Instructions for Classification of Underlying and Multiple Causes of Death – Section III – 2020

SECTION III – EDITING AND INTERPRETING ENTRIES IN THE MEDICAL CERTIFICATION

Selection of the underlying cause is based on selecting a single condition on the lowest used line in Part I since this condition is presumed to indicate the certifier’s opinion about the sequence of events leading to the immediate cause of death. However, it is recognized that certifiers do not always report a single condition on the lowest used line, nor do they always enter the related conditions in a proper order of sequence. Therefore, it is necessary to edit the conditions reported during the selection process. For this reason, standardized rules and guides are set forth in this manual.

The international coding guides are provided in this section. Also included are instructions for use in the United States designed to bring assignments resulting from reporting practices particular to the United States into closer alignment with the intent of the International Classification procedures.

The interpretations and instructions in this section are general in nature and are to be used whenever applicable. Those in Section IV apply to specific categories.

Guides for the determination of the probability of sequence

Assumption of intervening cause. Frequently on the medical certificate, one condition is indicated as due to another, but the first one is not a direct consequence of the second one. For example, hematemesis may be stated as due to cirrhosis of the liver, instead of being reported as the final event of the sequence, liver cirrhosis portal hypertension ruptured esophageal varices hematemesis.

The assumption of an intervening cause in Part I is permissible in accepting a sequence as reported, but it must not be used to modify the coding.

Codes for Record

I (a) Cerebral hemorrhage I619

(b) Chronic nephritis N039

Code to chronic nephritis (N03.9). It is necessary to assume hypertension as a condition intervening between cerebral hemorrhage and the underlying cause, chronic nephritis.

Codes for Record

I (a) Mental retardation F79

(b) Premature separation P021

Code to premature separation of placenta affecting fetus or newborn (P02.1). It is necessary to assume birth trauma, anoxia or hypoxia as a condition intervening between mental retardation and the underlying cause, premature separation of placenta.

Interpretation of “highly improbable.” The expression “highly improbable” has been used since the Sixth Revision of the ICD to indicate an unacceptable causal relationship. As a guide to the acceptability of sequences in the application of the General Principle and the selection rules, the following relationships should be regarded as “highly improbable”:
an infectious or parasitic disease (A00-B99) reported as “due to” any disease outside this chapter, except that:

septicemia (A40-A41, B94.8)
erysipelas (A46, B94.8)
gas gangrene (A48.0, B94.8) May be accepted as
bacteremia (A49.0-A49.9, B94.8) “due to” any other
Vincent angina (A69.1, B94.8) disease
mycoses (B35-B49, B94.8)

any infectious disease may be accepted as “due to” disorders of the immune mechanism such as human immunodeficiency virus [HIV] disease or AIDS
any infectious disease may be accepted as “due to” immunosuppression by chemicals (chemotherapy) and radiation
any infectious disease classified to A000-A090, A162-B199 or B250-B64 reported as “due to” a malignant neoplasm will also be an acceptable sequence
varicella and zoster infections (B01-B02) may be accepted as “due to” diabetes, tuberculosis and lymphoproliferative neoplasms;

a malignant neoplasm reported as “due to” any other disease, except human immunodeficiency virus [HIV] disease;
hemophilia (D66, D67, D68.0-D68.2) reported as “due to” any other disease;
diabetes (E10-E14) reported as “due to” any other disease except:

hemochromatosis (E83.1),
diseases of pancreas (K85-K86),
pancreatic neoplasms (C25.-, D13.6, D13.7, D37.7),
malnutrition (E40-E46);

rheumatic fever (I00-I02) or rheumatic heart disease (I05-I09) reported as “due to” any disease other than scarlet fever (A38), streptococcal septicemia (A40.-), streptococcal sore throat (J02.0) and acute tonsillitis (J03.-);
any hypertensive condition reported as “due to” any neoplasm except:

endocrine neoplasms,
renal neoplasms,
carcinoid tumors;

chronic ischemic heart disease (I20, I25) reported as “due to” any neoplasm;
(1) cerebrovascular diseases (I60-I69) reported as “due to” a disease of the digestive system (K00-K92), except Cerebral hemorrhage (I61.-) due to Diseases of liver (K70-K76);

(2) cerebral infarction due to thrombosis of precerebral arteries (I63.0)

cerebral infarction due to unspecified occlusion of precerebral arteries (I63.2)

cerebral infarction due to thrombosis of cerebral arteries (I63.3)

cerebral infarction due to unspecified occlusion of cerebral arteries (I63.5)

cerebral infarction due to cerebral venous thrombosis, nonpyogenic (I63.6)

other cerebral infarction (I63.8)

cerebral infarction, unspecified (I63.9)

stroke, not specified as hemorrhage or infarction (I64)

other cerebrovascular disease (I67)

sequela of stroke, not specified as hemorrhage or infarction (I69.4)

sequela of other and unspecified cerebrovascular diseases (I69.8)

reported as “due to” endocarditis (I05-I08, I09.1, I33-I38);

(3) occlusion and stenosis of precerebral arteries, not resulting in cerebral infarction (I65), except embolism occlusion and stenosis of cerebral arteries, not resulting in cerebral infarction (I66) except embolism sequela of cerebral infarction (I69.3), except embolism reported as “due to” endocarditis (I05-I08, I09.1, I33-I38);

i. any condition described as arteriosclerotic [atherosclerotic] reported as “due to” any neoplasm;
influenza (J09-J11) reported as “due to” any other disease;
a congenital anomaly (Q00-Q99) reported as “due to” any other disease of the individual, except for:

a congenital anomaly reported as “due to” a chromosome abnormality or a congenital malformation syndrome
pulmonary hypoplasia reported as “due to” a congenital anomaly

a condition of stated date of onset “X” reported as “due to” a condition of stated date of onset “Y,” when “X” predates “Y”;
any accident (V01-X59) reported as “due to” any other cause outside this chapter except:

(1) any accident (V01-X59) reported as due to epilepsy (G40-G41)

(2) a fall (W00-W19) due to a disorder of bone density (M80-M85)

(3) a fall (W00-W19) due to a (pathological) fracture caused by a disorder of bone density

(4) asphyxia reported as due to aspiration of mucus, blood (W80) or vomitus (W78) as a result of disease conditions

(5) aspiration of food (liquid or solid) of any kind (W79) reported as due to a disease which affects the ability to swallow

suicide (X60-X84) reported as “due to” any other cause.

The preceding list does not cover all “highly improbable” sequences, but in other cases the General Principle should be followed unless otherwise indicated.

Acute or terminal circulatory diseases reported as “due to” malignant neoplasm, diabetes or asthma should be accepted as possible sequences in Part I of the certificate. The following conditions are regarded as acute or terminal circulatory diseases:

I21-I22 Acute myocardial infarction

I24.- Other acute ischemic heart diseases

I26.- Pulmonary embolism

I30.- Acute pericarditis

I33.- Acute and subacute endocarditis

I40.- Acute myocarditis

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

I51.8 Other ill-defined heart diseases

I60-I68 Cerebrovascular diseases except I67.0-I67.5 and I67.9

Diagnostic entities
One-term entity: A one-term entity is a diagnostic entity that is classifiable to a single ICD-10 code.
A diagnostic term that contains one of the following adjectival modifiers indicates the condition modified has undergone certain changes and is considered to be a one-term entity.

adenomatous embolic hypoxemic necrotic, necrotizing

anoxic erosive hypoxic obstructed

congestive gangrenous inflammatory obstructive

cystic hemorrhagic ischemic ruptured

(Apply this instruction to these adjectival modifiers only)

For code assignment, apply the following criteria in the order stated.

(1) If the modifier and lead term are indexed together, code as indexed.

Code for Record

I (a) Embolic nephritis N058

Code to embolic nephritis (N058). The adjectival modifier “embolic” is indexed under Nephritis.

(2) If the modifier is not indexed under the lead term, but “specified” is, use the code for specified (usually .8)

Code for Record

I (a) Obstructive cystitis N308

Code to cystitis, specified NEC (N308). The adjectival modifier “obstructive” is not indexed under Cystitis, but “specified NEC” is indexed.

(3) If neither the modifier nor “specified” is indexed under the lead term, refer to Volume 1 under the NOS code for the lead term and look for a specified fourth character category.

Code for Record

I (a) Hemorrhagic cardiomyopathy I428

Code to the category for other cardiomyopathies (I428). “Hemorrhagic” is not indexed under cardiomyopathy, neither is cardiomyopathy, specified, NEC indexed. The Classification does provide a code, I428, for “Other cardiomyopathies” in Volume 1.

(4) If neither (1), (2) nor (3) apply, code the lead term without the modifier.

Code for Record

I (a) Adenomatous bronchiectasis J47

Code to bronchiectasis NOS (J47). “Adenomatous” is not an index term qualifying bronchiectasis. Code bronchiectasis only, since there is no provision in the Classification for coding “other bronchiectasis.”

Alzheimer dementia: Consider the following terms as one term entities and code as indicated:

When reported as: Code

Endstage Alzheimer, senile dementia

Senile dementia, Alzheimer G301

Senile dementia, Alzheimer type

Senile dementia of the Alzheimer

When reported as: Code

Alzheimer, dementia

Alzheimer; dementia

Alzheimer disease (dementia)

Dementia Alzheimer

Dementia, Alzheimer

Dementia – Alzheimer G309

Dementia, Alzheimer type

Dementia of Alzheimer

Dementia – Alzheimer type

Dementia; Alzheimer type

Dementia, probable Alzheimer (disease)

Dementia syndrome, Alzheimer type

Endstage dementia (Alzheimer)

Multiple one-term entity: A multiple one-term entity is a diagnostic entity consisting of two or more contiguous words on a line for which the Classification does not provide a single code for the entire entity but does provide a single code for each of the components of the diagnostic entity. Consider as a multiple one-term entity if each of the components can be considered as separate one-term entities, i.e., they can stand alone as separate diagnoses.

Codes for Record

I (a) Hypertensive arteriosclerosis I10 I709

Code to hypertension (I10). The complete term is not indexed as a one-term entity. Code “hypertensive” and “arteriosclerosis” as separate one-term entities.

EXCEPTION: When any condition classifiable to I20-I25 (except I250) or I60-I69 is qualified as “hypertensive,” code to I20-I25 or I60-I69 only.

Code for Record

I (a) Hypertensive myocardial ischemia I259

Code to myocardial ischemia (I259). Disregard “hypertensive” since it is modifying an ischemic heart condition.

Adjective reported at the end of a diagnostic entity

Code an adjective reported at the end of a diagnostic entity as if it preceded the entity. This applies whether reported in Part I or Part II.

Codes for Record

I (a) Arteriosclerosis, hypertensive I10 I709

Code to hypertension (I10). The complete term is not indexed as a one-term entity. “Hypertensive” is an adjectival modifier; code as if it preceded the arteriosclerosis.

Adjectival modifier reported with multiple conditions
If an adjectival modifier is reported with more than one condition, modify only the first condition.

Codes for Record

I (a) Arteriosclerotic nephritis and cardiomyopathy I129 I429

Code to arteriosclerotic nephritis (I129). The modifier is applied only to the first condition.

If an adjectival modifier is reported with one condition and more than one site is reported, modify all sites.

Codes for Record

I (a) Arteriosclerotic cardiovascular and

cerebrovascular disease I250 I672

Code to arteriosclerotic cardiovascular disease (I250). The modifier is applied to both conditions, but in this case the selected cause is not modified by the other condition on the record.

When an adjectival modifier precedes two different diseases that are reported with a connecting term, modify only the first disease.

Codes for Record

I (a) Arteriosclerotic cardiovascular disease

and cerebrovascular disease I250 I679

Code to arteriosclerotic cardiovascular disease (I250). The modifier is applied only to the first condition.

Parenthetical entries
When one medical entity is reported followed by another complete medical entity enclosed in parenthesis, disregard the parenthesis and code as separate terms.

Codes for Record

I (a) Heart dropsy I500

(b) Renal failure (CVRD) N19 I139

(c)

Code to hypertensive heart and renal disease (I132). Consider line (b) as two separate terms, both of which are complete medical entities.

When the adjectival form of words or qualifiers are reported in parenthesis, use these adjectives to modify the term preceding it.

Codes for Record

I (a) Collapse of heart I509

(b) Heart disease (rheumatic) I099

Code to rheumatic heart disease (I099). Use “rheumatic” as a modifier.

If the term in parenthesis is not a complete term and is not a modifier, consider as part of the preceding term.

Code for Record

I (a) Metastatic carcinoma (ovarian) C56

Code to primary ovarian carcinoma (C56).

Plural form of disease

Do not use the plural form of a disease or the plural form of a site to indicate multiple.

Codes for Record

I (a) Cardiac arrest I469

(b) Congenital defects Q899

Code to congenital defect (Q899); do not code as multiple (Q897).

Implied disease

When an adjective or noun form of a site is entered as a separate diagnosis, i.e., it is not part of an entry immediately preceding or following it, assume the word “disease” after the site and code accordingly.

Code for Record

I (a) Myocardial I515

(b)

(c)

Code to myocardial disease (I515).

Codes for Record

I (a) Coronary I251

(b) Hypertension I10

(c)

Code to coronary disease (I251). Line I(a) is coded as coronary disease since coronary hypertension is not indexed.

I (a) Renal I129

(b) Hypertension

Code to renal hypertension (I129). Consider the site, renal, to be a part of the condition that immediately follows it on line b, since Hypertension, renal is indexed.

Non-traumatic conditions

Consider conditions that are usually but not always traumatic in origin to be qualified as non-traumatic when reported due to or on the same line with a disease.

I (a) Fat embolism I749

(b) Pathological fracture M844

Code line I(a) as non-traumatic since reported due to a disease.

Relating and modifying

Certain conditions are classified in the ICD-10 according to the site affected, e.g.

atrophy enlargement obstruction

calcification failure perforation

calculus fibrosis rupture

congestion gangrene stenosis

degeneration hypertrophy stones

dilatation insufficiency necrosis stricture

embolism

(This list is not all inclusive)

Occasionally, these conditions are reported without specification of site. Relate conditions such as these for which the Classification does not provide an NOS code and conditions which are usually reported of a site. Generally, it may be assumed that such a condition was of the same site as another condition if the Classification provides for coding the condition of unspecified site to the site of the other condition. These coding principles apply whether or not there are other conditions reported on other lines in Part I. Use the following generalizations as a guide in assuming a site:

General instructions for implied site of a disease
Conditions of unspecified site reported on thesame line

(1) When conditions are reported on the same line with or without a connecting term that implies a due to relationship, assume the condition of unspecified site was of the same site as the condition of a specified site.

Codes for Record

I (a) Aspiration pneumonia J690

(b) Cerebrovascular accident due to I64

Code to cerebral thrombosis (I633). Since thrombosis (of unspecified site) is reported on the same line with a condition of a specified site, relate to the specified site.

(2) When conditions of different sites are reported on the same line with the condition of unspecified site, assume the condition of unspecified site was of the same site as the condition immediately preceding it.

Codes for Record

I (a) ASHD, infarction, CVA I251 I219 I64

(b)

Code to heart infarction (I219). Since infarction (of unspecified site) is reported on same line with two conditions of specified sites, relate to the specified site immediately preceding the condition. ASHD links (LMP) with heart infarction.

Conditions of unspecified site reported on aseparate line

(1) If there is only one condition of a specified site reported on the line above or below it, code to this site.

Codes for Record

I (a) Cholecystitis K819

(b) Calculus K802

Code to calculus of gallbladder with other cholecystitis (K801). Calculus of an unspecified site is reported on line (b). The condition on the line above is of a stated site (gallbladder). Therefore, consider line (b) as calculus of gallbladder (K802). This code links (LMC) with cholecystitis.

(2) If there are conditions of different specified sites on the lines above and below it and the Classification provides for coding the condition of unspecified site to only one of these sites, code to that site.

Codes for Record

I (a) Intestinal fistula K632

(b) Obstruction K566

Code to intestinal adhesions with obstruction (K565). Since the Classification does not provide a code for obstruction of the peritoneum, relate to the site reported on the line above (intestinal). Adhesions of peritoneum links (LMC) with intestinal obstruction.

(3) If there are conditions of different specified sites on the lines above and below and the Classification provides for coding the condition of unspecified site to both of these sites, code the condition unspecified as to site.

Codes for Record

I (a) CVA I64

(b) Thrombosis I829

Code to ASHD (I251). Since the thrombosis is classified to both sites (reported above and below), do not relate.

(4) Do not relate conditions which are not reported in the first position on a line to the line above. It is acceptable to relate conditions not reported as the first condition on a line to the line below.

Codes for Record

I (a) Kidney failure N19

(b) Vascular insufficiency with thrombosis I99 I219

Code to cardiac thrombosis (I219). Relate thrombosis to line below. ASHD links (LMP) with heart thrombosis.

Relating specific categories
When ulcer, site unspecified or peptic ulcer NOS is reported causing, due to, or on the same line with gastrointestinal hemorrhage, code peptic ulcer NOS (K279).

Codes for Record

I (a) Gastrointestinal hemorrhage K922

(b) Peptic ulcer K279

Code to peptic ulcer with hemorrhage (K274). Do not relate peptic ulcer to gastrointestinal. Peptic ulcer links (LMC) with gastrointestinal hemorrhage.

When ulcer NOS (L984) is reported causing, due to, or on the same line with diseases classifiable to K20-K22, K30-K31, and K65, code peptic ulcer NOS (K279).

Codes for Record

I (a) Peritonitis K659

(b) Ulcer K279

Code to peptic ulcer (K279).

When hernia (K40-K46) is reported with disease(s) of unspecified site(s), relate the disease of unspecified site to the intestine.

Codes for Record

I (a) Hernia with obstruction K469 K566

Code to hernia with obstruction (K460). Relate obstruction to intestine. Hernia links (LMC) with intestinal obstruction.

When calculus NOS or stones NOS is reported with pyelonephritis, code to N209 (urinary calculus).

Codes for Record

I (a) Calculus with pyelonephritis N209 N12

Code to urinary calculus (N209).

When arthritis (any type) is reported with

Contracture code contracture of the site
Deformity code deformity acquired of the site

If no site is reported or if site is not indexed, code contracture or deformity, joint.

Codes for Record

I (a) Phlebitis I809

(b) Deformities M219

Code to osteoarthritis lower limbs (M199).

When embolism, infarction, occlusion, thrombosis NOS is reported

from a specified site code the condition of the site reported
of a site from a specified site code the condition to both sites reported

Codes for Record

I (a) Congestive heart failure I500

(b) Embolism from heart I2190

Code to cardiac embolism (I219). Relate embolism to site reported.

Relate a condition of unspecified site to the complete term of a multiple site entity. If it is not indexed together, relate the condition to the site of the complete indexed term.

Codes for Record

I (a) Cardiorespiratory arrest with I469 I509

(b) insufficiency

Code to heart failure (I509). Since cardiorespiratory arrest is indexed to a heart condition, relate insufficiency to heart.

When vasculitis NOS is reported, apply the general instructions for relating and modifying.

Codes for Record

I (a) Renal failure N19

(b) Vasculitis I778

Code Vasculitis, kidney (I778). Relate vasculitis to the site reported on line I (a).

Exceptions to relating and modifying instructions:
Do not relate the following conditions:

Arteriosclerosis

Congenital anomaly NOS

Hypertension

Infection NOS (refer to Section III, Part K, #6)

Neoplasms

Paralysis

Vascular disease NOS

Codes for Record

I (a) Cardiac arrest I469

(b) Congenital anomaly Q899

Code to congenital anomaly NOS (Q899). Do not relate to cardiac.

Do not relate hemorrhage when causing a condition of a specified site. Relate hemorrhage to site of disease reported onsame line or line below only.

Codes for Record

I (a) Respiratory failure J969

(b) Hemorrhage R5800

Code to hemorrhage NOS (R58). Do not relate to respiratory.

Do not relate conditions classified to R00-R99 except:

Gangrene and necrosis               R02
Hemorrhage                              R5800
Stricture and stenosis                 R688

Codes for Record

I (a) Pneumonia with gangrene J189 J850

Code to gangrene of lung (J850). Relate gangrene to pulmonary, the site of the disease reported on the same line, since gangrene is one of the exceptions. Pneumonia is a direct sequel (DS) of pulmonary gangrene.

Do not relate a disease condition that, by the name of the disease, implies a disease of a specified site unless it is obviously an erroneous code. If not certain, refer to supervisor.

Codes for Record

I (a) Encephalopathy, cirrhosis G934 K746

Code to encephalopathy (G934). Do not relate encephalopathy to liver since the name of the disease implies a disease of a specific site, brain.

Coding conditions classified to injuries as disease conditions
Some conditions (such as injury, hematoma or laceration) of a specified organ are indexed directly to a traumatic category but may not always be traumatic in origin. Consider these types of conditions to be qualified as nontraumatic and code as nontraumatic when reported as below, unless a statement on the certificate indicates the condition was traumatic:

due to or on the same line with a disease
due to: drug poisoning drug therapy

If there is provision in the Classification for coding the condition that is considered to be qualified as nontraumatic as such, code accordingly. Otherwise, code to the category that has been provided for “Other” diseases of the organ (usually .8).

Codes for Record

I (a) OBS F069

(b)

(c)

II HTN, Diabetes, Traumatic brain injury I10 E149 S069 X599

Code to organic brain syndrome F069. In Part II, assign traumatic brain injury as indexed. Since qualified as traumatic, prefer the certifier’s statement and to not apply the instruction.

Codes for Record

I (a) Laceration heart I518

(b) Myocardial infarction I219

(c)

Code to myocardial infarction (I219) selected by General Principle. Since laceration heart is reported due to myocardial infarction, consider the laceration to be nontraumatic.

Codes for Record

I (a) Subdural hematoma I620

(b) CVA I64

(c)

Code to nontraumatic subdural hematoma (I620) since reported due to CVA. Cerebrovascular accident, selected by the General Principle, is considered a general term and nontraumatic subdural hematoma is preferred as the more informative term by application of Rule D (SMP).

Codes for Record

I (a) Cardiorespiratory failure R092

(b) Intracerebral hemorrhage I619

Code to cerebral meningioma (D320). Subdural hematoma is considered to be nontraumatic since it is reported on the same line with cerebral meningioma. The nontraumatic subdural hematoma selected by Rule 1 is a direct sequel (Rule 3) to cerebral meningioma.

Codes for Record

I (a) Fat embolism I749

(b) Pathological fracture M844

Code line I(a) as non-traumatic since reported due to a disease.

Some conditions are indexed directly to a traumatic category but the Classification also provides a nontraumatic category. When these conditions are reported due to or with a disease and an external cause is reported on the record or theManner of Death box is checked as Accident, Homicide, Suicide, Pending Investigation or Could not be determined, consider the condition as traumatic.

Codes for Record

I (a) Subdural hematoma S065

(b) CVA I64

(c)

II W18

Accident Fell while walking

Code to other fall on the same level (W18). Subdural hematoma is considered to be traumatic as indexed since “accident” is reported in the Manner of Death box.

Codes for Record

I (a) Cerebral hematoma with S068 I672

(b) cerebral arteriosclerosis

(c)

II X599

Accident

Code to accident NOS (X599). Cerebral hematoma is considered traumatic as indexed since “accident” is reported in the Manner of Death box.

Some conditions are indexed directly to a traumatic category, but the Classification also provides a nontraumatic category. When these conditions are reported and the Manner of Death box is checked as Natural, consider these conditions as nontraumatic unless the condition is reported due to or on the same line with an injury or external cause. This instruction applies only to conditions with the term “nontraumatic” in the Index.

Code for Record

I (a) Subdural hematoma I620

(b)

Natural

Code to nontraumatic subdural hematoma (I620). The subdural hematoma is considered to be nontraumatic since “Natural” is reported in the Manner of Death box and is selected by application of General Principle.

Codes for Record

I (a) Subdural hematoma I620

(b)

(c)

II Fracture hip S720 W19

Natural Fell in hospital

Codes for Record

I (a) Subdural hematoma S065

(b) Open wound of head S019

II Fell in hospital W19

Natural

Code to unspecified fall (W19). Even though Natural is reported in the Manner of Death box, the subdural hematoma is reported due to an injury.

Intent of certifier

In order to assign the most appropriate code for a given diagnostic entity, it may be necessary to take other recorded information and the order in which the information is reported into account. It is important to interpret this information properly so the meaning intended by the certifier is correctly conveyed. The following instructions help to determine the intent of the certifier. Apply Intent of Certifier instructions to “See also” terms in the Index and to any synonymous sites or terms as well.

For the following conditions, use the causation tables to determine if the NOS code from the title or the alternative code listed below the title should be used in determining a sequence. If the alternative code forms an acceptable sequence with the condition reported below it, then that sequence should be accepted.

Other and unspecified gastroenteritis and colitis of unspecified origin (A099)
Code A090 (Gastroenteritis and colitis of infectious origin)

When reported due to:

A000-B99

R75

Y431-Y434

Y632

Y842

Codes for Record

I (a) Enteritis A090

(b) Listeriosis A329

Code I(a) gastroenteritis and colitis of infectious origin, A090, since enteritis is reported due to a condition classified to A329.

EXCEPTION: When the enteritis is reported due to another infectious condition or an organism classified to A49 or B34, refer to Section III,
7. Organisms and Infections.

Code K529 (Noninfective gastroenteritis and colitis, unspecified) when reported due to conditions listed in the causation table under address code K529.

Codes for Record

I (a) Enteritis K529

(b) Abscess of intestine K630

Code to K630. The code K630 is listed as a subaddress to K529 in the causation table, so this sequence is accepted.

Cavitation of lung (A162)

Code J984 (Nontuberculous cavitation of lung):

When reported due to:

A000-A099
A200-B199
B201-B89
B91-F39
F531
F55
F71-F79
F840-F849
F99-G419
G459-G98
H650-H709
H720-H739
H950-J64
J660-L599
L930-L932
M000-N459
N480-N96
N980-O979
O981-P369
P371-R825
R826
R827-R892
R893
R894-R961
R98-R99
S000-Y899

Codes for Record

I (a) Cavitary lung disease J984

(b) COPD J449

(c)

Code I(a) nontuberculous cavitation of lung, J984, since cavitary lung disease is reported due to a condition classified to J449.

Codes for Record

I (a) Respiratory failure J969

(b) Cardiogenic shock R570

Code I(c) cavitation of lung, A162, since it is not reported due to any other conditions.

Spinal Abscess (A180)

Vertebral Abscess (A180)

Code M462 (Nontuberculous spinal abscess):

When reported due to:

A400-A419 H650-H669 M910-M939

A500 H950-H959 M960-M969

A509 J00-J399 N10-N12

A527 J950-J959 N136

A539 K650-K659 N151

B200-B24 K910-K919 N159

B89 L00-L089 N288

B99 M000-M1990 N340-N343

C412 M320-M351 N390

C760 M359 N700-N768

C795 M420-M429 N990-N999

C810-C969 M45-M519 R75

D160-D169 M600 S000-T983

D480 M860-M889

D550-D589 M894

Codes for Record

I (a) Spinal Abscess M462

(b) Staphylococcal septicemia A412

Code I(b) A412, staphylococcal septicemia. The code A412 is listed as a subaddress to M462 in the causation table; therefore, this sequence is accepted.

Charcot Arthropathy (A521)

Code G98 (Arthropathy, neurogenic, neuropathic (Charcot), nonsyphilitic):

When reported due to:

A30 Leprosy

E10-E14 Diabetes mellitus

E538 Subacute combined degeneration (of spinal cord)

F101 Alcohol abuse

F102 Alcoholism

G600 Hypertrophic interstitial neuropathy

G600 Peroneal muscular atrophy

G608 Hereditary sensory neuropathy

G901 Familial dysautonomia

G950 Syringomyelia

Q059 Spina bifida, unspecified

Y453 Indomethacin

Y453 Phenylbutazone

Y427 Corticosteroids

Codes for Record

I (a) Charcot arthropathy G98

(b) Diabetes E149

Code to diabetes with other specified complications (E146). Since the E149 is listed as a subaddress under G98 in the Causation Table, use G98 for the Charcot arthropathy. The diabetes selected by general principle links (LDC) with Charcot arthropathy.

General Paresis (A521)
Code G839 (Paralysis) when reported due to or on the same line with conditions listed in the causation table under G839.

Codes for Record

I (a) General paresis and CVA G839 I64

(b)

(c)

Code to CVA (I64). Since I64 is listed as a subaddress to G839 in the causation table, use G839 as the code for general paresis. The paresis selected by Rule 2 is a direct sequel (DS) to CVA.

Code T144 (Paralysis, traumatic) when reported due to or on the same line with a nature of injury or external cause.

Codes for Record

I (a) General paresis T144

(b) Brain injury S069

(c)

II Auto accident V499

Code to auto accident (V499). General paresis due to S069 is coded as traumatic. The codes S00-T98 are invalid for underlying cause so the external cause code is selected.

Viral Hepatitis (B161, B169, B171-B179)

Code:

For Viral Hepatitis in Chronic Viral

Categories Hepatitis

B161 B180

B169 B181

B171 B182

B172 B188

B178 B188

B179 B189

When reported as causing liver conditions in:

K721, K7210

K740-K742

K744-K746

Codes for Record

I (a) Cirrhosis of liver K746

(b) Viral hepatitis B B181

Code to chronic viral hepatitis B (B181). Code I(b) as chronic viral hepatitis B, since reported as causing a condition classified to K746.

Organisms and Infections NOS (B99)

To code organisms and infections correctly, it is necessary to recognize organisms and infectious conditions. In order to apply the correct instruction, it is also necessary to know how the organisms are classified. There are separate instructions depending on whether the organism is bacterial, viral or other organisms. Listed below are examples of organisms and infectious conditions.

Organisms

Baterial organisms Viral organisms Organisms classified

classified to A49.- classified to B34.- other than A49.- or B34.-

Escherichia coli Adenovirus Aspergillus

Haemophilus influenzae Coronavirus Candida

Pneumococcal Coxsackie Cytomegalovirus

Staphylococcal Enterovirus Fungus

Streptococcal Parvovirus Meningococcal

Infectious conditions

Abscess Infection Sepsis, Septicemia

Bacteremia Pneumonia Septic shock

Empyema Pyemia Words ending in “itis”

These lists are NOT all inclusive. Use them as a guide.

In order to arrive at the correct underlying cause, the medical entities must first be coded correctly. The following instructions demonstrate how to assign the codes for the record when dealing with infectious conditions. Once the codes for the record are assigned, the selection and modification rules are applied to determine the underlying cause.

In order to determine which infection instruction to use, refer to the Index under the named organism or under Infection, named organism.

Bacterial organisms and infections classified to A49 and Viral organisms and infections classified to B34

(1) When an infectious or inflammatory condition is reported and

(a) Is preceded or followed by a condition classified to A49 or B34 or

(b) A condition classifiable to A49 or B34 is reported as the only entry or the first entry on the next lower line or

(c) Is followed by a condition classified to A49 or B34 separated by a connecting term not indicating a due to relationship

(i) If a single code is provided for the infectious or inflammatory condition modified by the condition classified to A49 or B34, use this code. Do not assign a separate code for the condition classifiable to A49 or B34. It may be necessary to use “due to” or “in” in the Index to assign the appropriate code.

Code for Record

I (a) E. Coli diarrhea A044

Code to other intestinal E. coli infections (A044). Code as indexed under Diarrhea, due to, Escherichia coli.

Code for Record

I (a) Pneumonia J129

(b) Viral infection

Code to viral pneumonia, unspecified (J129). Code as indexed under Pneumonia, viral.

Codes for Record

I (a) Meningitis and sepsis G000 A413

(b) H. Influenzae

Code to Haemophilus meningitis (G000). Assign the codes for the record following the Index under Meningitis, Haemophilus (influenzae) and Septicemia, Haemophilus influenzae.

Code for Record

I (a) Sepsis with staph A412

Code to septicemia due to unspecified staphylococcus (A412). Code as indexed under Septicemia, staphylococcus.

Code for Record

I (a) Pneumonia c MRSA J152

Code to pneumonia due to staphylococcus (J152). Code as indexed under Pneumonia, MRSA (methicillin resistant staphylococcus aureus).

(ii) If (i) does not apply, and the Index provides a code for the infectious or inflammatory condition qualified as “bacterial,” “infectious,” “infective” or “viral,” assign the appropriate code based on the reported type of organism. Do not assign a separate code for the condition classified to A49 or B34.

Code for Record

I (a) Coxsackie virus pneumonia J128

Code to other viral pneumonia (J128). Since Coxsackie virus is not specifically listed under pneumonia, code as indexed under Pneumonia, viral, specified NEC.

Code for Record

I (a) Peritonitis K650

(b) Campylobacter

Code to acute peritonitis (K650). Since Campylobacter is not specifically listed under peritonitis, code as indexed under Peritonitis, bacterial.

Code for Record

I (a) Pneumonia with coxsackie virus J128

Code to other viral pneumonia (J128). Since coxsackie virus is not specifically listed under pneumonia, code as indexed under Pneumonia, viral, specified NEC.

(iii) If (i) and (ii) do not apply, assign the NOS code for the infectious or inflammatory condition. Do not assign a separate code for the condition classified to A49 or B34.

Code for Record

I (a) Klebsiella urinary tract infection N390

Code to urinary tract infection (N390). The Index does not provide a code for Infection, urinary tract specified as bacterial, infectious, infective, or Klebsiella; therefore, code as indexed under Infection, urinary tract.

Code for Record

I (a) Pyelonephritis N12

(b) Staphylococcus

Code to pyelonephritis, unspecified (N12). The Index does not provide a code for pyelonephritis specified as bacterial, infectious, infective, or staphylococcal; therefore, code pyelonephritis NOS.

Code for Record

I (a) Pyelonephritis and pseudomonas N12

Code to pyelonephritis, unspecified (N12). The index does not provide a code for pyelonephritis specified as bacterial, infectious, infective, or pseudomonas; therefore, code to pyelonephritis NOS.

Organisms and infections classified to categories other than A49 and B34

(1) When an infectious or inflammatory condition is reported and

(a) Is preceded by a condition classifiable to Chapter I other than A49 or B34

(i) Refer to the Index under the infectious or inflammatory condition. If a single code is provided for this condition, modified by the condition from Chapter I, use this code. It may be necessary to use “due to” or “in” in the Index to assign the appropriate code.

Code for Record

I (a) Cytomegaloviral pneumonia B250

Code to cytomegaloviral pneumonitis (B250). Code as indexed under Pneumonia, cytomegaloviral.

(ii) If (i) does not apply, refer to Volume 1, Chapter I to determine if the Classification provides an appropriate fourth character. Indications of appropriate fourth characters for sites would be “of other sites,” “other specified organs,” or “other organ involvement.”

Code for Record

I (a) Candidiasis peritonitis B378

Code to candidiasis of other sites (B378). Since this term is not indexed together, refer to Volume 1 and select the fourth character .8, candidiasis of other sites.

(iii) If (i) and (ii) does not apply, code as two separate conditions.

Codes for Record

I (a) Mononucleosis pharyngitis B279 J029

Code to infectious mononucleosis, unspecified (B279). To assign the codes for the record, note that this term is not indexed together and Volume 1 does not provide an appropriate fourth character under B27.-; therefore, consider as two separate conditions.

(b) A condition from Chapter I other than A49 or B34 is reported as the only entry or the first entry on the next lower line

(i) Code each condition as indexed where reported.

Codes for Record

I (a) Peritonitis K659

(b) Candidiasis B379

Code to candidiasis of other sites (B378). Candidiasis is selected by the General Principle, and is a (SDC) with peritonitis. To assign the codes for the record, note that candidiasis is classified to a condition other than A49 or B34.

(c) A condition from Chapter I other than A49 or B34 is reported separated by a connecting term not indicating a due to relationship

(i) Code each condition as indexed where reported.

Codes for Record

I (a) Pneumonia with candidiasis J189 B379

Code to candidiasis, unspecified (B379). Pneumonia, selected by Rule 2 is a direct sequel (DS) of the candidiasis. To assign codes for the record, note that candidiasis is classified to a condition other than A49 or B34.

Do not use HIV or AIDS to modify an infectious or inflammatory condition.

Consider as two separate conditions.

Codes for Record

I (a) HIV pneumonia B24 J189

Code to HIV disease with other infectious and parasitic diseases (B208). HIV, selected by Rule 2, links (LMC) with pneumonia into a combination code of B208.

When an infectious or inflammatory condition is reported and

(1) Infection NOS is reported as the only entry or the first entry on the next lower line

Code the infectious or inflammatory condition where it is entered on the certificate and do not enter a code for infection NOS, but take into account if it modifies the infectious condition.

Codes for Record

I (a) Cholecystitis & arthritis K819 M009

(b) Infection

Code to cholecystitis, unspecified (K819). To assign the codes for the record, note that infection is the only condition on (b). Code cholecystitis as indexed. Cholecystitis modified by infection is coded to cholecystitis NOS. Take into account that infection also modifies arthritis and code as indexed under Arthritis, infectious.

Codes for Record

I (a) Meningitis G039

(b) Infection & brain tumor D432

Code to neoplasm of uncertain or unknown behavior of brain (D432). To assign the codes for the record, note that infection is the first entry on (b). Code meningitis as indexed. Meningitis modified by infection is coded to meningitis NOS.

When any condition is reported and a generalized infection such as bacteremia, fungemia, sepsis, septicemia, systemic infection, viremia is reported on a lower line, do not modify the condition by the generalized infection.

Codes for Record

I (a) Bronchopneumonia J180

(b) Septicemia A419

Code to septicemia, unspecified (A419) by General Principle. To assign the codes for the record, note that septicemia is a generalized infection and doesn’t modify the bronchopneumonia.

Eaton-Lambert syndrome (C80)

Code G708 (Eaton-Lambert syndrome unassociated with neoplasm)

When reported on a record without a condition from the following categories also reported:

C000-D489

Male, 57 years old Codes for Record

I (a) Aspiration pneumonia J690

(b) Eaton-Lambert syndrome G708

Code Eaton-Lambert syndrome unassociated with neoplasm (G708) since there is no condition from categories C000 – D489 reported anywhere on the record.

Female, 69 years old Codes for Record

I (a) Eaton-Lambert syndrome C80

(b) Small cell lung cancer C349

Code to malignant neoplasm of lung (C349). Code I(a) Eaton-Lambert syndrome (C80) since there is a condition from categories C000-D489 reported on the record.

Erythremia(C940)

Code D751 (Secondary erythremia) when reported due to conditions listed in the causation table under address code D751.

Codes for Record

I (a) Septicemia A419

(b) Erythremia D751

Code to D45. The code D45 is listed as a subaddress to D751 in the causation table so this sequence is accepted.

Polycythemia (D45)

Code D751 (Secondary polycythemia) when reported due to conditions listed in the causation table under address code D751.

Codes for Record

I (a) Polycythemia D751

(b) Pneumonia J189

Code to J189. The code J189 is listed as a subaddress to D751 in the causation table so this sequence is accepted.

Hemolytic Anemia (D589)

Code D594 (Secondary hemolytic anemia) when reported due to conditions listed in the causation table under address code D594.

Codes for Record

I (a) Hemolytic anemia D594

(b) Hairy cell leukemia C914

(c)

Code to C914. The code C914 is listed as a subaddress to D594 in the causation table so this sequence is accepted.

Sideroblastic Anemia (D643)
Code D641 (Secondary sideroblastic anemia due to disease) when reported due to conditions listed in the causation table under address code D641.

Codes for Record

I (a) Pneumonia J189

(b) Sideroblastic anemia D641

Code to K703. The code K703 is listed as a subaddress to D641 in the causation table so this sequence is accepted.

Code D642 (Secondary sideroblastic anemia due to drugs or toxins) when reported due to conditions listed in the causation table under address code D642.

Codes for Record

I (a) CHF I500

(b) Sideroblastic anemia D642

Code to D642. The code Y402 is listed as a subaddress to D642 in the causation table so this sequence is accepted. Since the condition being treated is not stated for this drug therapy and the complication is indexed to Chapters I-XVIII, select the complication as the underlying cause.

Hemorrhagic Purpura NOS (D693)

Code D690 (Hemorrhagic purpura not due to thrombocytopenia) when reported due to conditions listed in the causation table under address code D690.

Codes for Record

I (a) CVA I64

(b) Hemorrhagic purpura D690

Code to C959. The code C959 is listed as a subaddress to D690 in the causation table so this sequence is accepted.

Thrombocytopenia (D696)

Code D695 (Secondary thrombocytopenia) when reported due to conditions listed in the causation table under address code D695.

Codes for Record

I (a) Multiple hemorrhages R5800

(b) Thrombocytopenia D695

Code to C349. The code C349 is listed as a subaddress to D695 in the causation table so this sequence is accepted.

Hyperparathyroidism (E213)

Code E211 (Secondary hyperparathyroidism) when reported due to conditions listed in the causation table under address code E211.

Codes for Record

I (a) Hypercalcemia E835

(b) Hyperparathyroidism E211

Code to C750. The code C750 is listed as a subaddress to E211 in the causation table so this sequence is accepted.

Korsakov Disease, Psychosis or Syndrome (F106)

Code F04 (nonalcoholic Korsakov disease) when reported due to conditions listed in the causation table under address code F04.

Codes for Record

I (a) Korsakoff psychosis F04

(b) Wernicke encephalopathy E512

(c)

Code to E512. The code E512 is listed as a subaddress to F04 in the causation table so this sequence is accepted.

Psychosis (any F29)

Code F09 (Psychosis, organic NEC) when reported due to or on the same line with conditions listed in the causation table under address code F09.

Codes for Record

I (a) Pneumonia J189

(b) Psychosis – cerebrovascular F09 I672

(d) Arteriosclerosis I709

Code to I672. The code I709 is listed as a subaddress to F09 in the causation table so this sequence is accepted. Arteriosclerosis will link (LMP) with cerebrovascular arteriosclerosis in the modification table.

Mental Disorder (any F99)

Code F069 (Organic mental disorder)

When reported due to or on the same line with conditions listed in the causation table under address code F069.

Codes for Record

I (a) Cardiorespiratory arrest I469

(b) Heart failure I509

(d) Multiple sclerosis G35

Code to G35. The code G35 is listed as a subaddress to F069 in the causation table so this sequence is accepted.

Parkinson Disease (G20)
Advanced Parkinson Disease (G2000)
Grave Parkinson Disease (G2000)
Severe Parkinson Disease (G2000)
CodeG214 (Vascular parkinsonism) when reported due to conditions listed in the causation table under address code G214.

Codes for Record

I (a) Parkinsonism G214

(b) Arteriosclerosis I709

(c)

Code to G214 (Vascular parkinsonism) when reported due to conditions listed in the causation table under G214.

Code G219 (Secondary parkinsonism) when reported due to:

A170-A179 B060 B949 R75 Y20-Y369

A504-A539 B200-B24 F200-F209 S000-T357 Y600-Y849

A810-A819 B261 G000-G039 T66-T876 Y850-Y872

A870-A89 B375 G041-G09 T900-T982 Y881-Y899

B003 B900 G20-G2000 T983

B010 B902 G218-G219 X50-X599

B021-B022 B91 G300-G309 X70-X84

B051 B941 I950-I959 X91-Y09

Codes for Record

I (a) Parkinsonism G214

(b) Arteriosclerosis I709

(c)

Code to G214 (Vascular parkinsonism) when reported due to conditions listed in the causation table under G214.

I (a) Parkinson disease G219

(b) Tuberculous meningitis A170

(c)

Code to G219 (Secondary parkinsonism) when reported due to conditions listed in the causation table under G219.

I (a) Secondary Parkinson disease G219

(b)

(c)

Code to G219 as indexed.

Cerebral Sclerosis (G379)

Code I672 (Cerebrovascular atherosclerosis):

When reported due to or on the same line with conditions listed in the causation table under address code I672.

Codes for Record

I (a) Cerebral sclerosis I672

(b) Diabetes E149

Code to E149. The code E149 is listed as a subaddress to I672 in the causation table so this sequence is accepted.

When reportedas causing

I600-I679
I690-I698

Codes for Record

I (a) Cerebral thrombosis I633

(b) Cerebral sclerosis I672

Code to I633. Code (b) as cerebrovascular atherosclerosis since reported as causing a cerebral thrombosis. Cerebrovascular atherosclerosis will link (LMP) with cerebral thrombosis.

Myopathy (G729)

Code I429 (Cardiomyopathy) when reported due to:

A150-A1690 E648-E649 R54

A178 E660-E669 R75

A181 E740 T360-T66

A188 E760-E769 T97

B332 E831 X45

B560-B575 E880-E889 X65

B948 I00-I259 Y15

D500-D649 I300-I4290 Y400-Y599

D758 I514-I5150 Y842

E100-E149 I700-I709 Y86-Y872

E40-E519 P200-P220 Y883

E639 P916

E641 R31

Codes for Record

I (a) Myopathy I429

(b) ASHD I251

(c)

Code to I251. The code I251 is listed as a subaddress to I429 in the causation table so this sequence is accepted.

Paralysis (any G81, G82, or G83 excluding senile paralysis)

Code the paralysis for decedent age 28 days and over to G80 (Infantile cerebral palsy) with appropriate fourth character:

When reported due to:

P000- P969

Female, 3 months Codes for Record

I (a) Pneumonia 1 wk J189

(b) Paraplegia 3 mos G808

Code to P115. Code the paraplegia to infantile cerebral palsy when reported due to a newborn condition.

Varices NOS and Bleeding Varices NOS (I839)
Code I859 (Esophageal varices) or
Code I850 (Bleeding esophageal varices):

When reported due to or on same line with:

Alcoholic disease classified to: F101-F109

Liver diseases classified to: B150-B199, B251, B942, K700-K769

Toxic effect of alcohol classified to: T510-T519, T97

Codes for Record

I (a) Varices I859

(b) Cirrhosis of liver K746

Code to K746. The code K746 is listed as a subaddress to I859 in the causation table; therefore, this sequence is accepted.

Pneumoconiosis (J64)

Code J60 (Coalworker pneumoconiosis):

When Occupation is reported as:

Coal miner

Coal worker

Miner

Codes for Record

Occupation: Coal Miner

I (a) Bronchitis J40

(b) Pneumoconiosis J60

Code to J60. Pneumoconiosis becomes coalworker pneumoconiosis when occupation is reported as coal miner.

Diaphragmatic Hernia in K44.-

Code Q790 (Congenital diaphragmatic hernia) when reported as causing hypoplasia or dysplasia of lung NOS (Q336).

Codes for Record

I (a) Lung dysplasia Q336

(b) Diaphragmatic hernia Q790

(c)

Code to congenital diaphragmatic hernia (Q790). The code Q790 is listed as a subaddress to Q336 in the causation tables; therefore, this sequence is accepted.

Laennec Cirrhosis NOS (K703)

Code K746 (Nonalcoholic Laennec cirrhosis):

When reported due to:

A000-B99
C000-D539
D730-D739
E02-E0390
E100-E149
E500-E519
E52
E530-E849
F110-F169
F180-F199
I050-I099
I110-I119
I130-I4250
I427-I519
I81
K500-K519
K630-K639
K710-K718
K730-K760
K761
K763
K768-K851
K853-K859
K861-K909
Q410-Q459
Q900-Q999
R75
T360-T509
T520-T659
T97
X40-X44
X46-X49
Y400-Y572
Y573
Y574-Y599
Y640
Y86
Y870-Y872
Y880
Y881

Codes for Record

I (a) Cardiac arrest I469

(b) Laennec cirrhosis K746

Code to E149. The code E149 is listed as a subaddress to K746 in the causation table; therefore, this sequence is accepted.

Biliary Cirrhosis NOS (K745)

Code K744 (Secondary biliary cirrhosis):

When reported due to conditions listed in the causation table under address code K744.

Codes for Record

I (a) Biliary cirrhosis K744

(b) Carcinoma pancreas C259

(c)

Code to C259. The code C259 is listed as a subaddress to K744 in the causation table; therefore, this sequence is accepted.

Lupus Erythematosus (L930)

Lupus (L930)

Code M321 (Systemic lupus erythematosus with organ or system involvement):

When reported as causing a disease of the following systems:

Anemia

Circulatory (including cardiovascular, lymph nodes, spleen)

Gastrointestinal

Musculoskeletal

Respiratory

Thrombocytopenia

Urinary

Codes for Record

I (a) Nephritis N059

(b) Lupus erythematosus M321

(c)

Code to M321. Lupus is reported as causing a disease of the urinary system; therefore, it is coded as systemic lupus erythematosus.

Gout (M109)

Code M104 (Secondary gout):

When reported due to conditions listed in the causation table under address code M104.

Codes for Record

I (a) Perforated gastric ulcer K255

(b) Gout M104

Code to C880. The code C880 is listed as a subaddress to M104 in the causation table; therefore, this sequence is accepted.

Kyphosis (M402)

Code M401 (Secondary kyphosis):

When reported due to conditions listed in the causation table under address code M401.

Codes for Record

I (a) COPD J449

(b) Kyphosis M401

Code to M479. The code M479 is listed as a subaddress to M401 in the causation table; therefore, this sequence is accepted.

Scoliosis (M419)

Code M415 (Secondary scoliosis):

When reported due to conditions listed in the causation table under address code M415.

Codes for Record

I (a) Pneumonia J189

(b) Scoliosis M415

Code to M340. The code M340 is listed as a subaddress to M415 in the causation table; therefore, this sequence is accepted.

Osteonecrosis (M879)

Code M873 (Secondary osteonecrosis):

When reported due to conditions listed in the causation table under address code M873.

Codes for Record

I (a) Septicemia A419

(b) Osteonecrosis hip M873

Code to M600. The code M600 is listed as a subaddress to M873 in the causation table; therefore, this sequence is accepted.

Cesarean Delivery for Inertia Uterus (O622)

Hypotonic Labor (O622)

Hypotonic Uterus Dysfunction (O622)

Inadequate Uterus Contraction (O622)

Uterine Inertia During Labor (O622)

Code O621 (Secondary uterine inertia):

When reported due to conditions listed in the causation table under address code O621.

Codes for Record

I (a) Uterine inertia O621

(b) Diabetes mellitus of pregnancy O249

Code to O249. The code O249 is listed as a subaddress to O621 in the causation table; therefore, this sequence is accepted.

Brain Damage, Newborn (P112)

Code P219 (Anoxic brain damage, newborn)

When reported due to:

A000-P029

P040-P082

P132-P158

P200-R825

R826

R827-R892

R893

R894-R961

R98

Male, 9 hours Codes for Record

I (a) Brain damage P219

(b) Congenital heart disease Q249

Code to Q249. The code Q249 is listed as a subaddress to P219 in the causation table; therefore, this sequence can be accepted.

Intracranial Nontraumatic Hemorrhage of Fetus and Newborn (P52)

Code P10 (Intracranial laceration and hemorrhage due to birth injury) with the appropriate fourth character:

When reported due to conditions listed in the causation table under address code P10:

Male, 9 hours Codes for Record

I (a) Cerebral hemorrhage P101

(b) Fractured skull during birth P130

Code to P130. The code P130 is listed as a subaddress to P101 in the causation table; therefore, this sequence is accepted.

Hypoplasia or Dysplasia of Lung NOS (Q336)

Code P280 (Primary atelectasis of newborn):

When reported anywhere on the record with the following codes and not reported due to diaphragmatic hernia in K44.- or in Q790, and there is no indication that the condition was congenital:

A500-A509 P280

B200-B24 P350-P399

P000-P009 P612

P011-P013 Q600-Q611

P050-P073 Q613-Q649

P220-P229 R75

Codes for Record

I (a) Hypoplasia lung P280

(b)

(c)

II Prematurity P073

Code to primary atelectasis of newborn (P280).

Female, 5 hrs. Codes for Record

I (a) Dysplasia of lung 5 hrs Q336

(b)

(c)

II Hyaline membrane disease P220

Code to Q336 since the duration and age are the same indicating that the condition was congenital.

Fracture (any site) (T142)

Code M844 (Pathological fracture):

When reported due to:

A180 D480 M320-M351 M854-M879 Q799

A500-A509 D489 M359 M893-M895 T810-T819

A521 E210-E215 M420-M429 M898-M939 T840-T849

A527-A539 E550-E559 M45-M519 M941-M949 T870-T889

A666 E896-E899 M600 M960

C000-C399 G120-G129 M843-M851 M966-M969

C430-C794 M000-M1990 Q770-Q789

C796-C97

D160-D169

When reported due to or on the same line with:

C40-C41 M83

C795 M88

M80-M81

NOTE: If a fracture qualifies as pathological, code all fractures reported of the same site pathological as well.

Codes for Record

I (a) Fracture hip M844

(b) Osteoarthritis M199

Code to M199. The code M199 is listed as a subaddress to M844 in the causation table; therefore, this sequence is accepted.

Codes for Record

I (a) Aspiration pneumonia J690

(b) Left hip fracture M844

II Hip fracture, anemia, osteoporosis M844 D649 M819

Code to M809. Hip fracture in Part II is reported on the same line with osteoporosis and is coded as pathological. Since fracture of the same site is reported on (b), it is coded as pathological as well. The sequence is accepted and Rule C is applied.

Starvation NOS (T730)

Code E46 (Malnutrition NOS):

When reported due to:

A000-E649 L100-L129 R13 T058

E670-F509 L400-L409 R54 T065-T08

F530-F539 L510-L539 R600-R609 T091-T099

F608-F609 L890-L899 R630 T141

F680-F73 L97 R633-R634 T148-T149

F920 L984 R75 T170-T217

F982-F983 M000-M1990 S010-S099 T270-T329

F989-G98 M300-N459 S110-S199 T360-T659

I00-J80 N700-N768 S210-S299 T800-T889

J82-J989 O000-Q079 S310-S399 T97

K020-K029 Q200-Q824 T019-T021 T983

K040-K069 Q850-Q999 T029 V010-X52

K080-K929 R11 T041 X54-Y05

Y070-Y899

Codes for Record

I (a) Anemia D649

(b) Starvation E46

Code to C159. Code I(b) as malnutrition since reported due to cancer of esophagus.

Compartment Syndrome (T796)

Code M622 (Nontraumatic compartment syndrome):

When reported due to conditions listed in the causation table under address code M622.

Codes for Record

I (a) Compartment syndrome M622

(b) Hemorrhagic pancreatitis K859

Code to K859. Code I (a) M622 since reported due to pancreatitis.

Effect of duration on classification

In evaluating the reported sequence of the direct and antecedent causes, the interval between the onset of the disease or condition and time of death must be considered. This would apply in the interpretation of “highly improbable” relationships (Section III, A, 2) and in Modification Rule F (Sequela).

Duration on a lower line in Part I shorter than that of one reported above it

If a condition in a “due to” position is reported as having a duration which is shorter than that of one above it, the condition on the lower line is not accepted as the cause.

Codes for Record

I (a) Congestive heart failure 2 days I500

(b) Pneumonia 10 days J189

Code to pneumonia (J189), selected by Rule 1. The duration on I(c) prevents the selection of cerebral embolism as the underlying cause of the condition on I(b).

Codes for Record

I (a) Congestive heart failure 1-10-99 I500

(b) Pneumonia 2-08-99 J189

Code to congestive heart failure (I500), selected by Rule 2. The stated date for the condition reported on I(a) predates those reported on I(b) and I(c); therefore, neither is accepted as the cause of the condition on I(a).

Two conditions with one duration

When two or more conditions are entered on the same line with one duration, the duration is disregarded since there is no way to establish the condition to which the duration relates.

Codes for Record

I (a) Chronic myocarditis 2 yrs I514

(b) Chronic nephritis 2 mos N039 N19

Code to chronic nephritis (N039), selected by Rule 1. The duration for the conditions reported on I(b) is disregarded.

Codes for Record

I (a) Myocardial ischemia 2 yrs I259 I219

(b) and myocardial

Code to I219. The duration is disregarded. Myocardial ischemia (I259), selected by Rule 2, links (LMP) with myocardial infarction (I219).

Qualifying conditions as acute or chronic
Usually the interval between onset of a condition and death should not be used to qualify the condition as “acute” or “chronic.” However, when assigning codes to certain conditions classified as “Ischemic heart diseases” the Classification provides the following specific guidelines for classifying a condition with astated duration as acute or chronic:

– acute or with a stated duration of 4 weeks or less

– chronic or with a stated duration of over 4 weeks

Code for Record

I (a) Nephritis 2 years N059

Code to nephritis, unqualified (N059). Do not use duration to qualify as chronic.

Code for Record

I (a) Acute myocardial infarction 3 mos. I258

(b)

(c)

Code to infarction, myocardium, acute, with a stated duration of over 4 weeks, I258.

For the purpose of interpreting these instructions:

Consider these terms: To mean:

brief 4 weeks or less

days or acute

hours

immediate

instant

minutes

recent

short

sudden

weeks (few) (several)

longstanding over 4 weeks

1 month or chronic

Duration Code for Record

I (a) Aneurysm heart weeks I219

(b)

(c)

Code to aneurysm, heart, with a stated duration of 4 weeks or less, I219. “Weeks” is interpreted to mean 4 weeks or less.

When the interval between onset of a condition and death is stated to be “acute” or “chronic,” consider the condition to be specified as acute or chronic.

Duration Codes for Record

I (a) Heart failure 1 hour I509

(b) Bronchitis acute J209

Code to “acute” bronchitis (J209) since “acute” is reported in the duration block.

Exacerbation

Interpret “exacerbation” as an acute phase of a disease. Code “exacerbation” of a chronic specified disease to the acute and chronic stage of the disease if the Classification provides separate codes for “acute” and “chronic.”

Codes for Record

I (a) Exacerbation of chronic

obstructive lung disease J441 J449

Code to the acute and chronic stages of the specified disease since the Classification provides separate codes for the “acute” and “chronic.” The underlying cause code is J441, selected by Rule 2.

Acute and chronic

Sometimes the terms, acute and chronic, are reported preceding two or more diseases. In these cases, use the term (“acute” or “chronic”) with the condition it immediately precedes.

Codes for Record

I (a) Chronic renal and liver failure N189 K7290

Code to renal failure, chronic and liver failure NOS. The underlying cause is N189, selected by Rule 2.

Conflict in durations

When conflicting durations are entered for a condition, give preference to the duration entered in the space for interval between onset and death.

Duration Code for Record

I (a) Ischemic ht dis – 2 weeks years I259

Use the duration in the block to qualify the ischemic heart disease. Code the underlying cause to I259, selected by the General Principle.

Span of dates

Interpret dates entered in the spaces for interval between onset and death that are separated by a slash (/), dash (-), etc., as meaning from the first date to the second date. Disregard such dates if they extend from one line to another and there is a condition reported on both of these lines since the span of dates could apply to either condition.

Date of death 10-6-98 Duration Codes for Record

I (a) MI 10/1/98 – I219

(b) Ischemic heart disease 10/6/98 I259

Disregard duration and code each condition as indexed since the dates extend from I(a) to I(b). Code the underlying cause to I219. Ischemic heart disease (I259), selected by the General Principle, links (LMP) with myocardial infarction (I219).

Date of death 10-6-98 Duration Codes for Record

I (a) Aneurysm of heart 10/1/98 – 10/6/98 I219

(b)

Since there is only one condition reported, apply the duration to this condition. The underlying cause is aneurysm, heart, acute or with a stated duration of 4 weeks or less, I219.

Date of death 10-6-98 Duration Codes for Record

I (a) Ischemic heart disease 10/1/98 – 10/6/98 I249

(b) Arteriosclerosis I709

Apply the duration to I(a). The underlying cause is I249. Arteriosclerosis, I709, selected by General Principle, links (LMP) with ischemic heart disease (I249).

Congenital malformations

Conditions classified as congenital malformations, deformations and chromosomal abnormalities (Q00-Q99), even when not specified as congenital on the death certificate, should be coded as such if the interval between onset and death and the age of the decedent indicate the condition existed from birth.

Female, 45 years Duration Codes for Record

I (a) Heart failure I509

(b) Stricture of aortic Q230

Code to congenital aortic stricture (Q230) because the interval between onset and death and the age of the decedent indicates the condition existed from birth.

Congenital conditions

When a sequence is reported involving a condition specified as congenital due to another condition not so specified, both conditions may be considered as having existed from birth provided the sequence is a probable one.

Codes for Record

I (a) Renal failure since birth P960

(b) Hydronephrosis Q620

Code to congenital hydronephrosis (Q620) since this condition resulted in a condition reported as existing since birth.

Do not use the interval between onset and death to qualify conditions classified to categories Q00-Q99, congenital anomalies, as acquired.

Duration Codes for Record

I (a) Renal failure 3 months N19

(b) Pulmonary stenosis 5 years Q256

Code to Q256, Stenosis, pulmonary. Do not use the duration to qualify the pulmonary stenosis as acquired.

Sequela

See Modification Rule F.

Subacute

In general, where ICD provides for acute forms of a disease but not for subacute, the subacute forms are classified as for acute. For example, subacute renal failure is coded to acute renal failure (N179).

Maternal conditions

Categories 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), and O970-O979 (Death from sequela of obstetric causes) classify obstetric deaths according to the time elapsed between the obstetric event and the death of the woman.

Category O95 is to be used when a woman dies during pregnancy, labor, delivery, or the puerperium and the only information provided is “maternal” or “obstetric” death. If the obstetric cause of death is specified, code to the appropriate category. Category O960-O969 is used to classify deaths from direct or indirect obstetric causes that occur more than 42 days but less than a year after termination of the pregnancy. Category O970-O979 is used to classify deaths from direct or indirect obstetric causes which occur one year or more after termination of the pregnancy.

Effect of “age of decedent” on classification
Age of the decedent should always be noted at the time the cause of death is being coded. Certain groups of categories are provided for certain age groups. There are many conditions within certain categories which cannot be properly classified unless the age is taken into consideration.

Generally the following definitions will apply to age at time of death:

Newborn, Neonatal, Neonatorum -less than 28 days, even though death may have occurred later

Infant or Infantile -less than 1 year

Child -less than 18 years

Male, 27 days Code for Record

I (a) G.I. hemorrhage P543

Code to gastrointestinal hemorrhage of newborn (P543).

Congenital malformations

Age at the time of death may be used for certain conditions to consider them congenital in origin. Assume the following conditions are congenital provided there is no indication that they were acquired after birth:

If the age of the decedent is:

Less than 28 days:

heart disease NOS

hydrocephalus NOS

Female, 27 days Codes for Record

I (a) Cerebral edema P524

(b) Hydrocephalus Q039

Code to congenital hydrocephalus (Q039) since the age of decedent is less than 28 days.

Less than l year:

aneurysm (aorta, aortic) (brain) (cerebral) (circle of Willis) (coronary) (peripheral) (racemose) (retina) (venous)
aortic stenosis
atresia
atrophy of brain
cyst of brain
deformity
displacement of organ
ectopia of organ
hypoplasia of organ
malformation
pulmonary stenosis
valvular heart disease (any valve)

Male, 2 months Codes for Record

I (a) Cardiac failure I509

(b) Aortic stenosis Q230

Code to congenital aortic stenosis (Q230) since the age of decedent is less than 1 year.

Sex and age limitations

Where the underlying cause of death is inconsistent with the sex or appears to be inconsistent with the age, the accuracy of the underlying cause of death should be re-examined and the age and/or sex should be verified.

If the sex and cause are inconsistent, the certificate is examined to determine if the medical and demographic data are accurately coded based on reporting. If the sex is determined to be incorrect, correct the data record. If the sex entry is correct but not consistent with the underlying cause of death, the death should be coded to the minimum necessary to be acceptable for either gender.

If the age and cause are inconsistent, the age should be verified by subtracting the date of birth from the date of death and the coded entry should be corrected. Care should be exercised in selecting the correct underlying cause of death in terms of age restrictions in ICD.

Detailed ICD category-age-sex cross edits are contained in the NCHS Instruction Manual, Part 11 (Computer Edits for Mortality Data). These edits are carried out through computer applications that provide listings for correcting data records to resolve data inconsistencies. These listings contain both absolute edits for which age-cause and/or sex-cause must be consistent and conditional edits of age-cause which are unlikely but acceptable following reverification of coding accuracy.

Interpretation of expressions indicating doubtful diagnoses
Doubtful qualifying expressions

Conditions qualified by expressions such as “apparently,” “presumably,” “?,” “perhaps,” and “possibly” which throw doubt on the statement of cause of death are to be accepted as though no such qualifications were made. The rules for selection will be followed in determining the underlying cause, with no special preference given to conditions which are not qualified by these expressions. When a condition is qualified by “rule out,” “ruled out,” “r/o,” etc., do not assign a code for the condition. When two conditions are reported on one line and both are preceded by one of these doubtful expressions, consider as a statement of either/or.

Codes for Record

I (a) Hemorrhage of stomach K922

(b) Probable ulcers of the stomach K259

Code to ulcer of stomach with hemorrhage (K254).

Interpretation of “either…or…”
When the condition is qualified by “either … or …” with respect to anatomical site, assign to the residual category for the group or anatomical system in which the sites are classified.

Code for Record

I (a) Cancer of kidney or bladder C689

Code to malignant neoplasm of unspecified urinary organs (C689).

When the condition is qualified by “either … or …” with respect to sites in different anatomical systems, assign to the residual category for the disease or condition specified.

Code for Record

I (a) Cancer of adrenal or kidney C80

Code to malignant neoplasm without specification of site (C80) since adrenal and kidney are in different anatomical systems.

When different diseases or conditions are qualified by “either … or …,” and only one anatomical site/system is involved, assign to the residual category relating to the anatomical site/system.

Code for Record

I (a) Tuberculosis or cancer of lung J9840

Code to disease of lung (J984). Both conditions involve the lung.

Code for Record

I (a) Stroke or heart attack I99

Code to disease, circulatory system (I99). Both conditions are in the circulatory system.

NOTE: When embolism and thrombosis are qualified by a statement of “either…or…”, code to Clot (I749).

Code for Record

I (a) Cardiac thrombosis vs pulmonary embolism I749

Code to I749, clot (blood). Embolism and thrombosis are both blood clots, and Clot NOS is a more specific category than Disease, circulatory system.

When different diseases or conditions are classifiable to the same three character category with different fourth characters, assign to the three character category with fourth character “9.”

Code for Record

I (a) ASCVD or ASHD I259

Code to the residual category for ischemic heart disease (I259).

When different diseases or conditions are classifiable to different three character categories and Volume 1 provides a residual category for the disease in general, assign the residual category.

Code for Record

I (a) MI or coronary aneurysm I259

Code to the residual category for ischemic heart disease (I259) using Volume 1.

When different diseases or conditions involving different anatomical systems are qualified by “either … or …,” assign to “other specified general symptoms and signs (R688).

Code for Record

I (a) Gallbladder colic or R688

(b) coronary thrombosis

Code to other specified general symptoms and signs (R688).

When diseases and injuries are qualified by “either … or …,” assign to “other ill-defined and unspecified causes of mortality” (R99).

Code for Record

I (a) Coronary occlusion or R99

(b) war injuries

Code to other ill-defined and unspecified causes of mortality (R99).

For doubtful diagnosis involving accidents, suicides, and homicides, refer to Section IV, B, Y10-Y34.

Interpretation of nonmedical connecting terms used in reporting

The following connecting terms should be interpreted as meaning “due to, or as a consequence of” when the entity immediately preceding and following these terms is a disease condition, nature of injury or an external cause:

after induced by

arising in or during occurred after

as (a) complication of occurred during

as a result of occurred in

because of occurred when

caused by occurred while

complication(s) of origin

during received from

etiology received in

following resulting from

for resulting when

from secondary to (2°)

in subsequent to

incident to sustained as

incurred after sustained by

incurred during sustained during

incurred in sustained in

incurred when sustained when

sustained while

2/2

The following terms are interpreted to mean that the condition following the term was due to the condition that preceded it:

as a cause of led to

cause of manifested by

caused producing

causing resulted in

followed by resulting in

induced underlying

leading to with resultant

with resulting

The following terms are interpreted to mean “or”:

and/or

versus

The following terms imply that the conditions are meant to remain on the same line. They are separated by “and” or by another connecting term that does not imply a “due to” relationship:

and (&) with (c)

accompanied by precipitated by

also predisposing (to)

associated with superimposed on

complicated by

complicating

consistent with

Numbering of causes reported in Part I

Where the certifier has numbered all causes or lines in Part I, that is, 1, 2, 3, etc., the originating antecedent is selected by applying Selection Rule 2. In the application of this rule, consideration is given to all causes which are numbered whether or not the numbering is extended into Part II. This provision applies whether or not the “due to” on lines I(b), I(c), and/or I(d) are marked through.

Codes for Record

I (a) 1. Coronary occlusion I219 E149 I10 I709 N289 J1110

(b) 2. Diabetes, chronic, severe

Renal disease

II 5. Influenza, 1 week

Code to coronary occlusion (I219) by applying Selection Rule 2.

Where part of the causes in Part I are numbered, the interpretation is made on an individual basis.

Codes for Record

I (a) Bronchopneumonia J180

(b) 1. Cancer of stomach C169 E149

Code to cancer of stomach (C169) by applying Selection Rule 1. The conditions numbered 1. and 2. are considered as if they were reported on I(b).

Terms that stop the sequence

Includes:

Cause not found Immediate cause unknown

Cause unknown No specific etiology identified

Cause undetermined No specific known causes

Could not be determined Nonspecific causes

Etiology never determined Not known

Etiology not defined Obscure etiology

Etiology uncertain Undetermined

Etiology unexplained Uncertain

Etiology unknown Unclear

Etiology undetermined Unexplained cause

Etiology unspecified Unknown

Final event undetermined ? Cause

Immediate cause not determined ? Etiology

Codes for Record

I (a) Cardiac arrest I469

(b) Stroke I64

(d) Diabetes E149

Code to stroke (I64) using Rule 1. “Cause unknown” on line (c) stops the sequence.

Codes for Record

I (a) Pneumonia J189

(b) Intestinal obstruction K566

(d) Ulcerative colitis K519

Code to ulcerative colitis (K519). “Undetermined” on line (c) stops the sequence. Intestinal obstruction, selected by Rule 1, is considered a direct sequel (DS) of the ulcerative colitis.

Codes for Record

I (a) Gastric ulcer, cause unknown K259

(b) Rheumatoid arthritis

Code to gastric ulcer (K259). “Cause unknown” on line (a) stops the sequence.

Querying cause of death

Because the selection of the underlying cause of death is based on how the physician reports causes of death as well as what he reports, State and local vital statistics offices should query certifying physicians where there is doubt that the manner of reporting reflects the true underlying cause of death. Querying is most valuable when carried out by persons who are thoroughly familiar with mortality medical classifi-cation.

It is possible to choose a presumptive underlying cause for any cause-of-death certification no matter how poorly reported. However, selecting the cause by arbitrary rules (Rules 1-3) is not only difficult and time consuming, but the end results often are not satisfactory. No set of arbitrary procedures can deduce what was in the physician’s mind when he certified the cause of death. Querying can be used to great advantage to inform physicians of the proper method of reporting causes of death. It is hoped that intensive querying and other educational efforts will reduce the necessity of resorting to arbitrary rules, and at the same time improve the quality and completeness of the reporting.

When a certifier is queried about a particular cause or for inadequate or missing information he may or may not have at hand, the query should be specific. It should be worded in such a manner that it requires a minimum amount of the certifier’s time. When the queries are sufficiently specific to elicit specific replies, the final coding should reflect this additional information from the certifier.

The NCHS uses the additional information (AI) filmed following the record or received on a separate supplemental document in assigning the underlying cause of death.

Codes for Record

I (a) Congestive heart failure I500

(b) Renal disease N059

AI Renal disease was nephritis

Code to N059, unspecified nephritic syndrome. It is assumed the query was to establish the specific renal disease.

Codes for Record

I (a) Congestive heart failure I500

(b) Hypostatic pneumonia J182

AI Underlying cause was cancer of lung

Code to C349, cancer of lung. It is assumed the query was to establish the cause of the hypostatic pneumonia.

Codes for Record

I (a) Pulmonary embolism I269

(b) Myocarditis I514

(d) C269

AI Underlying cause was cancer of g.i. tract

Code to I514, myocarditis. The additional information cannot be used to replace the reported underlying cause. The reply alone is not sufficient. If this case was queried, either the question or the circumstances of why the AI was included should also have been reported. If the AI had included “the conditions on (b) and (c) should be in Part II,” the reply would have been self-explanatory.

Page last reviewed: May 14, 2021

Content source: National Center for Health Statistics