Instructions for Classification of Underlying and Multiple Causes of Death – Section IV – 2018

SECTION IV – CLASSIFICATION OF CERTAIN ICD CATEGORIES

A. Infrequent and Rare Causes of Death in the United States

The ICD contains conditions which are infrequent causes of death in the United States. If one of these conditions (see Appendix A) is reported as a cause of death, the diagnosis should have been confirmed by the certifier or the State Health Officer when it was first reported. A notation of confirmation should be recorded on the copy of the certificate sent to NCHS. In the absence of this notation, the NCHS coder will code the disease as stated; the State Health Officer will be contacted at the time of reconciliation of rejected data record by control cycle to confirm the accuracy of the certification.

B. Coding Specific Categories

The following are the international linkages and notes with expansions and additions concerning the selection and modification of conditions classifiable to certain categories. They are listed in tabular order. Notes dealing with linkages appear at the category from which the combination is EXCLUDED. Therefore, reference should be made to the category or code within parentheses before making the final code assignment. For a more complete listing, refer to NCHS Instruction Manual, Part 2c, ICD-10 ACME Decision Tables for Classifying the Underlying Causes of Death, 2018.

The following notes often indicate that if the provisionally selected code, as indicated in the left-hand column, is present with one of the conditions listed below it, the code to be used is the one shown in bold type. There are two types of combination:

“with mention of” means that the other condition may appear anywhere on the certificate;

“when reported as the originating antecedent cause of” means that the other condition must appear in a correct causal relationship or be otherwise indicated as being “due to” the originating antecedent cause.

A00-B99 Certain infectious and parasitic diseases

Except for human immunodeficiency virus [HIV] disease (B20-B24), when reported as the originating antecedent cause of a malignant neoplasm, code C00-C97.

A15.- Respiratory tuberculosis, bacteriologically and histologically confirmed

Not to be used for underlying cause mortality coding.

A16.0 Tuberculosis of lung, bacteriologically and histologically negative

A16.1 Tuberculosis of lung, bacteriological and histological examination not done

Not to be used for underlying cause mortality coding.

A16.2-.9 Respiratory tuberculosis, not confirmed bacteriologically or histologically

with mention of:

J60-J64 (Pneumoconiosis), code J65

A17.- Tuberculosis of nervous system

A18.- Tuberculosis of other organs

with mention of:

A16.- (Respiratory tuberculosis), code A16.-, unless reported as the originating antecedent cause of and with a specified duration exceeding that of the condition in A16.-

A22.- Anthrax

Not to be used as the underlying cause if reported with accident, homicide, suicide anywhere on the record, could not be determined in the Manner of Death box only, or designated as an act of terrorism. Code accident (X58), homicide (Y08), suicide (X83), could not be determined (Y33), or terrorism (U016)

A35 Other tetanus

INCLUDES: accidents with mention of tetanus

Codes for Record

I (a) Tetanus A35

(b) Contusion, foot S903

II Accident: Fall W19

Code to tetanus (A35).

Codes for Record

I (a) Tetanus A35

(b) Fracture of hip S720

II X590

Code to tetanus (A35).

A39.2 Acute meningococcemia

A39.3 Chronic meningococcemia

A39.4 Meningococcemia, unspecified

with mention of:

A39.0 (Meningococcal meningitis), code A39.0

A39.1 (Waterhouse-Friderichsen syndrome), code A39.1

A40.- Streptococcal septicemia

A41.- Other septicemia

A46 Erysipelas

Code to these diseases when they follow a superficial injury (any condition in S00, S10, S20, S30, S40, S50, S60, S70, S80, S90, T00, T09.0, T11.0), or first degree burn; when they follow a more serious injury, code to the external cause of the injury.

Codes for Record

I (a) Septicemia A419

(b) Contusion, foot S903

II Accident: Fall W19

Code to septicemia, unspecified (A419).

Codes for Record

I (a) Septicemia A419

(b) Fracture of hip S720

II X590

Code to external event causing fracture of hip (X590).

A49.- Bacterial infection of unspecified site

This category INCLUDES infection by bacterial organisms unspecified as to location or disease and not classified elsewhere. Specific disease conditions indicated to have been bacterial in origin are classified to the specified disease rather than to A49. Examples: staphylococcal enteritis is classified to A04.8 and pseudomonas pneumonia is classified to J15.1.

A80.9 Acute poliomyelitis, unspecified

This category INCLUDES poliomyelitis specified as acute unless there is clear indication that death occurred more than one year after the onset of poliomyelitis. It also INCLUDES poliomyelitis not specified as acute if it is clearly indicated that death occurred less than one year after onset of the poliomyelitis. Otherwise, poliomyelitis should be assigned to Sequela of poliomyelitis (B91).

B16 Acute hepatitis B

B17 Other acute viral hepatitis

when reported as the originating antecedent cause of:

K72.1 (Chronic hepatic failure), code B18.-

K74.0-K74.2, K74.4-K74.6 (Fibrosis and cirrhosis of liver), code B18.-

B20-B24 Human immunodeficiency virus [HIV] disease

Modes of dying, ill-defined and trivial conditions reported as complications of HIV infection should not be linked to categories in B20-B24 and R75, unless there is a specific entry in Volume 3 to that effect.

Conditions classifiable to two or more subcategories of the same category should be coded to the .7 subcategory of the relevant category (B20 or B21).

If a condition classifiable to categories A00-B19, B25-B49, B58-B64, B99, to which sequela rules apply, is mentioned on the record with HIV (B200-B24, R75), use the active phase of the condition in the application of selection and modification rules.

When a blood transfusion is given as treatment for any condition (e.g. a hematological disorder) and an infected blood supply results in a HIV infection, code the HIV as the underlying cause and not the treated condition.

B22.7 HIV disease with multiple diseases classified elsewhere

This subcategory should be used when conditions classifiable to two or more categories from B20-B22 are listed on the certificate.

B34 Viral infection of unspecified site

This category INCLUDES viral infections unspecified as to location or disease and not classified elsewhere. Specific disease conditions indicated to have been viral in origin are classified to the specific disease rather than to B34. Examples: adenovirus enteritis is classified to A082, and acute viral bronchitis is classified to J208.

B95-B97 Bacterial, viral and other infectious agents

Not to be used for underlying cause mortality coding.

C00-D48 Neoplasms

Separate categories are provided for coding malignant primary and secondary neoplasms (C00-C96), Malignant neoplasms of independent (primary) multiple sites (C97), carcinoma in situ (D00-D09), benign neoplasms (D10-D36), and neoplasms of uncertain or unknown behavior (D37-D48). Categories and subcategories within these groups identify sites and/or morphological types.

Morphology describes the type and structure of cells or tissues (histology) as seen under the microscope and the behavior of neoplasms. The ICD classification of neoplasms consists of several major morphological groups (types) including the following:

Carcinomas including squamous cell carcinoma and adenocarcinoma

Sarcomas and other soft tissue tumors including mesotheliomas

Lymphomas including Hodgkin lymphoma and non-Hodgkin lymphoma

Site-specific types (types that indicate the site of the primary neoplasm)

Leukemias

Other specified morphological groups

The morphological types of neoplasms are listed following Chapter XX in Volume 1. They are also described in Volume 3 (the Alphabetical Index) with their morphology code and with an indication as to the coding by site. The morphological code numbers consist of five characters: the first four identify the histological type of the neoplasm and the fifth, following a slash, indicates its behavior. These morphological codes (M codes) are not used by NCHS for coding purposes.

The behavior of a neoplasm is an indication of how it will act. The following terms describe the behavior of neoplasms:

Malignant, primary site (capable of rapid growth C00-C76,
and of spreading to nearby and distant sites) C80-C97

Malignant secondary (spread from another C77-C79
site; metastasis)

In-situ (confined to one site) D00-D09

Benign (non-malignant) D10-D36

Uncertain or unknown behavior D37-D48
(undetermined whether benign or malignant)

Morphology, behavior, and site must all be considered when coding neoplasms. Always look up the morphological type in the Alphabetical Index before referring to the listing under “Neoplasm” for the site. This may take the form of a reference to the appropriate column in the “Neoplasm” listing in the Index when the morphological type could occur in several organs. For example:

Adenoma, villous (M8261/1) – see Neoplasm, uncertain behavior

Or to a particular part of that listing when the morphological type originates in a particular type of tissue. For example:

Fibromyxoma (M8811/0) – see Neoplasm, connective tissue, benign.

The Index may give the code for the site assumed to be most likely when no site is reported in a morphological type. For example:

Adenocarcinoma

– pseudomucinous (M8470/3)

– – specified site – see Neoplasm, malignant

– – unspecified site C56

Or the Index may give a code to be used regardless of the reported site when the vast majority of neoplasms of that particular morphological type occur in a particular site. For example:

Nephroma (M8960/3) C64

Unless it is specifically indexed, code a morphological term ending in “osis” in the same way as the tumor name to which “osis” has been added is coded. For example, code neuroblastomatosis in the same way as neuroblastoma. However, do not code hemangiomatosis which is specifically indexed to a different category in the same way as hemangioma.

All combinations of the order of prefixes in compound morphological terms are not indexed. For example, the term “chondrofibrosarcoma” does not appear in the Index, but “fibrochondrosarcoma” does. Since the two terms have the same prefixes (in a different order), code the chondrofibrosarcoma the same as fibrochondrosarcoma.

A. Malignant neoplasms

When a malignant neoplasm is considered to be the underlying cause of death, it is most important to determine the primary site. Morphology and behavior should also be taken into consideration. Cancer is a generic term and may be used for any morphological group, although it is rarely applied to malignant neoplasms of lymphatic, hematopoietic and related tissues. Carcinoma is sometimes used incorrectly as a synonym for cancer. Some death certificates may be ambiguous if there was doubt about the primary site or imprecision in drafting the certificate. In these circumstances, if possible, the certifier should be asked to give clarification.

The categories that have been provided for the classification of malignant neoplasms distinguish between those that are stated or presumed to be primary (originate in) of the particular site or types of tissue involved, those that are stated or presumed to be secondary (deposits, metastasis, or spread from a primary elsewhere) of specified sites, and malignant neoplasms without specification of site.

These categories are the following:

C00-C75 Malignant neoplasms, stated or presumed to be primary, of specified sites and different types of tissue, except lymphoid, hematopoietic, and related tissue

C76 Malignant neoplasms of other and ill-defined sites

C77-C79 Malignant secondary neoplasm, stated or presumed to be spread from another site, metastases of sites, regardless of morphological type of neoplasm

C80 Malignant neoplasm of unspecified site (primary) (secondary)

C81-C96 Malignant neoplasms, stated or presumed to be primary, of lymphoid, hematopoietic, and related tissue

C97 Malignant neoplasms of independent (primary) multiple sites

In order to determine the appropriate code for each reported neoplasm, a number of factors must be taken into account including the morphological type of neoplasm and qualifying terms. Assign malignant neoplasms to the appropriate category for the morphological type of neoplasm, e.g. to the code shown in the Index for the reported term. Morphological types of neoplasm include categories C40-C41, C43, C44, C45, C46, C47, C49, C70-C72, and C80. Specific morphological types include:

C40-C41 Malignant neoplasm of bone and articular cartilage of other and unspecified sites

Osteosarcoma

Osteochondrosarcoma

Osteofibrosarcoma

Any neoplasm cross-referenced as “See also Neoplasm, bone, malignant”

Code for Record

I (a) Osteosarcoma of leg C402

Code to osteosarcoma leg (C402). Code the morphological type “Osteosarcoma” to Neoplasm, bone, malignant.

C43 Malignant melanoma of skin

Melanosarcoma

Melanoblastoma

Any neoplasm cross-referenced as “See also Melanoma”

Code for Record

I (a) Melanoma C439

Code to melanoma, (C439) unspecified site as indexed.

Code for Record

I (a) Melanoma of arm C436

Code to melanoma of arm (C436) as indexed under site classification.

Code for Record

I (a) Melanoma of stomach C169

Code to melanoma of stomach (C169). Since stomach is not found under Melanoma in the Index, the term should be coded by site under Neoplasm, malignant, stomach.

C44 Other malignant neoplasm of skin

Basal cell carcinoma

Sebaceous cell carcinoma

Any neoplasm cross-referenced as “See also Neoplasm, skin, malignant”

Code for Record

I (a) Sebaceous cell carcinoma nose C443

Code to sebaceous cell carcinoma nose (C443). Code the morphological type “Sebaceous cell carcinoma” to Neoplasm, skin, malignant.

C49 Malignant neoplasm of other connective and soft tissue

Liposarcoma

Rhabdomyosarcoma

Any neoplasm cross-referenced as “See also Neoplasm, connective tissue, malignant”

Code for Record

I (a) Rhabdomyosarcoma abdomen C494

Code to rhabdomyosarcoma abdomen (C494). Code the morphological type “Rhabdomyosarcoma” to Neoplasm, connective tissue, malignant.

Code for Record

I (a) Sarcoma pancreas C259

Code to sarcoma pancreas (C259). Code the morphological type “Sarcoma” to Neoplasm, connective tissue, malignant. Refer to the “Note” under Neoplasm, connective tissue, malignant, concerning sites which do not appear on this list.

Code for Record

I (a) Angiosarcoma of liver C223

Code angiosarcoma of liver as indexed.

Code for Record

I (a) Kaposi sarcoma of lung C467

Code Kaposi sarcoma of lung to Kaposi’s, sarcoma, specified site (C467).

C80 Malignant neoplasm without specification of site

Cancer

Carcinoma

Malignancy

Malignant tumor or neoplasm

Any neoplasm cross-referenced as “See also Neoplasm, malignant”

Code for Record

I (a) Carcinoma of stomach C169

Code to carcinoma of stomach (C169) as indexed.

C81-C96 Malignant neoplasms of lymphoid, hematopoietic and related tissue

Leukemia

Lymphoma

Code for Record

I (a) Lymphoma of brain C859

Code to lymphoma NOS (C859). Neoplasms in C81-C96 are coded by morphological type and not by site.

B. Neoplasm stated to be secondary

Categories C77-C79 include secondary neoplasms of specified sites regardless of the morphological type of the neoplasm. The Index contains a listing of secondary neoplasms of specified sites under “Neoplasm.” If a secondary neoplasm of specified site is reported, code to the morphological type, unless it is a C80 morphological type. If the morphological type is C80, code to the secondary neoplasm.

Code for Record

I (a) Secondary carcinoma of intestine C785

Code to secondary carcinoma of intestine (C785).

Codes for Record

I (a) Secondary melanoma of lung C439 C780

Code to melanoma of unspecified site (C439).

C. Malignant neoplasms with primary site indicated

If a particular site is indicated as primary, it should be selected, regardless of the position on the certificate or whether in Part I or Part II. If the primary site is stated to be unknown, see Section H. The primary site may be indicated in one of the following ways:

Two or more sites with the same morphology are reported and one site is specified as primary in either Part I or Part II.

Codes for Record

I (a) Carcinoma of bladder C791

II Primary in kidney C64

Code to malignant neoplasm of kidney (C64).

The specification of other sites as “secondary,” “metastases,” “metastasis,”

“spread” or a statement of “metastasis NOS” or “metastases NOS.”

Codes for Record

I (a) Carcinoma of breast C509

(b) Secondaries in brain C793

Code to malignant neoplasm of breast (C509), since another site is specified as secondary.

Morphology indicates a primary malignant neoplasm.

If a morphological type implies a primary site, such as hepatoma, consider this as if the word “primary” had been included.

Codes for Record

I (a) Metastatic carcinoma C80

(b) Pseudomucinous adenocarcinoma C56

Code to malignant neoplasm of ovary (C56), since pseudomucinous adenocarcinoma of unspecified site is assigned to the ovary in the Alphabetical Index.

If two or more primary sites or morphologies are indicated, these should be coded according to Sections D, E and G.

D. Independent (primary) multiple sites (C97)

The presence of more than one primary neoplasm could be indicated in one of the following ways:

mention of two different anatomical sites
two distinct morphological types (e.g. hypernephroma and intraductal carcinoma)
by a mix of a morphological type that implies a specific site, plus a second site

It is highly unlikely that one primary would be due to another primary malignant neoplasm except for a group of malignant neoplasms of lymphoid, hematopoietic, and related tissue (C81 – C96), within which, one form of malignancy may terminate in another (e.g. leukemia may follow non-Hodgkin lymphoma).

If two or more sites mentioned in Part I are in the same organ system, see Section E. If the sites are not in the same organ system and there is no indication that any is primary or secondary, code to malignant neoplasms of independent (primary) multiple sites (C97), unless all are classifiable to C81-C96, or one of the sites mentioned is a common site of metastases or the lung (see Section G).

Codes for Record

I (a) Cancer of stomach 3 months C169

(b) Cancer of breast 1 year C509

Code to malignant neoplasms of independent (primary) multiple sites (C97), since two different anatomical sites are mentioned and it is unlikely that one primary malignant neoplasm would be due to another.

Codes for Record

I (a) Hodgkin disease C819

(b) Carcinoma of bladder C679

Code to malignant neoplasms of independent (primary) multiple sites (C97), since two distinct morphological types are mentioned.

Codes for Record

I (a) Acute lymphocytic leukemia C910

(b) Non-Hodgkin lymphoma C859

Code to non-Hodgkin lymphoma (C859), since both are classifiable to C81-C96 and the sequence is acceptable.

Codes for Record

I (a) Leukemia C959

(b) Non-Hodgkin lymphoma C859

Code to malignant neoplasms of independent (primary) multiple sites (C97), since, although two of the neoplasms are classifiable to C81-C96, there is mention of another morphology.

Codes for Record

I (a) Leukemia C959

II Carcinoma of breast C509

Code to leukemia (C959) because the carcinoma of breast is in Part II. When dealing with multiple sites, only sites in Part I of the certificate should be considered (see Section E).

E. Multiple sites

When dealing with multiple sites, generally only sites reported together in Part I or together in Part II of the certificate should be considered except for linkages provided for in the Classification.

If malignant neoplasms of more than one site are entered on the certificate, the site listed as primary should be selected. If there is no indication whether primary or secondary, see Sections C, D and G.

More than one neoplasm of lymphoid, hematopoietic or related tissue

If two or more morphological types of malignant neoplasm occur in lymphoid, hematopoietic or related tissue (C81-C96), code according to the sequence given since these neoplasms sometimes terminate as another entity within C81-C96. Acute exacerbation of, or blastic crisis (acute) in, chronic leukemia should be coded to the chronic form.

Codes for Record

I (a) Acute lymphocytic leukemia C910

(b) Non-Hodgkin lymphoma C859

Code to non-Hodgkin lymphoma (C859).

Codes for Record

I (a) Acute and chronic lymphocytic leukemia C910, C911

Code to chronic lymphocytic leukemia (C911).

Multiple sites in the same organ/organ system

Malignant neoplasm categories providing for overlapping sites designated by .8 are not used unless a site is specifically indexed to one of these categories, e.g. anorectum cancer.

If the sites mentioned are in the same organ/organ system .9 subcategories should be used. This applies when the certificate describes the sites as one site “and” another or if the sites are mentioned on separate lines. If one or more of the sites reported is a common site of metastases, see Section G.

If there is mention of two subsites in the same organ, code to the .9 subcategory of that three-character category.

Codes for Record

I (a) Carcinoma of descending colon and sigmoid C186 C187

Code to malignant neoplasm of colon (C189) since both sites are subsites of the same organ.

Codes for Record

I (a) Carcinoma of head of pancreas C250

(b) Carcinoma of tail of pancreas C252

Code to malignant neoplasm of pancreas, unspecified (C259) since both sites are subsites of the same organ.

If two or more sites are mentioned and all are in the same organ system, code to the .9 subcategory of that organ system, as in the following list:

C150-C269             Digestive system
C300-C399             Respiratory system
C400-C419             Bone and articular cartilage of limbs, other and unspecified sites
C490-C499             Connective and soft tissue
C510-C579             Female genital organ
C600-C639             Male genital organ
C64-C689               Urinary organ
C700-C729             Central nervous system
C73-C759               Thyroid and other endocrine glands

Codes for Record

I (a) Pulmonary embolism I269

(b) Cancer of stomach C169

Code to ill-defined sites within the digestive system (C269). Stomach and gallbladder are in the same organ system and reported together in the same part.

Codes for Record

I (a) Carcinoma of vagina and cervix C52 C539

Code to malignant neoplasm of female genital organs (C579). Vagina and cervix are in the same organ system and are reported together in the same part.

If there is no available .9 subcategory or different organ systems are reported, code to malignant neoplasms of independent (primary) multiple sites (C97).

Codes for Record

I (a) Cardiac arrest I469

(b) Carcinoma of prostate and bladder C61 C679

Code to malignant neoplasms of independent (primary) multiple sites (C97), since there is no available .9 subcategory.

Although, generally only sites in Part I should be considered, the Classification provides linkages for certain sites when reported anywhere on the certificate.

Codes for Record

I (a) Carcinoma of esophagus C159

(b)

(c)

II Carcinoma of stomach C169

Code to malignant neoplasm of esophagus and stomach (C160). Combine other parts of esophagus, C152 or C155 and stomach, C169 to code C160 in the same manner.

Codes for Record

I (a) Cancer of sigmoid colon C187

(b)

(c)

II Cancer of rectum C20

Code to malignant neoplasm of rectum and colon (C19). Combine colon NOS, C189 and rectum, C20 to code C19 in the same manner.

Other exceptions to the multiple sites concept

The following examples are exceptions to the multiple sites concept. Even though the malignant neoplasms are reported in Part I and Part II, apply the linkage as provided by the Classification and Part 2c, Modification Table (Table E).

Codes for Record

I (a) Cholangiocarcinoma C221

II Hepatoma C220

Code to hepatoma (C220).

Codes for Record

I (a) Kaposi sarcoma of soft palate C462

II Kaposi sarcoma of skin C460

Code to Kaposi sarcoma of multiple organs (C468).

Codes for Record

I (a) Carcinoma of facial lymph nodes C770

II Carcinoma of axillary lymph nodes C773

Code to malignant neoplasm of lymph nodes of multiple regions (C778).

Codes for Record

I (a) Cleaved cell diffuse lymphoma C831

II Large cell follicular lymphoma C822

Code to mixed small cleaved and large cell follicular lymphoma (C821).

Also, in the same manner, combine C820 and C822 to code C821; combine C833 and C830 to code C832; and combine C830 and C833 to code C832.

F. Implication of malignancy

Mention on the certificate (anywhere) that a neoplasm (D00-D449, D480-D489) has produced secondaries (C77-C79) according to the Index or instructions, or is stated as metastases NOS, or metastases of a site means that the neoplasm must be coded as primary malignant (whether or not on the list of common sites of metastases), even though this neoplasm without mention of metastases would be classified to some other section of Chapter II.

Codes for Record

I (a) Brain metastasis C793

(b) Lung tumor C349

Code to malignant lung tumor (C349).

Codes for Record

I (a) Metastatic involvement of chest wall C798

(b) Carcinoma in situ of breast C509

Code to malignant carcinoma of breast (C509).

G. Metastatic neoplasm

When a malignant neoplasm spreads or metastasizes it generally retains the same morphology even though it may become less differentiated. Some metastases have such a characteristic microscopic appearance that the pathologist can infer the primary site with confidence, e.g. thyroid. Widespread metastasis of a carcinoma is often called carcinomatosis. The adjective “metastatic” is used in two ways – sometimes meaning a secondary from a primary elsewhere and sometimes denoting a primary that has given rise to metastases. Neoplasms qualified as metastatic are always malignant, either primary or secondary.

Although malignant cells can metastasize anywhere in the body, certain sites are more common than others and must be treated differently (see list of common sites of metastases). However, if one of these sites appears alone on a death certificate and is not qualified by the word “metastatic,” it should be considered primary.

Common sites of metastases

Bone Lymph nodes

Brain Mediastinum

Central nervous system Meninges

Diaphragm Peritoneum

Heart Pleura

Ill-defined sites (sites classifiable to C76) Retroperitoneum

Liver Spinal cord

Lung

Code for Record

I (a) Cancer of brain C719

Code to primary cancer of brain since it is reported alone on the certificate.

Special instruction: lung

The lung poses special problems in that it is a common site for both metastases and primary malignant neoplasms. Lung should be considered as a common site of metastases whenever it appears in Part I with sites not on this list. If lung is mentioned anywhere on the certificate and the only other sites are on the list of common sites of metastases, consider lung primary. However, when the bronchus or bronchogenic cancer is mentioned, this neoplasm should be considered primary.

Code for Record

I (a) Carcinoma of lung C349

Code to malignant neoplasm of lung since it is reported alone on the certificate.

Codes for Record

I (a) Cancer of bone C795

(b) Carcinoma of lung C349

Code to primary malignant neoplasm of lung (C349) since bone is on the list of common sites of metastases and lung can, therefore, be assumed to be primary.

Codes for Record

I (a) Carcinoma of bronchus C349

(b) Carcinoma of breast C509

Code to malignant neoplasms of independent (primary) multiple sites (C97) because bronchus is excluded from the list of common sites.

Special Instruction: lymph node

Malignant neoplasm of lymph nodes not specified as primary should be assumed to be secondary.

Code for Record

I (a) Cancer of cervical lymph nodes C770

Code to secondary malignant neoplasm of cervical lymph nodes (C770).

Only one site reported and it’s a common site of metastases

If one of the common sites of metastases, except lung, is described as metastatic and no other site or morphology is mentioned, code to secondary neoplasm of the site (C77-C79). If the single site is lung, qualified as metastatic, code to primary of lung.

Code for Record

I (a) Metastatic brain cancer C793

Code to secondary malignant neoplasm of brain (C793).

Code for Record

I (a) Metastatic carcinoma of lung C349

Code to malignant neoplasm of lung (C349).

All sites reported are common sites of metastases

If all sites reported (anywhere on the record) are on the list of common sites of metastases, code to unknown primary site of the morphological type involved, unless lung is mentioned, in which case code to malignant neoplasm of lung (C349).

Codes for Record

I (a) Cancer of liver C787

(b) Cancer of abdomen C798

Code to malignant neoplasm without specification of site (C80), since both are on the list of common sites of metastases. (Abdomen is one of the ill-defined sites included in C76.-.)

Codes for Record

I (a) Cancer of brain C793

(b) Cancer of lung C349

Code to cancer of lung (C349), since lung in this case is considered to be primary, because brain, the only other site mentioned, is on the list of common sites of metastases.

One of the sites reported is a common site of metastases

If only one of the sites mentioned is on the list of common sites of metastases or lung, code to the site not on the list.

Codes for Record

I (a) Cancer of lung C780

(b) Cancer of breast C509

Code to malignant neoplasm of breast (C509). In this case, lung is considered to be a common site because breast is not on the list of common sites of metastases.

Common sites reported with other sites or morphological types

If one or more of the sites mentioned is a common site of metastases (see list of common sites of metastases) but two or more sites or different morphological types are also mentioned, code to malignant neoplasms of independent (primary) multiple sites (C97) (see Section D). If sites are in the same organ system see Section E.

Codes for Record

I (a) Cancer of liver C787

(b) Cancer of bladder C679

Code to malignant neoplasms of independent (primary) multiple sites (C97), since liver is on the list of common sites of metastases and there are still two other independent sites.

Multiple sites with none specified as primary

If one of the common sites of metastases, excluding lung, is reported anywhere on the certificate with one or more site(s), or one or more morphological type(s), none specified as primary, code to the site or morphological type not on list of common sites.

Codes for Record

I (a) Cancer of stomach C169

(b) Cancer of liver C787

Code to malignant neoplasm of stomach (C169). The cancer of liver is presumed secondary because it is on the list of common sites.

Codes for Record

I (a) Peritoneal cancer C786

II Mammary carcinoma C509

Code to malignant neoplasm of breast (C509). The peritoneal cancer is presumed secondary because it is on the list of common sites.

Codes for Record

I (a) Brain carcinoma C793

II Melanoma of scalp C434

Code to melanoma of scalp (C434). The brain carcinoma is presumed secondary because it is on the list of common sites.

NOTE: If a malignant neoplasm of lymphatic, hematopoietic, or related tissue (C81-C96) is reported in one part and one of the common sites of metastases is mentioned in the other part, code to the malignant neoplasm reported in Part I.

Codes for Record

I (a) Brain cancer C719

II Lymphoma C859

Code to malignant brain cancer (C719). Since the condition in Part II is a malignant neoplasm of lymphatic, hematopoietic, or related tissue, only Part I conditions are considered.

Codes for Record

I (a) Brain cancer C793

(b) Lymphoma C859

Code to lymphoma (C859). Brain cancer is presumed secondary, because it is reported in the same part as a malignant neoplasm of lymphatic, hematopoietic, or related tissue.

If lung is mentioned in the same part with another site(s), not on the list of common sites, or one or more morphological types(s), consider the lung as secondary and the other site(s) as primary. If lung is mentioned in one part, and one or more site(s), not on the list of common sites, or one or more morphological type(s) is mentioned in the other part, code to the malignant neoplasm reported in Part I.

Codes for Record

I (a) Lung cancer C780

(b) Stomach cancer C169

Code to malignant stomach cancer (C169). Lung cancer is presumed secondary because it is reported in the same part as another site.

Codes for Record

I (a) Lung cancer C780

(b) Leukemia C959

Code to leukemia (C959). Lung cancer is presumed secondary because it is reported in the same part as another morphological type.

Codes for Record

I (a) Bladder carcinoma C679

II Lung cancer, breast cancer C780 C509

Code to malignant bladder carcinoma (C679) because lung cancer and breast cancer are reported in Part II.

Codes for Record

I (a) Lung cancer C349

II Stomach cancer C169

Code to malignant lung cancer (C349), since lung cancer is reported in Part I and stomach is reported in Part II.

Metastatic from

Malignant neoplasm described as “metastatic from” a specified site should be interpreted as primary of that site.

Codes for Record

I (a) Metastatic teratoma from C80

(b) ovary C56

Code to malignant neoplasm of ovary (C56).

Metastatic to

Malignant neoplasm described as “metastatic to” a specified site should be interpreted as primary of the site or morphological type that produced the metastasis (metastatic to) and all other sites should be coded as secondary unless stated as primary, whether in Part I or Part II.

Malignant neoplasm described as metastatic of a specified site to a specified site should be interpreted as primary of the site specified as “of a site.”

Code for Record

I (a) Metastatic carcinoma to the rectum C785

Code to secondary malignant neoplasm of rectum (C785). The word “to” indicates that rectum is secondary.

Codes for Record

I (a) Metastatic osteosarcoma to brain C419 C793

Code to malignant neoplasm of bone (C419) since this is the code for unspecified site of osteosarcoma.

Codes for Record

I (a) Metastatic cancer of liver to brain C229 C793

II Esophageal cancer C788

Code to primary cancer of liver (C229). The word “to” indicates that the liver is primary.

A single malignant neoplasm described as “metastatic (of)”

The terms “metastatic” and “metastatic of” should be interpreted as follows:

If one site is mentioned and this is qualified as metastatic, code to malignant primary of that particular site if the morphological type is C80 and the site is not a common metastatic site excluding the lung.

Code for Record

I (a) Cervix cancer, metastatic C539

Code to malignant neoplasm of cervix (C539).

Code for Record

I (a) Metastatic cancer of lung C349

Code to primary malignant neoplasm of lung since no other site is mentioned.

If one site is qualified metastatic and there are other sites specified as “secondary”, “metastases”, “metastasis”, “spread”, or a statement of “metastasis NOS” or “metastases NOS”, code the site qualified metastatic as primary and all other sites, secondary whether in Part I or Part II. If, however, lung is mentioned in one part and the metastatic neoplasm in the other part, code lung primary.

Code for Record

I (a) Metastatic breast cancer with brain metastases C509 C793

II Lung cancer C349

Code to malignant breast cancer (C509). Code I(a) as primary malignant neoplasm of breast since there is a statement of metastases on the record. Part II is coded as primary lung cancer but is not considered since it is reported in a different part.

If no site is reported but the morphological type is qualified as metastatic, code as for primary site unspecified of the particular morphological type involved.

Code for Record

I (a) Metastatic oat cell carcinoma C349

Code to malignant neoplasm of lung (C349) since oat cell carcinoma of unspecified site is assigned to the lung in the Alphabetical Index.

If a single morphological type and a site, other than a common metastatic site (see list of common sites of metastases), are mentioned as metastatic, code to the specific category for the morphological type and site involved.

Code for Record

I (a) Metastatic melanoma of arm C436

Code to malignant melanoma of arm (C436), since in this case the ill-defined site of arm is a specific site for melanoma, not a common site of metastases classifiable to C76.

If a single morphological type is qualified as metastatic and the site mentioned is one of the common sites of metastasesexcept lung, code the unspecified site for the morphological type, unless the unspecified site is classified to C80 (malignant neoplasm without specification of site), in which case, code to secondary malignant neoplasm of the site mentioned.

Codes for Record

I (a) Metastatic osteosarcoma of brain C419, C793

Code to malignant neoplasm of bone, unspecified (C419), since brain is on the list of common sites of metastases.

Code for Record

I (a) Metastatic cancer of peritoneum C786

Code to secondary cancer of peritoneum (C786), since peritoneum is on the list of common sites of metastases and the morphological type of neoplasm is classified to C80.

Codes for Record

I (a) Metastatic rhabdomyosarcoma C499 C771

(b) of hilar lymph nodes

Code to unspecified site for rhabdomyosarcoma (C499).

Code for Record

I (a) Metastatic sarcoma of lung C349

Code to malignant neoplasm of lung (C349), since lung is not considered a common site for this instruction.

EXCEPTION: Metastatic mesothelioma or metastatic Kaposi sarcoma.

If site IS indexed under “Mesothelioma” or “Kaposi’s sarcoma,” assign that code.

Code for Record

I (a) Metastatic mesothelioma of liver C457

Code to mesothelioma, liver (C457).

Code for Record

I (a) Metastatic mesothelioma of mesentery C451

Code to mesothelioma of mesentery (C451).

If site is NOT indexed under “Mesothelioma” or “Kaposi’s sarcoma” and the site reported is NOT a common site of metastasis, code to specified site NEC.

Code for Record

I (a) Metastatic mesothelioma of kidney C457

Code to mesothelioma specified site NEC. Kidney is not a common site of metastases.

If site is NOT indexed under “Mesothelioma” or “Kaposi’s sarcoma” and site reported IS a common site of metastasis, code to unspecified site NEC.

Codes for Record

I (a) Metastatic mesothelioma of C459 C779

(b) lymph nodes

Code to mesothelioma (C459). Lymph nodes is on the list of common sites and is not indexed under mesothelioma.

Codes for Record

I (a) Metastatic Kaposi’s sarcoma of brain C469, C793

Code to Kaposi’s sarcoma (C469). Brain is on the list of common sites and is not indexed under Kaposi’s sarcoma.

Code for Record

I (a) Kaposi’s sarcoma of brain C467

Code to specified site of Kaposi sarcoma (C467) since not qualified as metastatic.

If there is a mixture of several sites qualified as metastatic and several other sites are mentioned, refer to the rules for multiple sites (see Sections D and E).
More than one malignant neoplasm qualified as metastatic
If two or more sites with the same morphology, not on the list of common sites of metastases, are reported and all are qualified as “metastatic,” code as primary site unspecified of the anatomical system and/or of the morphological type involved.

Codes for Record

I (a) Metastatic carcinoma of prostate C798

(b) Metastatic carcinoma of skin C792

Code to malignant neoplasm without specification of site (C80), since two or more sites of the same morphology, not on the list of common sites of metastases, are reported and all are qualified as metastatic.

Codes for Record

I (a) Metastatic stomach carcinoma C169

(b) Metastatic pancreas carcinoma C259

Code to ill-defined sites within the digestive system (C269) since both sites are in the same anatomical system.

If two or more morphological types are qualified as metastatic, code to malignant neoplasms of independent (primary) multiple sites (C97) (see Section D).

Codes for Record

I (a) Bowel obstruction K566

(b) Metastatic adenocarcinoma of bowel C260

Code to malignant neoplasms of independent (primary) multiple sites (C97).

If a morphology implying site and an independent anatomical site are both qualified as metastatic, code to malignant neoplasm without specification of site (C80).

Codes for Record

I (a) Metastatic colonic and renal cell carcinoma C785 C790

Code to malignant neoplasm without specification of site (C80).

If more than one site with the same morphology is mentioned and all but one are qualified as metastatic or appear on the list of common sites of metastases, code to the site that is not qualified as metastatic, irrespective of the order of entry or whether it is in Part I or Part II. If all sites are qualified as metastatic or on the list of common sites of metastases, including lung, code to malignant neoplasm without specification of site (C80).

Codes for Record

I (a) Metastatic carcinoma of stomach C788

(b) Carcinoma of gallbladder C23

Code to malignant neoplasm of gallbladder (C23).

Codes for Record

I (a) Metastatic carcinoma of stomach C788

(b) Metastatic carcinoma of lung C780

II Carcinoma of colon C189

Code to malignant neoplasm of colon (C189), since this is the only diagnosis not qualified as metastatic, even though it is in Part II.

Codes for Record

I (a) Metastatic carcinoma of ovary C796

(b) Carcinoma of lung C780

Code to malignant neoplasm without specification of site (C80).

Codes for Record

I (a) Metastatic carcinoma of stomach C788

(b) Metastatic carcinoma of breast C798

Code to malignant neoplasm without specification of site (C80), since breast and stomach do not belong to the same anatomical system and lung is on the list of common sites of metastases.

H. Primary site unknown

If the statement, “primary site unknown,” or its equivalent, appears anywhere on a certificate, code to the category for unspecified site for the morphological type involved (e.g. adenocarcinoma C80, fibrosarcoma C499, osteosarcoma C419), regardless of the site(s) mentioned elsewhere on the certificate.

Consider the following terms as equivalent to “primary site unknown”:

? Origin (Questionable origin)

? Primary (Questionable primary)

? Site (Questionable site)

? Source (Questionable source)

Undetermined origin

Undetermined primary

Undetermined site

Undetermined source

Unknown origin

Unknown primary

Unknown site

Unknown source

Codes for Record

I (a) Secondary carcinoma of liver C80 C787

(b) Primary site unknown

(c)

Code to carcinoma without specification of site (C80).

Codes for Record

I (a) Generalized metastases C80

(b) Melanoma of back C439 C798

Code to malignant melanoma of unspecified site (C439).

NOTE: When “primary site unknown” or its equivalent appears on the certificate and a doubtful expression such as presumed or probably is reported qualifying a specific site(s), interpret the primary to be the site(s) following the doubtful qualifying expression and code as primary.

I (a) Cancer unk primary, presumed lung C349

Code to primary lung cancer (C349).

I. Sites with prefixes or imprecise definitions

Neoplasms of sites prefixed by “peri,” “para,” “pre,” “supra,” “infra,” etc. or described as in the “area” or “region” of a site, unless these terms are specifically indexed, should be coded as follows: for morphological types classifiable to one of the categories C40, C41 (bone and articular cartilage), C43 (malignant melanoma of skin), C44 (other malignant neoplasms of skin), C45 (mesothelioma), C47 (peripheral nerves and autonomic nervous system), and C49 (connective and soft tissue), C70 (meninges), C71 (brain), and C72 (other parts of central nervous system), code to the appropriate subdivision of that category; otherwise code to the appropriate subdivision of C76 (other and ill-defined sites).

Code for Record

I (a) Fibrosarcoma in the region of the leg C492

Code to malignant neoplasm of connective and soft tissue of lower limb (C492).

Code for Record

I (a) Carcinoma in the lung area C761

Code to malignant neoplasm of other and ill-defined sites within the thorax.

J. Doubtful diagnosis

Malignant neoplasms described as one site “or” another, or if “or” is implied, should be coded to the category that embraces both sites. If no appropriate category exists, code to the unspecified site of the morphological type involved. This rule applies to all sites whether they are on the list of common sites of metastases or not.

I (a) Carcinoma of ascending or descending colon

Code to malignant neoplasm of colon, unspecified (C189).

I (a) Osteosarcoma of lumbar vertebrae or sacrum

Code to malignant neoplasm of bone, unspecified (C419).

K. Malignant neoplasms of unspecified site with other reported conditions

When the site of a primary malignant neoplasm is not specified, no assumption of the site should be made from the location of other reported conditions such as perforation, obstruction, or hemorrhage. These conditions may arise in sites unrelated to the neoplasm, e.g. intestinal obstruction may be caused by the spread of an ovarian malignancy.

Codes for Record

I (a) Obstruction of intestine K566

(b) Carcinoma C80

Code to malignant neoplasm without specification of site (C80).

L. Mass or lesion with malignant neoplasms

When mass or lesion is reported with malignant neoplasms, code the mass or lesion as indexed.

Codes for Record

I (a) Lung mass R91

(b) Carcinomatosis C80

Code to carcinomatosis (C80).

E10-E14 Diabetes mellitus

with mention of:

E87.2 (Acidosis), code E10-E14 with fourth character .1

R02 (Gangrene, not elsewhere classified), code E10-E14 with fourth character .5

R40.2 (Coma, unspecified), code E10-E14 with fourth character .0

R79.8 (Other specified abnormal findings of blood chemistry), if acetonemia, azotemia, and related conditions, code E10-E14 with fourth character .1

when reported as the originating antecedent cause of:

E15 (Nondiabetic hypoglycaemic coma), if unspecified hypoglycemic coma, code to E1x.0

E88.8 (Other specified metabolic disorders), code E10-E14 with fourth character .1

G58.- (Other mononeuropathies), code E10-E14 with fourth character .4

G62.9 (Polyneuropathy, unspecified), code E10-E14 with fourth character .4

G64 (Other disorders of peripheral nervous system), code E10-E14 with fourth character .4

G70.9 (Myoneural disorder, unspecified), code E10-E14 with fourth character .4

G71.8 (Other primary disorders of muscles), code E10-E14 with fourth character .4

G90.9 (Disorder of autonomic nervous system, unspecified), code E10-E14 with fourth character .4

G98 (Other disorders of the nervous system, not elsewhere classified), except Charcot arthropathy, non-syphilitic, code to E1x.4

G98 (Other disorders of the nervous system, not elsewhere classified), if Charcot arthropathy, non-syphilitic, code to E1x.6

H20.9 (Iridocyclitis, unspecified), code E10-E14 with fourth character .3

H26.9 (Cataract, unspecified), code E10-E14 with fourth character .3

H30.9 (Chorioretinal inflammation, unspecified), code E10-E14 with fourth character .3

H34.- (Retinal vascular occlusions), code E10-E14 with fourth character .3

H35.0 (Background retinopathy and retinal vascular changes), code E10-E14 with fourth character .3

H35.2 (Other proliferative retinopathy), code E10-E14 with fourth character .3

H35.6 (Retinal haemorrhage), code E10-E14 with fourth character .3

H35.9 (Retinal disorder, unspecified), code E10-E14 with fourth character .3

H49.9 (Paralytic strabismus, unspecified), code E10-E14 with fourth character .3

H54.- (Visual impairment including blindness (binocular or monocular)), code E10-E14 with fourth character .3

I70.2 (Atherosclerosis of arteries of extremities), code E10-E14 with fourth character .5

I73.9 (Peripheral vascular disease, unspecified), code E10-E14 with fourth character .5

I99 (Other and unspecified disorders of circulatory system), if angiopathy, code E10-E14 with fourth character .5

K31.8 (Other specified diseases of stomach and duodenum), if gastroparesis, code to E1x.4

L30.9 (Dermatitis, unspecified), code E10-E14 with fourth character .6

L92.1 (Necrobiosis lipoidica, not elsewhere classified), code E10-E14 with fourth character .6

L97 (Ulcer of lower limb, not elsewhere classified), code to E1x.5

L98.4 (Chronic ulcer of skin, not elsewhere classified), code to E1x.5

M13.9 (Arthritis, unspecified), code E10-E14 with fourth character .6

M79.2 (Neuralgia and neuritis, unspecified), code E10-E14 with fourth character .6

M89.9 (Disorder of bone, unspecified), code E10-E14 with fourth character .6

N03- N05 (Nephrotic syndrome), code E10-E14 with fourth character .2

N18.- (Chronic kidney disease), code E10-E14 with fourth character.2

N19 (Unspecified kidney failure), code E10-E14 with fourth character .2

N26 (Unspecified contracted kidney), code E10-E14 with fourth character .2

N28.9 (Disorder of kidney and ureter, unspecified), code E10-E14 with fourth character .2

N39.0 (Urinary tract infection, site not specified), code E10-E14 with fourth character .6

N39.1 (Persistent proteinuria, unspecified), code E10-E14 with fourth character .2

E40-E46, E63.9, E64.0, E64.9

when reported as the originating antecedent cause of:

E10.0-E10.9 (Insulin-dependent diabetes mellitus), code to E12

E11.0-E11.9 (Non-insulin dependent diabetes mellitus), code to E12

E14.0-E14.9 (Unspecified diabetes mellitus), code to E12

E86 Volume depletion

with mention of:

A00-A09 (Intestinal infectious diseases), code A00-A09

E89.- Postprocedural endocrine and metabolic disorders, not elsewhere classified

Not to be used for underlying cause mortality coding.

F03-F09 Organic, including symptomatic, mental disorders

Not to be used if the underlying physical condition is known.

F10-F19 Mental and behavioral disorders due to psychoactive substance use

with mention of:

X40-X49 (Accidental poisoning by and exposure to noxious substances), code X40-X49

X60-X69 (Intentional self-poisoning by and exposure to noxious substances), code X60-X69

X85-X90 (Assault by noxious substances), code X85-X90

Y10-Y19 (Poisoning by and exposure to drugs, chemicals and noxious substances), code Y10-Y19

Fourth character .0 (Acute intoxication), code X40-X49, X60-X69, X85-X90 or Y10-Y19

Fourth character .5 (Psychotic disorder) with mention of

Dependence syndrome (.2), code F10-F19 with fourth character .2

F10.- Mental and behavioral disorders due to use of alcohol

with mention of:

E24.4 (Alcohol-induced Cushing syndrome), code E24.4

G31.2 (Degeneration of the nervous system due to alcohol), code G31.2

G62.1 (Alcoholic polyneuropathy), code G62.1

G72.1 (Alcoholic myopathy), code G72.1

I42.6 (Alcoholic cardiomyopathy), code I42.6

K29.2 (Alcoholic gastritis), code K29.2

K70.- (Alcoholic liver disease), code K70.-

K72.- (Hepatic failure, not elsewhere classified), code K70.4

K73.- (Chronic hepatitis, not elsewhere classified), code K70.1

K74.0 (Hepatic fibrosis), code K70.2

K74.1- (Hepatic sclerosis), code K70.2

K74.2- (Hepatic fibrosis with hepatic sclerosis), code K70.2

K74.6. (Other and unspecified cirrhosis of liver), code K70.3

K75.9- (Inflammatory liver disease, unspecified), code K70.1

K76.0- (Fatty (change) of liver, not elsewhere classified), code K70.0

K76.9- (Liver disease, unspecified), code K70.9

K85.2 (Alcohol-induced acute pancreatitis), code K85.2

K86.0 (Alcohol-induced chronic pancreatitis), code K86.0

O35.4 (Maternal care for (suspected) damage to fetus from alcohol), code O35.4

F10.2 Dependence syndrome due to use of alcohol

with mention of:

F10.4, F10.6, F10.7 (Withdrawal state with delirium), (Amnesic syndrome), (Residual and late-onset psychotic disorder), code F10.4, F10.6, F10.7

F17.- Mental and behavioral disorders due to use of tobacco

Not to be used if the resultant physical condition is known.

F11.9, F12.9 Mental and behavioral disorders due to use of drugs

F13.9, F14.9

F15.9, F16.9

F18.9, F19.9

INCLUDES: “drug use NOS” and “named drug use” of named drugs indexed under Addiction\Dependence , Volume 3

EXCLUDES: “drug use NOS” and “named drug use” when reported as causing a complication. If there is a resulting complication, consider as drug therapy and apply instructions under Y40-Y59, Drugs, medicaments and biological substances causing adverse effects in therapeutic use.

Codes for Record

I (a) Heroin use F119

(b)

II Acute intravenous drug use F199

Code to heroin use (F119).

Codes for Record

I (a) Melanoma of back C435

(b)

II Use of hypnotics F139

Code to melanoma of back (C435).

Code for Record

I (a) Intravenous drug use F119

(b) (morphine)

Accident

Code to intravenous morphine use (F119).

F70-F79 Mental retardation

Not to be used if the underlying physical condition is known.

G25.5 Other chorea

with mention of:

I00-I02 (Acute rheumatic fever), code I02.-

I05-I09 (Chronic rheumatic heart disease), code I02.-

G40-G41 Epilepsy

INCLUDES: accidents resulting from epilepsy

EXCLUDES: epilepsy stated as traumatic (code to the appropriate category in Chapter XX; if the nature and cause of the injury are not known, code Y86)

G81.- Hemiplegia

G82.- Paraplegia and tetraplegia

G83.- Other paralytic syndromes

Not to be used if the cause of the paralysis is known.

G97.- Postprocedural disorders of nervous system, not elsewhere classified

Not to be used for underlying cause mortality coding.

H54.- Blindness and low vision

Not to be used if the antecedent condition is known.

H59.- Postprocedural disorders of eye and adnexa, not elsewhere classified

Not to be used for underlying cause mortality coding.

H90.- Conductive and sensorineural hearing loss

H91.- Other hearing loss

Not to be used if the antecedent condition is known.

H95.- Postprocedural disorders of ear and mastoid process, not elsewhere classified

Not to be used for underlying cause mortality coding.

I00-I09 Acute and chronic rheumatic heart diseases

Multiple heart conditions with one heart condition specified as rheumatic:

If rheumatic fever or any disease of the heart is stated to be of rheumatic origin or is specified to be rheumatic, such qualifications will apply to each specific heart condition reported (classified to I300-I319, I339, I340-I38, I400-I409, I429, I514-I519), even though it is not so qualified, unless another origin such as arteriosclerosis is mentioned.

Codes for Record

I (a) Acute bacterial endocarditis I330

(b) Mitral insufficiency I051

Code to rheumatic mitral insufficiency (I051). Rheumatic endocarditis, selected by the General Principle, links (LMP) with rheumatic mitral insufficiency. The mitral insufficiency is coded as rheumatic since it is reported with a heart disease specified as rheumatic.

When a condition listed in category I50.- is indicated to be “due to” rheumatic fever and there is no mention of another heart disease that is classifiable as rheumatic, consider the condition in I50.- to be described as rheumatic.

. Codes for Record

I (a) Heart failure I099

(b) Rheumatic fever I00

Code to rheumatic heart disease (I099). Consider the heart failure to be rheumatic since it is due to rheumatic fever and there is no other heart disease on the record classifiable as rheumatic.

Codes for Record

I (a) Acute congestive failure I500

(b) Hypertensive myocarditis I119

Code to hypertensive heart disease with congestive heart failure (I110). Even though rheumatic is stated on the record, it cannot be applied to the heart diseases reported.

When diseases of the mitral, aortic, and tricuspid valves, not qualified as rheumatic, are jointly reported, whether on the same line or on separate lines, code the disease of all valves as rheumatic unless there is indication to the contrary.

Codes for Record

I (a) Mitral endocarditis c I059 I051 I050

(b) insufficiency and stenosis

Code to disorders of both mitral and aortic valves (I080). Conditions of both valves are considered as rheumatic since the diseases of the mitral and aortic valves are jointly reported.

Codes for Record

I (a) Aortic and tricuspid regurgitation I061 I071

(b) Aortic stenosis I060

Code to disorders of both aortic and tricuspid valves (I082). Conditions of both valves are considered as rheumatic since the diseases of the aortic and the tricuspid valves are jointly reported.

When mitral insufficiency, incompetence, or regurgitation are jointly reported with mitral stenosis NOS (or synonym), code all these conditions as rheumatic unless there are indications to the contrary.

Codes for Record

I (a) Mitral stenosis I050

(b) Mitral insufficiency I051

Code to mitral stenosis with insufficiency (I052). Mitral insufficiency is considered as rheumatic since it is reported jointly with mitral stenosis.

I01.- Rheumatic fever with heart involvement

This category INCLUDES active rheumatic heart disease. If there is no statement that the rheumatic process was active at the time of death, assume activity (I010-I019) for each rheumatic heart disease (I050-I099) on the certificate in any one of the following situations:

Rheumatic fever or any rheumatic heart disease is stated to be active or recurrent.

Codes for Record

I (a) Mitral stenosis I011

(b) Active rheumatic myocarditis I012

Code to other acute rheumatic heart disease (I018). Active rheumatic mitral stenosis is classified to I011 when it is reported with an active rheumatic heart disease. Therefore, the underlying cause is I018 since this category includes multiple types of heart involvement.

The duration of rheumatic fever is less than 1 year.

Codes for Record

I (a) Congestive heart failure I018

(b) Rheumatic fever 2 months I00

Code to other acute rheumatic heart disease (I018) since the rheumatic fever is less than 1 year duration.

One or more of the heart diseases is stated to be acute or subacute (this does not apply to “rheumatic fever” stated to be acute or subacute).

Codes for Record

I (a) Acute myocardial dilatation I018

(b) Rheumatic fever I00

Code to other acute rheumatic heart disease (I018) since the myocardial dilatation is stated as acute.

Codes for Record

I (a) Acute myocardial insufficiency I012

(b) Rheumatic fever I00

Code to acute rheumatic myocarditis (I012) since the myocardial insufficiency is stated to be acute.

The term “pericarditis” is mentioned.

Codes for Record

I (a) Acute pericarditis I010

(b) Rheumatic mitral stenosis I011

Code to other acute rheumatic heart disease (I018) which includes multiple heart involvement since pericarditis is mentioned.

The term(s) “carditis,” “endocarditis (any valve),” “heart disease,” “myocarditis,” or “pancarditis,” with a stated duration of less than 1 year is mentioned.

Codes for Record

I (a) Congestive heart failure I500

(b) Endocarditis 6 mos I011

Code to acute rheumatic endocarditis (I011) since the endocarditis is of less than 1 year duration.

The term(s) in instruction E without a duration is mentioned and the age of the decedent is less than 15 years.

Age 5 years Codes for Record

I (a) Mitral and aortic endocarditis I011

(b) Rheumatic fever I00

Code to acute rheumatic endocarditis (I011) since the age of the decedent is less than 15 years.

I34.0-I38 Valvular diseases not indicated to be rheumatic

In the Classification, certain valvular diseases, i.e., disease of mitral valve (except insufficiency, incompetence, and regurgitation without stenosis) and disease of tricuspid valve are included in the rheumatic categories even though not indicated to be rheumatic. This classification is based on the assumption that the vast majority of such diseases are rheumatic in origin.

Do not use these diseases to qualify other heart diseases as rheumatic. Code these diseases as nonrheumatic if reported due to one of the nonrheumatic causes on the following list:

When valvular heart disease (I050-I079, I089 and I090) not stated to be rheumatic is reported due to:

A1690 C73-C759 E804-E806 J030

A188 C790-C791 E840-E859 J040-J042

A329 C797-C798 E880-E889 J069

A38 C889 F110-F169 M100-M109

A399 D300-D301 F180-F199 M300-M359

A500-A549 D309 I10-I139 N000-N289

B200-B24 D34-D359 I250-I259 N340-N399

B376 D440-D45 I330-I38 Q200-Q289

B379 E02-E0390 I420-I4290 Q870-Q999

B560-B575 E050-E349 I511 R75

B908 E65-E678 I514-I5150 T983

B909 E760-E769 I700-I710 Y400-Y599

B948 E790-E799 J00 Y883

C64-C65 E802 J020

Code nonrheumatic valvular disease (I340-I38) with appropriate fourth character.

Codes for Record

I (a) Mitral insufficiency I340

(b) Goodpasture syndrome & RHD M310 I099

Code to Goodpasture syndrome (M310). Mitral insufficiency is considered as nonrheumatic since it is reported due to Goodpasture syndrome (M310) by Rule 1.

Consider diseases of the aortic, mitral, and tricuspid valves to be nonrheumatic if they are reported on the same line due to a nonrheumatic cause in the previous list. Similarly, consider diseases of these three valves to be nonrheumatic if any of them are reported due to the other and that one, in turn, is reported due to a nonrheumatic cause in the previous list.

Codes for Record

I (a) Mitral stenosis and aortic stenosis I342 I350

(b) Hypertension I10

Code to mitral stenosis (I342). Conditions of both valves are considered as nonrheumatic since they are reported due to hypertension (I10).

Codes for Record

I (a) Mitral disease I349

(b) Aortic stenosis I350

Code to aortic (valve) stenosis (I350). Consider mitral disease as nonrheumatic since it is reported due to aortic stenosis which is, in turn, reported due to arteriosclerosis (I709).

Codes for Record

I (a) Congestive heart failure I500

(b) Mitral stenosis I342

Code to congenital cardiomyopathy (I424). Mitral stenosis is considered as nonrheumatic since it is reported due to congenital cardiomyopathy (I424).

I05.8 Other mitral valve diseases

I05.9 Mitral valve disease, unspecified

when of unspecified cause with mention of:

I34.- (Nonrheumatic mitral valve disorders), code I34.-

I08.- Multiple valve diseases

Not to be used for multiple valvular diseases of specified, but nonrheumatic origin. When multiple valvular diseases of nonrheumatic origin are reported on the same death certificate, the underlying cause should be selected by applying the General Principle or Rules 1, 2 or 3 in the usual way.

I09.1 Rheumatic diseases of endocardium, valve unspecified

I09.9 Rheumatic heart disease, unspecified

with mention of:

I05-I08 (Chronic rheumatic heart disease), code I05-I08

I10 Essential (primary) hypertension

with mention of:

I11.- (Hypertensive heart disease), code I11.-

I12.- (Hypertensive renal disease), code I12.-

I13.- (Hypertensive heart and renal disease), code I13.-

I20-I25 (Ischemic heart diseases), code I20-I25

I60-I69 (Cerebrovascular diseases), code I60-I69

N00.- (Acute nephritic syndrome), code N00.-

N01.- (Rapidly progressive nephritic syndrome), code N01.-

N03.- (Chronic nephritic syndrome), code N03.-

N04.- (Nephrotic syndrome), code N04.-

N05.- (Unspecified nephritic syndrome), code N05.-

N18.- (Chronic kidney disease), code I12.-

N19 (Unspecified renal failure), code I12.-

N26 (Unspecified contracted kidney), code I12.-

when reported as the originating antecedent cause of:

H35.0 (Background retinopathy and other vascular changes), code H35.0

I05-I09 (Conditions classifiable to I05-I09 but not specified as rheumatic), code I34-I38

I34-I38 (Nonrheumatic valve disorders), code I34-I38

I50.- (Heart failure), code I11.0

I51.4- (Complications and ill-defined descriptions of heart disease),

I51.9 code I11.-

I11.- Hypertensive heart disease

with mention of:

I12.- (Hypertensive renal disease), code I13.-

I13.- (Hypertensive heart and renal disease), code I13.-

I20-I25 (Ischemic heart diseases), code I20-I25

N18.- (Chronic kidney disease), code I13.-

N19 (Unspecified renal failure), code I13.-

N26 (Unspecified contracted kidney), code I13.-

I12.- Hypertensive renal disease

with mention of:
I11.- (Hypertensive heart disease), code I13.-

I13.- (Hypertensive heart and renal disease), code I13.-

I20-I25 (Ischemic heart diseases), code I20-I25

when reported as the originating antecedent cause of:

I50.- (Heart failure), code I13.0

I51.4- (Complications and ill-definedI51.9 descriptions of heart disease), code I13.-

I13.- Hypertensive heart and renal disease

with mention of:

I20-I25 (Ischemic heart disease), code I20-I25

I15.1 Hypertension secondary to other renal disorders

Not to be used for underlying cause mortality coding. Code to reported renal disorder.

I15.2 Hypertension secondary to endocrine disorders

Not to be used for underlying cause mortality coding. Code to reported endocrine disorder.

I15.8 Other secondary hypertension

Not to be used for underlying cause mortality coding. Code to reported underlying cause. If the cause is not stated, code to Other ill-defined and unspecified causes of mortality (R99).

I20.- Angina pectoris

I24.- Other acute ischemic heart diseases

I25.- Chronic ischemic heart disease

with mention of:

I21.- (Acute myocardial infarction), code I21.-

I22.- (Subsequent myocardial infarction), code I22.-

I21.- Acute myocardial infarction

with mention of:

I22.- (Subsequent myocardial infarction), code I22.-

I23.- Certain current complications following acute myocardial infarction

Not to be used for underlying cause mortality coding. Use code I21.- or I22.- as appropriate.

I24.0 Coronary thrombosis not resulting in myocardial infarction

Not to be used for underlying cause mortality coding. For mortality, the occurrence of myocardial infarction is assumed and assignment made to I21.- or I22.- as appropriate.

I25.2 Old myocardial infarction

Not to be used for underlying cause mortality coding. If the cause is not stated, code to Other forms of chronic ischemic heart disease (I25.8).

I27.9 Pulmonary heart disease, unspecified

with mention of:

M41.- (Scoliosis), code I27.1

I44.- Atrioventricular and left bundle-branch block

I45.- Other conduction disorders

I46.- Cardiac arrest

I47.- Paroxysmal tachycardia

I48 Atrial fibrillation and flutter

I49.- Other cardiac arrhythmias

I50.- Heart failure

I51.4-I51.9 Complications and ill-defined descriptions of heart disease

with mention of:

B57.- (Chagas disease), code B57.-

I20-I25 (Ischemic heart diseases), code I20-I25

I50.- Heart failure

I51.9 Heart disease, unspecified

with mention of:

M41.- (Scoliosis), code I27.1

I50.9 Heart failure, unspecified

I51.9 Heart disease, unspecified

with mention of:

J81 (Pulmonary edema), code I50.1

I60-I69 Cerebrovascular diseases

when reported as the originating antecedent cause of conditions in:

F01-F03, code F01

I65.- Occlusion and stenosis of precerebral arteries, not resulting in cerebral infarction

I66.- Occlusion and stenosis of cerebral arteries, not resulting in cerebral infarction

Not to be used for underlying cause mortality coding. For mortality, the occurrence of cerebral infarction is assumed and assignment made to I63.-.

I67.2 Cerebral atherosclerosis

with mention of:

I60-I64 (Cerebral hemorrhage, cerebral infarction, or stroke, occlusion and stenosis of precerebral and cerebral arteries), code I60-I64

when reported as the originating antecedent cause of conditions in:

F03 (Unspecified dementia), code F01.-

G20 (Parkinson disease), code G21.4.

G21.9 (Secondary parkinsonism, unspecified), code G21.4

I70.- Atherosclerosis

with mention of:

I10-I13 (Hypertensive disease), code I10-I13

I20-I25 (Ischemic heart diseases), code I20-I25

I50.- (Heart failure), code I50.-

I51.4 (Myocarditis, unspecified), code I51.4

I51.5 (Myocardial degeneration), code I51.5

I51.6 (Cardiovascular disease, unspecified), code I51.6

I51.8 (Other ill-defined heart diseases), code I51.8

I60-I69 (Cerebrovascular diseases), code I60-I69

when reported as the originating antecedent cause of:

I05-I09 (Conditions classifiable to I05-I09 but not specified as rheumatic), code I34-I38

I34-I38 (Nonrheumatic valve disorders), code I34-I38

I51.9 (Heart disease, unspecified), code I25.1

I71-I78 (Other diseases of arteries, arterioles and capillaries), code I71-I78

K55.- (Vascular disorders of intestine), code K55.-

N03 (Chronic nephritis), code I12.-

N26 (Unspecified contracted kidney), code I12.-

I70.9 Generalized and unspecified atherosclerosis

with mention of:

R02 (Gangrene, not elsewhere classified), code I70.2

when reported as the originating antecedent cause of:

F01.- (Vascular dementia), code F01.-

F03 (Unspecified dementia), code F01.-

G20 (Parkinson disease), code G21.4

G21.9 (Secondary parkinsonism, unspecified), code G21.4

I97.- Postprocedural disorders of circulatory system, not elsewhere classified

Not to be used for underlying cause mortality coding.

J00 Acute nasopharyngitis [common cold]

J06.- Acute upper respiratory infections of multiple and unspecified sites

when reported as the originating antecedent cause of:

G03.8 (Meningitis), code G03.8

G06.0 (Intracranial abscess and granuloma), code G06.0

H65-H66 (Otitis media), code H65-H66

H70.- (Mastoiditis and related conditions), code H70.-

J09-J18 (Influenza and pneumonia), code J09-J18

J20-J21 (Bronchitis and bronchiolitis), code J20-J21

J40-J42 (Unspecified and chronic bronchitis), code J40-J42

J44.- (Other chronic obstructive pulmonary disease), code J44.-

N00.- (Acute nephritic syndrome), code N00.-

J18.- Pneumonia, organism unspecified

with mention of:

R26.3 (Immobility), code to J18.2

H65-H66 (Otitis media), code H65-H66 J20.- Acute bronchitis

with mention of:

J41.- (Simple and mucopurulent chronic bronchitis), code J41.-

J42 (Unspecified chronic bronchitis), code J42

J44.- (Other chronic obstructive pulmonary disease), code J44.-

J40 Bronchitis, not specified as acute or chronic

J41.- Simple and mucopurulent chronic bronchitis

J42 Unspecified chronic bronchitis

with mention of:

J43.- (Emphysema), code J44.-

J44.- (Other chronic obstructive pulmonary disease), code J44.-

when reported as the originating antecedent cause of:

J45.- (Asthma), code J44.- (but see also note at J45.-, J46)

J43.- Emphysema

with mention of:

J40 (Bronchitis, not specified as acute or chronic), code J44.-

J41.- (Simple and mucopurulent chronic bronchitis), code J44.-

J42 (Unspecified chronic bronchitis), code J44.-

J44.8-J44.9 Other and unspecified chronic obstructive pulmonary disease

with mention of:

J12-J18 (Pneumonia), code J44.0

J20-J22 (Other acute lower respiratory infections), code J44.0

J45.- Asthma

J46 Status asthmaticus

When asthma and bronchitis (acute) (chronic) or other chronic obstructive pulmonary disease are reported together on the medical certificate of cause of death, the underlying cause should be selected by applying the General Principle or Rules 1, 2, or 3 in the normal way. Neither term should be treated as an adjectival modifier of the other.

J60-J64 Pneumoconiosis

with mention of:

A15-A16 (Respiratory tuberculosis), code J65

J81 Pulmonary edema

with mention of:

I50.9 (Heart failure, unspecified), code I50.1

I51.9 (Heart disease, unspecified), code I50.1

J95.- Postprocedural respiratory disorders, not elsewhere classified

Not to be used for underlying cause mortality coding.

K71 Toxic liver disease

with mention of:

T51.- (Toxic effect of alcohol), code K70.-

K72 Hepatic failure, not elsewhere classified

with mention of:

F10.- (Mental and behavioral disorders due to use of alcohol), code K70.4

T51.- (Toxic effect of alcohol), code K70.4

K73 Chronic hepatitis, not elsewhere classified

with mention of:

F10.- (Mental and behavioral disorders due to use of alcohol), code K70.1

T51.- (Toxic effect of alcohol), code K70.1

K74.0 Hepatic fibrosis

with mention of:

F10.- (Mental and behavioral disorders due to use of alcohol), code K70.2

T51.- (Toxic effect of alcohol), code K70.2

K74.1 Hepatic sclerosis

with mention of:

F10.- (Mental and behavioral disorders due to use of alcohol), code K70.2

T51.- (Toxic effect of alcohol), code K70.2

K74.2 Hepatic fibrosis with hepatic sclerosis

with mention of:

F10.- (Mental and behavioral disorders due to use of alcohol), code K70.

T51.- (Toxic effect of alcohol), code K70.2

K74.6 Other and unspecified cirrhosis of liver

with mention of:

F10.- (Mental and behavioral disorders due to use of alcohol), code K70.3

T51.- (Toxic effect of alcohol), code K70.3

K75.9 Inflammatory liver disease, unspecified

with mention of:

F10.- (Mental and behavioral disorders due to use of alcohol), code K70.1

T51.- (Toxic effect of alcohol), code K70.1

K76.0 Fatty (change) of liver, not elsewhere classified

with mention of:

F10.- (Mental and behavioral disorders due to use of alcohol), code K70.0

T51.- (Toxic effect of alcohol), code K70.0

K76.9 Liver disease, unspecified

with mention of:

F10.- (Mental and behavioral disorders due to use of alcohol), code K70.9

T51.- (Toxic effect of alcohol), code K70.9

K85.9 Acute pancreatitis, unspecified

with mention of:

F10.- (Mental and behavioral disorders due to use of alcohol), code K85.2

K91.- Postprocedural disorders of digestive system, not elsewhere classified

Not to be used for underlying cause mortality coding.

M41.- Scoliosis

with mention of:

I27.9 (Pulmonary heart disease, unspecified), code I27.1

I50.- (Heart failure), code I27.1

I51.9 (Heart disease, unspecified), code I27.1

M96.- Postprocedural musculoskeletal disorders, not elsewhere classified

Not to be used for underlying cause mortality coding.

N00.- Acute nephritic syndrome

when reported as the originating antecedent cause of:

N03.- (Chronic nephritic syndrome), code N03.-

N18.- Chronic kidney disease

N19 Unspecified renal failure

N26 Unspecified contracted kidney

with mention of:

I10 (Essential (primary) hypertension), code I12.-

I11.- (Hypertensive heart disease), code I13.-

I12.- (Hypertensive renal disease), code I12.-

N46 Male infertility

N97.- Female infertility

Not to be used if the causative condition is known.

N99.- Postprocedural disorders of genitourinary system, not elsewhere classified

Not to be used for underlying cause mortality coding.

O00-O99 Pregnancy, childbirth, and the puerperium

Conditions classifiable to categories O00-O99 are limited to deaths of females of childbearing age. Some of the maternal conditions are also the cause of death in newborn infants. Always refer to the age and sex of the decedent before assigning a condition to O00-O99.

Obstetric deaths are classified according to time elapsed between the obstetric event and the death of the woman:

O95 Obstetric death of unspecified cause

O960-O969 Death from any obstetric cause occurring more than 42 days but less than one year after delivery

O970-O979 Death from sequela of obstetric causes (death occurring one year or more after delivery)

The standard certificate of death contains a separate item regarding pregnancy. Any positive response to one of the following items should be taken into consideration when coding pregnancy related deaths.

☐ Pregnant at time of death

☐ Not pregnant, but pregnant within 42 days of death

☐ Not pregnant, but pregnant 43 days to 1 year before death

If one of the options from the previous list is marked and the decedent is greater than 54 years old, code as a pregnancy record only when there is a condition reported which indicates the person was pregnant either at the time of death or pregnant 43 days to 1 year before death.

Additionally, if the third option is checked, but there is a maternal condition reported with a duration that indicates the pregnancy was within 42 days of death, disregard the checkbox and prefer the duration.

Consider the pregnancy to have terminated 42 days or less prior to death unless a specified length of time is written in by the certifier. Take into consideration the length of time elapsed between pregnancy and death if reported as more than 42 days.

If an indirect maternal cause is selected as the originating antecedent cause, reselect any direct maternal cause on the line immediately above the indirect cause. If no direct cause is reported, the indirect cause will be accepted as the cause of death.

O08.- Complications following abortion and ectopic and molar pregnancy

Not to be used for underlying cause mortality coding. Use categories O00-O07.

O30.- Multiple gestation

Not to be used for underlying cause mortality coding if a more specific complication is reported.

O32.- Maternal care for known or suspected malpresentation of fetus

with mention of :

O33.- (Maternal care for known or suspected disproportion), code O33.-

O33.9 Fetopelvic disproportion

with mention of:

O33.0-O33.3 (Disproportion due to abnormality of maternal pelvis), code O33.0-O33.3

O64.- Obstructed labor due to malposition and malpresentation of fetus

with mention of:

O65.- (Obstructed labor due to maternal pelvic abnormality), code O65.-

O80.0-O80.9 Single spontaneous delivery

Not to be used for underlying cause mortality coding. If no other cause of maternal mortality is reported, code to Obstetric death of unspecified cause (O95).

O81-O84 Method of delivery

Not to be used for underlying cause mortality coding. If no other cause of maternal mortality is reported, code to Complication of labor and delivery, unspecified (O759).

P07.- Disorders related to short gestation and low birth weight, not elsewhere classified

P08.- Disorders related to long gestation and high birth weight

Not to be used if any other cause of perinatal mortality is reported. This does not apply if the only other cause of perinatal mortality reported is respiratory failure of newborn (P28.5).

P70.3-P72.0 Transitory endocrine and metabolic disorders specific to fetus and

P72.2-P74.9 newborn

Not to be used for underlying cause mortality coding. If no other perinatal cause of mortality is reported, code to Condition originating in the perinatal period, unspecified (P96.9). If another perinatal cause is reported, prefer this cause. If more than one perinatal cause is reported, apply the rules for conflict in linkage in selection of the other perinatal cause.

P95 Fetal death of unspecified cause

Not to be used for underlying cause mortality coding. Use P96.9 for fetal death in mortality coding.

Q44.6 Cystic disease of liver

with mention of:

Q61.1-Q61.3 (Polycystic kidney disease), code Q61.1-Q61.3

R69.- Unknown and unspecified causes of morbidity

Not to be used for underlying cause mortality coding. Use R95-R99 as appropriate.

S00-T98 Injury, poisoning, and certain other consequences of external causes

Not to be used for underlying cause mortality coding.

V01-Y89 Classification of external causes of morbidity and mortality

The codes for external causes permit the classification of environmental events and circumstances as the cause of injury, poisoning and other adverse effects.

Successive external causes. Where successive external events occur and cause death, assignment is to the initiating event except where this was a trivial accident leading to a more serious one. In the latter case, the trivial event may be disregarded.

Slight injuries.When a slight injury is involved as a cause of death, the Rules for Selection are applied. Slight injuries are trivial conditions rarely causing death unless a more serious condition such as tetanus resulted from the slight injury. Therefore, where a slight injury is selected, Rule B, Trivial conditions, is usually applied. For the purpose of these rules, slight injuries comprise superficial injuries such as:

abrasions exposure NOS

bite of insect minor cut

(non-venomous) prick

blister puncture except trunk

bruise scratch

burn of first degree splinter

contusion (external)

For slight injury resulting in streptococcal septicemia, septicemia, or erysipelas refer to Section IV, B, categories A40.-, A41.-, A46.

Accident information entered in space outside Part I and Part II. When information concerning an accident is reported only in a space specifically provided for such information outside of Parts I and II of the Medical Certification Section, inquiry should be made concerning the relationship of the accident to the death and to the other causes reported. If no information is received from the inquiry, the assignment is made by application of the Rules for Selection to the causes reported in Parts I and II.

Accident due to disease condition. When a disease condition, such as cerebral hemorrhage, heart attack, diabetic coma, or alcoholism is indicated by the certifier to be the underlying cause of an accident, the assignment is made to the accidental cause unless there is evidence that the death occurred prior to the accident. Thus, accidents are generally not accepted due to disease conditions. However, there are some exceptions to this concept:
asphyxia from aspiration of mucus or vomitus as a result of a disease condition
a fall from a pathological fracture or disease of the bone
aspiration of milk or other food due to diseases which presumably affect the ability to control the process of swallowing, for example, cancer of the throat or a disease resulting in paralysis
accidents resulting from epilepsy (G40-G41)

Found injured on highway. See category V892 in Volume 1.

Complication of trauma for purposes of applying Selection Rule 3. Refer to Section II, Selection Rule 3, Direct Sequel.

Selecting external causes as the underlying cause. External causes will be coded as the underlying cause even though a Chapter XIX code is not reported. When selecting the sequence responsible for death, no preference is given to the external cause. Apply selection and modification rules in the usual way.

Use of the Index and Tabular List. ICD-10 provides separate indexing in Volume 3, Section II for the external causes of injury, with frequent references to Volume 1. The External Causes of Injury Index provides a double axis of indexing—descriptions of the circumstances under which the accident or violence occurred and the agent involved in the occurrence. Usually, the “lead terms” in the External Causes of Injury Index describe the circumstances of the injury with a secondary (indented) entry naming the agent involved.

Code for Term

Fall from building W13

Locate the E-code for “fall”:

Fall

– from

– – building W13.-

After locating the external cause code in the Index, always refer to Volume 1 since certain external cause codes require a fourth character.

The ICD provides a fourth character for use with categories W00 – Y34, except Y06.- and Y07.-, to identify the place of occurrence of the external cause. NCHS uses a separate field for this purpose. Only the three-character category codes are assigned in underlying cause coding.

Code for Term

House fire X00

Locate the E-code for “House fire”:

House fire (uncontrolled) X00.-

V01-V99 Transportation Accidents

1. General Instructions

The main axis of classification for land transports (V01-V89) is the victim’s mode of transportation. The vehicle of which the injured person is an occupant is identified in the first two characters since it is seen as the most important for prevention purposes.

Definitions and examples relating to transport accidents are in Volume 1, Chp. XX. Refer to these definitions when any means of transportation (aircraft and spacecraft, watercraft, motor vehicle, railway, other road vehicle) is involved in causing death.

For classification purposes, a motor vehicle not otherwise specified is NOT equivalent to a car. Motor vehicle accidents where the type of vehicle is unspecified are classified to V87-V89.

A vehicle not otherwise specified is NOT equivalent to a motor vehicle unless the accident occurred on the street, highway, road(way), etc. Vehicle accidents where the type of vehicle is unspecified are classified to V87-V89.

Additional information about type of transports is given below:

Car (automobile) includes blazer, jeep, minivan, sport utility vehicle
Pick-up truck or van includes ambulance, motor home, truck (farm) (utility)
Heavy transport vehicle includes armored car, dump truck, fire truck, panel truck, semi, tow truck, tractor-trailer, 18-wheeler
A special all-terrain vehicle (ATV) or motor vehicle designed primarily for off-road use includes dirt bike, dune buggy, four-wheeler, go cart, golf cart, racecar, snowmobile, three-wheeler
Motor vehicle includes passenger vehicle (private), street sweeper

2. Use of the Index and tabular list

ICD-10 provides a Table of land transport accidents in Volume 3, Section II. This table is referenced with any land transport accident if the mode of transportation is known. Since the Index does not always provide a complete code, reference to Volume 1, Chapter XX is required.

For V01-V09, the fourth character indicates whether a pedestrian was injured in a nontraffic accident, traffic accident, or unspecified whether traffic or nontraffic accident.

For V10-V79, the fourth character represents the status of the victim, i.e., whether the decedent was driver, passenger, etc. For each means of transportation, there is a different set of fourth characters. Each means of transportation is preceded by its set of fourth characters in Volume 1.

Code for Term

Car overturned, killing driver V485

In the Index, refer to:

Overturning

– transport vehicle NEC (see also Accident, transport) V89.9

Accident

– transport (involving injury to) (see also Table of land transport accidents) V99

In the Table of land transport accidents, select the intersection of:

Under Victim and mode of transport, select
Occupant of:

– car (automobile)

Under In Collision with or involved in: select
Noncollision transport accident

The code is V48.-. From Volume 1 the fourth character is 5, driver injured in traffic accident.

Code for Term

Auto collision with animal V409

In the Index, refer to:
Collision (accidental) NEC (see also Accident, transport) V89.9

Accident
– transport (involving injury to) (see also Table of land transport accidents) V99

In the Table of land transport accidents, select the intersection of:

Under Victim and mode of transport, select
Occupant of:
– car (automobile)

Under In collision with or involved in: select
Pedestrian or animal

The code is V40.-. From Volume 1, determine the fourth character is 9, unspecified car occupant injured in traffic accident.

3. Classifying accidents as traffic or nontraffic

If an event is unspecified as to whether it is a traffic or nontraffic accident, it is assumed to be:

Atraffic accident when the event is classifiable to categories V02-V04, V10-V82, and V87.
Anontraffic accident when the event is classifiable to categories V83-V86. These vehicles are designed primarily for off-road use.
Consider category V05 to be unspecified whether traffic or nontraffic if no place is indicated or if the place is railroad (tracks).
Consider category V05 to be traffic if place is railway crossing.
Consider accidents involving occupants of motor vehicles as traffic when the place is railroad (tracks).

Codes for Record

I (a) Laceration lung S273

(b)

(c)

II V575

Accident Truck struck bridge – Driver

Code to occupant of pick up truck or van injured in collision with fixed or stationary object, driver (V575). When a motor vehicle strikes another vehicle or object, assume the collision occurred on the highway unless otherwise stated.

Codes for Record

I (a) Fractured skull S029

(b)

(c)

II V866

Accident Farm Dune buggy overturned – passenger

Code to passenger of all-terrain or other off road vehicle injured in nontraffic accident (V866).

Codes for Record

I (a) Drowning T751 V863

Accident Snowmobile ran off road and went into pond

Code to unspecified occupant of all-terrain or other off road motor vehicle injured in traffic accident (V863). Code as traffic accident since the accident originated on the road.

4. Status of victim

General coding instructions relating to transport accidents are in Volume 1, Chapter XX. Refer to these instructions for clarification of the status of the victim when not clearly stated.

Codes for Record

I (a) Multiple internal injuries T065

(b) Crushed by car on highway T147 V031

Code to pedestrian injured in collision with car, pickup truck or van, traffic (V031). Refer to Volume 1, Chapter XX, instruction #3, Crushed by car. The victim is classified as a pedestrian. Refer to Table of land transport accidents. Victim and mode of transport, pedestrian, in collision (with) car (V03.-). Refer to Volume 1 for fourth character.

In classifying motor vehicle traffic accidents, a victim of less than 14 years of age is assumed to be a passenger provided there is evidence the decedent was an occupant of the motor vehicle. A statement such as “thrown from car,” “fall from” “struck head on dashboard,” “drowning,” or “carbon monoxide poisoning” is sufficient.

Female, 4 years old Codes for Record

I (a) Fractured skull S029

(b) Struck head on windshield when V476

Code to car occupant injured in collision with fixed or stationary object, passenger (V476).

When the transport accident descriptions do not specify the victim as being a vehicle occupant and the victim is described as:

pedestrian versus (vs) any vehicle (car, truck, etc.)

any vehicle (car, truck, etc.) versus (vs) pedestrian

classify the victim as a pedestrian (V01-V09).

5. Coding categories V01-V89

When drowning occurs as a result of a motor vehicle accident NOS, code asnoncollision transport accident. The assumption is the motor vehicle ran off the highway into a body of water. If drowning results from a specified type of motor vehicle accident, code the appropriate E-code for the specified type of motor vehicle accident.

Codes for Record

I (a) Drowning T751 V589

Accident Street Truck accident

Code to occupant of truck injured in noncollision transport accident (V589).

Codes for Record

I (a) Drowning T751 V435

Accident Street Driver – 2 car collision driveway

Code to occupant of car injured in collision with car, driver (V435).

When falls from transport vehicles occur, apply the following instructions:

(1) Consider a transport vehicle to be in motion unless there is clear indication the vehicle was not in transit. Refer to Table of land transport accidents, specified type of vehicle reported, noncollision. Refer to Volume 1 for appropriate fourth character.

Codes for Record

I (a) Multiple injuries T07

II V583

Accident Home Fell from truck in driveway

Code to occupant of truck injured in noncollision transport accident (V583). Refer to Table of land transport accidents under Victim and mode of transport. Select occupant of pick-up truck, noncollision transport accident, (V58.-). Refer to Volume 1 for fourth character and select 3, unspecified occupant of pick-up truck, nontraffic accident.

(2) Consider statements like these as stationary:

(a) Coded as transports with 4th character .4

alighted leaving

boarding exiting

entering getting in or out of vehicle

(b) Coded as Fall

stationary

parked

not in transit

not in motion

Codes for Record

I (a) Head injury S099

II V784

Accident Street Fell alighting from bus

Code to occupant of bus injured in noncollision transport accident (V784). Refer to Table of land transport accidents under Victim and mode of transport. Select occupant of bus, noncollision transport accident, (V78.-). Refer to Volume 1 for fourth character and select 4, person injured while boarding or alighting.

Codes for Record

I (a) Head Injury S099

II V892

Accident Street Fell on curb as he was exiting his daughter’s vehicle

Code to occupant of motor vehicle in noncollision transport accident (V892). Refer to Table of land transport accidents under Victim and mode of transport. Select occupant of motor vehicle (traffic), noncollision transport accident (V892).

Codes for Record

I (a) Head injury S099

II W17

Accident Street Fell from parked car

Code to other fall from one level to another (W17). Code as indexed under Fall, from, vehicle, stationary.

6. Additional examples

Codes for Record

I (a) Fracture of ribs S223

(b)

(c)

II V234

Accident Was driver of motorcycle which collided with taxicab

Code to motorcycle rider injured in collision with car, pick-up truck or van, driver (V234).

Codes for Record

I (a) Third degree burns T303

(b) Auto accident – car overturned V489

(c)

Code to car occupant injured in noncollision transport accident, unspecified (V489).

Codes for Record

I (a) Fracture of ribs S223

(b)

(c)

II V892

Accident Street Vehicle accident

Code to person injured in unspecified motor vehicle accident, traffic (V892). Code as motor vehicle accident since the accident occurred on the street.

7. Occupant of special all-terrain or other motor vehicle designed primarily for off-road use, injured in transport accident (V86)

This category includes accidents involving an occupant of any off-road vehicle. The fourth character indicates whether the decedent was injured in a nontraffic or traffic accident. Unless stated to the contrary, these accidents are assumed to be nontraffic.

Codes for Record

I (a) Multiple injuries T07

(b) Driver of snowmobile which V860

Code to driver of all-terrain or other off-road motor vehicle injured in traffic accident since the collision occurred with an automobile (V860).

Codes for Record

I (a) Injuries of head S099

(b) Driver of ATV V865

Code to driver of all-terrain or other off-road motor vehicle injured in nontraffic accident (V865).

Codes for Record

I (a) Head injuries S099

(b) Overturning snowmobile V869

Code to unspecified occupant of all-terrain or other off-road motor vehicle injured in nontraffic accident (V869).

Codes for Record

I (a) Fracture skull S029

(b) ATV accident V869

Code to unspecified occupant of all-terrain or other off-road motor vehicle injured in nontraffic accident (V869).

8. Scooter (motorized) vs Motor scooter

It is often hard to distinguish between when a scooter should be considered a pedestrian conveyance or a motorcycle.

In most cases, a scooter or motorized scooter refers to a motorized chair for people with immobility issues, code as a pedestrian conveyance. In instances where there is a scooter accident and POI is Home (with no other details provided) code to X599. However, if POI is street (with no other details provided) code to V099.

A motor scooter is a small motorcycle type vehicle, code to motorcycle.

Codes for Record

I (a) Cardiopulmonary arrest I469

(b) Severe head injury S099

(c)

II W18

Accident Home Victim fell off of scooter

Code to fall, from, sitting height or position (W18). Code as pedestrian conveyance since scooter (motorized) is listed in Volume 1 under the definition (e) for pedestrian

Codes for Record

I (a) Multiple blunt force injuries T07 V299

(b) Motor scooter incident

(c)

Accident Street Scooter incident

Code to motorcycle rider (any) injured in unspecified traffic accident (V299). Code as a motorcycle since motor scooter is listed in Volume 1 under definition (k) for motorcycle.

Codes for Record

I (a) Injuries sustained in auto – motorized scooter collision T149 V031

(b)

(c)

II Chronic obstructive lung disease and generalized arteriosclerosis J449 I709

Accident Highway Collision between automobile and motorized scooter, driver

Code to pedestrian injured in collision with car, pick-up truck or van (V031). Code as pedestrian conveyance since scooter (motorized) is listed in Volume 1 under the definition (e) for pedestrian.

Codes for Record

I (a) Respiratory failure J969

(b) Pneumonia J189

II Scooter accident V299

Accident Street Moped crash

Code to motorcycle rider (any) injured in unspecified traffic accident (V299). Code as a motorcycle since moped is listed in Volume 1 under definition (k) for motorcycle.

PLACE I (a) Scooter accident T149 &X599

0 (b)

(c)

MOD II

Accident home

Code to exposure to unspecified factor causing other and unspecified injury (X599). Code as pedestrian conveyance since scooter is listed in Volume 1 under definition (e) for pedestrian.

I (a) Scooter accident T149 &V099

(b)

(c)

MOD II

Accident street

Code to pedestrian injured in unspecified transport accident (V099). Code as pedestrian conveyance since scooter(motorized) is listed in Volume 1 under the definition (e) for pedestrian. Scooter accidents occurring on the street are assigned to a transport category.

9. Traffic accident of specified type but victim’s mode of transport unknown (V87)

Non-traffic accident of specified type but victim’s mode of transport unknown (V88)

If more than one vehicle is mentioned, do not make any assumptions as to which vehicle was occupied by the victim unless the vehicles are the same. Instead, code to the appropriate categories V87-V88. Statements such as these do not indicate status of victim.

Auto (passenger) vs. truck • Passenger car vs. truck
Car vs. truck-driver • Car vs. truck, driver
Driver, car vs. truck • Driver-car vs. truck

Codes for Record

I (a) Intrathoracic injury S279

(b)

Do not make any assumption as to which vehicle the victim was occupying. Using the Index, code:

Accident

– transport (involving injury to) (see also Table of land transport accidents) V99

– – person NEC (unknown means of transportation) (in) V99

– – – collision (between)

– – – – car (with)

– – – – – two-or three-wheeled motor vehicle (traffic) V87.0

Codes for Record

I (a) Head injuries S099

(b) Driver – collision of car and bus V873

(c)

Do not make any assumption as to which vehicle the victim was driving. Using the Index, code:

Accident

– transport (involving injury to) (see also Table of land transport accidents) V99

– – person NEC (unknown means of transportation) (in) V99

– – – collision (between)

– – – – car (with)

– – – – – bus V87.3

If reported types of vehicles are not indexed under Accident, transport, person, collision, code V877 for traffic and V887 for nontraffic.

Codes for Record

I (a) Head injuries S099

(b) Bus and pick-up truck collision, driver V877

(c)

Do not make any assumption as to which vehicle the victim was driving. Collision between bus and pick-up is not indexed under Accident, transport, person, collision. Code V877.

10. Water transport accidents (V90-V94)

The fourth character subdivision indicates the type of watercraft. Refer to Volume 1, Chapter XX, Water transport accidents for a list of the fourth character subdivisions.

Codes for Record

I (a) Drowning T751 V929

(b) Fell over-board

(c)

Code to Drowning, due to fall overboard (V929). Use fourth character “9,” unspecified watercraft.

11. Air and space transport accidents (V95-V97)

For air and space transport accidents, the victim is only classified as an occupant.

Military aircraft is coded to V958, Other aircraft accidents injuring occupant, since a military aircraft is not considered to be either a private aircraft or a commercial aircraft. Where death of military personnel is reported with no specification as to whether the airplane was a commercial or private craft, code V958.

12. Miscellaneous coding instructions (V01-V99)

When multiple deaths occur from the same transportation accident, all the certifications should be examined, and when appropriate, the information obtained from one may be applied to all. There may be other information available such as newspaper articles. A query should be sent to the certifier if necessary to obtain the information.
When classifying accidents which involve more than one kind of transport, use the following order of precedence:

aircraft and spacecraft (V95-V97)

watercraft (V90-V94)

other modes of transport (V01-V89, V98-V99)

Codes for Record

I (a) Multiple fractures T029

(b) Driver of car killed when V973

(d) car on highway after forced landing

Code to person on ground injured in air transport accident following order of precedence. Refer to Volume 3, Accident, transport, aircraft, person, on ground (V973).

When no external cause information is reported and the place of occurrence of the injuries was highway, street, road(way), or alley, assign the external cause code to person injured in unspecified motor vehicle accident, traffic.

Codes for Record

I (a) Head injuries and fracture S099 S029

II V892

Accident Highway

Code to person injured in unspecified motor vehicle accident, traffic (V892).

W18 Other fall on same level

This category includes falls when other or additional information about the fall is reported such as:

Fell from standing height

Fell moving from wheelchair to bed

Fell striking head

Fell striking object

Fell to floor

Fell while transferring from chair to bed

Fell while walking

Lost balance and fell

Codes for Record

I (a) Fractured right hip S720

II Lost balance and fell to floor W18

Code to other fall on same level (W18).

W19 Unspecified fall

This category includes: fall, fell, or fell at a place.

Codes for Record

I (a) Fractured right hip S720

II Fell at nursing home W19

Code to unspecified fall (W19) since the only information is the place it occurred.

Falls with other external events

When fall is reported more information must be obtained in order to assign the most appropriate code. This information will be reported in Part I and Part II of the medical certification, also the place of injury and the description of how injruy occurred.

Is a vehicle or transport involved?

YES: Refer to coding instructions for categories V01 – V89. This includes reference to table of land transport accidents. This section also includes specific instructions for fall from transport vehicle.

NOTE: fall from animal: see V80-

Is a fire involved?

YES: See code categories X00 – X09.

Is machinery in operation involved?

YES: See code categories W28 – W31.

Is drowning or submersion in water involved?

YES: See code categories W65 – W74.

Is struck by a falling object involved?

YES: See code categories W20 – W49

Is a human stampede or pushed by a crowd involved?

YES: Code W52

If none of the above, see code categories W00 – W19 for specific codes.

W75 Accidental suffocation and strangulation in bed

This category INCLUDES suffocation of infants “while asleep” NOS or when reported with terms that involve sleep such as co-sleeping or sleeping.

W78 Inhalation of gastric contents

W79 Inhalation and ingestion of food causing obstruction of respiratory tract

W80 Inhalation and ingestion of other object causing obstruction of respiratory tract

EXCLUDES conditions in the above categories when reported as the underlying cause of:

J180 Bronchopneumonia, unspecified, code Pneumonitis due to solids and liquids, J69.-

J181 Lobar Pneumonia, unspecified, code Pneumonitis due to solids and liquids, J69.-

J189 Pneumonia, unspecified, code Pneumonitis due to solids and liquids, J69.-

J69 Pneumonitis due to solids and liquids, code J69.-

X30-X39 Exposure to forces of nature

These categories INCLUDE accidents resulting directly from forces over which man has no control, but EXCLUDES those resulting indirectly through a second event which is classified to the causative agent involved in the subsequent accident.

Codes for Record

I (a) Drowned T751 X37

(b) Car which decedent was driving was washed

Code to victim of cataclysmic storm (X37). The drowning was a direct result of the hurricane.

Codes for Record

I (a) Suffocation T71 X36

(b) Covered by landslide

Code to victim of avalanche, landslide and other earth movements (X36).

Codes for Record

I (a) Suffocated by smoke T598 X00

(b) Home burned after being

Code to exposure to uncontrolled fire in building or structure (X00). Category X33 includes only those injuries resulting from direct contact with lightning.

Codes for Record

I (a) Ruptured diaphragm S278

(b) Driver of auto which struck V475

Code to car occupant injured in collision with fixed or stationary object, driver (V475).

X40-X49 Accidental poisoning by and exposure to noxious substances

1. Poisoning by drugs

When the following statements are reported, see Table of drugs and chemicals for the external cause code and code as accidental poisoning unless otherwise indicated.

Interpret all these statements to mean poisoning by drug and code as poisoning whether or not the drug was given in treatment:

drug taken inadvertently
lethal (amount) (dose) (quantity) of a drug
overdose of drug
poisoning by a drug
toxic effects of a drug
toxic reaction to a drug
toxicity (of a site) by a drug
wrong dose taken accidentally
wrong drug given in error

Male, 2 years Codes for Record

I (a) Overdose of aspirin T390 X40

(b) Flu and cold J1110 J00

(c)

II Aspirin given for fever – 10 days T390, R509

Code to X40, accidental poisoning by and exposure to nonopioid analgesics, antipyretics, and antirheumatics.

Codes for Record

I (a) Poisoning by barbiturates T423 X41

Code to X41, accidental poisoning by and exposure to anti-epileptic, sedative-hypnotic, anti-parkinsonism and psychotropic drugs, not elsewhere classified.

Interpret “intoxication by drug” to mean poisoning by drug unless indicated or stated to be due to drug therapy or as a result of treatment for a condition. Refer to Section IV, B, Y40-Y59 for instructions regarding intoxication by drug.

Codes for Record

I (a) Respiratory failure J969

(b) Digitalis intoxication T460 X44

Code to X44, digitalis intoxication as poisoning when there is no indication the drug was given for therapy.

When components of combinations of medicinal agents classifiable to X40-X44 are involved, proceed as follows:

(1) When accidental poisoning from a single drug is reported in Part I with a combination of drugs in Part II, code the external cause code for the drug reported in Part I.

Codes for Record

I (a) Acute barbiturate intoxication T423 X41

II Accident – Took unknown amount of barbiturates and aspirin T423 T390

Code to X41, accidental poisoning by barbiturates since certifier indicated this drug was the cause of death.

(2) When accidental poisoning by a combination of drugs classified to different external cause codes is reported and (1) does not apply, code the external cause code to X44, accidental poisoning and exposure to other and unspecified drugs, medicaments, and biological substances. Note that this applies to accidental manner of death only. Use the following codes for the different manners of death: Suicide X64, Homicide X85 and Undetermined Y14. Note that this does not apply to chemicals such as carbon monoxide and acetone.

Codes for Record

I (a) Drug intoxication T509 X44

(b) Digitalis & cocaine intoxication T460 T405

Code to X44, accidental poisoning by and exposure to other and unspecified drugs, medicaments, and biological substances.

(3) Combinations of medicinal agents with alcohol should be coded to the medicinal agent.

Codes for Record

I (a) Acute respiratory failure J960

(b) due to synergistic action T519 X45 T404 X42

Code to X42, accidental poisoning by and exposure to narcotics and psychodysleptics (hallucinogens), not elsewhere classified. Synergistic action of alcohol and a medicinal agent is classified to poisoning by the medicinal agent.

Codes for Record

I (a) Alcohol and barbiturate intoxication T519 X45 T423 X41

Code to X41, accidental poisoning by and exposure to antiepileptic, sedative-hypnotic, antiparkinsonism and psychotropic drugs, not elsewhere classified. Alcoholic intoxication or poisoning reported in combination with medicinal agents is classified to poisoning by the medicinal agents.

EXCEPTION: When alcohol poisoning is reported in Part I and drug poisoning in Part II, code to the alcohol.

Codes for Record

I (a) Poisoning by alcohol T519 X45

(b)

II Toxic levels of heroin and flunitrazepam T401 X44 T424

Code to X45, accidental poisoning by and exposure to alcohol. Alcohol poisoning reported in Part I with drug poisoning in Part II is coded to the alcohol.

2. Carbon monoxide poisoning

Code carbon monoxide poisoning from motor vehicle exhaust gas to noncollision motor vehicle accident (traffic) according to type of motor vehicle involved unless there is indication the motor vehicle was not in transit. Consider statements of “sleeping in car,” “sitting in car,” “in parked car” or place stated as “garage” to indicate the motor vehicle was “not in transit.” Assume “not in transit” in self-harm (intentional) and self-inflicted cases.

X60-X84 Intentional self-harm

The categories X60-X84 include intentionally self-inflicted poisoning or injury as well as deaths specified as suicide (attempted). The codes are indexed under the event as well as under “Suicide” in the External causes of injury index.

Codes for Record

I (a) Hanging T71 X70

Suicide

Code to intentional self-harm by hanging, strangulation and suffocation (X70).

X85-Y09 Assault

The categories X85-Y09 include injuries inflicted by another person with intent to injure or kill by any means as well as deaths specified as homicide. The codes are indexed under the event as well as under “Assault” in the External causes of injury index.

When the manner of death block is marked as Homicide but the certifier specifies Accident elsewhere on the certificate, code as Accident. The definition of homicide as “death at the hands of another” may lead certifiers to mark Homicide in the checkbox when really the death itself was unintentional.

Words like deliberately, intentionally, purposefully or assault can be interpreted as intentional and coded as homicide.

Codes for Record

I (a) Gunshot wound T141 X95

Homicide

Code to assault by other and unspecified firearm discharge (X95).

Codes for Record

I (a) Accidental gunshot wound T141 W34

Homicide

Code to Discharge from other and unspecified firearms (W34).

Y07 Other maltreatment syndromes

Code to category Y070-Y079, if the age of the decedent is under 18 years and the cause of death meets one of the following criteria:
The certifier specifies abuse, beating, battering, or other maltreatment, even if homicide is not specified.

Male, 3 years Codes for Record

I (a) Traumatic head injuries S099

(b)

(c)

II Deceased had been beaten Y079

Home

Code to other maltreatment syndromes by unspecified person (Y079).

The certifier specifies homicide and injury or injuries with indication of more than one episode of injury, i.e., current injury coupled with old or healed injury consistent with a history of child abuse.

Male, 1-1/2 years Codes for Record

I (a) Anoxic encephalopathy G931

(b) Subdural hematoma S065

II Y079

Homicide

Code to other maltreatment syndromes by unspecified person (Y079).

The certifier specifies homicide and multiple injuries consistent with an assumption of beating or battering, if assault by a peer, intruder, or by someone unknown to the child cannot be reasonably inferred from the reported information.

Female, 1 year Codes for Record

I (a) Massive internal bleeding T148

(b) Multiple internal injuries T065

(c)

II Injury occurred by child being struck T149 Y079

Homicide

Code to other maltreatment syndromes by unspecified person (Y079).

Deaths at ages under 18 years for which the cause of death certification specifies homicide and an injury occurring as an isolated episode, with no indication of previous mistreatment, should not be classified to Y070-Y079. This excludes from Y070-Y079 deaths due to injuries specified to be the result of events such as shooting, stabbing, hanging, fighting, or involvement in robbery or other crime, because it cannot be assumed that such injuries were inflicted simply in the course of punishment or cruel treatment.

Female, 1 year Codes for Record

I (a) Hypovolemic shock T794

(b) Laceration of heart S268

II Stabbed with kitchen knife by mother T141

Homicide Home

Code to assault by sharp object (X99).

Y10-Y34 Event of undetermined intent

Y10-Y34 are for use when it is stated that an investigation by a medical or legal authority has not determined whether the injuries are accidental, suicidal, or homicidal. They include such statements as “jumped or fell,” “don’t know,” “accidental or homicidal,” “accidental or suicide,” “undetermined.” They also include self-inflicted injuries, other than poisoning, when not specified whether accidental or with intent to harm. When more than one manner of death is indicated on the certificate, code as could not be determined.

Codes for Record

I (a) Fx. skull, laceration of brain S029 S062

II Y34

Unknown whether accidental or homice

Code to unspecified event, undetermined intent (Y34).

Codes for Record

I (a) Barbiturate overdose T423 Y11

Undetermined

Code to poisoning by and exposure to antiepileptic, sedative-hypnotic, antiparkinsonism and psychotropic drugs, not elsewhere classified, undetermined intent (Y11).

Codes for Record

I (a) Cerebral hemorrhage S062

(b) Shot self in head S019 Y24

Code to other and unspecified firearm discharge, undetermined intent (Y24).

Y40-Y59 Drugs, medicaments and biological substances causing adverse effects in therapeutic use

1. Condition due to (named) drug or drug therapy

When a condition is reported due to a (named) drug or drug therapy, consider the condition to be a complication of a correct drug and medicinal substance properly administered providing the sequence is acceptable. This instruction also includes a condition reported due to drug use or named drug use unless:

The drug is one which is not used for medical purposes, e.g., LSD or heroin.

It was an analgesic, sedative, narcotic or psychotropic drug (or combination thereof) or drug NOS

AND the certifier indicated the death was due to an “accident”, “suicide”, or it occurred under “undetermined circumstances,”

One or more of these drugs was taken in conjunction with alcohol

If one of the exceptions apply, code to poisoning (refer to Section IV, B, X40-X49). Use the following instructions to select the correct underlying cause if a condition is reported due to a (named) drug or drug therapy.

If the condition for which the drug is being administered is stated, code this condition as the underlying cause applying any appropriate modification rule(s).

Codes for Record

I (a) Allergic reaction T887

(b) Drug therapy Y579

Code to pyelitis (N12), the condition requiring treatment.

Codes for Record

I (a) Diabetes E139

(b) Steroid Use Y427

II Rheumatoid Arthritis M069

Code to rheumatoid arthritis (M069), the condition requiring treatment.

Codes for Record

I (a) Pulmonary insufficiency J984

(b) Drug given for tachycardia Y579

Code to pulmonary insufficiency (J984), the complication of the drug. Tachycardia is selected as the condition for which the drug was administered, then disregarded by Rule A and the complication of the drug is reselected.

If the condition being treated is not stated, and the complication of the drug therapy is indexed to Chapters I-XVIII, code this condition as the underlying cause applying any appropriate modification rule(s).

Codes for Record

I (a) Respiratory arrest R092

(b) Ulcer of stomach K259

Code to ulcer of stomach (K259), the complication of the drug therapy as classified in Chapters I-XVIII.

Codes for Record

I (a) Cardiac arrest I469

(b) Drug therapy Y579

Code to Y579, drug or medicament unspecified. Cardiac arrest, the complication of the therapy, is selected as the TUC since the condition being treated is not stated. Rule A is applied and the code for the drug is reselected.

If the condition being treated is not stated, and the complication is indexed to Chapter XIX, code external cause Y40-Y59 as the underlying cause.

Codes for Record

I (a) Allergic reaction to T887 Y400

(b) penicillin

Code to adverse effect of penicillin in correct usage (Y400) since Allergic (reaction), drug is indexed T887 in Chapter XIX.

2. Intoxication by drug

When “intoxication by drug” is reported or indicated to be due to treatment for a condition or due to drug therapy, consider as a complication of drug therapy, not poisoning.

Codes for Record

I (a) Cardiac arrest I469

(b) Digitalis intoxication T887 Y520

Code to ASHD (I251), the condition requiring treatment. Digitalis intoxication is indicated to be drug therapy since it is reported due to a condition for which it could have been given.

3. Combined effects of two or more drugs

When a complication is reported due to the combined effects of two or more drugs:

When the drugs are classified to different fourth characters of the same three-character category, code the appropriate E-code with the fourth character for “other.”

Codes for Record

I (a) Adverse reaction T887

(b) Valium and sleeping pills Y478

Code to other sedatives, hypnotics and antianxiety drugs, the combination code for valium and sleeping pills (Y478).

When the drugs are classified to different three-character categories, code the E-code to Y578, “Other drugs and medicaments.”

Codes for Record

I (a) Adverse reaction T887

(b) Anticoagulant and aspirin Y578

Code to other drugs and medicaments, the combination code for anticoagulant and aspirin (Y578).

Y60-Y83 Adverse effects and misadventures occurring as a result of a surgical procedure

In determining a sequence of conditions involving surgery, first determine if a complication is reported. Therefore, it is necessary to know if a condition can be due to the surgery and thus be regarded as a complication. Although almost any condition reported due to surgery is regarded as a complication, there are a few diseases that are not considered complications. The following are not regarded as complications of surgery:

Infectious and parasitic diseases A000-A309, A320-A329, A360-A399,

A420-A449, A481-A488, A500-A690,

A692-B349, B500-B949

Neoplasms C000-D489

Hemophilia D66, D67, D680, D681, D682

Diabetes E10-E14

Alcoholic disorders E52, E244, F101-F109, G312, G405,

G621, G721, I426, K292, K700-K709,

K852, K860, L278, R780, R826, R893

Rheumatic fever or rheumatic heart I00-I099

disease

Hypertensive diseases I11-I139, I150, I159

Coronary artery disease I251

Coronary disease

Ischemic cardiomyopathy I255

Chronic or degenerative myocarditis I514

Arteriosclerosis and arteriosclerotic

conditions except those classified

to I219

Calculus or stones of any kind

Influenza J09-J118

Hernia except ventral (incisional) K400-K429, K440-K469

Diverticulitis K570-K579

Rheumatoid arthritis M050-M089

Collagen disease M300-M359

Congenital malformations Q000-Q999

This is not an all inclusive list.

Codes for Record

I (a) Myocardial infarction I219

(b) Arteriosclerosis I709

Code to myocardial infarction (I219) by Rules 1 and C, since arteriosclerosis is not accepted as due to surgery.

Code for Record

I (a) Diabetic gangrene E145

(b) Leg amputation

Code to diabetic gangrene (E145) since diabetes is not accepted as due to surgery.

When a sequence of conditions involving an operation is responsible for a death, the cause for which the operation was performed is coded, unless it is the result of another condition. In the latter case, the original cause is coded. If the reason for the operation is not stated or implied, select the external cause code for the operation as the underlying cause. However, when selecting the sequence responsible for death, no preference is given because an operation was involved.

If a term denoting an operation is selected as the cause of death without mention of the condition for which it was performed, or of the findings of the operation, and the Index provides no assignment for it:

It is assumed that the condition for which the operation is usually performed was present and assignment will be made in accordance with the rules for selection of the cause of death (e.g. code “appendectomy” to K37).

Use the following codes when these surgical procedures are reported and the condition necessitating the surgery is not reported:

Aorta (with any other vessel NEC) bypass or graft…… I779

Aorta coronary bypass or graft……………………. I251

Atrio-ventricular shunt………………………….. G919

Bariatric surgery……………………………….. E668

Billroth (I or II)……………………………… K3190

Brock valvulotomy……………………………….. Q223

Cardiac revascularization………………………… I251

Carotid endarterectomy…………………………… I679

Choledochoduodenostomy…………………………… K839

Cholecystectomy…………………………………. K829

Cholelithotomy………………………………….. K802

Colostomy………………………………………. K639

Coronary artery bypass graft (CABG)……………….. I251

Coronary endarterectomy………………………….. I251

Coronary revascularization……………………….. I251

Endarterectomy (artery) (aorta)…………………… I779

Femoral bypass………………………………….. I779

Femoral-popliteal bypass…………………………. I779

Gastrectomy……………………………………. K3190

Gastric stapling………………………………… E668

Gastroenterostomy……………………………….. K929

Gastro-intestinal surgery NOS…………………….. K929

Gastrojejunostomy……………………………….. K929

Gastrojejunectomy……………………………….. K929

Herniorrhaphy…………………………….. code hernia

Hip fixation………………………… code hip fracture

Hip pinning…………………………. code hip fracture

Hip prosthesis………………………………….. M259

Hip replacement…………………………………. M259

Hysterectomy……………………………………. N859

Ileal conduit…………………………………… N399

Ileal loop……………………………………… N399

Iliofemoral bypass………………………………. I779

Lobectomy – when indicating lung…………………. J9840

Mammary artery (internal) implant…………………. I251

Revascularization of heart……………………….. I251

Revascularization, myocardial…………………….. I251

T and A………………………………………… J359

Thoracoplasty…………………………………… J989

Tonsillectomy…………………………………… J359

Ureterosigmoid bypass……………………………. N399

Ureterosigmoidostomy…………………………….. N399

Vein stripping………………………………….. I839

Ventricular peritoneal shunt……………………… G919

Vineberg operation………………………………. I251

However, if the name of the operation leaves in doubt what specific morbid condition was present, additional information is to be sought.
If there is no further information concerning the condition for which the surgery was performed, code to the residual category fordisease of the site indicated by the name of the operation. Do not assume a disease condition for other medical care.
When neither the organ nor the site is indicated in the operative term, code the appropriate external cause code for the surgery.
If the reason for the operation is not stated or implied, code the appropriate external cause code for the surgery.
When the only reported condition indicates an operation and the record cannot be classified by the previous instructions, code to “Other ill-defined and unspecified causes of mortality” (R99).

These procedures include:

amputation pelvic exenteration

arteriovenous shunt portocaval shunt

chordotomy radical neck dissection

craniotomy rhizotomy

cystostomy sympathectomy

D & C tracheotomy

gastrostomy tracheostomy

laminectomy tubal ligation

laparotomy vagotomy

lobectomy NOS vasectomy

lobotomy vas ligation

If one of these types of procedures is the only entry on the certificate, code R99.

For complications of operations for purposes of applying Rule 3, Direct sequel, refer to Section II, Selection Rule 3.

Y84 Other medical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of procedure.

This category is not to be used if the reason for treatment is indicated. However, do not assume a condition for the reason medical care was administered.

Y60-Y69 Misadventures to patients during surgical and medical care

These categories are limited to deaths explicitly indicated to be the result of an error or accident during medical care. These categories are not to be used if the condition requiring treatment is indicated. When the condition requiring treatment is not stated or implied, code the underlying cause to Y60-Y69. This does not apply when serum hepatitis is reported as a complication of blood transfusion, in this case code the underlying cause to serum hepatitis provided the reason for treatment is not reported.

Codes for Record

I (a) Shock R579

(b) Laceration of liver T812

Code to accidental cut (laceration) during needle biopsy (Y606). “Laceration” is an explicit indication of accident during medical care. The condition requiring treatment is not stated.

Codes for Record

I (a) Peritonitis K659

(b) Perforated jejunum T812

(d) carcinoma of small bowel C179

Code to carcinoma of small bowel (C179), the reason for the surgery.

Codes for Record

I (a) Laceration of heart T812

(b) Open heart surgery Y600 I519

Code to I519, Disease, heart, as the condition for which the surgery was performed.

Codes for Record

I (a) Hemorrhage during T810

(b) craniotomy Y600

Code to hemorrhage during surgical and medical care (Y600). Interpret hemorrhage stated as “intraoperative” or “during” medical and surgical care as a misadventure during surgical and medical care.

Codes for Record

I (a) Serum hepatitis B169

(b) Blood transfusion Y640

Code to serum hepatitis (B169). The E-code for blood transfusion is not used since serum hepatitis is the complication.

Codes for Record

I (a) Rib fracture T818

(b) Cardiopulmonary resuscitation Y658

Code to Y658, Other specified misadventure during surgical and medical care. Interpret fracture (thoracic area) reported due to cardiopulmonary resuscitation as a misadventure during medical care.

Y85-Y89 Sequela of external causes of morbidity and mortality

A sequela is a late effect, an after effect, or a residual of a nature of injury or external cause. The Classification provides categories Y850-Y899 for sequela of external causes. If either the nature of injury or the external cause requires a sequela code, the selected external cause must be coded to a sequela category. Use the following guidelines to determine when the external cause should be coded to a sequela category.

Y850 Sequela of motor vehicle accident (includes V01-V89)

Y859 Sequela of other and unspecified transport accidents (includes V90-V99)

Y86 Sequela of other accidents (excludes W78-W80)

Y870 Sequela of intentional self-harm

Y871 Sequela of assault

Y872 Sequela of events of undetermined intent

Y880 Sequela of adverse effects caused by drugs, medicaments, and biological substances in therapeutic use

Y881 Sequela of misadventures to patients during surgical and medical procedures

Y882 Sequela of adverse incidents associated with medical devices in diagnostic and therapeutic use

Y883 Sequela of surgical and medical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure

Y890 Sequela of legal intervention

Y891 Sequela of war operations

Y899 Sequela of unspecified external cause

Stated sequela of external causes, injuries or trauma unless the interval between date of external cause and date of death is less than 1 year.

Codes for Record

I (a) Sequela of hip fracture T931

(b)

(c)

II Y86

Code to Y86 since a sequela of hip fracture is reported.

Injuries described as ancient, by history, healed, history, history of, late effect of, old, remote or delayed union, malunion or nonunion of a fracture regardless of duration.

Codes for Record

I (a) Old head injuries T909

(b) Gunshot wound T941 Y870

II Attempted suicide

Code to Y870, sequela of intentional self-harm, since injuries are “old.”

External causes described as ancient, by history, history, history of, old, remote, regardless of reported duration.

Codes for Record

I (a) Old fall, fractured hip 6 months T931 Y86

(b)

(c)

II Accident Fell and fractured hip T931

6 months ago

Code to Y86, sequela of other accidents, since the external cause is stated as “old.”

External causes, injuries, or trauma when interval between occurrence and death is 1 year or more.

Codes for Record

I (a) Fractured spine T911

(b) Automobile accident, 18 mos ago Y850

Code to Y850, sequela of automobile accident, since duration is one year or more.

Codes for Record

I (a) Renal failure N19

(b) Intestinal obstruction K566

II Surgery – 16 months ago Y883

Code to Y883, sequela of surgical and medical procedures, since surgery was performed one year or more before death.

A condition with a duration of one year or more reported due to the external cause, injuries, or trauma.

Codes for Record

I (a) Respiratory failure J969

(b) Paraplegia 2 years T913

Code to Y850, sequela of motor vehicle accident, since a condition with a duration of one year or more is reported due to the external cause. Category Y850 includes categories classified to V01-V89.