhage; but if the poisoning is reported as the underlying cause then select the poisoning. So in this case we might want to code the hemorrhage to I61.9 after all.

Patricia, is there any exceptions in Manual 2b, for example if the certificate states that the hemorrhage occurred before the trauma? Say that someone is driving a car and has a cerebral hemorrhage, and then collides with another car. Would the cerebral hemorrhage still be considered traumatic?

2007-04-03_01 POLG mutations

(Chapter XVII)

[Question from John G. O'Connor, Ireland:]

1 a Status Epilepticus 8 weeks
1 b Mitochondrial Disease
1 c POLG Mutations on exon 7 (A467T) and exon 13 (N7485)
2 -
Female Aged 19

Any suggested ICD9/10 Coding suggestions would be appreciated.


[Comments:]

2007-05-16:

Brazil /Ruy Laurenti and Heloisa Di Nubila/:
About this case, we would consider that an acceptable sequence is informed, and what is declared in c leads to b, and b leads to a. We would apply Modification Rule D (specificity) and the underlying cause would be status epilepticus combined with mitochondriopathy. For us, a good code would be

G40.3 that includes epileptic syndromes, as severe myoclonic epilepsies that are the pattern in some mitochondriopathies as MERRF and MELAS.

France /Albertine Aouba/:
I would like to add the comment below the to the question of G. O'Connor.

In France, the mitochondrial disease is coded E88.8, but in this specific case with the cPOL mutation given, this mitochondriopathy seems to correspond to the Alpers' disease which is the combination of neurological and hepatic failure.

Reference : Ferrari G, Lamantea E, Donati A, Filosto M, Briem E, Carrara F, Parini R, Simonati A, Santer R, Zeviani M. Infantile hepatocerebral syndromes associated with mutations in the mitochondrial DNA polymerase-gammaA. Brain. 2005 Apr;128(Pt 4):723-31. Epub 2005 Feb 2.

Alpers'disease is coded G31.8.

2007-04-24:

Japan /Tadahiro Ootsu/:
I almost agree with Lars Age on the ICD code. But, it may be better to select E88.8 because mitochondrial disease already is not "unspecified ".

Then, may I ask you another question ? ( If it is the same question before, I am sorry. ) What is the meaning of "unspecified " ? In Japan, probably, "specified ( .8 codes ) " is directly translated to Japanese. While, Japanese for "unspecified " means unknown details, is it correct translation?

Sweden /Lars Age Johansson/:
The difference between .8 "other" and .9 "unspecified" is not always evident, but in principle I think that the Japanese translation, as you describe it, is correct. The "other" category should contain well described medical entities that do not have an ICD category of their own. The "unspecified" should be used for entities that are not very well described, and you cannot decide to which of the more specific categories they would belong.

In the case of mitochondrial disease you could argue, of course, that "mitochondrial" is a kind of specification, but you could also think that "mitochondrial" just means that the metabolism was involved, since the term doesn't specify the exact mechanism or the manifestations. I suppose we in Sweden choose "unspecified" (E88.9) because we felt that "mitochondrial" didn't really add much useful information.

2007-04-17:

Japan /Tadahiro Ootsu/:
I think that the problem suggests two points below:

1) How should we classify diseases that have various manifestations in the whole body? For example, Behcet disease ( M352 ) have vascular, nervous and intestinal types.
2) How should we review the chapter XVII (Q codes) ? From chromosome to gene level ? While, it seems that Mitochondrial Disease should have a independent code. Then, I found a reference (attached file). Please see the last page, Table 2 (However, I am not good at gene because I am a classical epidemiologist!).
Reference:
Nat Rev Genet. 2005 May;6(5):389-402. Mitochondrial DNA mutations in human disease. Taylor RW, Turnbull DM.

Sweden /Lars Age Johansson/:
There have been discussions in the Update Reference Committee for years on this, but very few practical suggestions on how to solve the problem. The difficulty seems to be that mitocondrial diseases may have so very different manifestations, and especially the clinicians feel that important information is lost if we classify them all to the same ICD code.

Someone (I don't remember who) suggested that we code mitocondrial conditions by the main manifestation, the problem is how to capture that the conditions is caused by a mitocondrial disease.

You are absolutely right about the difficulties on coding of mitocondrial diseases. So the "solution" would probably be to code diseases with some major characteristic according to that major trait, but to code those with multiple manifestations to either an E code or a Q code. I would suppose that this will be one of the challenges for ICD-11.

In Sweden, we use G71.3 only if "myopathy" is actually mentioned on the certificate. In cases where there is no main manifestation, we use E88.9 for mitochondrial disease. Since the certificate presented by John O'Connor doesn't directly mention myopathy, I would suggest E88.9 as underlying cause of death in spite of the Status Epilepticus.

2007-04-10:

Japan /Tadahiro Ootsu/:
Concerning 2007-04-03 Q1, I think three points below.
1) According to genotype, is it necessary to divide into classes Mitochondrial Disease in ICD? It seems that the underlying cause of death for this case is Mitochondrial Disease.
2) In Japan, probably, we use G713 for Mitochondrial Disease. How about in Sweden or another countries?
3) The principal task of mitochondria is to provide the energy necessary for normal cell functioning and maintenance. Therefore, Mitochondrial Disease may be included in metabolic diseases ( E codes ). How about it ?

Reference
1: Curr Top Dev Biol. 2007;77:113-55. Mitochondrial disease--its impact, etiology, and pathology.McFarland R, Taylor RW, Turnbull DM.

2007-05-16_01 Acute coronary syndrome and ischemic heart disease

(Rule C, Chapter IX)

[Questions from Sam Rubin and David Lidsky, Israel:]

We would appreciate the help of Mortality Forum participants with the following certificate:
I a Acute coronary syndrome:
I b Ischemic heart disease

The General Principle gives ischemic heart disease as the tentative underlying cause, and there is no linkage, or other rule, of which we are aware (we have searched the ICD-10 updates), which allows us to take acute coronary syndrome (which we code as I24.8) as underlying cause.

However, if the certifier had written the closely similar diagnosis "acute myocardial infarction" in Ia we would take that as the underlying cause according to the linkage of I25._ to I21._ (ICD-10 page55, volume 2). Would it be worthwhile to add a linkage between I25._ and I24.8 in the next edition of ICD-10 updates?


[Comments:]

2007-06-12:

Japan /Tadahiro Ootsu/:
According to comment from Lars Age, I read 4.1.11 of ICD-10 Volume 2 (second edition, page 58-59). And, I think that we should consider a linkage between I20._ and I25._. For example, how about I20._ and I25.1 ?

2007-05-29:

Sweden /Lars Age Johansson/:
I'll bring this to the Mortality Reference Group, which prepares recommendations for ICD updates concerning mortality. We might have to look into other expressions close to "myocardial infarction" too. Any suggestions for such other terms that should be included in the discussion?

2007-05-16_02 Cerebral and precerebral arteries

(Chapter IX)

[Questions from Sam Rubin and David Lidsky, Israel:]

Block I63 (Cerebral infarction) in ICD-10 distinguishes between cerebral arteries and precerebral arteries. Several arteries such as the basilar artery and the arteries of the circle of Willis are situated on the surface of the brain, or are closely adjacent to it. Do such vessels count as cerebral or precerebral?


[Comments:]

2007-06-19:

Cyprus /Pavlos Pavlou/:
I suggest that the terms "Unstable angina" and "Acute myocardial ischemia" are included in the discussion at the Mortality Reference Group.

2007-05-29:

Japan /Tadahiro Ootsu/:
I think that they are precerebral. Please see ( http://en.wikipedia.org/wiki/Circle_of_Willis ).

2007-05-16_03 Code for metabolic syndrome

(Chapter IV)

[Question from Elisabeth Gantenbein, Switzerland]:

How do you code "Metabolic syndrome" or "Syndrome X"? E889, E669, E129 or ?

Because this syndrom describes several diagnosis like obesity, diabetes, hypertension, lipid abnormality, we choose E889 when there is no other related disease listed. With other diseases certified we try to find a chain according to one of diseases associated with the syndrome and choose this disease as underlying cause if death.

Our newest example:
Metabolic syndrome with gangrene of a toe, which induced sepsis and cerebral infarct. For this example we tend to choose finally the cerebral infarct as underlying cause of death. - What's your suggestion?


[Comments:]

2007-06-12:

Sao Paulo Classification Centre /Ruy Laurenti/:
In the example, the sequence is: metabolic syndrome leading to gangrene of a toe, leading to septicemia, leading to cerebral infarct. We accept the sequence. It is clear, for us, that the metabolic syndrome is the underlying cause and cerebral infarct is the terminal cause. The best code is E66.9.

2007-05-29:
[Unfortunately, the ">" and "<" symbols got mixed up in Tadahiro's reply last week. Here are the correct relationships. /Lars Age]

1) Indispensable item
Waist male: equal to or greater than 85 cm ( 1 inch is equal 2.54 cm )
female: equal to or greater than 90 cm

2) At least, it is necessary to correspond to two items below.
a. Triglyceride : equal to or greater than 150 mg/dl
and / or
HDL cholesterol : less than 40 mg/dl b. Fasting blood sugar : equal to or greater than 110 mg/dl c. Systolic blood pressure : equal to or greater than 130 mmHg
and / or
Diastolic blood pressure : equal to or greater than 85 mmHg

2007-05-22:

Japan /Tadahiro Ootsu/:
In Japan, the definition of " Metabolic syndrome " is below:
1) Indispensable item
Waist male : > 85cm
female : > 90cm
2) At least, it is necessary to correspond to two items below.
a. Triglyceride > 150mg/dl
and / or
HDL cholesterol > 40mg/dl
b. Fasting blood sugar > 110mg/dl
c. Systolic blood pressure > 130mmHg
and / or
Diastolic blood pressure > 85mmHg

Because obesity is an indispensable item of " Metabolic syndrome ", E66 would be suitable code for it. And, we have the definition of " Metabolic syndrome ", probably, it is better to use E668. By the way, about the example, I think that sepsis and cerebral infarct are direct causes, so the underlying cause is Metabolic syndrome.

2007-05-29_01 P codes - valid for which ages?

(Chapter XVI)

[Question from Monica Pace, Italy:]

Dear mortality forum participants, how would you code the following certificate?

Female, age 9 years
a) respiratory failure J96.9
b) spastic quadriplegia G80.8
c) neonatal asphyxia P21.9
d)
II

The issue was in part discussed by the forum (21-IV-1997 Q1 When to use Chapter XVI (P codes)?) but still I have a doubt about this certificate. The originating condition it is stated to be neonatal (not perinatal, strictly speaking as in the Vol.1, inclusion note page 739); would you assume the condition occurred at birth and use the P code? Is P219 still acceptable at this age of death?

Moreover, this certificate elicited an "alarm" during the check for causes phase, because the deceased is older than 1 year of age. We compared checks criteria from three different countries and it seem that in all 3 cases "P" codes are not accepted as u.c. cause of death for deceased older than one year. Input from the forum participants will be very much appreciated.


[Comments:]

2007-06-19:

Cyprus /Pavlos Pavlou/:
I would prefer to use P21.9 as the underlying cause. It is more useful to focus preventive measures on the originating condition, despite the fact that death occurred much later.

The introduction to chapter XVI states that it "includes conditions that have their origin in the perinatal period even though death or morbidity occurs later".

In my opinion, it is prudent to have an alarm for P codes in combination with age > 1 yr, but it should not preclude the use of P codes as UCOD.

2007-06-12:

Sao Paulo Classification Centre /Ruy Laurenti/:
In the Death Certificate there is in Part I an acceptable sequence and by General Principle the U.C. is "neonatal asphyxia" (P21.9).

In the Volume I and in Volume II there is no instruction regarding the codes P and age. We accept code P in cases like this, independent of the age. It is very clear that the girl (9 years old) had an asphyxia at the birth and had a sequelae (spastic quadriplegia) and the terminal cause was a consequence of the sequelae.

Death in the first seven days (part of the perinatal deaths) is included in the Neonatal period. The codes P are intended for conditions originated in the "perinatal period" and, of course, in the first 7 days of the neonatal period (27 days of life).

2007-06-04:

Canada /Patricia Wood/:
We, like Monica, have an age-and-cause correlation edit that detects "P"codes in decedents over 1 year of age. The edit is conditional though, and if there is evidence that the underlying cause of death originated in the perinatal period we will accept the "P" code, regardless of the age of the decedent. I believe that this is in line with the intent of the inclusion note at the beginning of Chapter XVI.

I agree with Monica that the difference between the "perinatal" and "neonatal" period complicates matters. Chapter XVI, Certain conditions originating in the perinatal period includes some "neonatal" conditions that may or may not have their origin in the perinatal period. For example, I suppose it's possible for a newborn to get develop sepsis at 10 days of age and for him to die from it later. By definition the sepsis does not have its origin in the perinatal period, but the correct code is surely P36.9 as per the index.

We often use the age of the decedent and/or the interval between the onset of a condition and death (duration) as a guide to assigning a "P" code from the index. In reality, I think that our coding practice in Canada is to use the "P" codes when the underlying cause arose in the neonatal period which is longer than the perinatal period.

In Monica's specific example I think we're OK. The asphyxia is specified as "neonatal" which is indexed to P21, BIRTH asphyxia so I think it's safe to assume that this condition actually arose in the perinatal period and that the underlying cause of death is P21.9, even though the decedent is nine.

2007-06-04_01 "Inebriation" and "intoxication"

(Chapter XX)

[Question from Maria Giulia Gatti and Laura Gardenghi, Italy:]

We have a doubt about an exclusion term related to a class "Poisoning by drugs, medicaments and biological substances (T36-T50)" inserted in 2003 October Update.

We don't understand what word "inebriation" means in the phrase "Intoxication meaning inebriation". This term in the Italian language means "inebriamento", that means acute syndrome related to "drug or psychoactive substance use". If possible, please give us an explanation about this.


[Comments:]

2007-06-19:

Canada /Patricia Wood:
"Overdose" is indexed (in English) in the Alphabetical index to diseases and nature (not "natury" as in the second edition) as:

Overdose, overdosage (drug) T509
- specified drug or substance - see Table of drugs and chemicals

And in the External causes of injury index as:
Overdose (drug) - see Table of drugs and chemicals where the codes X44.- (accidental), X64.- (intentional self-harm) and Y14.- (undetermined intent) are offered at Drug NEC.

All this to say that we would code "overdose" without specification as T509 with the appropriate external cause code, assuming "drug".

Japan /Tadahiro Ootsu/:
Q1. In Japanese version for Volume 1, I can read a supplementary explanation at ..0 acute intoxication of F10-F19 that "intoxication" has two meanings, "inebriation" and "poisoning". According to this explanation, for example about opioids ( opium ), we should use F11.0 for "inebriation" and T40.0 for "poisoning".

Then, Japanese translation for "inebriation" is same as "drunkenness".

Q2. Probably, it is suitable to use T50.9.

2007-06-04_02 How to classify "overdose" with no further specification

(Chapter XX)

[Question from Maria Giulia Gatti and Laura Gardenghi, Italy:]

How do you codify a death caused by "overdose", without any other indication or specific pathology ?


[Comments:]

2007-06-19:

Canada /Patricia Wood:
"Overdose" is indexed (in English) in the Alphabetical index to diseases and nature (not "natury" as in the second edition) as:

Overdose, overdosage (drug) T509
- specified drug or substance - see Table of drugs and chemicals

And in the External causes of injury index as:
Overdose (drug) - see Table of drugs and chemicals where the codes X44.- (accidental), X64.- (intentional self-harm) and Y14.- (undetermined intent) are offered at Drug NEC.

All this to say that we would code "overdose" without specification as T509 with the appropriate external cause code, assuming "drug".

Japan /Tadahiro Ootsu/:
Q1. In Japanese version for Volume 1, I can read a supplementary explanation at ..0 acute intoxication of F10-F19 that "intoxication" has two meanings, "inebriation" and "poisoning". According to this explanation, for example about opioids ( opium ), we should use F11.0 for "inebriation" and T40.0 for "poisoning".

Then, Japanese translation for "inebriation" is same as "drunkenness".

Q2. Probably, it is suitable to use T50.9.

Comments