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External Cause-of-Injury Coding in Hospital Discharge Data -- United States, 1994

Although analysis of hospital discharge data (HDD) can provide important information about severe nonfatal injuries, HDD often do not include information about the causes of these injuries (e.g., motor-vehicle crashes and assaults). Inconsistent reporting of causes of injury has limited the usefulness of HDD for injury surveillance. The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) includes codes for classifying external causes of injury (E-codes). This report describes progress in implementing E-code reporting in states.

In June 1991, the National Committee on Vital and Health Statistics (NCVHS) (a legislatively mandated advisory committee of the U.S. Department of Health and Human Services) recommended that E-codes be included in hospital discharge data sets. In addition, because the uniform billing form for hospitals is used frequently as the source for HDD, the NCVHS recommended that the revised uniform billing form (UB-92) designate a space for an E-code (1). In February 1992, a UB-92 that included a labeled space for E-codes was approved by the National Uniform Billing Committee (a committee comprising representatives from payor and provider organizations and recognized by the Health Care Financing Administration) for use by all U.S. hospitals (1). During October 1993-April 1994, all U.S. hospitals implemented use of the UB-92.

From April 1992 through April 1994, the number of states that required reporting of E-codes in HDD increased from six to 15 *. Legislatures in nine of these states enacted laws requiring E-code reporting; six states used another administrative mechanism (e.g., regulations). Two states also required reporting of E-codes for persons treated in outpatient settings (e.g., emergency departments and outpatient clinics). In eight states, the state health department assists institutions in implementing E-code reporting and monitors compliance with reporting requirements; in seven states, other organizations (e.g., organizations that gather state health data) maintain this responsibility.

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

Editorial Note

Editorial Note: Because of the importance of collecting information about causes of injury, the 1993 national plan for injury prevention and control includes a recommendation for mandatory reporting of E-codes in HDD whenever injury is the principal diagnosis (2). The Council of State and Territorial Epidemiologists, the American Public Health Association, the American Health Information Management Association, the National Association of Health Data Organizations (NAHDA), and other organizations also support the mandatory reporting of E-codes in HDD.

As of April 1994, 27 states had HDD systems that were actively gathering information; in 21 (78%) of these states, the UB-92 was used to collect these data (M. Epstein, NAHDA, personal communication, 1994). The availability of a labeled space for an E-code on the UB-92 has prompted states to collect more consistently these data in HDD.

Reporting of E-codes is useful for establishing priorities for state injury-control programs and for evaluating the etiology of severe injuries -- including brain and spinal cord injuries. HDD that include E-codes also are useful in conducting surveillance for childhood injuries (3) and assessing the cost of injuries by external cause (e.g., motorcycle-related injuries) (4). To plan, implement, and evaluate injury-prevention programs, states should require the reporting of E-codes in HDD to obtain information about the causes of severe nonfatal injuries (5).

CDC is evaluating the ICD-9-CM E-coding system, including the list of E-codes and coding index, and is developing and testing coding guidelines and training materials. Additional information on E-coding is available to state and local health departments from CDC's National Center for Injury Prevention and Control, telephone (404) 488-4652.


  1. CDC. External cause-of-injury coding in hospital discharge data -- United States, 1992. MMWR 1992;41:249-51. 

  2. CDC. Injury control in the 1990's: a national plan for action. Atlanta: US Department of Health and Human Services, Public Health Service, CDC, National Center for Injury Prevention and Control, 1993. 

  3. Gallagher SS, Finison K, Guyer B, Goodenough S. The incidence of injuries among 87,000 Massachusetts children and adolescents: results of the 1980-81 statewide Childhood Injury Prevention Program Surveillance System. Am J Public Health 1984;74:1340-7. 

  4. Rivara FP, Morgan P, Bergman AB, Maier RV. Cost estimates for statewide reporting of injuries by E coding hospital discharge abstract data base systems. Public Health Rep 1990;105:635-6. 

  5. Sniezek JE, Finklea JF, Graitcer PL. Injury coding and hospital discharge data. JAMA 1989;262:2270-2.

* California, Connecticut, Delaware, Maryland, Massachusetts, Missouri, Nebraska, New Jersey, New York, Pennsylvania, Rhode Island, South Carolina, Vermont, Washington, and Wisconsin.

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