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Coding and classification of causes of deathin accordance with the Tenth Revision of theInternational Classification of DiseasesArialdi Miniño, MPH

The InternationalClassification of Diseases(ICD)

DefinitionThe ICD is a system of categories to which morbidentities of either external or pathological causationare assigned according to established criteria.The ICD is developed collaboratively between theWorld Health Organization (WHO) and variousinternational centers.

Dates for ICD Revisions Implementedin the United StatesFirst Revision: 1900-1909Second Revision: 1910-1920Third Revision: 1921-1929Fourth Revision: 1930-1938Fifth Revision: 1939-1948Sixth Revision: 1949-1957Seventh Revision: 1958-1967Eighth Revision: 1968-1978Ninth Revision: 1979-1998Tenth Revision: 1999 to present

Differences between the ICD and ICD-CMThe ICD is maintained and coordinated by WHO; ICDCM is maintained by the United States, butcoordinated with WHOThe ICD is updated every 10-20 years; ICD-CM isupdated annuallyThe ICD-CM has greater detail than the ICD

Standardizing functions of the ICDThe ICD defines:Death certificate formCodes, categories and chaptersRules for uniformly selecting the UCLists for presenting and tabulating mortality andmorbidity statisticsTerms such as “low birth weight,” “pre-term,”“neonatal period,” “maternal death.”

Structure of ICD-10Volume I: main classification, list of 3-charactercategories, tabular list for inclusions, and 4character subcategories; also morphology codes,tabulation lists, definitions and regulationsVolume II: coding rules and history of the ICDVolume III: alphabetical index

Structure of ICD-10ICD-10 is based on 3-digit categories ranging fromA00-Z99Each 3-digit category can be divided into 10 4-digitsubcategoriesICD-10 contains 21 chaptersThe first character of each ICD-10 code is a letter, andletters are associated with chapters.

Structure of ICD-10Chapters I to XVII relate to diseases and other conditionsChapter XVIII relates to symptoms, signs and abnormalfindingsChapter XIX relates to injuries and other consequences ofexternal causesChapter XX relates to external causes of morbidity andmortalityChapter XXI is exclusive to morbidity relating to reasonsfor seeking medical care

Important definitionsinvolving causes of deathCause of deathUnderlying cause: “The disease or injury whichinitiated the train of morbid events leading directly todeath, or the circumstances of the accident orviolence which produced the fatal injury" Multiple causes: causes of death including not onlythe underlying cause but also immediate cause ofdeath and all other intermediate and contributoryconditions entered by the certifying physician

Approximateinterval:Onset to deathCAUSE OF DEATH (See instructions and examples)32. PART I. Enter the chain of events - - diseases, injuries, or complications - - that directly caused the death. DO NOT enterterminal events such as cardiac arrest, respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOTABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.IMMEDIATE CAUSE (Finaldisease or condition resulting in death)Part I: Lines 1-4a.Due to (or as a consequence of):Causes of death areentered sequentiallystarting with immediatecause and ending withthe underlying cause.To Be Completed By:MEDICAL CERTIFIERb.Sequentially list conditions,if any, leading to the causelisted on line a. Enter theUNDERLYING CAUSE (diseaseor injury that initiated the eventsresulting in death) LASTDue to (or as a consequence of):c.Due to (or as a consequence of):d.PART II. Enter other significant conditions contributing to death but not resulting in the underlying causegiven in Part I.33. WAS AN AUTOPSY PERFORMED?YesNoPartII34.WERE AUTOPSY FINDINGS AVAILABLETO COMPLETE THE CAUSE OF DEATH?35. DID TOBACCO USECONTRIBUTE TO DEATH?YesNoProbablyUnknown38. DATE OF INJURY36. IF FEMALE:Not pregnant within past yearPregnant at time of deathNot pregnant but pregnant within 42 days of deathNot pregnant but pregnant 43 days to 1 year before deathUnknown if pregnant within the past year39. TIME OF INJURY(Mo/Day/Yr)(Spell Month)42. LOCATION OF INJURY: State:Street & Number:43. DESCRIBE HOW INJURY OCCURREDOther significantYesNocontributing29. MANNERconditionsOF cideHomicideCould not beDetermined40. PLACE OF INJURY (e.g., Decedent’s home, constructionsite, restaurant, wooded area)41. INJURY AT WORK?YesCity or Town:Apartment No.NoZip Code:Box 43. How44.injuryoccurredIF TRANSPORTATION INJURY, SPECIFYDriver/OperatorGenerally determinesexternal cause ofPassengerPedestriandeaths involving injuries.Other (Specify)

ICD-10 rules for selection ofunderlying cause of deathSelection RulesGeneral PrincipleRule 1Rule 2Rule 3Rules for Modification of Selected CauseRule A: Senility and other ill-defined conditionsRule B: Trivial conditionsRule C: LinkageRule D: SpecificityRule E: Early and late stages of diseaseRule F: Sequelae

NCHS' Automated Coding System for producingunderlying cause of deathSoftware for Capturing Software for Converting Software for Applying ICD's SelectionMedical TermsText of Medical Terms& Modification Ruleson Death Certificateinto ICD Codesto select Underlying CauseSuperMICARinputACMEoutput

The Concept of “Sequence”The term refers to two or more conditions enteredon successive lines of Part I, each condition beingan acceptable cause of the one entered on the lineabove it. If there is more than one cause of death ina line of the certificate, it is possible to have morethan one reported sequence.

General PrincipleWhen more than one condition is entered onthe certificate, select the condition enteredalone in the lowest-used line of Part I only if itcould have given rise to all the conditionsentered above it.

Two Ways to Apply the GeneralPrincipleImmediate cause reportedon Part I (a) of certificate is an acceptable cause of YESIntermediate cause reportedon Part I (b) of certificateYES is an acceptable cause of Intermediate cause reportedon Part I (c) of certificateYES is an acceptable cause of Tentative underlying causereported on Part I (d) of certificate

Two Ways to Apply the GeneralPrincipleIntermediate cause reportedon Part I (c) of certificateImmediate cause reportedon Part I (a) of certificateIntermediate cause reportedon Part I (b) of certificate is an acceptable cause of every conditionreported on lines above itTentative underlying causereported on Part I (d) of certificate

Example 1Cerebral hemorrhage1 monthNephritis6 monthsCirrhosis of liver2 years

Example 1Cerebral hemorrhage1 monthNephritis(I61.9)(N05.9)Cirrhosis of liver(K74.6)2 yearsReported underlying cause is K74.6(“Other and unspecified cirrhosis of liver”)6 months

Example 1Cerebral hemorrhage1 monthNephritis(I61.9)(N05.9)Cirrhosis of liver(K74.6)2 yearsTentative underlying cause is K74.6(“Other and unspecified cirrhosis of liver”)6 months

Example 2Cardiac arrest with terminal hypostatic pneumoniaHypertension

Example 2(I46.9) (J18.2)Cardiac arrest with terminal hypostatic pneumoniaHypertensionReported underlying cause is I10[“Essential (primary) hypertension”](I10)

Example 2(I46.9) (J18.2)Cardiac arrest with terminal hypostatic pneumoniaHypertensionTentative underlying cause is I10[“Essential (primary) hypertension”](I10)

Example 2(I46.9) (J18.2)Cardiac arrest with terminal hypostatic pneumoniaHypertensionTentative underlying cause is I10[“Essential (primary) hypertension”](I10)

General PrincipleThe General Principle does not apply: When more than one condition has beenentered on the lowest-used line of Part I If the single condition entered in the lowestused line of Part I could not have given rise toall the conditions entered above itWhat then ?

Selection RulesRule 1“If the General Principle does not apply and there is areported sequence terminating in the condition firstentered on the certificate, select the originating causeof this sequence. If there is more than one sequenceterminating in the condition mentioned first, select theoriginating cause of the first-mentioned sequence.”

Example 3(I61.9) (J18.2)Cerebral hemorrhage and hypostatic pneumoniaχProstate hypertrophy and Diabetes(N40) (E14.9)Tentative underlying cause is E14.9 via Rule 1;General Principle not applicable;more than one condition entered in last-used line of Part I

Selection RulesRule 2“If there is no reported sequence terminating in thecondition first entered on the certificate, select thisfirst-mentioned condition.”

Example 4Pernicious anemia and comaAtherosclerosis

Example 4χ AtherosclerosisPernicious anemia and coma(D51.0) (R40.2)(I70.9)General Principle not applicable;single condition entered in the lowest-used line of Part Icould not have given rise to all the conditions entered above i

Example 4χ AtherosclerosisPernicious anemia and coma(D51.0) (R40.2)(I70.9)Rule 1 not applicable; no valid sequence terminatingin the condition first entered on the certificate.

Example 4Pernicious anemia and coma(D51.0) (R40.2)Atherosclerosis(I70.9)Tentative underlying cause is D51.0via Rule 2: select the first-mentionedcondition.

Selection RulesRule 3 (“direct sequel”)“If the condition selected by the General Principleor by Rule 1 or Rule 2 is obviously a directconsequence of another reported condition,whether in Part I or Part II, select this primarycondition.”

Example 5Cardiac arrestGastric hemorrhageGastric ulcer(I46.9)(K92.2)(K25.9)Through “direct sequel” Rule 3 a third code K259 isselected instead of K922 as tentative underlying causebecause the gastric hemorrhage is a direct sequel ofK25.9 as per Table E (Part 2c).

Modification RulesRule A (“senility and other ill-definedconditions”)“Where the selected cause is ill-defined and acondition classified elsewhere is reported on thecertificate, re-select the cause of death as if the illdefined condition had not been reported, except totake account of that condition if it modifies thecoding.”

The following are regarded as ill-defined: I46.9 (Cardiac arrest, unspec.);I95.9 (Hypotension, unspec.);I99 (Other and unspec. disorders of circulatory system);J96.0 (Acute respiratory failure);J96.9 (Respiratory failure, unspec.);P28.5 (Respiratory failure of newborn);R00-R94, R96-R99* (Chapter of Ill-defined & unknowncauses of mortality)* Note that R95, Sudden infant death syndrome,is not considered an “ill-defined” condition.

Example 5Senility and hypostatic pneumonia (R54) (J18.2)Rheumatoid arthritis(M06.9)Senility is considered ill-defined. Reselect TUC as if R54had not been reported.M06.9 is selected as TUC via General Principle.No modifications (IDDC, SENMC, SENDC) warranted.

Modification RulesRule B (“trivial conditions”)*“Where the selected cause is a trivial condition unlikely tocause death, and a more serious condition (any conditionexcept an ill-defined or another trivial condition) isreported, reselect the underlying cause as if the trivialcondition had not been reported. If the death was theresult of an adverse reaction to treatment of the trivialcondition, select the adverse reaction.When a trivial condition is reported as causing any othercondition, the trivial condition is not discarded and Rule Bis not applicable.”*For a list of trivial conditions, see instructionmanual Part 2c, table H.

Modification RulesRule C (“linkage”)“Where the selected cause is linked by a provision in theClassification or in the notes for use in underlying cause codingwith one or more of the other conditions on the certificate, codethe combination.Where the linkage provision is only for the combination of onecondition specified as due to another, code the combination onlywhen the correct causal relationship is stated or can be inferredfrom application of the selection rules.Where a conflict in linkages occurs, link with the condition thatwould have been selected if the cause initially selected had notbeen reported. Make any further linkage that is applicable.”