Instructions for Classification of Underlying and Multiple Causes of Death – Section II – 2021

SECTION II – PROCEDURES FOR SELECTION OF THE UNDERLYING CAUSE OF DEATH FOR MORTALITY TABULATION

The following are the international rules for selecting the underlying cause of death for mortality tabulation. Some examples have been omitted and additional examples and explanations presented.

When only one cause of death is reported, this cause is used for tabulation.

When more than one cause of death is recorded, the first step in selecting the underlying cause is to determine the originating antecedent cause by application of the General Principle or of Selection Rules 1, 2 and 3.

In some circumstances, the ICD allows the originating cause to be superseded by one more suitable for expressing the underlying cause in tabulation. For example, there are some categories for combinations of conditions, or there may be overriding epidemiological reasons for giving precedence to other conditions on the certificate.

The next step, therefore, is to determine whether one or more of the Modification Rules A to F, which deal with the above situations, apply. The resultant code number for tabulation is that of the underlying cause.

Where the originating antecedent cause is an injury or other effect of an external cause classified to Chapter XIX, the circumstances that gave rise to that condition should be selected as the underlying cause for tabulation and coded to V01-Y89.

Rules for selection of the originating antecedent cause

Sequence

The term “sequence” refers to two or more conditions entered on successive lines of Part I, each condition being an acceptable cause of the one entered on the line above it.

I (a) Bleeding of esophageal varices

(b) Portal hypertension

(d) Hepatitis B

If there is more than one cause of death on a line of the certificate, it is possible to have more than one reported sequence. In the following example, four sequences are reported:

I (a) Coma

(b) Myocardial infarction and cerebrovascular accident

The sequences are:

coma due to myocardial infarction due to atherosclerosis

coma due to cerebrovascular accident due to atherosclerosis

coma due to myocardial infarction due to hypertension

coma due to cerebrovascular accident due to hypertension

General Principle

The General Principle states that when more than one condition is entered on the certificate, the condition entered alone on the lowest used line of Part I should be selected only if it could have given rise to all the conditions entered above it.

Selection Rules:

Rule 1. If the General Principle does not apply and there is a reported sequence terminating in the condition first entered on the certificate, select the originating cause of this sequence. If there is more than one sequence terminating in the condition mentioned first, select the originating cause of the first-mentioned sequence.

Rule 2. If there is no reported sequence terminating in the condition first entered on the certificate, select this first-mentioned condition.

Rule 3. If the condition selected by the General Principle or by Rule l or Rule 2 is obviously a direct consequence of another reported condition, whether in Part I or Part II, select this primary condition.

Some considerations on selection rules:

In a properly completed certificate, the originating antecedent cause will have been entered alone on the lowest used line of Part I and the conditions, if any, that arose as a consequence of this initial cause will have been entered above it, one condition to a line in ascending causal order.

I (a) Uremia

(b) Hydronephrosis

(d) Hypertrophy of prostate

I (a) Bronchopneumonia

(b) Chronic bronchitis

II Chronic myocarditis

In a properly completed certificate the General Principle will apply. However, even if the certificate has not been properly completed, the General Principle may still apply provided that the condition entered alone on the lowest used line of Part I could have given rise to all the conditions above it, even though the conditions entered above it have not been entered in the correct causal order.

I (a) Generalized metastases 5 weeks

(b) Bronchopneumonia 3 days

The General Principle does not apply when more than one condition has been entered on the lowest used line of Part I, or if the single condition entered could not have given rise to all the conditions entered above it. Guidance on the acceptability of different sequences is given at the end of the rules, but it should be borne in mind that the medical certifier’s statement reflects an informed opinion about the conditions leading to death and about their interrelationships, and should not be disregarded lightly.

Where the General Principle cannot be applied, clarification of the certificate should be sought from the certifier whenever possible, since the selection rules are somewhat arbitrary and may not always lead to a satisfactory selection of the underlying cause. Where further clarification cannot be obtained, however, the selection rules must be applied. Rule l is applicable only if there is a reported sequence, terminating in the condition first entered on the certificate. If such a sequence is not found, Rule 2 applies and the first-entered condition is selected.

The condition selected by the above rules may, however, be an obvious consequence of another condition that was not reported in a correct causal relationship with it; e.g., in Part II or on the same line in Part I. If so, Rule 3 applies and the originating primary condition is selected. It applies, however, only when there is no doubt about the causal relationship between the two conditions; it is not sufficient that a causal relationship between them would have been accepted if the certifier had reported it.

Examples of the General Principle and Selection Rules

General Principle

When more than one condition is entered on the certificate, select the condition entered alone on the lowest used line of Part I only if it could have given rise to all the conditions entered above it.

Interpretations and Examples

The General Principle is the rule under which the certifier’s report is accepted using the following criteria in the order stated:

One condition is entered on the lowest used line and all the conditions entered above it must be entered in a “reported sequence” and there must be only one condition per line.

Codes for Record

I (a) Cerebral hemorrhage 1 mo I619

(b) Nephritis 6 mos N059

Select cirrhosis of liver. This is a reported sequence. Each condition on the successive lines in Part I is an acceptable cause of the one entered on the line above it. The sequence is cerebral hemorrhage due to nephritis due to cirrhosis of liver.

Or it must be probable that the condition reported alone on the lowest used line could have given rise to all the conditions entered above it.

Codes for Record

I (a) Apoplexy with pneumonia 8 days I64 J189

(b)

II Myocarditis I514

Select diabetes. Diabetes can give rise to both conditions reported on I(a). Apoplexy is due to diabetes and pneumonia is due to diabetes.

Codes for Record

I (a) Congestive heart failure 1 yr I500

(b) Cerebral hemorrhage 2 days I619

II Large bowel obstruction K566

Select chronic alcoholism. It is not necessary for the conditions on (a) and (b) to be causally related since the condition entered alone on (c) can give rise to both conditions. Congestive heart failure is due to chronic alcoholism and cerebral hemorrhage is due to chronic alcoholism.

Rule 1. Reported sequence terminating in the condition first entered on the certificate

If the General Principle does not apply and there is a reported sequence terminating in the condition first entered on the certificate, select the originating cause of this sequence. If there is more than one sequence terminating in the condition mentioned first, select the originating cause of the first-mentioned sequence.

Interpretations and Examples

Codes for Record

I (a) Pulmonary embolism I269

(b) Arteriosclerotic heart disease I251

Select arteriosclerotic heart disease (ASHD). The General Principle is not applicable because influenza cannot cause ASHD. The reported sequence terminating in the condition first entered on the certificate is pulmonary embolism due to arteriosclerotic heart disease.

Codes for Record

I (a) Bronchopneumonia J180

(b) Cerebral infarction and

hypertensive heart disease I639 I119

Select cerebral infarction. The General Principle is not applicable since there are two conditions on the lowest used line in Part I. There are two reported sequences terminating in the condition first entered on the certificate; bronchopneumonia due to cerebral infarction, and bronchopneumonia due to hypertensive heart disease. The originating cause of the first-mentioned sequence is selected.

Codes for Record

I (a) Cerebral hemorrhage & hypostatic I619 J182

(b) pneumonia

Select diabetes. The General Principle is not applicable since there are two conditions on the lowest used line. Cerebral hemorrhage is not due to prostate hypertrophy; therefore, diabetes is selected by Rule 1.

Rule 2. No reported sequence terminating in the condition first entered on the certificate

If there is no reported sequence terminating in the condition first entered on the certificate, select this first-mentioned condition.

Interpretations and Examples

Codes for Record

I (a) Pernicious anemia and

gangrene of foot D510 R02

(b) Atherosclerosis I709

Select pernicious anemia. Neither the General Principle nor Rule 1 is applicable. Pernicious anemia due to atherosclerosis is not an acceptable sequence. There is a reported sequence, gangrene of foot due to atherosclerosis, but does not terminate in the condition first entered on the certificate.

Codes for Record

I (a) Rheumatic and atherosclerotic

heart disease I099 I251

Select rheumatic heart disease. There is no reported sequence; both conditions are on the same line.

Codes for Record

I (a) Coronary occlusion I219

(b) Cerebrovascular disease I679

Select coronary occlusion. Neither the General Principle nor Rule 1 is applicable. Since cerebrovascular disease is an unacceptable cause of coronary occlusion, or any other ischemic heart disease, there is no reported sequence terminating in the condition first entered on the certificate.

Rule 3. Direct sequel

If the condition selected by the General Principle or by Rule l or Rule 2 is obviously a direct consequence of another reported condition, whether in Part I or Part II, select this primary condition.

Abbreviations

The following abbreviations are used to identify different types of direct sequel code relationships:

DS: (Direct sequel) When the tentative underlying cause is considered a direct sequel of another condition on the certificate in Part I (must be on same or lower line as tentative underlying cause) or Part II, and the code for the other condition is preferred over the code for the tentative underlying cause.

DSC: (Direct sequel combination) When the tentative underlying cause is considered a direct sequel of another condition on the certificate in Part I (must be on same or lower line as tentative underlying cause) or Part II, and the codes for the tentative underlying cause and the other condition combine into a third code.

Assumed direct consequences of another condition

Kaposi sarcoma, Burkitt tumor and any other malignant neoplasm of lymphoid, hematopoietic, and related tissue, classifiable to C46.- or C81-C96, should be considered to be a direct consequence of HIV disease, where this is reported. No such assumption should be made for other types of malignant neoplasm.

Any infectious disease classifiable to A000-A310, A318-A427, A429-A599, A601-A70, A748-B001, B003-B004, B007, B009-B069, B080, B082-B085, B09-B199, B250-B279, B330-B349, B370-B49, B580-B64, B99 or J12-J18 should be considered to be a direct consequence of reported HIV disease.

Enterocolitis due to Clostridium difficile should be assumed to be an obvious consequence of antibiotic therapy

Heart failure (I50.-) and unspecified heart disease (I519) should be considered an obvious consequence of other heart conditions.

Oesophageal varices (I85.-) should be considered an obvious consequence of liver diseases classifiable to B18.-, K70.-, K73.-, K74.-, and K76

Pulmonary edema (J81) should be considered an obvious consequence of heart disease (including pulmonary heart disease); of conditions affecting the lung parenchyma, such as lung infections, aspiration and inhalation, respiratory distress syndrome, high altitude, and circulating toxins; of conditions causing fluid overload, such as renal failure and hypoalbuminemia; and of congenital anomalies affecting the pulmonary circulation, such as congenital stenosis of pulmonary veins.

Lobar pneumonia, unspecified (J18.1) should be considered an obvious consequence of dependence syndrome due to use of alcohol (F10.2). Pneumonia in J12-J18 should be considered an obvious consequence of conditions that impair the immune system. Pneumonia in J150-J156, J158-J159, J168, J180 and J182-J189 should be assumed to be an obvious consequence of wasting diseases (such as malignant neoplasm and malnutrition) and diseases causing paralysis (such as cerebral hemorrhage or thrombosis), as well as serious respiratory conditions, communicable diseases, and serious injuries. Pneumonia in J150-J156, J158-J159, J168, J180, J182-J189, J690, and J698 should be considered an obvious consequence of conditions that affect the process of swallowing. Pneumonia in J18.- (except lobar pneumonia) reported with immobility or reduced mobility should be coded to J18.2.

Other common secondary conditions (such as pulmonary embolism, decubitus ulcer, and cystitis) should be considered an obvious consequence of wasting diseases (such as malignant neoplasm and malnutrition) and diseases causing paralysis (such as cerebral hemorrhage or thrombosis) as well as communicable diseases, and serious injuries. However, such secondary conditions should not be considered an obvious consequence of respiratory conditions.

Acidosis (E87.2); Other specified metabolic disorders (E88.8); Other mononeuropathies (G58.-); Polyneuropathy, unspecified (G62.9); Other disorders of peripheral nervous system (G64); amyotrophy not otherwise specified in Other primary disorders of muscles (G71.8), Disorder of autonomic nervous system, unspecified (G90.9), and Neuralgia and neuritis, unspecified (M79.2); Iridocyclitis (H20.9); Cataract, unspecified (H26.9); Chorioretinal inflammation, unspecified (H30.9); Retinal vascular occlusions (H34); Background retinopathy and retinal vascular changes (H35.0); Other proliferative retinopathy (H35.2); Retinal haemorrhage (H35.6); Retinal disorder, unspecified (H35.9); Peripheral vascular disease, unspecified (I73.9); Atherosclerosis of arteries of extremities (I70.2); Arthritis, unspecified (M13.9); Nephrotic syndrome (N03- N05); Chronic kidney disease (N18.-); Unspecified kidney failure (N19); Unspecified contracted kidney (N26); renal disease in Disorder of kidney and ureter, unspecified (N28.9) and Persistent proteinuria, unspecified (N39.1); Gangrene, not elsewhere classified (R02); Coma, unspecified (R40.2); and Other specified abnormal findings of blood chemistry (R79.8) for acetonemia, azotemia, and related conditions should be considered an obvious consequence of Diabetes mellitus (E10-E14).

Embolism (any site) or any disease described or qualified as “embolic” may be assumed to be a direct consequence of venous thrombosis, phlebitis or thrombophlebitis, valvular heart disease, childbirth or any operation. However, there must be a clear route from the place where the thrombus formed and the place of the embolism. Thus, venous thrombosis or thrombophlebitis may cause pulmonary embolism. Thrombi that form in the left side of the heart (for example on mitral or aortic valves), or are due to atrial fibrillations, may cause embolism to the arteries of the body circulation. Similarly, thrombi that form around the right side heart valves (tricuspid and pulmonary valves) may give rise to embolism in the pulmonary arteries. Also, thrombi that form in the left side of the heart could pass to the right side if a cardiac septal defect is present.

Arterial embolism in the systemic circulation should be considered an obvious consequence of artrial fibrillation. When pulmonary embolism is reported due to atrial fibrillation, the sequence should be accepted. However, pulmonary embolism should not be considered an obvious consequence of atrial fibrillation.

Unspecified dementia (F03) and Alzheimer disease (G30.-) should be considered an obvious consequence of Down syndrome (Q90 .-).

Dementia without a mention of specified cause, should be considered a consequence of conditions that typically involve irreversible brain damage. However, when a specified cause is given, only a condition that may lead to irreversible brain damage should be accepted as cause of the dementia, even if irreversible brain damage is not a typical feature of the condition.

Any disease described as secondary should be assumed to be a direct consequence of the most probable primary cause entered on the certificate.

Secondary or unspecified anemia, malnutrition, marasmus or cachexia may be assumed to be a consequence of any malignant neoplasm, paralytic disease, or disease which limits the ability to care for oneself, including dementia and degenerative diseases of the nervous system.

Any pyelonephritis may be assumed to be a consequence of urinary obstruction from conditions such as hyperplasia of prostate or ureteral stenosis.

Nephritic syndrome may be assumed to be a consequence of any streptococcal infection (scarlet fever, streptococcal sore throat, etc).

Acute renal failure should be assumed as an obvious consequence of a urinary tract infection, provided that there is no indication that the renal failure was present before the urinary tract infection.

Dehydration should be considered an obvious consequence of any intestinal infectious disease.

Primary atelectasis of newborn (P28.0) should be considered an obvious consequence of congenital kidney conditions (Q60, Q61.0-Q61.1, Q61.3-Q61.9, Q62.1, Q62.3, Q62.4), premature rupture of membranes (P01.1), and oligohydramnios (P01.2).

Fetus and newborn affected by premature rupture of membranes or oligohydramnios (P01.1-P01.2) should be assumed to be a direct consequence of congenital kidney conditions (Q60, Q61.0-Q61.1, Q61.3-Q61.9, Q62.1, Q62.3, Q62.4).

An operation on a given organ should be considered a direct consequence of any surgical condition (such as malignant tumor or injury) of the same organ reported anywhere on the certificate.

Hemorrhage should be considered an obvious consequence of anticoagulant poisoning or overdose. However, hemorrhage should not be considered an obvious consequence of anticoagulant therapy without mention of poisoning or overdose. Gastric hemorrhage should be considered an obvious consequence of steroid, aspirin, and non-steroidal anti-inflammatory drugs (NSAIDs).

Mental Retardation should be considered an obvious consequence of perinatal conditions in P00-P04 (Fetus and newborn affected by maternal factors and by complications of pregnancy, labor and delivery), P05 (Slow fetal growth and fetal malnutrition), P07 (Disorders related to short gestation and low birth weight, not elsewhere classified), P10 (Intracranial laceration and hemorrhage due to birth injury), P11.0 (Cerebral edema due to birth injury), P11.1 (Other specified brain damage due to birth injury), P11.2 (Unspecified brain damage due to birth injury), P11.9 (Birth injury to central nervous system, unspecified), P15.9 (Birth injury, unspecified), P20 (Intrauterine hypoxia), P21 (Birth asphyxia), P35 (Congenital viral disease), P37 (Other congenital infectious and parasitic diseases), P52 (Intracranial nontraumatic hemorrhage of fetus and newborn), P57 (Kernicterus), P90 (Convulsions of newborn) and P91 (Other disturbances of cerebral status of newborn).

Interpretations and examples

Rule 3 is applicable when the condition selected by the General Principle, Rule 1, or Rule 2 is obviously the result of another condition reported on the same line, on a lower line in Part I, or in Part II. It applies only when there is no doubt about the causal relationship between the two conditions; it is not sufficient that a causal relationship between them would have been accepted if the certifier had reported it. If the selected cause is considered a direct sequel of two or more conditions on the record, the priority order for re-selection is from left to right, (1) on the same line, (2) on a lower line in Part I, and (3) in Part II. Conditions reported above the selected cause are not considered in the application of Rule 3.

For assistance in determining whether a selected condition is a direct sequel of another, refer to Part 2c, ICD-10 ACME Decision Tables for Classifying Underlying Causes of Death, 2021. The symbol “DS” identifies Direct Sequel, and the symbol “DSC” identifies Direct Sequel Combination.

Codes for Record

I (a) Bronchopneumonia J180

(b) Congestive heart failure and I500 I050

Select mitral stenosis. Congestive heart failure, selected by Rule 1, is considered a direct sequel of mitral stenosis.

Codes for Record

I (a) Cardiac arrest I469

(b) Gastric hemorrhage K922

(c)

II Gastric ulcer K259

Select gastric ulcer, chronic or unspecified with hemorrhage (K254). The hemorrhage is considered a direct sequel (DSC) of the gastric ulcer and combines gastric ulcer with gastric hemorrhage.

Complications of surgery

Certain conditions that are common postoperative complications can be considered as direct sequels to an operation unless the surgery is stated to have occurred 28 days or more before death. Use Rule 3 for the complications listed below:

Acute renal failure

Aspiration

Atelectasis

Bacteremia

Cardiac arrest (any I469)

Disseminated intravascular coagulopathy (DIC)

Embolism (any site)

Gas gangrene

Hemolysis, hemolytic infection

Hemorrhage NOS

Infarction (any site)

Infection NOS

Occlusion (any site)

Phlebitis (any site)

Phlebothrombosis (any site)

Pneumonia (J120-J168, J180-J189, J690, J698)

Pneumothorax

Pulmonary insufficiency

Renal failure (acute) NOS

Septicemia (any A400-A419)

Shock (R570-R579)

Thrombophlebitis (any site)

Thrombosis (any site)

Consider Peritonitis or Intestinal obstruction (K560-K567) to be a direct sequel of abdominal or pelvic surgery unless surgery is stated to have occurred 28 days or more before death.

Consider Hemorrhage of a site or Fistula of site(s) to be a direct sequel of surgery of same site or region unless surgery is stated to have occurred 28 days or more before death.

Consider Adhesions to be a direct sequel of surgery regardless of date of surgery.

Codes for Record

I (a) Mesenteric thrombosis K918

(b)

(c)

II Colectomy for cancer of sigmoid Y836 C187

Code to cancer of sigmoid (C187). Thrombosis is a common post-operative complication and the surgery is not stated to have occurred 28 days or more before death.

Codes for Record

I (a) Coronary thrombosis I219

(b)

(c)

II Removal of gallbladder (gallstones)
2 months ago K802

Code to coronary thrombosis (I219). The operation is stated to have occurred more than 28 days before death.

Codes for Record

I (a) Renal failure N19

(b)

II Surgery – for diverticulitis Y839 K579

Code to diverticulitis K579, the condition necessitating surgery.

Modification of the selected cause

The selected cause of death is not necessarily the most useful and informative condition for tabulation. For example, if senility or some generalized disease such as hypertension or atherosclerosis has been selected, this is less useful than if a manifestation or result of aging or disease had been chosen. It may sometimes be necessary to modify the selection to conform with the requirements of the Classification, either for a single code for two or more causes jointly reported or for preference for a particular cause when reported with certain other conditions.

The modification rules that follow are intended to improve the usefulness and precision of mortality data and should be applied after selection of the originating antecedent cause. The interrelated processes of selection and modification have been separated for clarity.

Some of the modification rules require further application of the selection rules, which will not be difficult for experienced coders, but it is important to go through the process of selection, modification and, if necessary, re-selection.

After application of the modification rules (A-F), selection Rule 3 should be reapplied.

The modification rules

Rule A. Senility and other ill-defined conditions

Rule B. Trivial conditions

Rule C. Linkage

Rule D. Specificity

Rule E. Early and late stages of disease

Rule F. Sequela

Rule A. Senility and other ill-defined conditions

Where the selected cause is ill-defined and a condition classified elsewhere is reported on the certificate, reselect the cause of death as if the ill-defined condition had not been reported, except to take account of that condition if it modifies the coding.

The following conditions are regarded as ill-defined:

I461 (Sudden cardiac death, so described)

I469 (Cardiac arrest, unspecified)

I959 (Hypotension, unspecified)

I99 (Other and unspecified disorders of circulatory system)

J960 (Acute respiratory failure)

J969 (Respiratory failure, unspecified)

P285 (Respiratory failure, newborn)

R00-R94 or R96-R99 (Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified). Note that R95 (Sudden infant death) is not regarded as ill-defined.

Abbreviations

The following abbreviations are used when coding senility and other ill-defined conditions:

IDDC: (Ill-defined due to combination) When the tentative underlying cause is an ill-defined condition in the due to position to another condition, and the codes for the tentative underlying cause and the other condition combine into a third code.

SENMC: (Senility with mention of combination) When the tentative underlying cause is senility (R54), and is reported with mention of another condition on the certificate, and the codes for the tentative underlying cause and the other condition combine into a third code.

SENDC: (Senility due to combination) When the tentative underlying cause is senility (R54) and is reported in a due to position to another condition, and the codes for the tentative underlying cause and the other condition combine into a third code.

Interpretation and Examples

Codes for Record

I (a) Senility and hypostatic pneumonia R54 J182

(b) Rheumatoid arthritis M069

Code to rheumatoid arthritis (M069). Senility, selected by Rule 2, is ignored and the General Principle applied.

Codes for Record

I (a) Anemia D649

(b) Splenomegaly R161

Code to splenomegalic anemia (D648). Splenomegaly, selected by the General Principle, is ignored by Rule A. Anemia, reselected by the General Principle, is modified by the ill-defined cause. The Modification Table E entry R161 is identified as IDDC “maybe” with anemia D649. The reporting on this certificate satisfies the maybe reason defined in Table F, Reasons for Ambivalent Relationships in Modification Table, and the modification is made.

Codes for Record

I (a) Myocardial degeneration and I515 J439

(b) emphysema

Code to myocardial degeneration (I515). Senility, selected by the General Principle, is ignored and Rule 2 applied.

Codes for Record

I (a) Cough and hematemesis R05 K920

Code to hematemesis (K920). Cough, selected by Rule 2, is ignored.

Codes for Record

I (a) Terminal pneumonia J189

(b) Spreading gangrene and R02 I639

Code to cerebrovascular infarction (I639). Gangrene, selected by Rule 1, is ignored and the General Principle is applied.

Rule B. Trivial conditions

(A) Where the selected cause is a trivial condition unlikely to cause death (see Table H in the 2c ACME Decision Tables) and a more serious condition (any condition except an ill-defined or another trivial condition) is reported, reselect the underlying cause as if the trivial condition had not been reported.

Codes for Record

I (a) Dental caries K029

II Diabetes E149

Code to diabetes (E149). Dental caries, selected by the General Principle, is ignored.

Codes for Record

I (a) Ingrowing toenail and

acute renal failure L600 N179

Code to acute renal failure (N179). Ingrowing toenail, selected by Rule 2, is ignored.

(B) If the death was the result of an adverse reaction to treatment of the trivial condition, select the adverse reaction.

Codes for Record

I (a) Intraoperative hemorrhage T810 Y600

(b) Tonsillectomy

Code to hemorrhage during surgical operation (Y600). Code to the adverse reaction to treatment of the hypertrophy of tonsils, selected by General Principle.

Codes for Record

I (a) Acute renal failure N179

(b) Aspirin taken for Y451

Code to acute renal failure (N179), the adverse reaction to the drug taken for treatment of a trivial condition. The external cause code for the drug is not used as the underlying cause since the adverse reaction is not classifiable to Chapter XIX.

(C) When a trivial condition is reported as causing any other condition, the trivial condition is not discarded (i.e. Rule B is not applicable).

Codes for Record

I (a) Septicemia A419

(b) Impetigo L010

Code to impetigo (L010). The trivial condition selected by the General Principle is not discarded since it is reported as the cause of another condition.

Codes for Record

I (a) Respiratory insufficiency R068

(b) Upper respiratory infection J069

Code to upper respiratory infection (J069). The trivial condition selected by the General Principle is not discarded since it is reported as the cause of another condition.

Rule C. Linkage

Where the selected cause is linked by a provision in the Classification or in the notes for use in underlying cause mortality coding with one or more of the other conditions on the certificate, code the combination.

Where the linkage provision is only for the combination of one condition specified as due to another, code the combination only when the correct causal relationship is stated or can be inferred from application of the selection rules.

Where a conflict in linkages occurs, link with the condition that would have been selected if the cause initially selected had not been reported. Make any further linkage that is applicable.

Interpretations and Examples

Linkage is the assignment of a preference or combination code for two or more jointly reported causes of death in accordance with a provision in the ICD. The provision may be for linking one condition with mention of the other, or for linking one condition when reported as “due to” the other.

Guideline notes and instruction for applying the mandatory international linkages are listed in category order, Volume 2, Fifth Edition, pages 69 – 97. They have been repeated in this manual along with other preferences and instructions pertinent to coding practices in the United States. In addition, the codes for specific linkages are contained in Part 2c, Modification Table (Table E). These decision tables present the linkages as described below for use in classifying the underlying cause of death.

Application of the linkage rule, as with the use of all other international rules for determining the underlying cause of death, must be carried out in a sequential step-by-step process to comply with the intention of ICD and to achieve standardization of data. This is particularly essential in the linkage rule. It is the most complex step in determining the underlying cause of death and is used more than any other modification rule.

The following abbreviations identify the linkages in Part 2c, Modification Table (Table E):

LMP: (Linkage with mention of preference) is used when another condition is preferred over the selected underlying cause regardless of the placement of either of the two conditions on the record.

LMC: (Linkage with mention of combination) is used when the selected underlying cause and another condition link to become a combination code regardless of the placement of either of the two conditions on the record.

LDP: (Linkage “due to” preference) is used when another condition stated as “due to” the selected underlying cause is preferred.

LDC: (Linkage “due to” combination) is used when the selected underlying cause is merged with another condition stated as “due to” the selected underlying cause into a combination code.

Placement of Condition for “due to” Linkages

Placement of the conditions on the record is of paramount importance in determining when “due to” linkages (LDP, LDC) may be made. For this purpose, the following criteria are to be applied. If the General Principle is applied, every condition on every line above it is considered to have a “due to” relationship with the selected underlying cause. If Rule 1 is applied, only the conditions on the next higher line are in “due to” relationship with the selected underlying cause.

Situation 1: One linkage on the record

This is the most straightforward kind of linkage wherein the selected underlying cause links with only one other condition on the record through any one of the four types of linkages.

Codes for Record

I (a) Coronary thrombosis I219

(b) Old myocardial degeneration I515

II Hypertension, arteriosclerosis I10 I709

Code to coronary thrombosis (I219). Arteriosclerotic heart disease, selected by the General Principle, links (LMP) with coronary thrombosis.

Codes for Record

I (a) Emphysema J439

(b)

II Cerebral arteriosclerosis I672

Code to other specified chronic obstructive pulmonary disease (J448). Bronchitis, selected by the General Principle, links (LMC) with emphysema into a combination code of J448.

Codes for Record

I (a) Bronchopneumonia J180

(b) Heart disease I519

Code to hypertensive heart disease without (congestive) heart failure (I119). Hypertension, selected by Rule 1, links (LDC) in “due to” position with heart disease into a combination code.

Codes for Record

I (a) Thrombotic mesenteric infarction K550

(b) Arteriosclerosis I709

Code to acute vascular disorder of intestine (K550). Arteriosclerosis, selected by the General Principle, links (LDP) in “due to” position with mesenteric infarction.

Situation 2: Two or more concurrent linkages (conflict in linkage)

When the selected underlying cause links with more than one condition on the record, a conflict in linkage exists. When there is a conflict, linkage is with the condition that would have been selected if the selected cause had not been reported. Therefore, prefer a linkage in Part I over one in Part II. If the conflict is in Part I, reapply the selection rules as though the selected cause had not been reported. If the reselected cause is one of the linkage conditions, make this linkage. If the reselected cause is not one of the linkage conditions, again apply the selection rules as though the initially selected and reselected causes had not been reported. Continue this process until a reselected cause is one of the conditions to which the initially selected underlying cause links. Then link the initially selected underlying cause to that condition.

Codes for Record

I (a) Stroke I64

(b) Hypertension I10

II CAD I251

Code to stroke (I64). Hypertension selected by General Principle links (LMP) with stroke and also links (LMP) with coronary artery disease. Even though hypertension links with two conditions, a linkage in Part I is preferred over one in Part II.

I (a) CVA

(b) Aortic aneurysm

Codes for Record Linkage Record

I (a) I64 I64

(b) I719 I719

Code to Aortic aneurysm (I719).

Arteriosclerosis, selected by the General Principle, links (LDP) in “due to” position with aortic aneurysm and also links (LMP) with mention of CVA.

The linkage record is constructed and the selection rules applied. Aortic aneurysm would have been selected by the General Principle and is, therefore, the condition that is preferred.

I (a) Cardiac arrest and pneumonia

(b) Cerebrovascular accident, ischemic heart disease

II Hypertension and contracted kidney

Codes for Record Linkage Record

I (a) I469 J189 I469 J189

(b) I64 I259 I64 I259

II I10 N26 I10 N26

Code to cerebrovascular accident (I64).

Arteriosclerosis, selected by the General Principle, links (LMP) with cerebrovascular accident; (LMP) with ischemic heart disease; and (LMP) with hypertension.

The linkage record is constructed, consisting of all conditions except the selected underlying cause and the selection rules are reapplied to the linkage record. Cerebrovascular accident would have been selected by Rule 1 and is thus identified as the condition to be linked with the initially selected cause.

I (a) Pneumonia

(b) Congestive heart failure, chronic myocarditis

Codes for Record Linkage Record

I (a) J189 J189

(b) I500 I514 I500 I514

Code to hypertensive heart disease with (congestive) heart failure (I110) Hypertension, selected by Rule 1, links (LDC) in “due to” position with congestive heart failure and also links (LDC) in “due to” position with the term chronic myocarditis.

Construct the linkage record with all conditions except the selected underlying cause of death and apply the selection rules to this record.

Reselect arteriosclerosis. Since this is not one of the linkage conditions, the selection rules are reapplied. Select congestive heart failure (I500). Congestive heart failure is identified as the condition to be linked with the initially selected underlying cause into the combination code I110.

Situation 3: Further linkage

After initial linkage is made, the preferred condition or combination category may further link with another condition on the record to create a sequence of linkages.

Codes for Record

I (a) Pneumonia, hypertension J189 I10

(b) Arteriosclerosis & renal sclerosis I709 N26

Code to hypertensive renal disease (I129). Arteriosclerosis, selected by Rule 1, links (LMP) with hypertension. Hypertension further links (LMC) with renal sclerosis into a combination code of I129.

Codes for Record

I (a) Ventricular aneurysm I253

(b) Hypertensive heart disease I119

Code to aneurysm of heart (I253). Chronic renal failure, selected by the General Principle, links (LMC) with hypertensive heart disease into a combination code of I131, hypertensive heart and renal disease with renal failure. This combination (I131) further links (LMP) with ventricular aneurysm (I253).

I (a) Heart and renal failure

(b) Renal atrophy

Codes for Record Linkage Record

I (a) I509 N19 I509 N19

(b) N26 N26

Code to hypertensive heart and renal disease with both (congestive) heart failure and renal failure (I132). Arteriosclerosis, selected by Rule 1, links (LMP) with hypertension, (LMP) with heart failure, and (LDC) in “due to” position with renal atrophy. This is a conflict in linkage; therefore, construct the linkage record consisting of all conditions except the selected underlying cause and apply the selection rules to this linkage record.

Since hypertension would have been selected by the General Principle, it is thus identified as the condition to be linked. Make this linkage (—I709—LMP I10). Conditions classifiable to I10 further link (LMC) with renal atrophy and (LDC) in “due to” position with heart failure, and (LMC) with renal failure. This conflict in linkage requires that a second linkage record be constructed.

Linkage Record

I (a) I509 N19

(b) N26

(c)

Apply the selection rules to the new linkage record. Renal atrophy would have been selected by the General Principle and is identified as the term to be linked with hypertension into the combination code of I129. This further links (LDC) with heart failure into the combination code of I130 and further links (LMC) with the renal failure into the combination code of I132 by continuing to apply the “conflict in linkage rule.”

Rule D. Specificity

Where the selected cause describes a condition in general terms and a term that provides more precise information about the site or nature of this condition is reported on the certificate, prefer the more informative term. This rule will often apply when the general term becomes an adjective, qualifying the more precise term.

The following abbreviations identify selected levels of specificity:

SMP: (Specificity with mention of preference) When the tentative underlying cause describes a condition in general terms, and a condition which provides more precise information about the site or nature of this condition is reported anywhere on the certificate, and the code for the more precise condition is preferred over the code for the tentative underlying cause.

SMC: (Specificity with mention of combination) When the tentative underlying cause describes a condition in general terms, and a condition which provides more precise information about the site or nature of this condition is reported anywhere on the certificate, and the codes for the tentative underlying cause and the other condition combine into a third code.

SDC: (Specificity due to combination) When the tentative underlying cause is reported in the due to position to another condition, and can be regarded as an adjective modifying this condition, and the codes for the tentative underlying cause and the other conditions combine into a third code.

Codes for Record

I (a) Cerebral thrombosis I633

(b) CVA I64

Code to cerebral thrombosis (I633). Cerebrovascular accident selected by the General Principle, is considered a general term and cerebral thrombosis is preferred as the more informative term.

Codes for Record

I (a) Meningitis G039

(b) Tuberculosis A1690

Code to tuberculous meningitis (A170). The conditions are stated in the correct causal relationship.

Code for Record

I (a) Pneumonia J13

(b) Pneumococcus

Code to pneumococcal pneumonia (J13). Since an infection is reported due to a specific organism, use the organism on (b) to modify the infection on (a).

Refer to Section III, J, 7 for further instructions regarding organisms and infections.

Conflict in Specificity

When there are two or more conditions on the certificate to which the specificity rule applies, reapply the selection rules as though the general term had not been reported. If the reselected condition is not one of the more specified conditions to which

Rule D applies, again apply the selection rules as though the general term and the reselected condition had not been reported. Continue this reselection process until the reselected condition is one of the more specified terms that would take preference over the general term. After the more specified condition has been identified, any applicable linkage (Rule C) may be made.

Codes for Record

I (a) Pulmonary fibrosis J841

(b) Chronic lung disease and J9840 J439

Code to emphysema (J439). Chronic lung disease is selected by Rule 1. Both emphysema and pulmonary fibrosis are more specified lung diseases. Emphysema would have been selected if chronic lung disease had not been mentioned and is, therefore, identified as the condition that would take preference.

Codes for Record

I (a) Urinary tract obstruction N139

(b) Kidney stones N200

Code to calculus of kidney (N200). Renal disease (N289) is selected by the General Principle. Both urinary tract obstruction and kidney stones are specified renal diseases. Kidney stones (N200) would have been selected if renal disease had not been reported and is, therefore, the preferred condition.

Rule E. Early and late stages of disease

Where the selected cause is an early stage of a disease and a more advanced stage of the same disease is reported on the certificate, code to the more advanced stage. This rule does not apply to a “chronic” form reported as due to an “acute” form unless the classification gives special instructions to that effect.

Codes for Record

I (a) Tertiary syphilis A529

(b) Primary syphilis A510

Code to tertiary syphilis (A529), a more advanced stage of syphilis.

Codes for Record

I (a) Eclampsia during pregnancy O150

(b) Pre-eclampsia O149

Code to eclampsia in pregnancy (O150), a more advanced stage of pre-eclampsia.

Codes for Record

I (a) Chronic myocarditis I514

(b) Acute myocarditis I409

Code to acute myocarditis (I409). Acute myocarditis is selected by the General Principle. No “special instruction” is given to prefer chronic myocarditis over acute myocarditis.

Codes for Record

I (a) Chronic nephritis N039

(b) Acute nephritis N009

Code to chronic nephritis, unspecified (N039). Chronic nephritis is preferred when it is reported as secondary to acute nephritis. The General Principle and linkage are applicable.

Rule F. Sequela

Where the selected cause is an early form of a condition for which the Classification provides a separate “Sequela of …” category, and there is evidence that death occurred from residual effects of this condition rather than from those of its active phase, code to the appropriate “Sequela of …” category.

“Sequela of …” categories are as follows:

B90.- Sequela of tuberculosis

B91 Sequela of acute poliomyelitis

B92 Sequela of leprosy

B94.- Sequela of other and unspecified infectious and parasitic diseases

E64.- Sequela of malnutrition and other nutritional deficiencies

E68 Sequela of hyperalimentation

G09 Sequela of inflammatory diseases of central nervous system

I69.- Sequela of cerebrovascular disease

O97.- Death from sequela of obstetric causes

Y85-Y89 Sequela of external causes

NOTE #1: When conditions in categories A000-A310, A318-A427, A429-A599, A601-A70, A748-B001, B003-B004, B007, B009-B069, B080, B082-B085, B09-B199, B25-B279, B330-B349, B370-B49, B58-B64, B99 are mentioned on the record with HIV (B20-B24, R75), do not consider the infectious or parasitic condition as a sequela.

NOTE #2: Sequela categories (except G09) do not apply to decedents with an age less than 1 year old.

Interpretations and Examples

These sequela categories are to be used for underlying cause mortality coding to indicate that death resulted from late (residual) effects of a given disease or injury rather than during the active phase. Rule F applies in such circumstances.

B90.- Sequela of tuberculosis

Use these subcategories for the classification of tuberculosis (conditions in A162-A199) if:

(a) A statement of a late effect or sequela of the tuberculosis is reported.

Codes for Record

I (a) Calcification lung J984

(b) Sequela of pulmonary tuberculosis B909

Code to sequela of pulmonary tuberculosis (B909) since “sequela of” is stated.

(b) The tuberculosis is stated to be ancient, arrested, by history, cured, healed, history, history of, inactive, old, quiescent, or remote, whether or not the residual (late) effect is specified, unless there is evidence of active tuberculosis.

Code for Record

I (a) Arrested pulmonary tuberculosis B909

Code to arrested pulmonary tuberculosis (B909), since there is no evidence of active tuberculosis.

(c) When there is evidence of active and inactive (arrested, by history, cured, healed, history, history of, old, quiescent) tuberculosis of different sites, consider as active or inactive tuberculosis as stated.

Codes for Record

I (a) Acute miliary tuberculosis A190

(b) of bone 6 mos

II Old pulmonary tuberculosis B909

Code to active acute miliary tuberculosis of bone (A190) as selected by the General Principle. Evidence of inactive tuberculosis of a different site does not change the status of the active tuberculosis.

(d) When there is evidence of active and inactive (arrested, by history, cured, healed, history, history of, old, quiescent) tuberculosis of the same site, consider as active tuberculosis.

Codes for Record

I (a) Recurrent pulmonary tuberculosis A162

(b) Old pulmonary tuberculosis A162

(c)

Code to active pulmonary tuberculosis (A162). Evidence of inactive and active tuberculosis of the same site is coded to active tuberculosis of the site.

NOTE: Do not use duration to code sequela of tuberculosis.

Codes for Record

I (a) Respiratory failure J969

(b) Pneumonia J189

Code to pulmonary tuberculosis (A162). Do not use duration of the tuberculosis to code the tuberculosis as sequela.

B91- Sequela of acute poliomyelitis

Use this category for the classification of poliomyelitis (conditions in A800-A809) if:

(a) A statement of a late effect or sequela of the poliomyelitis is reported.

Code for Record

I (a) Sequela of acute poliomyelitis B91

Code to sequela of poliomyelitis (B91) as indexed.

(b) A chronic condition or a condition with a duration of one year or more that was due to poliomyelitis is reported.

Codes for Record

I (a) Paralysis 1 year G839

(b) Acute poliomyelitis B91

Code to sequela of poliomyelitis (B91), since the paralysis has a duration of 1 year.

(c) The poliomyelitis is stated to be by history, history, history of, old, or the interval between onset of the poliomyelitis and death is indicated to be one year or more whether or not the residual (late) effect is specified.

Code for Record

I (a) Old polio B91

Code to old polio (B91).

(d) The poliomyelitis is not stated to be acute or active and the interval between the onset of the poliomyelitis and death is not reported.

Code for Record

I (a) Poliomyelitis B91

(b)

(c)

Code to sequela of poliomyelitis (B91) since the poliomyelitis is not stated to be acute or active and there is no duration reported.

Codes for Record

I (a) Poliomyelitis with B91 G839

(b) paralysis

(c)

Code to sequela of poliomyelitis (B91) since the poliomyelitis is not stated to be acute or active and there is no duration reported.

B92 Sequela of leprosy

Use this category for the classification of leprosy (conditions in A30) if:

(a) A statement of a late effect or sequela of the leprosy is reported.

(b) A chronic condition or a condition with a duration of one year or more that was due to leprosy is reported.

B94.0 Sequela of trachoma

Use this subcategory for the classification of trachoma (conditions in A710-A719) if:

(a) A statement of a late effect or sequela of the trachoma is reported.

Code for Record

I (a) Late effects of trachoma B940

(b) The trachoma is stated to be healed or inactive, whether or not the residual (late) effect is specified.

Code for Record

I (a) Healed trachoma B940

Code to sequela of trachoma (B940) since it is stated “healed.”

(c) A chronic condition such as blindness, cicatricial entropion or conjunctival scar that was due to the trachoma is reported unless there is evidence of active infection.

Codes for Record

I (a) Conjunctival scar H112

(b) Trachoma B940

Code to sequela of trachoma (B940) since it caused the chronic condition, conjunctival scar, and there is no evidence of active infection.

B94.1 Sequela of viral encephalitis

Use this subcategory for the classification of viral encephalitis (conditions in A830-A839, A840-A849, A850-A858, A86) if:

(a) A statement of a late effect or sequela of the viral encephalitis is reported.

Code for Record

I (a) Late effects of viral encephalitis B941

Code to sequela of viral encephalitis (B941) as indexed.

(b) A chronic condition or a condition with a duration of one year or more that was due to the viral encephalitis is reported.

Codes for Record

I (a) Chronic brain syndrome F069

(b) Viral encephalitis B941

Code to sequela of viral encephalitis (B941), since a resultant chronic condition is reported.

(c) The viral encephalitis is stated to be ancient, by history, history, history of, old, remote, or the interval between onset of the viral encephalitis and death is indicated to be one year or more whether or not the residual (late) effect is specified.

Code for Record

I (a) St. Louis encephalitis 1 yr B941

Code to sequela of viral encephalitis (B941), since a duration of 1 year is reported.

Code for Record

I (a) Old viral encephalitis B941

Code to sequela of viral encephalitis (B941), since it is stated “old.”

(d) Brain damage, CNS damage, cerebral fungus, epilepsy, hydrocephalus, mental retardation, paralysis (G810-G839) is reported due to the viral encephalitis.

Codes for Record

I (a) Paralysis G839

(b) Viral encephalitis B941

Code to sequela of viral encephalitis (B941) since paralysis is reported due to viral encephalitis.

B94.2 Sequela of viral hepatitis

Use this category for the classification of viral hepatitis (conditions in B150-B199) if:

A statement of a late effect or sequela of the viral hepatitis is reported.

B94.8 Sequela of other specified infectious and parasitic diseases

B94.9 Sequela of unspecified infectious and parasitic diseases

Use B948 for the classification of specified infectious and parasitic diseases (conditions in A000-A099, A200-A289, A310-A70, A740-A799, A811-A829, A870-B09, B250-B89)

AND

Use B949 for the classification of only the terms “infectious disease NOS” and “parasitic disease NOS” if:

(a) A condition that is stated to be a late effect or sequela of the infectious or parasitic disease is reported.

(b) The infectious or parasitic disease is stated to be ancient, arrested, by history, cured, healed, history, history of, inactive, old, quiescent, or remote, whether or not the residual (late) effect is specified, unless there is evidence of activity of the disease.

(c) A chronic condition or a condition with a duration of one year or more that was due to the infectious or parasitic disease is reported.

Codes for Record

I (a) Reye syndrome 1 yr. G937

(b) Chickenpox B948

Code to sequela of other specified infectious and parasitic diseases (B948) since chickenpox caused a condition with a duration of one year or more.

Codes for Record

I (a) Chronic brain syndrome F069

(b) Meningococcal encephalitis B948

Code to sequela of other specified infectious and parasitic diseases (B948) since the infectious disease caused a chronic condition.

Codes for Record

I (a) Acute and Chronic UTI N390

(b) Clostridium difficile colitis B948

Code to sequela of other specified infectious and parasitic diseases (B948) since the infectious disease caused a chronic condition.

(d) There is indication that the interval between onset of the infectious or parasitic disease and death was one year or more, whether or not the residual (late) effect is specified.

E640-E649 Sequela of malnutrition and other nutritional deficiencies

Use Sequela Code For Categories

E640 E40-E46

E641 E500-E509

E642 E54

E643 E550-E559

E648 E51-E53

E56-E60

E610-E638

E649 E639

Use these subcategories for the classification of malnutrition and other nutritional deficiencies (conditions in E40-E639) if:

(a) A statement of a late effect or sequela of malnutrition and other nutritional deficiencies is reported.

Codes for Record

I (a) Cardiac arrest I469

(b) Sequela of malnutrition E640

Code to sequela of protein-energy malnutrition (E640) since I(b) is stated as “sequela of.”

(b) A condition with a duration of one year or more is qualified as rachitic or that was due to rickets is reported.

Codes for Record

I (a) Thyroid disorder 3 years E079

(b) Rickets E643

Code to sequela of rickets (E643) since rickets caused a condition with a duration of one year or more.

E68 Sequela of hyperalimentation

Use this category for the classification of hyperalimentation (conditions in E67 and hyperalimentation NOS in R632) if:

(a) A statement of a late effect or sequela of the hyperalimentation is reported.

(b) A condition with a duration of one year or more that was due to hyperalimentation is reported.

G09 Sequela of inflammatory diseases of central nervous system

Use this category for the classification of intracranial abscess or pyogenic infection (conditions in G000-G009, G030-G049, G060-G069, G08) if:

(a) A statement of a late effect or sequela of the condition in G000-G009, G030-G049, G060-G069, G08 is reported.

(b) A condition with a duration of one year or more that was due to the condition in G000-G009, G030-G049, G060-G069, G08 is reported.

(c) The condition in G000-G009, G030-G049, G060-G069, G08 is stated to be ancient, by history, history, history of, old, remote, or the interval between onset of this condition and death is indicated to be one year or more, whether or not the residual (late) effect is specified.

Codes for Record

I (a) Compression of brain G935

(b) Old cerebral abscess G09

Code to sequela of cerebral abscess since stated as old.

(d) Brain damage, CNS damage, cerebral fungus, epilepsy, hydrocephalus, mental retardation, paralysis (G810-G839) is reported due to a condition in G000-G009, G030-G049, G060-G069, G08.

Codes for Record

I (a) Hydrocephalus G919

(b) Meningitis G09

Code to sequela of inflammatory diseases of CNS (G09) since meningitis (G039) is reported as causing hydrocephalus.

I690-I698 Sequela of cerebrovascular disease

Use this category for the classification of cerebrovascular disease (conditions in I600-I6400, I670-I671, I674-I679) if:

(a) A statement of late effect or sequela of a cerebrovascular disease is reported.

Code for Record

I (a) Sequela of cerebral infarction I693

Code to sequela of cerebral infarction (I693) since “sequela of” is stated.

(b) A condition with a duration of one year or more was due to one of these cerebrovascular diseases.

Codes for Record

I (a) Hemiplegia 1 year G819

(b) Intracranial hemorrhage I692

Code to sequela of other nontraumatic intracranial hemorrhage (I692) since the residual effect (hemiplegia) has a duration of one year.

(c) The condition in I600-I64, I670-I671, I674-I679 is stated to be ancient, by history, history, history of, old, remote, or the interval between onset of this condition and death is indicated to be one year or more, whether or not the residual (late) effect is specified.

Codes for Record

I (a) Brain damage G939

(b) Remote cerebral thrombosis I693

Code to sequela of cerebral thrombosis (I693) since the cerebral thrombosis is reported as remote.

Code for Record

I (a) Old intracerebral hemorrhage I691

Code to sequela of intracerebral hemorrhage (I691) since the intracerebral hemorrhage is stated as old.

Code for Record

I (a) Cerebrovascular occlusion 6 years I693

Code to sequela of cerebrovascular occlusion since the duration is one year or more.

Code for Record

I (a) History of CVA 9 months I694

Code to sequela of CVA (I694) since history of CVA is reported.

(d) The condition in I600-I64, I670-I671, I674-I679 is reported with paralysis (any) stated to be ancient, by history, history, history of, old, remote, or the interval between onset of this condition and death is indicated to be one year or more whether or not the residual (late) effect is specified.

Codes for Record

I (a) CVA with old hemiplegia I694 G819

Code to sequela of CVA (I694) since it is reported with hemiplegia stated as old.

O970-O979 Sequela of obstetric cause

Use this category for the classification of a direct obstetric cause (conditions in O00-O927) if:

(a) A statement of a late effect or sequela of the direct obstetric cause is reported.

(b) A condition with a duration of one year or more that was due to the direct obstetric cause is reported.

Y85-Y89 Sequela of external causes of morbidity and mortality

Refer to Section IV, Y85-Y89, Sequela of external causes of morbidity and mortality.

Application of Rule 3 following modification

After application of the modification rules, selection Rule 3 should be reapplied. However, Rule 3 should not be applied if the originating cause selected by application of the modification rules is correctly reported as due to another condition, except when this other condition is ill-defined or trivial.

Codes for Record

I (a) Arteriosclerosis aorta I700

II Cerebral embolism, endocarditis I634 I38

Code to endocarditis (I38). Arteriosclerosis aorta, selected by the General Principle links (LMP) with cerebral embolism. Cerebral embolism is considered a direct sequel (DS) of the endocarditis.

Codes for Record

I (a) Cerebral embolism I634

(b) Arteriosclerosis aorta I700

II Endocarditis I38

Code to cerebral embolism (I634). Arteriosclerosis aorta, selected by the General Principle links (LMP) with cerebral embolism. Although cerebral embolism can be considered a direct consequence of the endocarditis, it is reported due to arteriosclerosis aorta on this certificate. Rule 3 is, therefore, not applied.