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mort97_5

16-XI-1997 Q1 – 13

16-XI-1997 Q1 /Definition of "underlying cause"/

16-XI-1997 Q2 (m) - accidents due to diseases (Rule 4.2.2. / UC Chapter XX)

16-XI-1997 Q3 Format for reporting of external causes (UC Chapter XX)

16-XI-1997 Q4 Submersion due to myocardial infarction (Rule GP / UC Chapter XX)

16-XI-1997 Q5 Submersion due to subarachnoid haemorrhage (Rule GP / UC Chapter XX)

16-XI-1997 Q6 Submersion obvious consequence of heart failure  (Rule 3 / UC Chapter XX)

16-XI-1997 Q7 Submersion due to cerebrovascular attack  (Rule GP / UC Chapter XX)

16-XI-1997 Q8 Cerebral contusion due to ischaemic heart disease  (Rule GP / UC Chapter XX)

16-XI-1997 Q9 Angina pectoris obvious consequence of epidural haemorrhage  (Rule 3 / UC Chapter IX)

16-XI-1997 Q10 Pneumonia obvious consequence of fracture of neck of femur  (Rule 3 / UC Chapter XX)

16-XI-1997 Q11 Epidural haemorrhage due to angina pectoris (Rule GP / UC Chapter XX)

16-XI-1997 Q12 Pneumonia obvious consequence of epidural haemorrhage or of angina attack  (Rule 3 / UC Chapter XX)

16-XI-1997 Q13 Epidural haemorrhage obvious consequence of angina attack  (Rule 3 / UC Chapter XX)

[We have new answers from Canada:]

1. Interpretation of definition of underlying cause of death

*Canada /Patricia Wood/: In Canada "morbid events" as in " the disease or injury which initiated the train of 'morbid events' leading directly to death ..." are interpreted to be diseases and/or injuries.

England /Wendy Child/: We take the 'morbid event' to be the disease or condition causing the disease or condition which directly led to death or the injury directly leading to death.

Sweden /Lars Age Johansson/: We take the term "morbid event" to include both injuries and diseases.

2. Interpretation of "highly improbable", (m) -

*Canada /Patricia Wood/: I agree that the interpretation of Volume 2, page 67, 4.2.2 Interpretation of "highly improbable", (m) should be that any accident, and the injury produced, can not be due to any disease condition other than epilepsy. I really like Wendy's examples because they very clearly demonstrate this interpretation.

England /Wendy/: Injuries or accidents cannot be due to diseases except epilepsy. so, for example,

1a Fracture Skull
1b Myocardial Infarction

following the ICD guidelines, this is not an acceptable sequence and if no further information is available, Rule 2 will apply and the underlying cause will be X599 and S029 if the nature of the injury is tabulated in your country.......but.......

1a Fracture Skull
1b Epileptic attack

the same guidelines tell us we can accept an injury due to epilepsy so the underlying cause will be G409.

Sweden /Lars Age/: We would answer "yes" to the question, and say that an injury or accident may never be due to a disease, except epilepsy. To be honest, I do not quite understand why there should be an exception for epilepsy. Of course, epilepsy may cause a fall which may cause an injury, but that is true of many other diseases as well (cerebrovascular stroke, myocardial infarction...). As the instruction now stands, however, we cannot allow an injury to be due to any other disease.

3 (a). Reporting of accidents:

*Canada /Patricia /: (a) Theoretically injuries are certified in Part I or Part II of Canadian death certificates with the external cause information being certified in a separate "how did injury occur" field. In reality, external cause information gets certified practically any where on the death certificate!

England /Wendy/: In this country the injuries are reported in Part 1 and sometimes in Part 1 and Part 11 of the certificate but the event which produced the injuries (the external cause) may also be entered in Part 1 or Part11 but are usually on a separate document.

Sweden /Lars Age /: In our country, the injury (or injuries) are reported in Part I and/or Part II of the certificate, but the event that produced the injuries (the accident, method of suicide/murder etc) is described in a separate field. We generally place the code for the external cause of the injury immediately after the code for the injury itself.

3 (b). Selection of underlying cause in cases with a reported accident:

*Canada /Patricia /: (b) If an external cause and other causes are reported on the death certificate and we can not determine, by applying the rules for selecting underlying cause, what to select we would initiate a query seeking clarification from the certifier.

England /Wendy/: We have national instructions on how to deal with accidents, injuries and other causes on the same certificate. Most violent/traumatic deaths are referred to a Coroner who conducts an inquest into the circumstances of the death, we will code the external cause according to the Coroner's verdict, for example, Accident, Misadventure, Natural Causes, Suicide, Assault, etc.

This means that most of the sample certificates you would like us to code would all have an Inquest Verdict stated and we would code accordingly. For example

Case 1. 1a Submersion
             1b Acute myocardial infarction
             1c -
              11 hypertension

this would have been referred to a Coroner because of trauma in Part 1, if the Coroner's verdict was 'Accidental death', we would record an underlying cause of W74 and T751 in a secondary cause position.

Given the same circumstances and a verdict of 'Natural Causes' we would record an underlying cause of I129. This appears to go against the guidelines in Volume 2 but we have to consider the Coroners verdict for our tabulations and if this states the death is due to 'natural causes' we would not assign it to an External cause. BUT, if injury of submersion is mentioned with Epilepsy and the Coroner's verdict is 'Accident', we assign the underlying cause to Epilepsy.

If we did not have to follow these special internal instructions, we would adhere to the guidelines in Volume 2 and the underlying causes in Cases 4 - 8 and Cases 10 -13 would be the External code for the circumstances of the accident and a code for the injury in a secondary position.

Case 9 - we would apply the General Principle and select angina pectoris I209 as the underlying cause.

Lengthy answers, I'm afraid, our special national instructions on dealing with External causes not easy to explain.

Sweden /Lars Age /: We try to apply the rules and guidelines in Volume 2, but we have some additional national instructions. They are mainly on details of coding (e.g. that the coder should assume that a small boat NOS has an engine), and do not - we hope - change any of the instructions in Volume 2.
 

[Certificates to code:]

4.     I a) submersion
          b) acute myocardial infarction
        II hypertension

5.      I a) submersion
           b) subarachinoid haemorrhage
         II

6.      I a) submersion
         II heart failure

7.      I a) submersion
           b) unconsciousness due to cerebrovascular attack

8.       I a) cerebral contusion
            b) acute heart failure
            c) ischamic heart disease

9.       I a) angina pectoris
          II Epidural haemorrhage

10.     I a) pneumonia
          II fracture of neck of femure

11.     I a) Epidural haemorrhage
            b) angina pectoris

12.     I a) Pneumonia
          II Epidural haemorrhage
          note: Patients had a angina attack and hit himself with his head on the ground.

13.      I a) Epidural haemorrhage
           II
          note: Patients had a angina attack and hit himself with his head on the ground.


[Suggested coding:]

                      Multiple causes                         Underlying cause

4.
*Canada         T751 W749/I219*I10              W749

Sweden           T751 W74/I219 T751              W74

5.
*Canada         T751 W749/I609                    W749

Sweden          T751 W74/I609                        T751 W74

6.
*Canada        T751 W749*I509                     W749

Sweden          T751 W74*I509                       T751 W74

7.
*Canada         T751 W749/R402/I64              W749

Sweden          T751 W74/R402/I64                T751 W74

8.
*Canada        S062 X599/I509/I259                X599

Sweden         S0620 X59/I509/I259                 S0620 X59

9.
*Canada        I209*S064 X599                       I209

Sweden          I209*S0640 X59                      I209

10.
*Canada        J189*S720 X599                      X599

Sweden         J189*S7200 X59                       S7200 X59

11.
*Canada      S064 X599/I209                          X599

Sweden        S0640 X59/I209                         S0640 X59

12.
*Canada       J189*S064 W199 I209              W199

Sweden         J189*S0640 W19 I209              S0640 W19

13.
*Canada        S064 W199*I209                      W199

Sweden         S0640 W19*I209                       S0640 W19


[Comments:]

Q4

*Canada /Patricia/: I applied Rule 2 using Volume 2, page 68, 4.2.2 Interpretation of "highly improbable", (m) any accident (V01-X59) reported as due to any other cause outside this chapter except epilepsy, to select W749 as the underlying cause of death.

Sweden /Lars Age/: The sequence is quite OK from a purely medical point of view, but it is still "highly improbable" according to Vol. 2, p. 68 (m). We will submit to this, of course, and consequently select the submersion as the underlying cause of death.

Q5

*Canada /Patricia /: I applied Rule 2 using Volume 2, page 68, 4.2.2 Interpretation of "highly improbable", (m) any accident (V01-X59) reported as due to any other cause outside this chapter except epilepsy, to select W749 as the underlying cause of death.

Sweden /Lars Age/: The same - this is also a "highly improbable" sequence, and the submersion is the underlying cause here as well.

Q6

*Canada /Patricia /: I applied the General Principle to select W749 as the tentative underlying cause of death. In the absence of any further modifications or linkages I selected W749 as the underlying cause of death.

Sweden /Lars Age / : The General Principle gives submersion in this case. We cannot apply Rule 3, since the sequence "submersion due to heart failure" would not have been accepted.

Q7

*Canada /Patricia /: I applied Rule 2 using Volume 2, page 68, 4.2.2 Interpretation of "highly improbable", (m) any accident (V01-X59) reported as due to any other cause outside this chapter except epilepsy, to select W749 as the underlying cause of death.

Sweden /Lars Age/: Another "highly improbable" (but medically acceptable) sequence, resulting in submersion as the underlying cause.

Q8

*Canada /Patricia /: I applied Rule 2 using Volume 2, page 68, 4.2.2 Interpretation of "highly improbable", (m) any accident (V01-X59) reported as due to any other cause outside this chapter except epilepsy, to select X599 as the underlying cause of death.

Sweden /Lars Age/ : Also "highly improbable", according to Volume 2. Cerebral contusion, an injury, may not be due to acute heart failure, a disease. The contusion is the underlying cause.

Q9

*Canada /Patricia /: I applied the General Principle to select I209 as the tentative underlying cause of death. In the absence of any further modifications or linkages I selected I209 as the underlying cause of death.

Sweden /Lars Age/ : General Principle: the angina is the only condition mentioned in Part I, and it cannot be an obvious consequence of the epidural haemorrhage, cf. Q6.

Q10

*Canada /Patricia /: I applied the General Principle to select J189 as the tentative underlying cause of death. Then I applied Rule 3 (Volume 2, page 39) to select X599 as the underlying cause of death.

Sweden /Lars Age /: The pneumonia, selected according to the General Principle, is a direct consequence of the fracture (Vol. 2, p. 39: "... bronchopneumonia should be assumed to be an obvious consequence of ... non-trivial injuries."). The instruction on p. 39 speaks of bronchopneumonia, not pneumonia in general, but we have decided not to make any distinction between the two conditions when selecting the underlying cause of death, since the terms are used interchangeably in Sweden.

Q11

*Canada /Patricia/: Since there was no option in the index to code the epidural hemorrhage as nontraumatic, I applied Rule 2 using Volume 2, page 68, 4.2.2 Interpretation of "highly improbable", (m) any accident (V01-X59) reported as due to any other cause outside this chapter except epilepsy, to select X599 as the underlying cause of death.

Sweden /Lars Age/: Another case where note (m) on "highly improbable" applies - the haemorrhage is assumed to be traumatic, and may consequently not be due to a disease.

Q12

*Canada /Patricia /: I applied the General Principle to select J189 as the tentative underlying cause of death. Then I applied Rule 3 (Volume 2, page 39) to select W199 as the underlying cause of death.

Sweden /Lars Age /: Like in Q10, the pneumonia is considered an obvious consequence of the non-trivial injury (here an epidural haemorrhage). We will code the angina as a contributory cause of death, but not select it as underlying cause, since the sequence "angina attack causing a fall" would not have been accepted.

Q13

*Canada /Patricia /: I applied the General Principle to select W199 as the tentative underlying cause of death. In the absence of any further modifications or linkages I selected W199 as the underlying cause of death.

Sweden /Lars Age /: We would select the haemorrhage (General Principle). As in Q12, we would code the angina attack as a contributory cause.
 
 
 

24-XI-1997 Q1 Code for "Wiedemann- Rautenotrach syndrome"

(UC Chapter XVI)

[A new comment from Canada:]

1a Weidemann-Rauterstrauch(?) neonatal progeroid syndrome

Infant born with the condition. Died at 5 months.


[Suggested coding:]

                   Multiple causes        Underlying cause

*Canada      E348                      E348

England       Q878                      Q878


[Comments:]

*Canada /Patricia Wood/: We have encountered this syndrome. It was spelled as Wiedemann-Rautenotrach Syndrome when we saw it. At the time our research indicated that it was a "rare progeroid condition with contractures and diminished subcutaneous fat." We made an ICD-9 classification decision to code it to 2598, which includes Progeria. Applying the same logic (without further research) as we did then we would make an ICD-10 classification decision to code it to E348.

England /Wendy Child/: Correct spelling is Wiedemann etc. We would code this syndrome to Q87.8 It is similar to Hallerman-Streiff syndrome which is indexed at Q87.0
 

24-XI-1997 Q2 Enterocolitis obvious consequence of congenital heart lesion?

(Rule 3 / UC Chapter XVI)

[The question was from Ireland. Coding and comments from Julia Raynor:]


1  a Septicaemia (6 weeks)
1  b Pneumonia
1  c Necrotising Enterocolitis
2     Complex congenital heart lesion (9 weeks)


[Suggested coding:]

                Multiple causes                      Underlying cause

Brazil        7718/486/7775*7469            7775

Canada     7718/486/7775*7469            7775

England    A419/J189/P77*Q249            P77

                 7718/486/7775*7469           7775

*USA       7775/486/7775*7469            7775


[Comments:]

*USA /Julia E Raynor/: I did some " interpreting" also, as Patricia stated. The duration of the congenital heart lesion is 9 weeks, so the age is 9 weeks. The duration of septicemia reported due to necrotising enterocolitis is 6 weeks, therefore, enterocolitis must have occurred during the newborn period. According to the Inclusion Note in Volume 1, page 439, Chapter XV includes conditions which have their origin in the perinatal period even though death or morbidity occurs later.

Brazil /Augusto Hasiak Santo/: As Patricia says, sometimes our opinion is conducted by those comments already done about a question and in this case I agree with her. Nevertheless, the diagnoses "necrotising enterocolitis" that has brought difficulties to be coded in Ireland, has been also matter of confusion for codification in Brazil on account of different qualifications that appear.

For instance, enteritis appear as "necrotic", "necroticans", "necrotizing of foetus or newborn", with specific codes, but that may be mentioned as combined qualified diagnoses or mentioned for a neonatal death with a qualification that is not appropriate for the period.

Canada /Patricia Wood/: I applied the General Rule to select 7775 as the tentative underlying cause of death. In the absence of any further modifications or linkages I selected 7775 as the underlying cause of death.

I did a little bit of "interpretation" in that I coded the necrotizing enterocolitis as perinatal reasoning that if it caused the septicemia which had a duration of six weeks in a nine week old decedent it too must have arisen in the perinatal period.
 
 
 

24-XI-1997 Q3 Is cardiac arrest more specific than chronic heart decompensation?

(Rule D / UC Chapter IX)

[A comment from the US. Isn't it nice to see that at least sometimes everybody agrees? /Lars Age Johansson]

What would you code as the underlying cause? Would you consider "cardiac arrhythmia" more specific than "heart decompensation"?

1a Cardiac arrhythmia
1b Heart decompensation
1c Generalized arteriosclerosis


[Suggested coding:]

                   Multiple causes            Underlying cause

Brazil          I499/I519/I709            I499

Canada       I499/I519/I709            I499

England       I499/I519/I709            I499

*USA         I499/I519/I709            I499


[Comments:]

*USA /Julia E Raynor/: General principle, Rule C and Rule D We used Rule D, specificity, because the title of I519 is Complications and ill-defined descriptions of heart disease.

England /Lin Shane/: We agree with Patricia. Applying the General principle, Rule C and specificity.

Brazil /Augusto Hasiak Santo/: Rules General Principle, C and D were applied.

Canada /Patricia Wood/: I applied the General Principle to select I709 as the tentative underlying cause of death. Then I applied Rule C to reselect I519 as the tentative underlying cause of death. Then I applied Rule D to select I499 as the underlying cause of death considering it to be more specific than I519.
 
 
 

1-XII-1997 Q1 – 9

1-XII-1997 Q1 Pulmonary embolism obvious consequence of tibia fracture and epilepsy?   (Rule 3)

1-XII-1997 Q2 Chronic IHD due to carcinoma of pancreas  (Rule GP)

1-XII-1997 Q3 Renal failure obvious consequence of diabetes?  (Rule 3)

1-XII-1997 Q4 Acute myocardial infarction due to diabetes  (Rule G)

1-XII-1997 Q5 Hypertension due to diabetes  (Rule GP)

1-XII-1997 Q6 Chronic ischaemic heart disease and stroke due to diabetes  (Rule GP, 2)

1-XII-1997 Q7 Fourth character for diabetes with complications  (Rule C)

1-XII-1997 Q8 Coronary heart disease due to diabetes  (Rule GP)

1-XII-1997 Q9 Coronary heart disease obvious consequence of diabetes?  (Rule 3)

 

 

[Comments on question 8 and the coding of "coronary heart disease" from Germany:]


Question 1:

I a) Pulmonary embolism
II    Status epilepticus, tibia fracture

Question 2:

I a) heart failure due to chronic ischemic heart disease
   b) carcinoma of pancreas

Question 3:

I a) renal failure
II    heart failure, CIHD, diabetes mellitus

Question 4:

I a) acute myocardial infarction
  b) arrhythmia
  c) diabetes mellitus
II  chronic asthmoid bronchitis

Question 5:

I a) acute heart failure
  b) hypertension
  c) diabetes mellitus
II    general arteriosclerosis

Question 6:

I a) CIHD
  b) stroke 6 months ago
  c) NIDDM

Question 7:

I a) Diabetes with diabetic
  b) nephropathy, late diabetes syndrome
  c) general arteriosclerosis, CIHD
II   status post amputation of both lower legs
    arterial hypertension

Question 8:

I a) acute myocardial infarction
  b) coronary heart disease
  c) diabetes mellitus

Question 9:

I a) acute myocardial infarction
  b) coronary heart disease
II diabetes mellitus



 

[Suggested coding:]

                    Multiple causes                                         Underlying cause

1.
Brazil            I269*G410 S822                                    G410

Canada         I269*G419 S822 X599                          I269

England         I269*G419 S822                                    I269

Germany                                                                      G419

Sweden         I269*G419 S8220 X59                         I269

USA             I269*G419 S822 X59                            I269

2.
Brazil            I509/I259/C259                                     I259

Canada         I509/I259/C259                                     I259

England         I509/I259/C259                                     I259

Germany                                                                      I259

Sweden         I509/I259/C259                                     I259

USA              I509/I259/C259                                     I259

3.
Brazil            N19*I509 I259 E149                              E142

Canada         N19*I509 I259 E149                             N19

England         N19*I509/I259/E149                             N19

Germany                                                                     N19

Sweden        N19*I509 I259 E149                             N19

USA             N19*I509 I259 E149                             N19

4.
Brazil            I219/I499/E149*J459                             E149

Canada        I219/I499/E149*J459                              E149

England       I219/I499/E149*J448                               E149

Germany                                                                      E149

Sweden        I219/I499/E149*J448                             E146

USA            I219/I499/E149*J448                              E149

5.
Brazil           I509/I10/E149*I709                                 E149

Canada        I509/I10/E149*I709                                 E149

England        I509/I10/E149*I709                                 E149

Germany                                                                       E149

Sweden        I509/I10/E149*I709                                 E146

USA            I509/I10/E149*I709                                  E149

6.
Brazil           I259/I64/E119                                            E119

Canada        I259/I64/E119                                           E119

England        I259/I641/E119                                         E119

Germany                                                                        E149

Sweden       I259/I64/E119                                            E116

USA            I259/I64/E119                                            E119

7.
Brazil            E149 E142/I709 *Z897 I10 E142            I259

Canada         E142//I709 I259*I739 I10                       E142

England         E149/E142/I149/I709I259 *Y835 I10     E142

Germany                                                                        E147

Sweden         E149 E142/I709 I259 *Z897 I10            E142 or E147

USA            E149 E142//I709 I259*I10                       E142

8.
Brazil          I291/I251/E149                                         E149

Canada       I219/I251/ E149                                        E149

England       I219/I259/E149                                        E149

Germany                                                                      E149

Sweden       I219/I251/E149                                        E146

USA            I219/I251/E149                                       E149

9.

Brazil           I219/I251*E149                                       I219

Canada        I219/I251*E149                                      I219

England        I219/I259*E149                                      I219

Germany                                                                      I219

Sweden        I219/I251*E149                                     I219

USA            I219/I251*E149                                      I219


1.

England /Lin Shane/: We would accept this sequence and apply the General Principle to select I269 as the underlying cause.

Canada /Patricia Wood/: I applied the General Principle to select I269 as the tentative underlying cause of death. In the absence of any further modifications or linkages I selected I269 as the underlying cause of death.

Although I agree with everyone that these conditions, if reported on successive lines of Part I, would constitute an acceptable causal sequence, I do not see a way to make any modifications or linkages the way they are certified.

USA /Julia E Raynor/: We also would accept the sequence if reported in Part 1. But since pulmonary embolism is reported in Part 1 and other conditions in Part II, we would select pulmonary embolism by Rule 2 and would not apply Rule 3.

Brazil /Augusto Hasiak Santo/: Pulmonary embolism is accepted as due to tibia fracture and a fall may be assumed as resulting from status epilepticus.

Germany /Michael Schopen/: I would accept this as a sequence in part I:

I a) pulmonary embolism
  b) tibia fracture
  c) status epilepticus

and I would code status epilepticus as UC G41.9 I tend to accept it in part II, as well, applying the general principle (-- pulmonary embolism), rule 3 (-- tibia fracture) and again rule 3 (-- status epilepticus). How is your opinion?

Sweden /Lars Age Johansson/: We would certainly, like Augusto and Michael, accept the sequence if it had been reported in Part I. As the certificate stands, however, with no information on the sequence of events, or even if the fracture was recent or not, we would not apply Rule 3, but accept the pulmonary embolism as the underlying cause of death.

2.

England /Lin /: We agree with the rest of the group, and having consulted the 'highly improbable' list assigned C259 as the underlying cause.

Canada /Patricia /: I did a bit of reformatting because "due to" was written in on line a) and then I applied Rule 1 (based on the note in Volume 2, page 68, 4.2.2 Interpretation of "highly improbable", item (g)) to select I259 as the tentative underlying cause of death. In the absence of any further modifications or linkages I selected I259 as the underlying cause of death.

USA /Julia /: We would select I259, chronic ischemic heart disease based on "highly improbable" list, Volume 2, page 68, item g. Rule 1

Gemany /Michael /: According to the rules, we cannot accept carcinoma of pancreas as UC, as chronic ischemic heart disease is not among the acute or terminal circulatory diseases (pg. 68, 69). Do you agree?

Sweden /Lars Age /: I agree that ischaemic heart disease may not be due to a malignant neoplasm, but I would rather base that on item (g) on page 68. After all, the instructions and the list on p. 69 only specify which *acute* circulatory conditions we would accept as due to a malignant neoplasm, they do not say that any other sequence would not be permitted.

3.

England /Lin /: Since diabetes is entered in part 2 we would not assume a sequence and therefore select the renal failure as the underlying cause.

Canada /Patricia /: I applied the General Principle to select N19 as the tentative underlying cause of death. In the absence of any further modifications or linkages I selected N19 as the underlying cause of death.

USA /Julia /: We would select renal failure, N19 by Rule 2 and would not link with diabetes nor consider renal failure as a direct sequel of diabetes.

Germany /Michael /: I would code renal failure (N19) as UC, but some of our coders would link renal failure with diabetes mellitus and code E14.2 as UC. I would not, as it is in part II and we don't know whether renal failure is "due to" diabetes or not. How is your opinion?

Sweden /Lars Age /: I agree with Michael, it is quite possible that the renal failure was present before the diabetes developed, so without more information on the case than this, I would select the renal failure.

4.

England /Lin /: We agree with the comments so far, and would accept the certifier's intent that the diabetes contributed to this death. Applying the General Principle we would accept the sequence and underlying cause code to E149. Our coders would not have a problem with this.

Canada /Patricia /: Although specification of the diabetes as insulin-dependent or noninsulin-dependent would lead to different ICD-10 codes the lack of such specification simply means that E14- is the appropriate code. Similarly the lack of specification of duration of the diabetes should not influence the coding of it or the assessment of the acceptability of the causal relationships. The fact that the certifier recorded diabetes alone on the lowest used line of Part I should be an indication that he considered it to have contributed to the death.

I applied the General Principle, using the note in Volume 2, page 68, 4.2.2 Interpretation of "highly improbable", regarding acute and terminal circulatory conditions due to diabetes, to select E149 as the tentative underlying cause of death. In the absence of any further modifications or linkages I selected E149 as the underlying cause of death.

I, like Julia, am inclined to use the fourth-character subdivisions for E10-E14 when the diagnostic statement I am coding is indexed to them, or when some linkage provision is made.

USA /Julia/: We would accept the certifier's statement of sequence and code diabetes even though type of diabetes is not reported. We will code 4th digit 0-.8 only when the condition is indexed to these 4th digits or when the classification provides a linkage.

Germany /Michael /: I would accept the sequence in I and code E14.9 as UC (according to the rules). Our coders object that we do not know whether it is NIDDM or IDDM, whether diabetes was present just a few weeks before death or a few years, whether it contributed to death or not. They would code I21.9 as UC.

Sweden /Lars Age /: It is true that we do not know the type of the diabetes or the duration of the disease, but since it is an acceptable sequence reported in Part I, that should not affect the coding. As long as the sequence is not "highly improbable", as defined on pp. 67-68, we are to accept it (cf p. 35 in Vol 2: "... it should be borne in mind that the medical certifier's statement reflects an informed opinion about the conditions leading to death and about their interrelationships, and should not be disregarded lightly").

We have selected another subcategory of E14 than Brazil and Germany, please see our comment to certificate no. 8 on that.

5.

England /Lin /: Again our coders would have no problem using the General Principle to select E149 as the underlying cause.

Canada /Patricia /: I applied the General Principle to select E149 as the tentative underlying cause of death. In the absence of any further modifications or linkages I selected E149 as the underlying cause of death.

USA /Julia/: As in example 4 we will accept the sequence but will not link diabetes with the other conditions.

Germany /Michael /: Again, I would accept the sequence in I, coding E14.9 as UC. Again, many of our coders would not.

Sweden /Lars Age /: The same - we cannot say the the sequence is "highly improbable", consequently the ICD instructions give us no right to reject it.

6.

England /Lin /: General principle applied.

Brazil /Augusto /: I would ask you to correct a code that I have given for the acronym NIDDM. The correct code is E11.9, both as multiple and as underlying cause, instead of E14.9. I must apologise for that.

Canada /Patricia /: I applied the General Principle, because the condition entered alone on the lowest used line of Part I can give rise to each of the conditions entered above it, to select E119 as the tentative underlying cause of death. In the absence of any further modifications or linkages I selected E119 as the underlying cause of death.

USA /Julia/: We would select NIDDM, E119 using General Principle and the explanation in Volume 2, page 35, example 5. We interpret the instruction as meaning it is not necessary for the conditions on each line to be causally related when the condition entered alone on the lowest used line can give rise to all the conditions entered above it. Consider the first sequence as chronic ischemic heart disease due to diabetes and the second sequence as stroke due to diabetes.

Germany /Michael /: I would apply rule 2 first, selecting CIHD, then rule 3 and select NIDDM as UC (E14.9). Many of our coders, however, would code I25.9 as UC.

Sweden /Lars Age/: Since the conditions have all been reported in Part I, I think we can use the General principle and select diabetes. The General principle does not require that all conditions entered above the condition on the lowest used line follow in sequential order, only that the condition on the lowest used line can explain (=is an acceptable cause of) all conditions entered above it, cf. Example 5 on p. 35 in Volume 2.

7.

England /Lin /: We have coded 'late diabetes syndrome' to E149 and 'diabetes with diabetic nephropathy' to E142, selecting this as the underlying cause .

Canada /Patricia /: I did not assign a code to "late diabetes syndrome" because I don't know what it is (!) and I was hoping that coding "diabetes with diabetic nephropathy" to E142 would cover both diagnostic statements. I applied Rule 2 (using Volume 2, 4.2.2 Interpretation of "highly improbable", page 68, item (d)) to select E142 as the tentative underlying cause of death. I see that others have made an assumption that the lower leg amputation was due to peripheral vascular disease and then linked the peripheral vascular disease (I739) to the diabetes with diabetic nephropathy (E142) to yield diabetes with multiple complications (E147). I have no objection to this, but I do wonder if there are any instructions or guidelines to support this approach?

USA /Julia/: We code diabetes syndrome to E149, although I do not think the term is frequently used in the U.S. and I am not sure what it means either. It seems that the U.C. should be E147, diabetes with multiple complications, linking renal complications, E142 in Pt 1 with implied peripheral circulatory disease requiring amputation of both lower legs in Pt 2. We will link diabetes with different types of complications (E140-E145) to E147, therefore, preferring diabetes with multiple complications over each specified type of complication. Of course, we have the specified types of complications in our multiple cause data.

Germany /Michael /: Here, we agreed on diabetes as UC (rule 2), however, we could not agree on the fourth character. For me, it's E14.7 (multiple complications: nephropathy, peripheral vascular complications). The coders selected E14.2 with the reason that it is "more specific" to code the first mentioned complication than to code E14.7. I can't find anything in the rules related to specificity of codes.

Sweden /Lars Age /: I'm not quite sure about this one, since the term "late diabetes syndrome" is seldom used in our country and I am not quite sure of what it stands for. If it denotes "multiple complications of diabetes", then the underlying cause should be E14.7, I believe. As I read Rule D, specificity, you can apply it only if you first select something classifiable to an "unspecified" category, and then find that there is a more precise description of the same condition somewhere else on the certificate. I do not think you can say that "diabetes with multiple complications" is a less informative term than "diabetes with renal complications", rather the reverse - if you select E14.2, you suppress the fact that the patient had other complications as well.

8.

*Germany /Michael /: I guess the update you mention refers to

Disease
- coronary
- - artery I25.1

which has been added to the index. Coronary heart disease is consistently indexed to I25.9. When I prepared the German index, I corrected that to I25.1, but this year I had to withdraw my "correction". I had to learn that coronary heart disease only means "oxygene supply lower than oxygene need", it does not say anything about the etiology. Although in most cases ( 90%) the etiology is coronary sclerosis, there are other reasons for CHD, e.g. anemia, hypoxemia, stenosis of aortic valve, certain cardiomyopathies. Thus, if we don't know the etiology (in coronary _artery_ disease we do know it), we have to index I25.9.

It would be interesting to know if other countries changed the code for CHD from I25.9 to I25.1 (see the multiple cause answers to Q8), as this code indeed is more specific for at least 90% of the certificates.

[The addition of Disease - coronary - artery was new for 1997, but I think the Index change of Disease - heart - coronary to I25.1 was distributed in 1996. Unfortunately I do not have that year's updates available at the moment. However, the term "coronary disease" is listed under I25.1 in Volume 1, so perhaps the ICD presumes that the cause of an CHD is coronary arteriosclerosis, even if it has not been stated. I'll try to find out more about this "correction". /Lars Age]

England /Lin /: We had no problem assigning E149 as the underlying cause. We did not consider CHD as a complication, but as a consequence of the diabetes. However we should like to ask the group how they arrived at the multicause code of I251 for 'Coronary Heart Disease'? This is indexed as Disease - - Heart - - Coronary = I259 (although we realise that I251 may seem more specific).

[This is one of the corrections to Volume 3 we have received. Unfortunately, I do not have a copy of that document available at the moment, so I cannot say when it was distributed. /Lars Age]

Canada /Patricia /: I applied the General Principle to select E149 as the tentative underlying cause of death. In the absence of any further modifications or linkages I selected E149 as the underlying cause of death.

I agree that the absence of "coronary heart disease" on a list of "acute or terminal circulatory diseases" is not unexpected and I did not take this as an indication of an unacceptable causal relationship.

Regarding the assignment of the fourth digit to the diabetes code, in this case I agree with Julia. I would not consider chronic ischemic heart disease due to diabetes as a "complication" of diabetes. I am inclined to apply .0-.8 to the diabetes codes only when indicated in the index or in the linkage notes at the back of Volume 2. This is the reason I was looking for some written indication for coding the peripheral vascular disease as a complication of the diabetes in Q7.

USA /Julia/: We would accept the sequence and code the UC E149. I agree with Lars that the list of acute or terminal circulatory diseases in Volume 2, pages 68-69 is not an all inclusive list of circulatory conditions that can be accepted as due to diabetes. We will consider conditions due to diabetes as "consequences of" rather than "complications". The exception is when the condition due to diabetes is indexed as "diabetic" or "with diabetes". We will link those conditions together and code diabetes with appropriate 4th digit complication..

Example  a) dermatitis L309
               b) diabetes E149

We would select diabetes and link with dermatitis for UC E146 since dermatitis is indexed "diabetic".

Germany /Michael /: I would apply the General Principle and code E14.9. The coders stated that coronary heart disease is not among the acute and terminal circulatory diseases and thus coronary heart disease "due to" diabetes cannot be accepted. Those, who accepted the sequence, coded E14.5 (peripheral vascular complications), which I think is not suitable, or E14.6 (other complications), which I think is not suitable either, as CHD is not a "complication" of diabetes but just a consequence.

Sweden /Lars Age /: Well, the list covers *acute* circulatory diseases, so you would not expect a chronic disease like CHD to appear on it anyway. So, that a condition is not on the list of acute or terminal circulatory diseases does not necessarily imply that it might not be due to a malignant neoplasm or diabetes (neither metastases or diabetic coma are on the list, but I think most of us would accept them as due to a neoplasm, or diabetes respectively). As for the fourth character, we have had some (quite lively) discussions on that here in Sweden. Finally we agreed that, since the distinction between "complication" in the classical sense and "consequence" would be very difficult to maintain, it would be best to code all cases of diabetes with reported complications or consequences to "diabetes with complication" (E1X.0-.7). I suppose there might be different opinions on that...

9.

England /Lin /: We agree. No application of rule C.

Canada /Patricia/: I applied the General Principle to select I251as the tentative underlying cause of death. Then I applied Rule C (based on the linkage in Volume 2, 4.1.11 Notes for use in underlying cause mortality coding, page 55) to reselect I219 as the tentative underlying cause of death. In the absence of any further modifications or linkages I selected I219 as the underlying cause of death. I did not consider either of the conditions in Part I to be "obviously a direct consequence of" diabetes so I did not apply Rule 3.

USA /Julia/: I agree with Lars and Michael. General principle, rule c and not apply rule 3.

Germany /Michael /: In this certificate, I would select CHD (general principle), link with AMI (rule C) and code I21.9 as UC. I would not apply rule 3 to diabetes in part II. Do you agree?

Sweden /Lars Age /: I agree. There is not enough information on the diabetes to apply Rule 3 here. May I add, as a general comment to the diabetes certificates, that the coding is supposed to reflect the certifying physician's opinion on the cause of death, not the coder's... But it is very tempting to set out to correct the doctors.
 
 
 

1-XII-1997 Q10 Suicide due to disease

(Rule GP / (UC Chapter XX)

[Gerard Pavillon's question was on suicide reported as due to disease - again we all seem to agree that such cases should be coded as suicides:]

In France, and I think in most of the countries, we use to select suicide as the underlying cause. With ICD10, vol 2 mentions that "any accident (V01-X59) reported as due to any other cause outside this chapter except epilepsy (G40-G41)" is an highly improbable sequence (Vol 2, p68, note m).

This allows suicide (X60-X84) to be due to a cause outside chapter XX. For instance, in the following death certificate:

I a) hanging
b) suicide
c) Recurrent depressive disorder

the sequence is consistent from the medical point of view and is now allowed by ICD10 rules. This could lead some countries to select the Depressive disorder as the underlying cause. However some other countries may continue to select suicide because they do not want to modify the trends and/or because they think that a suicide ought to appear as the underlying cause.

This is more an epidemiological issue than an usual coding problem. I don't know what is the right decision, but I think that there should be an international agreement on the final decision with a clear argumentation. That is why I submit this case to the discussion of the group.


[Comments:]

*USA /Julia E Raynor/: For the 10th Revision, as in the 9th, the U.S. will code this certificate to suicide. We agree with Lars and will regard instruction (m) as incomplete. We don't interpret the "highly improbable" list as being all inclusive but follow the instruction on page 68 that states "The above list does not cover all "highly improbable" sequences". I was pleased to see this addition to the "highly improbable" list since it documents how we have treated externals due to diseases in the past. Clarification on how to interpret instruction (m) would be welcome.

England /Lin Shane/: In England this death would have been certified by a coroner, and we would code the underlying cause as Suicide.

Brazil /Augusto Hasiak Santo/: I agree that the clarification of how to assume external causes in coding the underlying cause is an urgent matter. In Brazil, external causes are coded as during the use of the Ninth Revision, i.e., an external cause is not accepted as due to a natural one. Comprehensive instructions about the coding of external causes are required for a long time.

Canada /Patricia Wood/: This most certainly is a situation requiring immediate international clarification. I am sure that no one wants to see suicide statistics trends altered by the implementation of a new classification. Can you imagine the headlines; "International decrease in suicides in both sexes and all age groups!" What a epidemiological nightmare. Although I have not discussed this with any of our analysts I am sure that they will be alarmed to hear of this situation and its implications. I am interested to read Julia's response to this question and to see what the automated mortality classification system will do with these deaths.

Sweden /Lars Age Johansson/: This is indeed a candidate for clarification, and a rather urgent one too. In Sweden, we have decided to regard the instruction in note (m) as incomplete, and to select the suicide as the underlying cause in a case like this one. We made this decision since the suicide rate is one of the most important statistics derived from the mortality registers. In my report on the need for clarification of the coding instructions to this year's Centre Heads Meeting, I also suggested an update to effect that suicide would be selected, and not the depression.
 
 
 
 
 

1-XII-1997 Q11-12 Triple vessel disease

(UC Chapter IX)

[Coding from Lin Shane:]

Question 11

1a (Triple cardiac vessel disease) - 4 days
    Cardiac arrest
1b triple vessel disease

Question 12

1a Acute myocardial infarction
1b triple vessel disease
1c hypertension
2 dementia


[Suggested coding:]
 

                 Multiple causes                Underlying cause
11.
Brazil         4140 4275/4140             4140

Canada      4140 4275/4140             4140

*England    4149 4275/4149             4149

Sweden      4140 4275/4140             4140

USA          4140 4275/4140             4140

12.

Brazil         410/4140/4019*2989      410

Canada      410/4140/4019*2989       410

*England    410/4149/4019*2989       410

Sweden      410/4140/4019*2989      410

USA          410/4140/4019*2989      410


[Comments:]

Brazil /Augusto Hasiak Santo/: I agree with Julia and Lars Age: Question 11:

General Rule. Question 12: General Rule + Rule 7 (conflict resolution) + Rule 7

Canada /Patricia Wood/: We have a classification decision to code triple vessel (cardiac) disease to ICD-9 code 4140. [For Q11,] I applied the general rule to select 4140 as the tentative underlying cause of death. In the absence of any modifications or linkages I selected 4140 as the underlying cause of death.

[For Q12,] I applied the general rule to select 4019 as the tentative underlying cause of death. I applied Rule 7 to select 4140 as the tentative underlying cause of death because there was a conflict in linkage (with 4019 linking to 4140 and 410) which I solved by linking with 4140 which would have been selected if 4109 had not been reported. I applied Rule 7 again to select 410 as the tentative underlying cause of death. In the absence of any further modifications or linkages I selected 410 as the underlying cause of death.

USA /Julia E Raynor/: We agree with Lars. Triple vessel or triple cardiac vessel disease, 4140.

Sweden /Lars Age Johansson/: Triple vessel disease = coronary disease that affects all three main coronary arteries. (I hope my ICD-9 coding has not become too rusty!)
 
 
 
 

12-XII-1997 Q1 Gastroenteritis: infectious or not infectious?

(UC Chapter I, XI)

[The question was from Norway, new comments England:]

We are discussing the notes to code A09 and K52.9. We consider our country, Norway to be a country where the conditions can be presumed to be of noninfectious condition. But even if we 'feel' that gastroenteritis with a short duration belong in the A09 (probably infectious origin), it is a K52.9 as long as it is not specified as infectious. What is your opinion about that?

Woman, 78 years living in a nursing home

1  a) Gastroenteritis 1 week
II     Senile dementia 6 years


[Suggested coding:]

                  Multiple causes       Underlying case

Brazil                                        A09

Canada                                     A09

*England K529*F03                 K529

Sweden                                    K529

USA                                         K529


*England /Lin Shane/: Our ICD9 coders would not code this case to infectious gastroenteritis. We would not use the duration to assume infectious gastroenteritis.

Australia /Maryann Wood/: You were correct in assuming that we have undertaken investigation into presumed versus non-infectious gastroenteritis. I do not have figures but the opinion appears to be that in the majority of cases the gastroenteritis would be infectious. This is particularly the case in certain areas (e.g. Aboriginal reserves). As a result a query process is undertaken to determine if the gastroenteritis is of infectious origin.

Finland / Martti Virtanen/: Correct me if i am wrong but the main book (part I) says very clearly A09 'Diarrhoea and gastroenteritis of presumed infectious origin' and at K52.9 that a disease with probably infectious origin should be coded to A09. That means to me that in doubt one should code A09.

Sweden /Lars Age Johansson/: I have read the instructions in the same way as Martti: if the physician believes that the gastroenteritis is infectious, and says so on the certificate, we are to code it to A09. As far as I can see, that means that even in "K52.9 countries" (countries where you would presume that an unspecified gastroenteritis is not infectious) the code A09 is sometimes correct, namely for conditions which have been specified as infectious, but without any information on the infectious organism. And that makes automated validity checks a bit complicated: you have to check the exact wording of the certificate before you can decide if the correct code is K52.9 or A09. It seems wise to do like Australia and query these cases.

Brazil /Augusto Hasiak Santo/: In Brazil, the underlying cause for the death certificate would be A09, since the note about assuming diarrhoea and gastroenteritis as noninfectious is not applied.

I would also to comment a related problem. During the Ninth Revision, infectious colitis, enteritis and gastroenteritis (009.0) and infectious diarrhoea (009.2) were considered as highly improbable infectious diseases and were not accepted as due to other diseases. In the Tenth Revision, these affections receive the code A09 and are considered as exceptions of highly improbable infectious and parasitic diseases. Accordingly, using the Tenth Revision, an infectious enteritis, so stated, will be accepted as due to malnutrition, a typical Brazilian death certificate. The point I would like to raise is that, in my opinion, the code that in the Tenth Revision is more adequate for infectious enteritis is A08.5, instead of A09. This code was being used by us before the publication of the Index (Volume III) of ICD.

Canada /Patricia Wood/: As so often happens, this question seems easier than it actually is. Bearing in mind that we have not yet implemented ICD-10 in Canada, we assume any term listed in 0091 and 0093 without further specification to be of noninfectious origin and we code them to 558. In other words, we will only code terms listed in 0091 and 0093 to those codes if they are specified as infectious. Terms in 0090 and 0092 are coded as indexed. In ICD-10 A09 is not subdivided like 009 is in ICD-9. This leaves me confused. Reading the note at A09 and taking it literally (as I am wont to do!) I suppose that I will code ALL terms listed in A09 to K529 unless they are specified as infectious. This will represent a change from ICD-9 coding and I am curious to read what others have to say in response to this question.

USA /Julia E Raynor/: The U.S. also considers gastroenteritis to be noninfectious. We would not use the duration to code infectious gastroenteritis.

Sweden /Lars Age /: We would do like the US - follow the instruction in the ICD and code this one to K529. I agree with my Norwegian colleagues, however, that this is probably a case of infectious gastroenteritis. If I remember correctly, the Australians also found that most cases of gastroenteritis were indeed infectious, even if they had not been specified as such on the certificate. Any suggestions for how to go with this?

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