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External Cause-of-Injury Coding in Hospital Discharge Data -- United States, 1992

Accurate and reliable data regarding the external causes of injury (e.g., motor-vehicle crashes and assaults) are critical for planning, implementing, and evaluating injury-control programs (1). In the United States, approximately 25% of the total population is injured annually (2), and nonfatal injuries account for one of every 6 hospital days and 10% of all hospital discharges (3). Although hospital discharge data (HDD) are an important source of information for severe nonfatal injuries (4), external causes of injury have not been routinely reported in HDD, limiting the usefulness of these data for injury surveillance. This report summarizes recent efforts to improve the uniform reporting of external causes of injury in HDD by the National Committee on Vital and Health Statistics (NCVHS) and the National Uniform Billing Committee (NUBC). NCVHS

The NCVHS is a legislatively mandated advisory committee to the Department of Health and Human Services. In June 1991, the NCVHS approved a report by the NCVHS Subcommittee on Ambulatory and Hospital Care Statistics on the need to include external cause-of-injury codes (E-codes) in HDD (5). Key recommendations in the report were: 1) the external cause of injury should be recorded in the medical record whenever an injury is the principal diagnosis or directly related to the principal diagnosis; 2) E-codes should be included in HDD sets; 3) the revised uniform billing form for hospitals should provide a designated space for an E-code; 4) a hospital record or bill should be regarded as incomplete if there is evidence of an injury but no E-code is recorded; and 5) national guidelines and training materials for E-coding should be developed.

The NCVHS report was provided to the NUBC for use in its deliberations and is being used by CDC to guide state E-coding activities. NUBC

The NUBC, a committee comprising representatives from payor and provider organizations and recognized by the Health Care Financing Administration, is responsible for maintaining a standard billing form for hospitals. In February 1992, the NUBC completed final revisions and approved a new standard billing form for hospitals (the UB-92), which will replace the current form (the UB-82) used by hospitals to bill third-party payors. The UB-92 includes a labeled space for an E-code and is scheduled for implementation in the fall of 1993.

Reported by: Office of Planning and Extramural Programs, National Center for Health Statistics; Div of Injury Control, National Center for Environmental Health and Injury Control, CDC.

Editorial Note

Editorial Note: A primary objective of the collection of external cause-of-injury data is to assist in the implementation of injury-control programs. However, such information also is required to assess progress toward achievement of the national health objectives for the year 2000 that relate to the reduction of injury morbidity and injury-control interventions (e.g., objectives 7.3, 9.3(a-f), 9.4, 9.5, 9.6, and 9.8) (3). In addition to the efforts of the NCVHS and NUBC, in 1988, the Council of State and Territorial Epidemiologists recommended that "all hospital discharge summaries of injured patients include the E-code to describe the external cause of injury" (6). CDC and state health departments are using this recommendation to encourage the reporting of E-codes in HDD.

Thirty states use HDD to evaluate hospital use and costs; in 23 (77%) of these states, the uniform hospital billing form is used to collect this information. Six states (Arizona, California, New York, Rhode Island, Vermont, and Washington) require the reporting of E-codes in HDD. The efforts of the NCVHS and NUBC to improve the uniform reporting of E-codes in HDD will facilitate states' efforts to collect E-codes in HDD and increase the availability of information on the external cause of nonfatal injuries.

CDC is evaluating the use of E-coded HDD by the states and is planning to develop national E-coding guidelines and training materials. To plan, implement, and evaluate injury-prevention programs, states should require the reporting of E-codes in HDD to obtain information on severe nonfatal injuries (6). Additional information on E-coding in HDD is available to state and local health departments from CDC's Program Development and Implementation Branch, Division of Injury Control, National Center for Environmental Health and Injury Control; telephone (404) 488-4662.


  1. Committee to Review the Status and Progress of the Injury Control Program at the CDC. Injury control: a review of the status and progress of the injury control program at the CDC. Washington, DC: National Academy Press; 1988.

  2. Rice DP, MacKenzie EJ, and associates. Cost of injury in the United States: a report to Congress. San Francisco: University of California, Institute for Health and Aging, and Johns Hopkins University, Injury Prevention Center, 1989.

  3. Public Health Service. Healthy people 2000: national health promotion and disease prevention objectives. Washington, DC: US Department of Health and Human Services, Public Health Service, 1990; DHHS publication no. (PHS)91-50213.

  4. Smith GS, Langiois JA, Buechner JS. Methodological issues in using hospital discharge data to determine the incidence of hospitalized injuries. Am J Epidemiol 1991;134:1146-58.

  5. National Committee on Vital and Health Statistics Subcommittee on Ambulatory and Hospital Care Statistics. Report on the need to collect external cause-of-injury codes in hospital discharge data. Hyattsville, Maryland: US Department of Health and Human Services, Public Health Service, 1991. (NCHS working paper; series no. 38).

  6. Council of State and Territorial Epidemiologists. (CSTE position statement no. 7;adopted in 1988). In: Sniezek JE, Finklea JF, Graitcer PL. Injury coding and hospital discharge data. JAMA 1989;262:2270-2.

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