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7-VIII-1997 Q1 Linkage hepatic failure - alcoholism

(Rule C / UC Chapter V, XI)

[The question, from England, was:]

How would the group underlying cause code the following certificate?

1a Hepatic failure (K72.9)
b Alcoholism (F10.2)

Can we use the 'due to' sequence to UC code to K70.4 (alcoholic hepatic failure)

[Suggested coding:]

                        Multiple causes                     Underlying cause

*Brazil              K729/F102                         K704

Canada             K729/F102                         K704

Sweden             K729/F102                         K704

*USA               K792/F102                         K704


*Brazil /Augusto Hasiak Santo/:

Rules: GP + RC.

I must say that I have some guilt and responsibility regarding the problems around linkages with alcoholism. At the London Meeting, in 1990, I proposed to withdraw all linkages with alcoholism, that is, I considered more important to remark clearly the importance of alcohol as a cause of death instead of disguise it among linkages with its physical complications. There was not common agreement and a before lunch extra discussion was convened, when it was agreed that all linkages would be withdrawn from the notes, except the one with "alcoholic liver disease".

However, at that time Volume I, the Tabular List, was already finished and included entries of affections linked with alcohol abuse. These ones will be considered for clarification. As I persevere with the idea of emphasising the importance of alcohol as the underlying cause of death, for the Eleventh Revision I would propose to convert alcohol rubric as a dagger code and their physical manifestations as asterisk categories.

[I believe most epidemiologists working on alcoholism would support Augusto wholeheartedly in this - ICD-9, with all its linkages for alcoholism and physical complications, was a nightmare to all those who wanted a figure on deaths due to alcohol. /Lars Age Johansson]

*USA /Julia E Raynor/: Select alcoholism, F102, by General Principle. Next, use alcoholism as a modifier since failure, hepatic, alcoholic is indexed. This will be "specificity due to combination" (SDC) in ACME tables.

Canada /Patricia Wood/: Making a manual selection of underlying cause, I would certainly select K704, alcoholic hepatic failure. In ICD-10 there is an index entry for failure, hepatic, alcoholic whereas there was not in ICD-9. I wonder if ACME for ICD-10 will be programmed to process this record the way ACME for ICD-9 handles liver cirrhosis reported as due to alcoholism ... that is, to a multiple cause input of 5715/303, it applies the General Rule to select a tentative underlying cause of 303 and then reselects the underlying cause as 5712 by applying Rule 7 to link 303 to 5715 and combine them to 5712? So I am suggesting that the multiple cause input for ACME for ICD-10 might be K729/F102 and that the underlying cause may be K704.

Sweden /Lars Age Johansson/: I think the certificate states quite clearly that this is an alcoholic hepatic failure, and using the Note on F10.- (Vol. 2, p. 52) I would code it to K70.4. The problem is how to justify that coding if we start with "entity axis" multiple cause codes. If we do, we would not take the alcoholism into consideration while coding the hepatic failure, and that would leave us with K72.9 for the hepatic failure. Since there is no Note on F10 that deals with K72.-, we might feel that F10.2 is the correct underlying cause.

On the other hand, if we use "record axis" multiple codes (as we did in Sweden for ICD-9), and consider all information on the certificate already at the multiple cause coding stage, we would get K70.4 as the multiple cause code for the hepatic failure. In that case, there would have been no difficulties, and K70.4 would have been the underlying cause.

The ICD does not specify which multiple cause coding method we are to use, entity axis, record axis or something in between. The entity axis method is easier to apply and preserves more information on how the certificate is written, but I believe we have to think in a "record axis" way when we apply the linkage rules. Surely the selection of the underlying cause should not depend on which multiple cause coding method we choose?

7-VIII-1997 Q2 Linkage chronic nephritis due to arteriosclerosis

(Rule C / UC Chapter IX, XIV)

[Also from England:]

Cert. 1

1a Uraemia (N19)
  b Chronic Nephritis (N039)
  c Arteriosclerosis (I70.9)

UC I70.9?

Since I70.9 does not link with N03 or N19, would we code this to UC I70.9? There would seem to be an inconsistency when compared to the next certificate.

Cert. 2

1a Uraemia (N19)
  b Arteriosclerotic chronic nephritis (I12.9)
UC I12.0?

Can we go one step further and use the due to sequence to produce I12.0 (hypertensive renal disease with renal failure)?

[Suggested coding:]

                    Multiple causes                      Underlying cause


*Brazil         N19/N039/I709                     I120

Canada        N19/N039/I709                    I120

Sweden        N19/N039/I709                   I120

*USA          N19/N039/I709                   I120


*Brazil         N19/I129                             I120

Canada        N19/I129                            I120

Sweden      N19/I129                             I120

*USA         N19/I129                             I120


*Brazil /Augusto Hasiak Santo/: Rules (1): GP + RC + RC, (2) GP + RC

*USA /Julia E Raynor/: I agree that these certificates have the same condition stated in a different way. We will code the same UC for both, but the rules and ACME table entries will be slightly different. For this certificate, select arteriosclerosis, I709, by General Principle. Use arteriosclerosis as a modifier of chronic nephritis since Nephritis, chronic, arteriosclerotic is indexed. In the ACME tables, I709, arteriosclerosis, will be "specificity due to combination" (SDC) with N039, chronic nephritis, for combination code of I129. Nephritis, chronic, arteriosclerotic (see also Hypertension, kidney) I129. Hypertension, kidney, with, renal failure I120. This will be I129 "linkage with mention of combination" (LMC) N19 for combination code I120. This is using General Principle, Rule D, Specificity and Rule C, Linkage.

Certificate 2

We will code the same UC for arteriosclerotic chronic nephritis as the chronic nephritis due to arteriosclerosis in certificate 1. Select I129 by General Principle. Nephritis, chronic, arteriosclerotic (see also Hypertension, kidney) I129. Hypertension, kidney, with, renal failure, I120. General Principle and Rule C, Linkage

Canada /Patricia Wood/: I agree with Lars Age that these two certificates simply show two different ways of recording death by the same underlying cause, I120, hypertensive renal disease with renal failure, and making a manual selection of underlying cause I would select I120 in each case. We will have to hear from Julia to be sure, but again I find myself wondering if ACME for ICD-10 will be programmed to take multiple cause input of N19/N039/I709 and N19/I129 and select an underlying cause of I120 in each case? (The same certificates processed through ACME for ICD-9, with multiple cause input of 586/5826/4409 and 586/4039, each end up with the underlying cause as 4039.)

Sweden /Lars Age Johansson/: As in the previous question ( 7-VIII-1997 Q 2) I would argue that this is simply two ways of writing the same thing, and that we should have the same underlying cause for both certificates. Again, it depends on which multiple cause coding method you use, and again I would maintain that the choice of method should not affect the selection of the underlying cause of death.

I expect that some of you might think differently...

7-VIII-1997 Q3 Cerebral thrombosis due to cerebral arteriosclerosis due to hypertension

(Rule C / UC Chapter IX)


We have another brain teaser for you!

How would the group code the following certificate, What rules would you apply and what would the final underlying cause be?

1a Cerebral Thrombosis
  b Cerebral Atherosclerosis
  c Essential Hypertension

[Suggested coding:]

                       Multiple causes               Underlying cause

*Brazil             I669/I672/I10                 I633

Canada:          I669/I672/I10                  I672?

Sweden:         I669/I672/I10                  I633? /Sorry, I got the wrong code last time! Lars Age/

*USA:            I633/I672/I10                 I633


*Brazil /Augusto Hasiak Santo/: Considering that codes I65.- and I66.- are not to be used for underlying cause mortality coding, when similar cases occur, our decision was to open a dialogue box during the processing and ask the coder to choose a code among I63.0 and I63.2 (instead of I65.-) or among I63.3 and I63.9 (instead of I66.-). As cerebral thrombosis was mentioned, in this death certificate I63.3 was chosen. This decision was done because in Brazil ICD-10 is being used since 1996 for mortality coding. Nevertheless, this problem is also candidate for clarification: when should the codes I65.- and I66.- be used if not for underlying cause? Only for multiple causes coding?

*USA /Julia E Raynor/: This certificate looks so simple, doesn't it, but indeed it is not. Instructions in Volume 2, page 66, Table 2 states I65 and I66 are not to be used for underlying cause and the substitute code is I63. Therefore, the classification is making the assumption that the precerebral artery conditions indexed to I65 and the cerebral artery conditions indexed to I66 caused a cerebral infarction even though a cerebral infarction is not reported. The U.S. has decided to consider I65 and I66 as invalid for multiple cause coding also. The multiple cause substitute code for I65 and I66 will be I63 with appropriate 4th digit.

For example, cerebral thrombosis indexed to I669 will be coded to I633 for multiple cause and UC. Carotid embolism indexed to I652 will be coded I631 for multiple cause and UC.

For this certificate, we will select I10, hypertension, by General Principle. Following linkages in Volume 2, page 54, I10 links with mention of I60-I69. There is a conflict in linkage. We will link with I672, the condition we would have selected if the selected cause had not been reported. There is an additional linkage, I672 links with I60-I64. (Volume 2, page 56) We will link I672 with I633. UC I633

Canada /Patricia Wood/: I would apply the same multiple cause codes as Lars Age: I669/I672/I10 and I would apply the General Principle to select a tentative underlying cause of I10. Then referring to the note in ICD-10, Volume 2, page 54 I would apply Rule C to reselect an underlying cause of either I669 or I672. I would consider there to be a conflict in linkage with I10 linking to both I669 and I672 and I would resolve this by linking with the condition that would have been selected if the cause initially selected had not been reported. I would apply Rule C to reselect the underlying cause as I672. I am not sure whether to go further by applying Rule D or not. I agree that this requires some clarification

Sweden /Lars Age Johansson/: If the certifier had written "cerebral infarction" instead of "cerebral thrombosis", there would have been no problems. I10, of course, links with both cerebral atherosclerosis and cerebral infarction, and since cerebral atherosclerosis links with cerebral thrombosis to I63.9, that would have been the underlying cause. The problem is that I67.2, according to Volume 2, links only with I60-I64, and not with I66 (cerebral thrombosis). I have still coded the certificate to I63.9, since I think that Rule D, Specificity, could be used to select cerebral thrombosis rather than cerebral atherosclerosis. Then I would apply the Note on I66 (Vol. 2, p. 56) and select I63.9 as the underlying cause of death. But I think that we have still another candidate for clarification here.

7-VIII-1997 Q4 Coding of multiple injuries - link with both Part I and Part II?

(Rule C / UC Chapter XIX)

In the Swedish C-o-D register, we have two underlying causes for violent deaths: one external cause (Chapter XX) and one injury (Chapter XIX). While coding the external cause in ICD-10 is much as before, we feel a bit confused over how to use the new categories for multiple injuries (in Chapter XIX). So, how would you code the following two certificates? Would you take all injuries into account when coding the underlying injury (Chapter XIX), or just the injuries in Part I?


1 (a) Brain injury with fracture of base of skull
1 (b) Cyclist run over by truck.
2 Internal chest injuries


1 (a) Traumatic intracerebral haemorrhage
1 (b) Fall from bed
2 Senile dementia, haematoma in the region of the left eye

[Suggested coding:]

                      Multiple causes                            Underlying cause


*England        S069 S021/V139*S279 V139     S021


*England          S062/W069*F03 S058 W069   S062


*England /Wendy Child/: We would take the injuries stated in Part 1 as a "clear indication" of cause of death , but would take into account the injuries stated in part 2 if they modified the coding, ie linkage or specificity.

Canada /Patricia Wood/: I think that another area requiring clarification is identified with this question! In the notes in ICD-10, Volume 2, page 86, 4.2.10 Nature of Injury, I see "where more than one kind of injury to a single body region .. is mentioned and THERE IS NO CLEAR INDICATION as to which caused death .. " Taking into account the format of each of the certificates I am tempted to consider the fact that one injury was reported in part I and another in part II to be a "clear indication" as to which caused death and code the injury in part I. However reading on in note 4.2.10 the last paragraph instructs, "when more than one body region is involved, coding should be made to the relevant category of Injuries involving multiple body regions." Should this be done even when a "clear indication" as to which injury caused death may be interpreted from the format of the certification? For the first certificate the injuries would not be considered as injuries of a single body region but for the second they would be. I confess that I have quite thoroughly confused myself on this issue and I am not sure what to code!

7-VIII-1997 Q5 Aspiration due to acute pancreatitis

(Rule GP / UC Chapter XI)

[From Sweden:]

How would you code this one:

1 (a) Terminal aspiration, suffocation
1 (b) Acute pancreatitis
2 Calculi of gall bladder and biliary ducts. Aortic stenosis, hypertrophy of heart. Generalized arteriosclerosis. Fatty liver.

[Suggested coding:]

                        Multiple causes                                                                         Underlying cause

Brazil                W849 T179/k85*k802 K805 I350 I517 I709 K760                K802

Canada            W849/K85*K802 K805 I350 I517 I709 K760                        K802

*England         W849 T179/K85*K802 K805 I350 I517 I709 K760                K802

USA               T179 W84/K85*K802 K805 I350 I517 I709 K760                  K802


*England /Wendy Child/: Using the General Principle we would select acute pancreatitis K85, then using Rule 3, would consider this to be a direct sequel of calculi gallbladder K802.

Brazil /Augusto Hasiak Santo/: Rules: GP+R3.

For processing this death certificate the same decision table used by Patricia was also used. The code T17.9 is being used in Brazil when asphyxia or suffocation without any other specification is mentioned on the death certificate.

USA /Julia E Raynor/: The 10th Revision Index has not provided a nature of injury code for "aspiration". The U.S. will code T179, foreign body in respiratory tract, part unspecified.

I would select, as Patricia indicated, acute pancreatitis, K85, by General Principle. Next, using Rule 3, I would consider acute pancreatitis, K85 as a direct sequel of calculi of gallbladder, K802. UC K802 Acute pancreatitis, K85 would also be considered a direct sequel of calculi of biliary ducts, K805, but our order of priority for direct sequel is from left to right (1) on the same line (2) on a lower line in Part I, and (3) in Part II. We will code E code, W84 to a three digit code and our place of occurrence codes will be coded separately.

Canada /Patricia Wood/: For multiple cause codes I would select W849/K85*K802 K805 I350 I517 I709 K760 and applying the General Principle I would select the tentative underlying cause as K85 and then (using ACME for ICD-9 decision tables for guidance) I would consider K85 to be a direct sequel of K802 and I would apply Rule 3 to reselect the underlying cause as K802. By the way, I am having trouble finding a suitable nature of injury code for this record.

Any thoughts?

18-VIII-1997 Q1 Code for "metastatic melanoma"

(Rule II)

[Augusto Hasiak Santo send us this question:]

How should "metastatic melanoma" be coded as underlying cause of death? The guidance about metastatic neoplasm, regarding this kind of mention when a single malignant neoplasm is described as metastatic, on page 77 of the Instruction Manual, states that "( ii ) If no site is reported but the morphological type is qualified as metastatic, code as for the primary site unspecified of the particular morphological type involved".

This guidance is equivalent to the one of the Ninth Revision on page 729 of Volume I. Accordingly, metastatic melanoma should be coded as C43.9. Nevertheless, the Index of the Tenth Revision, on page --- has the following entry:

"Melanoma, metastatic, unspecified site (M8720/6) C80", that definitely contradicts the above guidance. This entry is also different from that of the Index of the Ninth Revision, which states:
"Melanoma, metastatic, unspecified site 172.9"

In Brazil the coders are being taught to code according the guidances of the Instruction Manual in C43.9. It is our opinion that the information about the morphological type of the neoplasm is very important and can't be missed.

[Coding of "metastatic melanoma":]

*Canada C439

Sweden C439

USA C439

*Canada /Patricia Wood/: I completely agree with Augusto. The index entry for Melanoma, metastatic, unspecified site C80 seems to contradict the instructions for coding a single malignant neoplasm described as metastatic when no site is reported (ICD-10, Volume 2, page 77, (ii)). Is this an error in the index or is that entry intended for a use other than mortality classification?

Sweden /Lars Age Johansson/: We too agree with Augusto, the C80 in the Index must be a mistake.

USA /Julia E Raynor/: The U.S. agrees with Brazil. We will code metastatic melanoma to C439 following instruction in Volume 2, page 77, (c) ii.

1-IX-1997 Q1 (h) - cerebrovascular disease due to other conditions

(Rule 4.2.2 / UC Chapter IX)

[The question, from Norway, was:]

We have a few problems with the interpretation of item (h) in "highly improbable" (Vol. 2, 4.2.2), cerebrovascular diseases due to diseases of the digestive system, etc.

a) Does it mean that conditions in I65-I66, occlusion without cerebral infarction, may be due to diseases of the digestive system (Chapter XI); but that I63, occlusion *with* cerebral infarction, may not be due to diseases of the digestive system?

b) Does it mean that conditions in Chapter XI and endocarditis may cause intracranial haemorrhage, even a subarachnoidal haemorrhage?

If so, we have that I63, I64, I67, (I68), and I69 may *not* be due to conditions in Chapter XI and endocarditis. We do not quite see the logic in this, but we hope that you can help us!

[Comments - the interpretations differ somewhat, I'm afraid. Another

candidate for clarification, apparently:]

*England /Wendy Child/: We interpret this to mean that:

I60-I69 due to K00-K92 is highly improbable

I60-I69 due to I05-I08, I09, I33-I38 is highly improbable

except that I65 and I66 and I60-I62 from the range of I60-I69 can be due to

K00-K09 and I05-I08, I09.1, I33-I38.

However, our Dr Rooney has expressed surprise/disquiet/doubt at 'cerebral embolisms and 'intracranial haemorrhages' due to diseases of the 'digestive system' being acceptable. So further guidance in the interpretation of this paragraph is clearly needed.

Canada /Patricia Wood/: Perhaps it is the "literalist" in me (smile!) but I have a slightly different interpretation of 4.2.2 (h). It could be taken to mean that it is "highly improbable" that any cerebrovascular disease (I60-I69) can be "due to" a disease of the digestive system (K00-K92) or endocarditis (I05-I08, I09.1, I33-I38), except cerebral embolism ONLY, i.e. NO OTHER INCLUSION TERM, in I65-I66 or intracranial hemorrhage ONLY, i.e. NO OTHER INCLUSION TERM, in I60-I62. So a sequence with cerebral embolism of the basilar artery (I65.1) due to a digestive disease or endocarditis would be acceptable, but narrowing of basilar artery (also I65.1) due to a digestive disease or endocarditis would be "highly improbable."

Even with this slightly narrower interpretation of 4.2.2 (h) I do not understand the logic of the guideline. Is it based on some pathological or clinical information that is transparent to a medical practitioner but less so to a nosologist? There seems to be a need for clarification of the application of this guideline if any consistency is to be achieved.

Sweden /Lars Age Johansson/: As I understand the instruction in 4.2.2 (h) it means that

- I60-I69 may NOT be due to K00-K92

- I60-I69 may NOT be due to I05-I08, I09.1, or I33-I38

except that

- I60-I62 may be due to I05-I08, I09.1, and I33-I38

- I65-I66 may be due to I05-I08, I09.1, and I33-I38

As the text now stands, I cannot say if the ICD also intends to make an exception for embolism and haemorrhage due to gastrointestinal conditions, but I cannot understand how a gastrointestinal disease could be the cause of a cerebral haemorrhage. Perhaps someone can enlighten me?

I agree with you that if we accept that conditions in I65-I66 may be due to endocarditis and conditions in K00-K92, then you must also accept that embolisms and thromboses coded to I63 may be due to endocarditis and conditions in K00-K92.

It seems to be an arbitrary decision of the ICD to exclude I64, I67 and I69, since a "stroke" might very well be caused by an embolism or thrombosis. On the other hand, several countries apply the instruction literally (embolism and thrombosis due to endocarditis is OK, but stroke due to endocarditis is not OK), and in the interest of international comparability, we should perhaps all do the same, even if the logic is not quite apparent.

USA /Julia E Raynor/: Volume 2, highly improbable list, (h), page 68

The U.S. decision on coding categories I65 and I66 is explained in detail in Email dated 7-VIII-1997 Q3, update 1. We will code embolisms indexed to I65 to I631 and embolisms indexed to I66 to I633. We interpret instruction (h) as meaning that embolism, I631 and I633 can be due to digestive system K00-K92, endocarditis, I05-I08, I091, I33-I38. Also, intracranial hemorrhage, I60-I62 can be due to K00-K92, endocarditis, I05-I08, I091, I33-I38. Any other cerebrovascular disease in I60-I69 cannot be due to K00-K92, I05-I08, I091, I33-I38.

1-IX-1997 Q2 Pulmonary embolism due to valvular disease

(Rule 3 / UC Chapter IX)

[The question, from Norway, was:]

Here is a certificate we would like you to consider:

1 (a) Pulmonary embolism
2      Aortic stenosis

According to Rule 3, we are to regard any "embolic" disease as an obvious consequence of, e.g., valvular heart disease. As far as we can see, however, it is for anatomical reasons rather unlikely that an aortic stenosis would be the cause of a pulmonary embolism, and we are reluctant to apply Rule 3. Would you agree with us?


*England /Wendy Child/: As in the past ONS used an extension to Rule 3 which included Pulmonary Embolism, we would not have a problem in applying the instruction given on Page 39 in Vol 2, but we would also support asking WHO for clarification.

USA /Julia E Raynor/: We agree with your anatomical reason for using pulmonary embolism as a direct sequel of valvular heart disease as an exception of the direct sequel instruction in Volume 2, page 39. We support uniform coding instructions but also agree that exceptions, when necessary, should be used to provide correct data. We support asking WHO for clarification.

Canada /Patricia Wood/: This certificate seems to indicate the need for clarification of the application of another part of Rule 3. Putting aside the specific question of the clinical relationship between aortic stenosis and pulmonary embolism for a moment, I think that coders may have difficulty interpreting the meaning of this part of Rule 3. If pulmonary embolism is considered to be a "disease described or qualified as 'embolic,'" it would be accepted as a direct consequence of valvular heart disease (including aortic stenosis). If, on the other hand, pulmonary embolism is not considered to be a "disease described or qualified as 'embolic,'" it would not be accepted as a direct consequence of valvular heart disease (including aortic stenosis). It seems that rather than answering this question, I am compounding it!

Sweden /Lars Age Johansson/: I agree that it is unlikely that an aortic stenosis would be the direct cause of a pulmonary embolism, you would expect the blood flow to carry an embolus from the aortic valve away from the lungs rather than towards them (I am very much aware that my medical knowledge is fairly fragmentary, so I would appreciate corrections on this). But again: the instruction you cite make no exception for the aortic valve and pulmonary embolism, so if you want to adhere strictly to the coding instructions, you have to select the stenosis as the underlying cause of death, in spite of the medical difficulties. Perhaps we should try to have a clarification of the coding instructions on this point.

9-IX-1997 Q1 "Renovascular hypertension"

(Rule C / UC Chapter IX)

[A question from Augusto Hasiak Santo. The answers do indeed indicate that we need some clarification here as well.]

I would like to submit to the discussion of the group the following death certificate:

I(a) Failure of multiple organs
I(b) Septicaemia
I(c) Renovascular hypertension

I must remark that, in my opinion, some guidelines on the Table 2 of the Instruction Manual, among which this death certificate can be included, are not very clear and I would appreciate very much the comments of the group.

[Suggested coding:]

                              Multiple causes                   Underlying cause

Canada                  R688/A419/I150                A419

England                 R99/A419/I150                  A419

Sweden                R688/A419/I150                 A419

USA                    R688/A419/I129                 I129


*England /Wendy Child/: Further to your follow up question on this question from Brazil: we would consider R68.8 a valid code for mortality coding for the term 'failure of multiple organs'. We suggested R99 because that is equivalent to the code we would have used in ICD-9, but we agree that R68.8 is probably 'better'.

With reference to Augusto's comment on Table 2 of the Instruction Manual, our practise is to use both this and Table 1 as an endorsement of the 'Notes for Use in underlying cause mortality' or as a quick reference.

As Lars says, the explanation of the use of the notes at Para. 4.1.11 is somewhat deficient as it does not mention that other instructions are included, they are not just covering linkages.

Canada /Patricia Wood/: In the absence of a "highly improbable" causal relationship (ICD-10, Volume 2, pages 67-69) I applied the General Principle to select a tentative underlying cause of I150. Referring to the "Notes for use in underlying cause mortality coding," (ICD-10, Volume 2, pages 50-62), specifically the one indicating that I15.- is not to be used for underlying cause mortality coding, (ICD-10, Volume 2, page 55), I reselected the tentative underlying cause of R99. Then I applied Rule A to reselect the underlying cause as if R99 had not been reported and selected a new tentative underlying cause of A419. In the absence of any linkages or further modifications, I selected A419 as the underlying cause of death!

Regarding the use of R688 versus R99 for the coding of multiorgan failure: I can see no reason that R688 would not be a suitable code for the term multiorgan failure.

I think that classification decisions (i.e. the coding of terms that are not indexed in the ICD-10) are something else that could fall into the realm of responsibility of the NRG. We are all regularly faced with making classification decisions and, I suppose, many of us are making them in isolation. If a list of decisions were to be included in the kind of dynamic standards manual that Sue Walker suggests international consistency would be further enhanced.

USA /Julia E Raynor/: Line a) For 9th revision, we coded failure of multiple organs to 7999, other unknown and unspecified cause. This is R99 in 10th revision. The 10th revision classification has provided a new category, R688, other specified general symptoms and signs. We consider that code to be more informative than R99.

Line c) Renovascular hypertension indexed to I150 is, as others have stated, listed in Volume 2, page 66, Table 2. We interpret Table 2 as meaning that these listed codes are invalid for UC and the substitute code is R99 if the substitute code is not given.

The U.S. will consider this list of codes as invalid for multiple cause coding also. We have an exception to this decision, renovascular hypertension, I150. Our substitute code for renovascular hypertension is I129, hypertensive renal disease without renal failure. We based this code substitution on the 9th revision code assignment for renovascular hypertension, 4039. We, as Sweden, accept septicemia as due to many conditions.

England /Wendy/: Like Sweden, using the General Principle we would select I150 but the note on page 55, Volume 2, tells us that this should not be used for Underlying Cause and to use R99. We would then apply modification Rule A and re-select the underlying cause as if R99 had not been reported which gives us A419 - Septicaemia - as the Underlying cause.

[A follow-up question from Sweden: We have used R68.8 for "failure of multiple organs", while England has used R99. Would you consider R68.8 invalid for mortality coding?]

Sweden /Lars Age Johansson/: The General Principle would give I15.0 as the originating cause (I do not quite understand how a septicaemia can develop from a hypertension, but in Sweden we accept a septicaemia as due to almost anything). Before going on to the Modification Rules, I will look up I15.0 in the Notes (Vol 2, pp 50-66). There is no clear instruction in Vol 2 as to when we are to apply the Notes, except that they are mentioned in the text of Rule C (linkage). However, several of the Notes are not on linkage but give general directions (e.g. valid codes and code substitutions), so I conclude that we are supposed to check our temporary underlying cause in the Notes each time we arrive at a new one, and not just after applying Rule C.

The Note on I15 (Secondary hypertension, Vol 2, p 55) tells me not to use that code for the underlying cause, and instructs me to code R99 (Other ill-defined ... causes) if the certificate does not state the cause of the secondary hypertension. That would leave me with R99 as the underlying cause of death. I would then apply Modification Rule A (Senility and other ill-defined conditions), and re-select the underlying cause as if the cause coded to R99 had not been reported. That gives A41.9, septicaemia, as the underlying cause of death.

I look forward to more coding suggestions, and to comments on when to use the Notes...

9-IX-1997 Q2 – 5

9-IX-1997 Q2 Diabetes (Rule GP / UC Chapter IV)

9-IX-1997 Q3 Diabetes  (Rule 3 / UC Chapter IV)

9-IX-1997 Q4 Diabetes  (Rule 3 / UC Chapter IV)

9-IX-1997 Q5 Diabetes  (Rule 3 / UC Chapter IV)

[Mary Heanue's questions were all on diabetes, …]

Here are some certs we have on diabetes that we would like the advice of the group on. We are looking for the underlying cause of death in ICD9.

1a Diabetes
1b ischaemic heart disease

1a Acute Myocardial Infarction minutes
2 Diabetes Mellitus        15 years

1a Cerebrovascular accident          minutes
2 Insulin Diabetes Mellitus          years
Partially sighted          years
20 Glaucoma

1a Acute Myocardial Infarction       4 days
2 Non Insulin Diabetes Mellitus
Bronchogenic Carcinoma

[Suggested coding:]

                        Multiple causes           Underlying cause

*Canada          2500/4149                   2500

England                                                2500

Sweden           E149/I259                    E149 (2500)

*USA 9th        2500/4149                   2500

          10th       E149/I259                     E149

*Canada         410*2500                      410

England                                                 410

Sweden           I219*E149                    I219 (410)

*USA 9th      410*2500                        410

          10th      I219*E149                     I219

*Canada        436*2500 3699 3659     436

England                                                 436

Sweden          I64*E109 H547 H409    I64 (436)

*USA 9th        436*2500 3699 3659    436

          10th     I64*E109 H547 H409     I64

*Canada        410*2500 1629              410

England                                               410

Sweden       I219*E119 C349             I219 (410)

*USA 9th   410*2500 1629                 410

        10th     I219*E119 C349              I219


*Canada /Patricia Wood/: Q2 - Referring to the notes for Interpretation of "highly improbable" (ICD-9, Volume 2, page 722), I applied Rule 2 to select a tentative underlying cause of 2500. In the absence of any linkages or further modifications, I selected 2500 as the underlying cause of death.

Lars Age, I notice that you used 2509 for diabetes. I always use 2500 for diabetes (mellitus).

[Sorry, a coding mistake. There are no complications mentioned, so the code is quite clearly 250.0. Perhaps I am already forgetting what I once knew about ICD-9. /Lars Age]

Q3 - I selected a tentative underlying cause of 410 and, in the absence of any linkages or further modifications, I selected 410 as the underlying cause of death.

Q4 - I selected a tentative underlying cause of 436 and, in the absence of any linkages or further modifications, I selected 436 as the underlying cause of death.

Q5 - I selected a tentative underlying cause of 410 and, in the absence of any linkages or further modifications, I selected 410 as the underlying cause of death.

*USA /Julia E Raynor/: For 9th revision, we use the "highly improbable" list in Volume 1, pages 721-722, (d). We do not accept diabetes as due to any disease except the listed exceptions. For 10th revision, we will use the "highly improbable" list in Volume 2, pages 67-68 (d) and not accept the sequence.

Also, as Sweden and England, we do not consider these conditions as a direct consequence of diabetes.

[Thanks, Wendy, for sending us England's answers to Mary's questions. I have added ICD-9 codes to my answers, I suppose I was too preoccupied by ICD-10 last week - as you know we started production coding in ICD-10 last Monday - to think of ICD-9. /Lars Age]

Sweden /Lars Age/: Diabetes is notoriously difficult to code, since the complications, and the severity of the cases, vary so much. It is well known that coding practices differ enormously between countries, so if we could agree on some principles here, we would have achieved a great deal...

As you can see from my coding, we do not allow diabetes to be due to IHD (cf Vol 2, p 68, note (d)). Also, we do not regard an acute circulatory disease, like a myocardial infarction or a cerebrovascular accident, as an obvious consequence of diabetes mentioned in part II.

9-IX-1997 Q6 Is I25.2 a valid underlying cause code?

(Rule C / UC Chapter IX)

[We had a question from Finn Gjertsen, Norway:]

Use of I25.2

In April 1997 Norway started training in ICD-10 (3 new coders and 2 who have used 9.rev). We would like to discuss with you the use of I25.2, old myocardial infarction (healed), as underlying cause (UC).

We are not sure when to use I25.2 and I25.8. How would you code these two cases:
1a Pneumonia 2 days
1b Insuff. cordis
1c Infarctus cordis 2 months
1a Mors subita
1b Inf. cordis vetus 7 years

We have a note about mortality coding and ICD-9 code 412, (we believe that it was sent us from WHO? in 1986/87?):

"412. To be used for mortality only in multiple coding, for such statements as old myocardial infarction or scarring of myocardium. It is difficult to see how it could be used as an underlying cause code." We can't see that this "rule" is part of ICD-10?

[Suggested coding:]

                              Multiple cause               Underlying cause

*Canada                                                     I258

*England                                                     4148 (I258)

Sweden               J189/I509/I258                I258

*USA  9th          486/4280/4148                 4148

          10th         J189/I509//I258                 I258

*Canada                                                      I252

*England                                                     4148 (I258)

Sweden              R960/I252                        I252

*USA 9th          /412                                   412

          10th        /I252                                   I252


*Canada /Patricia Wood/: In the first case, the myocardial infarction is not specified as "old" but has a stated duration of more than 4 weeks so it is excluded from I21 and included in I258. In the second case, the myocardial infarction is specified as "old" AND has a stated duration of more than 4 weeks so it is definitely excluded from I21. I258 includes conditions in I21-I22 and I24 with a stated duration of more than 4 weeks but makes no mention of conditions in I252 with the same duration. Therefore, I would be inclined to code an myocardial infarction, specified as old, with or without a stated duration of more than 4 weeks, to I252.

Currently, If "old myocardial infarction" is certified is selected as the underlying cause of death it is coded as 412 and included in Statistics Canada cause of death statistics. I was not aware of a WHO message instructing us not to use 412 for underlying cause of death.

*England /Wendy Child/: Regarding the question from Norway when to use I252 and I258: We would also code to I258 as the condition is more than 28 days old. In ICD9 we also had the note telling us not to use OLD MI 412 for U/C, but to use 4148, which we applied. However our automatic system does not apply this and uses 412. Do we also need clarification from WHO on this?.

*USA /Julia E Raynor/: For multiple cause coding, we do not assign a code for sudden death if other conditions are reported on the record. For 9th revision, we follow Volume 2 and the inclusions under categories 410-414. If the myocardial infarction is qualified as chronic or has a stated duration of over 8 weeks, we code 4148. If myocardial infarction is modified as healed, old, remote, or past with or without a duration, we code 412. I am not aware of a note from WHO concerning not using 412 for uc. It may have missed the U.S. as well as Sweden. For 10th revision, we will continue to follow the index and code I258 or I252.

Sweden /Lars Age/: In the first case, the infarction is not described as "old" or "sequelae of". It is more than four weeks old, however, and according to the exclusion note on I21 (Vol 1, p 478) such cases belong to I25.8. In the second case we do get I25.2, since the infarction is described as "old". The text under I25.2 certainly gives the impression that this category is not intended for underlying cause coding, but there is no formal instruction to that effect. In Sweden we have tried to solve the problem by using I25.8 rather than I25.2 in cases where the old myocardial infarction is the cause of later complications, like heart failure or insufficiency. In cases without reported cardiac complications, we accept I25.2 as the underlying cause. I suppose that "sudden death" does not give any information on cardiac complications to the infarction, so here I would accept I25.2 as the underlying cause.

The message from WHO Finn refers to never reached Statistics Sweden, and we have plenty of deaths due to 412 in our ICD-9 statistics. How many of you got the message, and how did you handle ICD-9 deaths due to old myocardial infarctions?