Mortality Forum Apr1997-July1997
Linkage diabetes - renal complication
(Rule C /UC Chapter IV)
An answer from Canada.
I think Augusto Hasiak Santo has raised a very important question here:
should we apply only such linkages that are explicitly mentioned in the ICD, or
should we also link in medically equivalent cases? The advantage of coding like
the Americans is, of course, that you will have fewer arguments about when to
link and when not to. On the other hand, it might be difficult to get the users
of the statistics to understand why we code "nephropathy due to diabetes" as
"diabetes with renal complication", but not "renal failure due to diabetes".
I think this is a general problem - should we apply the instructions in the
ICD literally, or should we use them as guidelines, and try to figure out to
what similar cases they should also apply? If we decide to use them as
guidelines, then there will be some need of international coordination...
Opinions and suggestions are very welcome!]
[Augustos question was: ]
I would like also to propose a discussion on linkages of diabetes and renal
involvement, in particular with renal failure, N17, N18 and N19, or, 584, 585
and 586 in the Ninth Revision. The physicians (in Brazil) don't mention diabetes
with renal diseases or nephopathy but with renal failure.
The ACME decision tabe D (1992 edition) provides linkages of diabetes (2500
and 2509) with the following codes in order to obtain 250.3: 581.9, 582.6,
582.7, 582.9, 583.9 and 593.9. (582.6 and 582.7 are created codes).
Some examples of death certificates with this problem:
[or, approximately translated into diagnostic statements:
1 (a) Respiratory arrest
1 (b) Renal failure
1 (a) Electrolyte imbalance
1 (b) Chronic renal failure
1 (c) Diabetes mellitus
1 (a) Respiratory arrest
1 (b) Renal failure
UC(#1) UC(#2) UC(#3)
*Canada E149 E149 N19
England 2503 2503 ?
Sweden E142 E142 N19
USA E149 E149 N19
*Canada /Patricia Wood/: (An advantage to falling so far behind with my
correspondence with this group is that I have the benefit of reading everyone
else's opinion before offering mine!)
As usual I will point out that in Canada we use the NCHS ACME Decision Tables
(either manually or in automation) so our approach to the diabetes with renal
manifestation situations is as described by Julia. I think that, as you
articulate Lars Age, there is a fundamental decision to be made regarding these
and all other linkages; do we restrict our applications to those specified in
the classification or use them as indications of appropriate coding in similar
circumstances? If the latter approach is used internationally consistent
decisions would certainly be best.
Australia /John Donovan/: This message of yours and Augusto's question relate
to some of the proposals for revision of the renal section of ICD-10 which we
sent to Björn [Smedby at the Nordic WHO Centre] in April. If you have not
already seen them, please ask him for a copy.
USA /Julia E Raynor/ : The U.S. uses only the linkages provided by ICD. For
the 9th revision, they are included in Volume 1, Notes for use in underlying
cause mortality coding, pages 713-721, in Volume 1 under the specific categories
and in Volume 2. In 10th revision, they are in Volume 2, Notes for use in
underlying cause mortality coding, pages 50-65, Volume 1 under the specific
categories and in Volume 3. Apparently, the U.S. is more restrictive in using
linkages than some other countries.
We do not treat diabetes linkages differently than other conditions with
linkage. We will link diabetes, E109, E119, E129, E139 and E149 with renal
conditions indexed "diabetic" in Volume 3, indexed "with or due to diabetes" in
Volume 3 and those listed in Volume 1, categories E10-E14 with .2 "With renal
complications." We have not considered adding any linkages based on other
frequently reported renal conditions.
For direct consequence of renal conditions to diabetes, we will use the same
renal conditions we used for diabetes linkage.
U.S. codes for examples
R092/N19/E149 UC E149
E878/N189/E149 UC E149
R092/N19*E149 UC N19
This is an example of when we WOULD use linkage with diabetes.
a) nephropathy N289
b) diabetes E149
UC E142 Indexed Diabetes, diabetic, nephropathy E142 Also indexed
Nephropathy, diabetic E142
England /Lin Shane/: When manually coding to ICD-9 we would have linked
diabetes with any resulting renal connection (except conditions coded to 589 and
590). The ACME decision table D does not agree with the linkages listed in ICD-9
volume 1 for 2503.
Is it true to say that for ICD-10 we should only make the link with diabetes
and renal manifestations is the renal manifestation is coded to N083? We will
need some guidance on this before we start ICD-10 training.
Sweden /Lars Age Johansson/: We have assumed that "renal manifestations" (as
the rubric of 250.3 said in ICD-9) included renal failure as well. Perhaps that
was not technically quite correct in ICD-9, since both dagger and asterisks
appeared in the rubric and 586 (renal failure) was not one of the listed
asterisk categories. In ICD-10, however, the asterisks have been moved to the
example terms below the rubric, and I suppose that allows us to include other
renal complications as well, eg renal failure. So we would code E14.2 as the
underlying cause in the first two examples (we do not use asterisk codes for the
underlying cause of death). In the third example, we would not assume that the
renal failure is a consequence of diabetes. About ten years ago we returned
quite a few certificates of that type (diabetes in Part II, a renal disease that
might be a complication to diabetes in Part I) to the certifiers and asked if
there was any connection between the diabetes and the renal condition. We found
that the diabetes was often fairly mild and/or with a late onset, and that the
renal condition in many cases was caused by something that the patient had had
before he/she got diabetes, e.g. chronic pyelitis or chronic nephritis. Our
conclusion was that it is not safe to assume that a renal condition in Part I is
a direct consequence of diabetes in Part II. I do not know if this would apply
in other countries as well, the situation in Sweden might be due to the fact
that we have a quite old population, and many E11 (non-insulin-dependent
diabetes mellitus) cases.
Pulmonary edema an obvious consequence of myocardial
(Rule C / UC Chapter IX)
[The question, from Sweden:]
1 (a) Cardiac arrest
1 (b) Myocardial infarction
1 (c) Pulmonary
In ICD-9, we would have regarded the pulmonary oedema as ill-defined,
disregarded it, and then re-selected the underlying cause of death as if the
oedema had not been reported, and thus arrived at myocardial infarction as the
underlying cause of death. However, I conclude from the discussions we had
earlier in this group on cardiac arrest etc, that most of you would not consider
pulmonary oedema an ill-defined cause of death. So what would we get in this
case as the underlying cause? Both the infarction and the arrest are reported as
consequences of the oedema (and I suppose that is an acceptable sequence, even
if another order of events might have been more plausible). That means, as far
as I understand, that we cannot use Rule 3 here. Would we end up with the
pulmonary oedema as the underlying cause of death?
[An answer from Canada:]
*Canada /Patricia Wood/: multiple causes (ICD-9) codes: 4275 410 514
underlying cause (ICD-9) code: 410
Selected by Rule 1 using ACME Decision Table C where 4275 can be due to 514
but 410 can not be due to 514 therefore eliminating an application of the
General Rule, and 4275 can be due to 410 establishing a reported sequence
terminating in a condition first entered on the certificate. No further linkages
or modifications confirming that the underlying cause code is (ICD-9) 410.
England /Lin Shane/: In ICD-9 we also would have coded this death to the
myocardial infarction. This is consistent with the Acme tables. However it is
quite different in ICD-10. There is an inconsistency between Volume 3, the
index, and Volume 1, the tabular list.
The index reads Edema - Lung - acute - with heart condition or failure, which
we would have taken to include myocardial infarction. he exclusion note in the
tabular list under J81 reads 'with mention of heart disease NOS or heart
failure', which would not include myocardial infarction. The coder may therefore
stay with J81 and select the underlying cause as the Pulmonary Oedema.
Which conditions are an obvious cause of pulmonary edema?
(Rule 3 / UC Chapter IX)
[Another question from Sweden:]
Would you consider pulmonary oedema a direct consequence of no other
diseases, of some heart diseases, of any heart disease, of any other conditions,
or??? In other words: what coding practice do you have as regards pulmonary
oedema and Rule 3 (direct consequence)?
*Canada /Patricia Wood/: Using ACME Decision Table D as a reference pulmonary
edema (ICD-9 514) would be considered to be a direct sequel of conditions coded
to ICD-9 0010-2899, 2900-319, 3200-4599, 460-4878, 490-5199, 5200-7799 and
nature of injury 800-9999. Rule 3 relationship would be applied if pulmonary
edema was the tentative underlying cause and if the condition it is a direct
sequel of was reported on the same or lower used line of Part I or in Part II.
Using ACME Decision Table D as a reference acute pulmonary edema (ICD-9 5184)
would be considered to be a direct sequel of conditions coded to ICD-9
0010-2899, 2900-319, 3200-4281, 4282-4284, 4290-4298, 4300-5131, 515-5199,
5200-7799, and nature of injury 800-9999. Again, Rule 3 would be applied if
acute pulmonary edema was the tentative underlying cause and if the condition it
is a direct sequel of was reported on the same or lower used line of Part I or
in Part II.
Since the ACME Decision Tables are used (either manually or in automation) in
Canada these are the direct sequel relationships that we would make with
pulmonary edema and acute pulmonary edema.
(One disadvantage of falling so far behind with my correspondence with this
group is that I sound so very repetitive in my answers!)
England /Lin Shane/: For ICD-9 coding we would consider conditions in 514,
Pulmonary oedema, to be terminal events and apply rule 3. We would not apply the
same reasoning to conditions in 5184, Acute pulmonary oedema. The difficulty in
ICD-10 is that Pulmonary oedema and Acute pulmonary oedema are both coded to
Underlying cause of surgery without stated reason for the
[An answer from Patricia Wood:]
[And yet another question from us Swedes:]
On page 71 of Volume 2 there is an instruction on coding of operations
without mention of the condition for which the operation was performed. It says
that "if the operation does not indicate an organ or a site ... code to ... R99
... unless there is a mention of a therapeutic misadventure classifiable to
Y60-Y84 or a postoperative complication." Where do the postoperative
complications come into it? The instructions in the Notes on postoperative
complications (eg on I97, page 57) say that codes for postprocedural disorders
are not to be used for underlying cause mortality coding.
*Canada /Patricia Wood/: When I try to interpret the instruction on page 71,
Volume 2, ICD-10 I complete it like so, ". . . if the operation does not
indicate an organ or site code to R99 unless there is a mention of a therapeutic
misadventure classified to Y60-Y82, in which case code the underlying cause to
the therapeutic misadventure, or there is mention of a postoperative
complication, in which case code the underlying cause to the surgery (as the
cause of abnormal reaction or later complication, without mention of
misadventure at the time of the procedure) Y83."
I would only code the underlying cause to R99 if an operation that does not
indicate the organ or site is certified as the cause of death with no
therapeutic misadventure and no postoperative complication mentioned.
USA /Julia E Raynor/ :We interpret instruction in Volume 2, page 71,
Operations, as meaning if surgery, such as laparotomy, that does not indicate an
organ or site is reported without a complication, code UC to R99.
Example a) laparotomy UC R99
If there is mention of a complication indexed to T code, code E code for
surgery as UC.
Example a) septicemia T814
b) laparotomy Y838 UC Y838
If complication of surgery is indexed to postprocedural disorder in disease
chapters, code E code for surgery as UC.
Example a) renal failure N990
b) laparotomy Y838 UC Y838
Volume 2, page 66, Table 2 lists all the postprocedural categories, not just
I97, as invalid for UC.
England /Lin Shane/: The note on page 57 of Volume 2 refers to
'postprocedural disorders of circulatory system', not all or any postprocedural
condition. There are other postprocedural conditions which it is acceptable to
use for underlying cause if no further information is available. Surely the only
real solution is to make further enquiries of the certifier.
[My comment:] The same instruction is given in the Notes for E89, G97, H59,
H95, I97, J95, K91, M96 and N99. Is the intention that we should code, eg
Y83.9/T81.4 if a patient dies in a postsurgical septicaemia, but R99 if s/he
dies in a postsurgical renal failure?
Code for "acute cerebrovascular lesion"?
(UC Chapter IX)
[An answer from Patricia Wood:]
[And yet a very Swedish question:]
Acute cerebrovascular lesion
Most conditions coded to 436 in ICD-9 are now coded to I64. There are a few
exceptions, notably "acute cerebrovascular disease" (I678) and "cerebrovascular
leasion" (I679). What should we do with "acute cerebrovascular lesion"? Should
we put the stress on "acute" and code it to I678, or on "lesion" and code it to
I679 as well? (We're well aware that this is no major point, but it is quite
possible to spend much time debating even small details...)
[Suggested codes for "Acute cerebrovascular lesion":
*Canada /Patricia Wood/: When coding "acute cerebrovascular lesion" I would
use "lesion" as the lead term in the index and I would find the modifier
"cerebrovascular" but no subsequent modifier "acute" so I would select ICD-10
USA /Julia E Raynor/: If index does not provide a code for the modifier
"acute", we usually assign NOS code. Lesion, cerebrovascular, acute I679
England /Lin Shane/: Our feeling is that we would code Acute cerebrovascular
lesion to I67.9.
When to use Chapter XVI (P codes)?
(UC Chapter XVI)
[An answer from England:]
[The question, from Sweden, was:]
We are not quite sure when to use the special perinatal codes (Chapter XVI,
P00-P96), and when to use the "ordinary" codes from the other chapters. The
introduction to Chapter XVI says that it covers "conditions that have their
origin in the perinatal period". Does that mean that ALL conditions in the
perinatal period should be coded to Chapter XVI, even if the origin is not
something directly related to the delivery, but, e.g. an accident or surgery?
Should we use a Chapter XVI code even if there is no specific code for the
In other words, how would you code the following certificates (they are both
for perinatal deaths):
1 (a) Mesenteric infarction
1 (b) Thrombosis
of abdominal aorta
1 (a) Myocardial infarction
1 (b) Surgery for
transposition of great arteries
[Suggested coding of cert #1:]
*England I740 K550/I740
USA I740 K550/I740
[Suggested coding of cert #2:]
Q203 T814/Y839 Q203
*England Q203 T818/Y839/Q203
USA Q203 T818/Y839 Q203
*England /Lin Shane/ : We also would only use a 'P' code if the condition is
indexed to Chapter XVI.
Canada /Patricia Wood/: Since none of these conditions are indexed to the
Chapter XVI Certain conditions originating in the perinatal period I did not use
a "P" code for any of them. I will use "P" codes if the condition I am coding is
indexed to Chapter XVI or is indexed with a modifier "neonatal" or "perinatal"
and there is an indication on the certificate that the condition did arise in
the perinatal period (i.e. the decedent is a perinate or the duration of the
condition and the age of the decedent indicate that the condition originated in
the perinatal period). Our processing system will flag "P" codes assigned as the
underlying cause of death for any decedent who is over one year old so the
record will be checked but if an indication that the condition arose in the
perinatal period is confirmed the underlying cause will not be changed. So, we
can have a 90 year old with an underlying cause of death code from Chapter XVI.
Sweden /Lars Age Johansson/: We would accept the P code for any age, if it is
evident from the certificate that the condition did indeed arise in the
perinatal period. On the other hand, we will check all cases coded to Chapter
XVI if the deceased was more than 1 year old, to make sure that the code is
Finland / Martti Virtanen, Stakes, Finland /: This problem has special
interest to me as a neonatologist as well as a problem with classification
especially with regard to DRG. The question how long the codes in Chapter XIV
can be used is relevant also for morbidity coding.
So: How long would you accept the P codes after the neonatal period? Some of
the children with severe birth injuries for example may live many years with
The DRG-systems have set the limit to 12 months age. Our old system had a
limit of 24 months. We have not changed the rules, so these codes can be used as
the actual principal diagnosis only during the two first years of life.
Thereafter they are accepted only as secondary diagnoses. For deaths this could
mean that basic cause of death could be a perinatal diagnosis, but the immediate
cause would need to be something else.
USA /Julia E Raynor/: If age of decedent is less than 28 days, and reported
condition is indexed neonatal or newborn, we assign newborn code (Chapter XVI).
Otherwise, we use "ordinary" or NOS code.
None of these conditions [on cert # 1-2] are indexed to a newborn category,
therefore, NOS codes are used. We interpret Chapter XVI inclusion note to mean
codes from Chapter XVI can be assigned if age is 28 days or more if there is
indication the condition was present during the perinatal period.
age 31 days
(a) anoxia duration 2 weeks
We would code anoxia, newborn, P219, even though age is over 28 days. Death
occurred after newborn period but duration of anoxia indicates the condition
originated during the perinatal period.
Interpretation of "tumour"
(UC Chapter II)
[This was the first of three questions from Mary
Tumours, all sites:
Can these be automatically taken as malignant? At the moment we take tumours
of the Brain and the Lung as automatically malignant.
[I think we have found one more point where coding practice differs
considerably, as you can see from the answers - i.e., should we try to correct
the certificates using the knowledge we have of the physicians' certification
habits, or should we accept them at face value?]
*England /Lin Shane/: We agree entirely with Patricia. In England & Wales
we would make no assumptions regarding malignancy and without further
clarification would code as indicated in the index. What an interesting
Brazil /Augusto Hasiak Santo/: Regarding the question from Mary Heanue,
Ireland, about assuming tumors as malignant, I would like to inform that in
Brazil, since the 8th Revision, the words "tumor" and "neoplasm", are taken as
"malignant tumor" and as "malignant neoplasm" when appearing in death
certificates. This decision was done after the results of the Interamerican
Studies of Mortality (Adults in 1962-1964 and Childhood in 1968-1969), in which
the death certificates were revised with data from the families of the dead,
hospital records, autopsies data and all other available information, providing
a new and "more correct" underlying cause of death. It was found that when the
physicians mentioned tumor or neoplasm, they really wanted to mean malignant
tumor or neoplasm. It was noticed that when a benign neoplasm caused the death,
this fact was so unexpected that the physicians mentioned them as benign or
informed the morphological type, such as "adenoma" or "meningioma". After those
two investigation, many other studies have given the same results, with the same
methodology, that we use to call "Puffer Method", after Ruth Rice Puffer, that
Canada /Patricia Wood/: We classify all tumours (of all sites) as indexed. We
make no assumptions of nature unless there is an implication of malignancy (as
outlined on page 728, Volume I, ICD-9). In Canada, brain tumour (without any
further specification and no implication of malignancy) would be assigned ICD-9
code 239.6 and lung tumour would be assigned ICD-9 code 239.1.
Sweden /Lars Age Johansson/: We code the neoplasms as reported, i.e. as
"unspecified" if they are described as "tumours", and there is no other
indication of malignancy, such as metastases. On the other hand, we will send a
query to the certifier if the deceased was less than 75 years old, and for all
ages if there was an autopsy or the patient had had recent surgery. The decision
not to code "tumour" as "malignant neoplasm" was based on a Swedish study of
certificates with "brain tumour", where it was found that a substantial part of
the cases were in fact benign (meningiomas). I do not know if that result would
hold for other sites as well, Augusto's answer indicates that it would not.
Code for "ischaemic leg"
(UC Chapter IX)
[Mary's second question was:]
There doesn't appear to be a code for this. Perhaps 440.9
Artheriolosclerosis would do?
*England /Lin Shane/: We also would code 'ischemic leg to ICD-9 4439. This
has been the practice since ICD-9 was introduced and was coded similarly even to
ICD-8. The Micar dictionary in the automated system also assigns 4439 to this
Brazil /Augusto Santo/: Regarding the diagnoses of "Ischemic leg", maybe it
would be wise to send queries to the physicians. Ischemic leg does not appear in
Brazilian death certificates or hospital records.
Canada /Patricia Wood/: An errata published by Statistics Canada's Nosology
Reference Centre in November, 1984 classifies Ischemia, extremity (lower)
(upper) to ICD-9 code 443.9 and, if specified as arteriosclerotic to ICD-9 code
Sweden /Lars Age Johansson/: In ICD-9, we coded "ischaemia of leg" to 443.9.
Code for "immunosuppression" = AIDS?
(UC Chapter III)
[Mary's third question:]
Can this be automatically considered as AIDS? Can it also be related to renal
*England /Lin Shane/: Without any further clarification we would use a code
for an immunosuppressive drug (ICD-9 E 9331). We would certainly not assume it
Brazil /Augusto Santo/: Regarding "immunosuppression" appearing alone in a
death certificate, it would not be considered automatically as AIDS since it can
be a complication of the treatment of many diseases, like malignant neoplasms as
well as transplants procedures, as mentioned by Mary.
Canada /Patricia Wood/: We do not automatically consider Immunosuppression as
AIDS. It can be certified as part of the sequence of events leading to the death
of an organ transplant recipient as well as a condition related to HIV Infection
so we try to classify it in whatever context we see it in.
Sweden /Lars Age Johansson/: We have had cases were the term
"Immunosuppression" was indeed used as a euphemism for AIDS, but we would not
take that for granted - the term is also used for immunosuppressive treatment.
So we would try to get more information from the physician.
Why is self-inflicted poisoning coded differently from other self-inflicted
(UC Chapter XX)
[Sue Walker's (Australia) question has revealed quite
important differences between the countries, so here we have another candidate
for clarification. Does anyone know something more about the reason behind the
I have an honours student working with me at the moment, writing a
dissertation on suicide coding. We are puzzled by the note on page 628 of the
ICD-9 which states:
"Categories E980-E989 are for use when it is stated that an investigation by
a medical or legal authority has not determined whether the injuries are
accidental, suicidal or homicidal. They include self-inflicted injuries, *but
not poisoning*, when not specified whether accidental or with intent to harm."
Our question is - what is the reason behind excluding poisonings?
*England /Lin Shane/: If presented with the text 'self inflicted poisoning'
and a coroner's verdict was 'Open', then we WOULD use codes E980-E989. Although
this appears to go against the ICD-9 instruction, the note on page 628 of Volume
1 could be interpreted as referring to morbidity.
The exception would be 'self inflicted poisoning' with a mention of drug
abuse. Even with a coroners 'Open' verdict we would assign an underlying cause
*USA /Julia E Raynor/: In the U.S. , both poisoning and self-inflicted
poisoning are coded as accidental. We assign the accidental code since
E9800-E9809 excludes self-inflicted poisoning and poisoning NOS is classified to
accidental. There is not (or at least we cannot find one) a direct instruction
on how to code self-inflicted poisoning. Suicide categories E950-E959 includes
self-inflicted injuries specified as intentional. Our instruction in
"Instruction Manual, Part 2b " states to assume poisoning (self-inflicted) by a
substance to be accidental unless otherwise indicated. We have used this
instruction since the beginning of the 9th revision.
In the 10th revision, the problem appears to be solved by the index. In
Volume 3, Self-inflicted, poisoning NEC X49. X49 is an accidental category. I
agree the international feedback will be interesting.
Canada /Patricia Wood/: I agree with your interpretation of the ICD-9 index
and that "unspecified poisoning" should be coded as accidental poisoning.
However, if poisoning, not specified whether accidental or with intent to harm,
is specified as "self-inflicted" I would code it as suicidal poisoning. In
Canada the "self-inflicted" specification of poisoning, not specified whether
accidental or with intent to harm, makes the difference between coding poisoning
as accidental or suicidal. Would poisoning, not specified whether accidental or
with intent to harm, but specified as "self-inflicted" be coded as accidental
poisoning in Sweden? If so, we are consistent in that self-inflicted poisoning,
when not specified whether accidental or with intent to harm, is excluded from
ICD-9 code block E980-E989, but inconsistent in where it is coded. (It seems
that there is no light shed by referring to ICD-10 code block Y10-Y34 as the
wording of the note regarding self-inflicted injuries is the same as in ICD-9!)
You are right when you describe this as a very interesting discovery and now
I wonder how other countries have, as you say, filled the gap in this situation.
Sue's student's question may have set off an international coding debate.
Perhaps she will include this in her dissertation paper!
Sweden /Lars Age Johansson/: In Sweden, we have coded unspecified poisonings
as accidental, not as suicides. The reason is that the Alphabetical Index has
"Poisoning (accidental)" (Vol 2, p 567), so we coded "Poisoning NOS" in the same
way as "Poisoning, accidental". Do you think that was wrong? I have tried to
find some instruction in the ICD-9 on how to code the unspecified poisonings,
but have not found anything except that they are excluded from E98x. Quite
clearly ICD-9 had an important gap here, and perhaps different countries filled
that gap in quite different ways. A very interesting discovery - you learn much
from this email network!
Canada /Patricia Wood/: I will be very interested in the international
feedback to Sue's student's question. I remember having many discussions with
Elizabeth Taylor about this exact issue ... why is self-inflicted poisoning,
when not specified whether accidental or with intent to harm, not included with
other self-inflicted injuries, when not specified whether accidental or with
intent to harm, in ICD-9 code block E980-E989? Although Elizabeth has recently
retired (and is enjoying herself very much) I talked it over with her again last
week when this email came in.
Some thoughts . . . Can it be that self-inflicted poisoning implies a certain
amount of intent by its very nature? A self-inflicted gun shot can quite
feasibly be an accident (several possible scenarios come to mind) so when not
specified whether accidental or with intent to harm an assumption is not made
either way and the self-inflicted gun shot is coded as undetermined. On the
other hand a self-inflicted poisoning implies that the decedent consumed, by his
own hand, enough of whatever substance to suffer toxic effects. While not
inconceivable, an accidental self-inflicted poisoning is probably far less
likely than a suicidal one. Perhaps this is why a self-inflicted poisoning, when
not specified whether accidental or with intent to harm, is not coded as
undetermined but rather as suicidal.
Linkage pneumonia - measles - leukemia
(Rule 3 / UC Chapter I, X, III)
[We had this question from Gerard
Here is a death certificate we would like to submit to the group. Two
1a. Do you agree with leukaemia as the underlying cause ?
underlying cause an automatic coding system would select and which rules would
be applied? In particular, how many times rule 3 would apply?
1 (a) Cardiocirculatory arrest
1 (b) Interstitial pneumonia, measles
II. Immunosuppression (chemotherapy), acute lymphoblastic leukaemia
causes Underlying cause
Brazil [R092/J849 B059*Y433 D848 C910 J849]
R092/J189 B059*Y433 D848 C910 C910
*Canada I469/J849 B058*C910 J849
Sweden I469/J849B059*D848 Y433 C910 B052
[Comments from Canada:]
*Canada /Patricia Wood/: I would code this record to I469/J849 B058*C910
(ICD-9: 4275/5168 0559*2040). Since arrest, cardiac and arrest, circulatory are
both indexed to I469 I reasoned that cardiocirculatory arrest could be coded
there. Since interstitial pneumonia is not indexed as a complication of measles
(like pneumonia NOS is) I did not code it as such. I also did not code it as an
adverse effect of the immunosuppression because a "due to" relationship was not
specified as would seem to be required when coding complications of drug
therapy, (ICD-10, Volume 2, Page 84), if I am interpreting this guideline
properly. Making a manual selection of underlying cause I would apply Rule 1 for
an underlying cause of J849. I did not apply Rule 3 as I did not see the
interstitial pneumonia as "obviously a direct consequence" of another reported
condition. I believe that ACME for ICD-9 would select the same underlying cause
of death with multiple cause codes 4275/5168 0559*2040 as input.
I understand, and agree with, the comments that coding should reflect
clinical reality but I think that many coders do not know whether, clinically
speaking, interstitial pneumonia can be considered a complication of measles
and/or immunosuppression or not, and will rely on the format of the conditions
certified on the record and the way they are indexed in the ICD to make their
coding decision. The clearer the rules and guidelines the more consistent the
coding will be.
Incidentally, in Canada, multiple subsequent applications of Rule 3 are
handled the same way that Julia indicated in her response to this question.
Sweden /Lars Age Johansson/: I agree with Martti that we must take current
clinical thinking, and the purpose of the statistics, into account when we make
our decisions on how to code. But it is also very important that mortality
coding is internationally consistent. As far as I can see, the only way to
achieve that is to have quite detailed international coding instructions which
are uniformly applied by coders all over the world, and that does not leave too
much room for the individual coder's personal judgement. Let's see if we can
find some mechanism for bringing clinical thinking and international coding
instructions closer to each other. I suspect, though, that we would see as much
differences in opinion among clinicians as among coders.
But not in this case, I suppose, and perhaps we should try to have a
clarification of Rule 3 and the "highly improbable" section on this.
Julia is right: my coding of Part II is inconsistent. Since I did not select
the leukemia, I should not have coded the immunosuppression as an adverse
effect. I suppose I did so because I felt that the leukemia was "really" the
underlying cause. But, as I said before, you should not let your personal
opinion influence the coding...
Finland /Martti Virtanen/: I would like to comment this case from the
clinical point of view. I have the feeling that the rules should be changed
according to the reality and not vice versa.
Why did the child die? In developed countries like France children rarely die
in measles. This is not true with malnourished children. They very easily get
serious complications for example from measles. Even measles pneumonia usually
does not cause fatality in otherwise healthy children. Therefore one should in
most cases have some other underlying cause than measles ( for example
malnutrition or as here immunosuppressive therapy).
Why do we collect these data?
Because the society needs to know how successful the treatment of leukemia
is?! In that case we have to be able to tell how many died because of the
leukemia in spite our therapeutic efforts. Therefore a traffic accident during
the therapy should not be counted as due to leukemia but measles, varicella and
various sepsis deaths definitely should. Or to know how many measles deaths
occur? In third world countries measles is an important killer! However it would
be false to mix the malnutrition related deaths of third world with deaths
related to therapeutic immunosuppression.
USA /Julia E Raynor/:
b) 5168 0559
UC 5168 Rule 1
In the 9th revision, the U.S. treats interstitial pneumonia, 5168,
differently than pneumonia. We use interstitial pneumonia somewhat as an
idiopathic condition, accepting it as due to very few conditions. The U.S.
automated system (ACME) would not apply Rule 3 and code interstitial pneumonia
as a direct sequel of measles or leukemia. In Part II, we would not assign a
code for immunosuppression (chemotherapy) since we do not consider there is a
complication or adverse effect of the therapy.
In the 10th revision, we will continue to treat interstitial pneumonia and
pneumonia as we do in the 9th, at least for the first year. Conversion of our
automated systems and implementation of the 10th revision must take
priority over making changes not directly related to the revision itself.
It is correct, as Lars stated, that it is possible to apply Rule 3 more than
one time. We do have an established priority order if a selected condition can
be considered a direct sequel of two or more conditions. The order is from left
to right (1) on the same line, (2) on lower line in Part 1, and (3) in Part II.
This instruction is included in the NCHS Instruction Manual Part 2a, page 23.
Brazil /Augusto Santo/: The death certificate that Gerard submitted to
discussion is very interesting as well are important the questions he has
addressed. Before discussing these points, some assumptions must be done:
1 - The death certificate coded according to the Ninth Revision guidelines
would have "measles with pneumonia" (055.1) as the underlying cause of death.
2 - For the Tenth Revision, we should consider the note (a) on Infectious
diseases and malignant neoplasms that appear on page 84 of the Instruction
Manual (Volume 2) that states : "Owing to the effect of chemotherapy on the
immune system, some cancer patients become prone to infectious diseases and die
of them. Therefore, any infectious disease classified to A00-B19 or B25-B64
reported as due to cancer will be an acceptable sequence whether in Part I or
3 - The ACME decision table D (1992 edition), regarding modifications for the
code for interstitial pneumonia (516.8), only has provision for a possible
specification with mention of pneumocystosis (136.3), giving preference for this
The proposed death certificate was coded for our SCB System as follows:
R092/J849 B059*Y433 D848 C910 that leads to interstitial pneumonia as the
underlying cause because of lack of provision for modifications.
Nevertheless, interstitial pneumonia was changed for pneumonia, as follows:
R092/J189 B059*Y433 D848 C910
that has provided Acute Lymphoblastic leukaemia (C910) as the underlying
And now we can answer Gerard's questions.
Question 1 - The underlying cause of death is acute lymphoblastic leukaemia,
but we do not totally agree with the guidelines that directs to this decision.
It is not peaceful the conception that ANY infectious disease classified to
A00-B19 or B25-B64 reported as DUE TO cancer will be an acceptable sequence
whether in Part I or II. It is difficult to accept leprosy, poliomyelitis,
dengue, leptospirosis, malaria and trypanosomiasis (Chagas disease), only to
mention some examples, as due to cancer. On the other hand, sequences are
admitted only in Part I (see last paragraph on page 22 of the Intructiona
Manual). We may state that this guideline is a serious candidate for
clarification. Maybe someone might forward this message to Connie so we could
share her sights about this matter.
Question 2 - Considering the above assumptions, an automatic coding system
should select acute lymphoblastic leukaemia as the underlying cause. Celso
Escobar Pinheiroand I will include for interstitial pneumonia (J84.9) the
appropriate modifications in our SCB system and consider the modifications that
prevail to pneumonia in preparing them.
Regarding the rules that were applied, we can distinguish between automatic
and manual coding. In automatic processing, Rule 1 selected interstitial
pneumonia, then a Direct Sequel Combination was applied and measles complicated
with pneumonia was reselected (DSC means Rule 3 followed by Linkage with Mention
resulting in a Combination code) and then a new Rule 3 finally identified acute
lymphoblastic leukaemia. In manual coding, Rule 1 selects interstitial
pneumonia, Rule 3 reselects measles, Rule C links measles complicated by
pneumonia, then another Rule 3 for immunossuppression, another Rule 3 for
chemotherapy and finally another Rule 3 for acute lymphoblastic leukaemia.
Sweden /Lars Age Johansson/: Our automated coding system (which is still in
its cradle) would produce multiple codes somewhat different from Augusto's, and
it will be interesting to see how ACME will handle them. Perhaps we will have to
make some modifications to our software.
When selecting the underlying cause, we would first use Rule 1 to select the
pneumonia, and then, as Augusto says, apply Rule 3 to get measles with pneumonia
(B05.2+ J17.1*). There is a parallell to "conflict in linkage" here, since we
could apply Rule 3 either to the measles or to any of the conditions in Part II.
There are no instructions in Vol 2 on how to solve such a conflict, but if we
use the same method as for "conflict in linkage" (Vol 2, p 43), we will arrive
at the measles.
Then I'm getting a bit uneasy, because even if I would very much like to code
the leukemia as the underlying cause of death, I cannot find any instruction in
either Vol 1 or 2 that tells us to regard measles as a direct consequence of
either immunosuppression or neoplasms. It is true that the instructions (Vol 2,
p 67 and p 84) say that infections should be accepted as *due to* malignant
neoplasms, but this certificate does not state that the infection was due to
either the therapy or the leukemia. As far as I can see, I cannot get any
further but have to accept the measles as the underlying cause of death. I'm
very probably wrong, and I hope that someone can correct me. I agree
wholeheartedly with Augusto: this is indeed a serious candidate for
As to Gerard's second question, I think it is possible to apply Rule 3
several times on a certificate. There is no specific instruction on that, but if
you do not do it, it would mean that you would never arrive at the originating
cause if the physician has reported a disease process with more than one step.
2-VII-1997 Q2 – Q4
2-VII-1997 Q2 Malignant
neoplasm due to ischaemic heart disease (Rule GP / UC Chapter
2-VII-1997 Q3 Ischaemic
heart disease in Part I, malignant neoplasm in Part II (Rule 3 / UC
2-VII-1997 Q4 Carcinoid due
to carcinoid syndrome (Rule GP / UC Chapter IX)
[Mary Heanue has
three questions on ICD-9:]
We have some cancer medical certs here that we could do with some advise on.
We only code to underlying cause in Ireland and we do not do multiple cause
coding. The replies to the last set of questions were most helpful. We are now
querying all tumours to see if they are malignant or benign.
1 (a) Cancer of the Bowel (2 months)
Ischaemic Heart Disease/(Myocardial Infarction)
Would you code this as 414.9 or a 159.0?
1 (a) Acute myocardial infarction
Ischaemic Heart Disease (eight years)
2 Carcinoma of the rectum (one week)
Would you take into account the cancer in part 2 or just leave it as 410? If
not, would you take the cancer into account if the duration of the cancer was
1 (a) Carcinoid tumour of liver
1 (b) Carcinoid
2 Congestive Cardiac Failure/atrial fibrillation associated
with mitral regurgitation
How would you code this one?
Multiple causes Underlying
*Canada 1590/4149 410 1590
*Canada 410/4149*1541 410
Brazil 2353/2592*4280 4273 4240 2353
Brazil C229/E340*I500 I48 I340 C229
2353/2592*4280 4273 4240 2353
Sweden 2353/2592*4280 4273
*Canada /Patricia Wood/:
2-VII-1997 Question 2
I would code this record to 1590/4149 410 and making a manual selection of
underlying cause, I would consider ICD-9, Volume 2, page 721 B. Interpretation
of highly improbable ... (b) a malignant neoplasm reported as "due to" any other
disease, and I would apply Rule 2 for an underlying cause of 1590.
2-VII-1997 Question 3
I would code this record to 410/4149*1541 and making a manual selection of
underlying cause I would apply the General Rule for a tentative underlying cause
of 4149 and then I would apply Rule 7 to reselect the underlying cause as 410.
Considering ICD-9, Volume 2, page 721 B. Interpretation of highly improbable ...
(h), I would not apply Rule 3 for a direct sequence to the cancer regardless of
2-VII-1997 Question 4
I would code this record to 2353/2592*4280 4273 4240 and making a manual
selection of underlying cause I would select 2353 considering the coding
instruction in ICD-9, Volume 1, page 154 re: carcinoid syndrome not being used
as the primary code for carcinoid tumour.
US /Julia Raynor/:
The U.S. would code the underlying cause to cancer bowel, 1590, based on the
"highly improbable " list, Volume 1, pages 721-722, (b).
The U.S. would code the underlying cause to 410 using General Rule and Rule
7. We would code 410 as U.C. even if duration of cancer in part II was longer.
Underlying Cause 2353
Brazil /Augusto Hasiak Santo/:
Regarding question 2 (first of Mary's), the underlying cause of death
is coded as cancer of the bowel (159.0 in ICD9 and C26.0 in ICD10). The
interpretation of *highly improbable* are practically the same in both
Revisions. It should be regarded as highly improbable ...a malignant neoplasm
reported as due to any other disease - added in ICD-10 - except human
immunodeficiency virus [HIV] disease.
Regarding question 3 (second of Mary's) the underlying cause would be
left as acute myocardial infarction (410 in ICD-9 and I21.9 in ICD-10) even if
the duration of the cancer was longer and the carcinoma mentioned on line c of
Part I. The interpretations of *highly improbable* are also the same for both
revisions. It should be regarded as *highly improbable* ... chronic ischaemic
heart disease (412-414 or I20, I25) reported as due to any neoplasm.
Regarding the last question (4) (third of Mary's) and considering
that the cross-reference in the Index for the Ninth Revision ( "see also
Neoplasm, uncertain behaviour") differs from the one of the Tenth Revision (
"see also Neoplasm, malignant"), the underlying cause of death would be
carcinoid tumour of liver (235.3 in ICD-9 and C229 in ICD-10) and the death
would be coded as follows:
2353/2592*4280 4273 4240 in ICD9, or
C229/E340*I500 I48 I340 in ICD10".