Instructions for Classifying Multiple Causes of Death, 2020 – Section IV

SECTION IV – CLASSIFICATION OF CERTAIN ICD CATEGORIES

General information

Separate categories are provided in ICD-10 for coding malignant primary and secondary neoplasms (C00-C96), carcinoma in situ (D00-D09), benign neoplasms (D10-D36), and neoplasms of uncertain or unknown behavior (D37-D48). Categories and subcategories within these groups identify sites and/or morphological types.

Morphology describes the difference in type and structure of cells or tissues (histology) as seen under the microscope and behavior. The ICD classification of neoplasms consists of several major morphological groups (types) of neoplasms including the following:

Carcinomas including squamous cell carcinoma and adenocarcinoma

Sarcomas and other soft tissue tumors including mesotheliomas

Lymphomas including Hodgkin lymphoma and non-Hodgkin lymphoma

Site specific types (types that indicate the site of the primary neoplasm)

Leukemias

Other specified morphological groups

The morphological types of neoplasms are listed in ICD-10 following Chapter XX in Volume 1 and also appear in Volume 3. Morphology, behavior, and site must all be considered when coding neoplasms. This may take the form of a reference to the appropriate column in the “Neoplasm” listing in the Index when the morphological type could occur in several organs. For example:

Adenoma, villous (M8261/1) – see Neoplasm, uncertain behavior

Or to a particular part of that listing when the morphological type originates in a particular type of tissue. For example:

Fibromyxoma (M8811/0) – see Neoplasm, connective tissue, benign

The Index may give the code for the site assumed to be most likely when no site is reported for a morphological type. For example:

Adenocarcinoma

– pseudomucinous (M8470/3)

– – specified site – see Neoplasm, malignant

– – unspecified site C56

Or the Index may give a code to be used regardless of the reported site when the vast majority of neoplasms of that particular morphological type occur in a particular site. For example:

Nephroma (M8960/3) C64

Always look up the morphological description in the Index before referring to the listing under “Neoplasm” for the site.

The morphological code numbers consist of five characters: the first four identify the histological type of the neoplasm and the fifth, following a slash, indicates its behavior. These morphological codes (M codes) are not used by NCHS for coding purposes.

The behavior of a neoplasm is an indication of how it will act. The following terms describe the behavior of neoplasms:

Malignant, primary site (capable of rapid growth C00-C76,
and of spreading to nearby and distant sites) C80-C96

Malignant secondary (spread from another C77-C79
site; metastases)

In-situ (confined to one site) D00-D09

Benign (non-malignant) D10-D36

Uncertain or unknown behavior (undetermined D37-D48
whether benign or malignant)

Unless it is specifically indexed, code a morphological term ending in “osis” in the same way as the tumor name to which “osis” has been added is coded. For example, code neuroblastomatosis in the same way as neuroblastoma. However, do not code hemangiomatosis that is specifically indexed to a different category in the same way as hemangioma.

All combinations of the order of prefixes in compound morphological terms are not indexed. For example, the term “chondrofibrosarcoma” does not appear in the Index, but “fibrochondrosarcoma” does. Since the two terms have the same prefixes (in a different order), code the chondrofibrosarcoma the same as fibrochondrosarcoma.

A. Malignant neoplasms (C00-C96)

The categories that have been provided for the classification of malignant neoplasms distinguish between those that are stated or presumed to be primary (originate in) of the particular site or types of tissue involved, those that are stated or presumed to be secondary (deposits, metastases, or spread from a primary elsewhere) of specified sites, and malignant neoplasms without specification of site. These categories are the following:

C00-C75 Malignant neoplasms, stated or presumed to be primary, of specified sites and different types of tissue, except lymphoid, hematopoietic, and related tissue

C76 Malignant neoplasms of other and ill-defined sites

C77-C79 Malignant secondary neoplasm, stated or presumed to be spread from another site, metastases of sites, regardless of morphological type of neoplasm

C80 Malignant neoplasm of unspecified site (primary) (secondary)

C81-C96 Malignant neoplasms, stated or presumed to be primary, of lymphoid, hematopoietic, and related tissue

In order to determine the appropriate code for each reported neoplasm, a number of factors must be taken into account including the morphological type of neoplasm and qualifying terms. Assign all malignant neoplasms to the appropriate category for the morphological type of neoplasm, i.e., to the code shown in the Index for the reported term. Morphological types of neoplasm include categories C40-C41, C43, C44, C45, C46, C47, C49, C70-C72, and C80. Specific morphological types include:

C40-C41 Malignant neoplasm of bone and articular cartilage of other and unspecified sites

Osteosarcoma

Osteochondrosarcoma

Osteofibrosarcoma

Any neoplasm cross-referenced as “See also Neoplasm bone, malignant”

I (a) Osteosarcoma of leg C402

Code the morphological type “Osteosarcoma” to Neoplasm, malignant, bone of the specified site as cross-referenced.

C43 Malignant melanoma of skin

Melanosarcoma

Melanoblastoma

Any neoplasm cross-referenced as “See also Melanoma”

I (a) Melanoma of arm C436

Based on the note in the Index, code melanoma of arm as indexed under Melanoma, site classification.

I (a) Melanoma of stomach C169

Melanoma of stomach is not found under Melanoma in the Index. The term should be coded by site under Neoplasm, malignant.

C44 Other malignant neoplasm of skin

Basal cell carcinoma

Sebaceous cell carcinoma

Any neoplasm cross-referenced as “See also Neoplasm skin, malignant”

I (a) Sebaceous cell carcinoma nose C443

Code the morphological type “Sebaceous cell carcinoma” to Neoplasm, malignant, skin of the specified site as cross-referenced.

C49 Malignant neoplasm of other connective and soft tissue

Liposarcoma

Rhabdomyosarcoma

Any neoplasm cross-referenced as “See also Neoplasm, connective tissue, malignant”

I (a) Rhabdomyosarcoma abdomen C494

Code the morphological type “Rhabdomyosarcoma” to Neoplasm, malignant, connective tissue of the specified site as cross-referenced.

I (a) Sarcoma pancreas C259

Code the morphological type “Sarcoma” to Neoplasm, malignant, connective tissue of the specified site as cross-referenced. Refer to the “Note” under Neoplasm, malignant, connective tissue concerning sites that do not appear in this list.

C80 Malignant neoplasm without specification of site

Cancer

Carcinoma

Malignancy

Malignant tumor or neoplasm

Any neoplasm cross-referenced as “See also Neoplasm, malignant”

I (a) Carcinoma of stomach C169

Code the morphological type “Carcinoma” to Neoplasm, malignant, stomach as indexed.

I (a) Cancer prostate C61

Code the morphological type “Cancer” to Neoplasm, malignant, prostate as indexed.

I (a) Adenosarcoma breast C509

Code the morphological type “Adenosarcoma” to Neoplasm, malignant, of the specified site as cross-referenced.

C81-C96 Malignant neoplasms of lymphoid, hematopoietic, and related tissue

Leukemia

Lymphoma

I (a) Lymphoma of brain C859

Code Lymphoma NOS, C859, as indexed. Neoplasms in C81-C96 are coded by morphological type and not by site.

1. Neoplasms stated to be secondary

Categories C77-C79 include secondary neoplasms of specified sites regardless of the morphological type of the neoplasm. The Index contains a listing of secondary neoplasms of specified sites under “Neoplasm.” Secondary neoplasms of specified sites without indication of the primary site require an additional code to identify the morphological type of neoplasm if the morphological type is classifiable to one of the following categories: C40, C41, C43, C44, C45, C46, C49, C70, C71, and C72.

I (a) Secondary melanoma of lung C439 C780

Melanoma is classified to C43; therefore, when stated secondary of a site, code Melanoma, unspecified site and secondary neoplasm of the reported site.

I (a) Secondary carcinoma of intestine C785

The morphological type of the term “carcinoma” is C80; therefore, code a secondary neoplasm code only.

2. Malignant neoplasms with primary site indicated

NOTE: If two or more malignant neoplasms are indicated as primary, refer to instructions under 5. Independent (primary) sites.

If a particular site is indicated as primary, it should be coded as primary and other neoplasms coded as secondary whether in Part I or Part II. The primary site may be indicated in one of the following ways:

(1) If two or more sites with the same morphology are reported, and one site is specified as primary in either Part I or II

I (a) Carcinoma of bladder C791

II Primary in kidney C64

Code carcinoma of bladder as secondary and code primary malignant neoplasm of kidney.

I (a) Primary cancer of lung C349

(b) Cancer of breast C798

Code primary malignant neoplasm of lung and code cancer of breast as secondary.

NOTE: This also applies when the same site is reported more than once and qualified as primary

I (a) Met lung cancer C780

(b) Primary lung cancer C349

Code metastatic lung cancer on I(a) as secondary and code primary malignant cancer of lung on I(b).

(2) The specification of other sites as “secondary,” “metastases,” “metastasis,” “spread,” or a statement of “metastasis NOS” or “metastases NOS”

I (a) Carcinoma of breast C509

(b) Secondaries in brain C793

Code I(a) primary malignant neoplasm of breast, and I(b) to secondary malignant neoplasm of brain.

I (a) Stomach metastases C788

(b) Lung cancer C349

Code I(a) secondary neoplasm of stomach and I(b) primary malignant neoplasm of lung.

I (a) Brain metastases C793

(b) Liver cancer C229

Code I(a) secondary neoplasm of brain and I(b) primary malignant neoplasm of liver.

I (a) Lung cancer with metastases C349 C80

Code I(a) primary cancer of lung followed by the NOS code for metastases.

(3) Morphology indicates a primary malignant neoplasm

If a morphological type implies a primary site, such as hepatoma, consider this as if the word “primary” had been included.

I (a) Hepatoma C220

Code hepatoma as a primary neoplasm.

I (a) Carcinoma C80

(b) Pseudomucinous C56

adenocarcinoma

Code I(a) Carcinoma as neoplasm malignant, unspecified site. Code I(b) to primary malignant neoplasm of ovary, since pseudomucinous adenocarcinoma of unspecified site is assigned to the ovary in the Index.

If a morphological type of malignant neoplasm indicating primary is reported in Part I or Part II with a different morphological type of malignant neoplasm that is stated primary, consider both neoplasms to be primary.

I (a) Sarcoma of thigh C492

II Primary liver carcinoma C229

Code each neoplasm as indexed. Both I(a) Sarcoma of thigh and Part II Primary liver carcinoma are primary malignant neoplasms.

3. Site specific neoplasms

Certain neoplasms are classified or indexed directly to a specific site. Classify morphological types of neoplasms that appear in the Index with specific codes (site specific neoplasms) e.g. “Hepatocarcinoma (M8170/3) C220,” as indexed.

I (a) Renal cell carcinoma C64

Code renal cell carcinoma as indexed.

If there is a conflict between the code for a site specific neoplasm and the stated site, code the site specific neoplasm as indexed and code the stated site as secondary. Enter the code for the secondary neoplasm on the same line with and immediately following the code for the site specific neoplasm.

I (a) Hepatocarcinoma of brain C220 C793

Code hepatocarcinoma as indexed and code secondary malignant neoplasm of brain as the second entry on I(a).

When a site specific neoplasm is reported due to the same site specific neoplasm, code each as indexed.

I (a) Bronchogenic carcinoma C349

(b) Bronchogenic carcinoma C349

Code I(a) and I(b) to bronchogenic carcinoma, as indexed.

If the only thing reported is a site specific neoplasm and a malignant neoplasm of the same site, with or without metastases, code both as primary.

I (a) Hepatocellular cancer C220

(b) Liver cancer C229

Code both the hepatocellular cancer and liver cancer as primary.

I (a) Oat cell cancer C349

(b) Lung cancer C349

Code both the oat cell cancer and lung cancer as primary.

I (a) Liver cancer and hepatocellular carcinoma with mets C229 C220 C80

Code both the liver cancer and hepatocellular carcinoma as primary. Code metastases to NOS as indexed.

4. Other morphological types of neoplasms

If adenocarcinoma, cancer, carcinoma, neoplasm (malignant) or tumor (malignant) of a site, except neoplasms classifiable to C81-C96, are reported due to a morphological type of neoplasm of unspecified site, code the neoplasm on the upper line qualified by the morphological type, and do not enter a code for the morphological type of unspecified site on the lower line if:

The morphological type of neoplasm reported on the lower line is C80.

I (a) Tumor of upper lung C341

(b) Carcinoma

Code the tumor on I(a) modified by the morphological type (C80) on I(b). Leave line I(b) blank.

I (a) Cancer of bladder C679

(b) Papillary carcinoma

Code the cancer on I(a) modified by the morphological type (C80) on I(b). Leave line I(b) blank.

The morphological type of neoplasm of unspecified site on the lower line is classified to the same site as the neoplasm on the upper line.

I (a) Cancer of brain C719

(b) Astrocytoma

Code the specified site on I(a) modified by the morphological type of unspecified site on I(b) since they are classified to the same site. Leave I(b) blank.

I (a) Adenocarcinoma of stomach C169

(b) Linitis plastica

Code the specified site on I(a) modified by the morphological type of unspecified site on I(b) since they are classified to the same site. Leave I(b) blank.

The morphological type of neoplasm of unspecified site on the lower line is classified according to the site affected, e.g., the malignant neoplasms classifiable to the following categories: C40, C41, C43, C44, C47, C49, C70, C71, and C72. Code the neoplasm on the upper line qualified by the morphological type on the lower line, and do not enter a code for the morphological type of unspecified site on the lower line.

I (a) Adenocarcinoma of face C433

(b) Melanoma

Code melanoma of face on I(a) and leave I(b) blank.

I (a) Carcinoma of leg C492

(b) Fibroliposarcoma

Code fibroliposarcoma of leg on I(a) and leave I(b) blank.

5. Independent (primary) sites

The presence of more than one primary neoplasm could be indicated in one of the following ways:

mention of two different anatomical sites
or two distinct morphological types (e.g., hypernephroma and intraductal carcinoma)
or by a mix of a morphological type that implies a specific site, plus a second site.

It is highly unlikely that one primary would be due to another primary malignant neoplasm except for a group of malignant neoplasms of lymphoid, hematopoietic, and related tissue (C81-C96), within which, one form of malignancy may terminate in another (e.g., leukemia may follow non-Hodgkin lymphoma).

If two or more sites are mentioned in Part I and there is no indication that either site is primary or secondary, code each site as indexed.

I (a) Cancer of stomach 3 months C169

(b) Cancer of breast 1 year C509

Code to primary malignant neoplasm of each site mentioned, since it is unlikely that one primary malignant neoplasm would be due to another.

I (a) Carcinoma of colon and rectum C189 C20

Code both sites as primary and enter both on I(a).

If two or more morphological types of malignant neoplasm occur, one reported due to the other or reported anywhere on the record, code each as indexed.

I (a) Lymphosarcoma of mesentery C850

II Adenocarcinoma of cecum C180

Code each as though the other had not been reported since there are two different morphological types of malignant neoplasms.

I (a) Cancer of esophagus C159

(b) Hodgkin sarcoma C817

Code the cancer of the esophagus as primary and code the Hodgkin sarcoma as indexed. They are different morphological types.

I (a) Leukemia C959

II Carcinoma of breast C509

Code each neoplasm as indexed. Two different morphological types are mentioned.

If two or more morphological types of malignant neoplasm occur in lymphoid, hematopoietic, or related tissue (C81-C96), code each as indexed. When acute exacerbation of, orblastic crisis (acute) in, chronic leukemia is reported, code both the acute form and chronic form. If stated acute and chronic, code both as indexed.

I (a) Acute lymphocytic leukemia C910

(b) Non-Hodgkin lymphoma C859

Code each as indexed since both are morphological types classified within the categories C81-C96.

I (a) Chronic lymphocytic C911 C910

leukemia with blastic crisis

Code both chronic lymphocytic leukemia and acute lymphocytic leukemia.

I (a) Acute exacerbation of chronic C910 C911

(b) lymphocytic leukemia

Code to the acute and chronic form when reported as acute exacerbation of a chronic form of leukemia and code both on the same line.

Do not use a neoplasm in a due to position to determine secondary and primary.

I (a) Carcinoma of head of pancreas C250

(b) Carcinoma of tail of pancreas C252

Code primary malignant neoplasm of head of pancreas for I(a) and code primary malignant neoplasm of tail of pancreas for I(b).

I (a) Cancer of stomach C169

(b) Cancer of gallbladder C23

Code each site primary.

I (a) Cancer of breast C509

(b) Cancer of endometrium C541

Code each site primary.

6. Metastases

Metastases is the spread of a primary malignant neoplasm to another site; therefore, metastases of a site is always secondary.

When malignancy NOS or any morphological type classifiable to C80 is reported with metastases of a site on a line, code C80 and the secondary neoplasm.

I (a) Malignancy with metastases C80 C791

of bladder

Code malignancy as first entry on I(a) and code secondary bladder neoplasm as the second neoplasm on I(a).

Although malignant cells can metastasize anywhere in the body, certain sites are more common than others and must be treated differently. If one of the common sites of metastases (excluding lung) is qualified by the word “metastatic,” it should be coded as secondary (see other neoplasm instructions). However, if one of these sites appears alone on a death certificate and is not qualified by the word “metastatic,” it should be considered primary.

Common sites of metastases:

Bone Lymph nodes

Brain Mediastinum

Central nervous system Meninges

Diaphragm Peritoneum

Heart Pleura

Liver Retroperitoneum

Lung Spinal cord

Ill-defined sites (sites classifiable to C76)

I (a) Cancer of brain C719

Code primary cancer of brain since it is reported alone on the certificate.

(1)Special Instruction: Lung

The lung poses special problems in that it is a common site for both metastases and primary malignant neoplasms.

Lung should be considered as a common site of metastases whenever it appears in Part I with sites not on this list.
If lung is mentioned anywhere on the certificate and the only other sites are on the list of common sites of metastases, consider lung primary.
However, when the bronchus or bronchogenic cancer is mentioned, this neoplasm should be considered primary.

I (a) Carcinoma of lung C349

Code primary malignant neoplasm of lung since it is reported alone on the certificate.

I (a) Cancer of bone C795

(b) Carcinoma of lung C349

Code primary malignant neoplasm of lung on I(b) since bone is on the list of common sites of metastases and lung can, therefore, be assumed to be primary.

I (a) Carcinoma of bronchus C349

(b) Carcinoma of breast C509

Code primary malignant neoplasm of bronchus on I(a) and primary malignant neoplasm of breast on I(b). Do not code I(a) as secondary malignant neoplasm, because bronchus is excluded from the list of common sites.

(2)Special Instruction: Lymph Node

Malignant neoplasm of lymph nodes not specified as primary should be assumed to be secondary.

I (a) Cancer of cervical lymph nodes C770

Code secondary malignant neoplasm of cervical lymph nodes.

7. Multiple sites

If all sites reported (anywhere on certificate) are on the list of common sites of metastases, code to secondary neoplasm of each site of the morphological type involved, unless lung is mentioned, in which case code to (C349) primary malignant neoplasm of lung.

I (a) Cancer of liver C787

(b) Cancer of abdomen C798

Code to secondary neoplasm of both sites since both are on the list of common sites of metastases. Abdomen is one of the ill-defined sites included in the C76.- category.

I (a) Malignant carcinoma of pleura C782 C781

and mediastinum

Code secondary malignant neoplasm of pleura and secondary malignant neoplasm of mediastinum on I(a).

I (a) Peritoneal carcinoma C786

II Liver carcinoma C787

Code secondary malignant neoplasm of peritoneum on I(a) and secondary malignant neoplasm of liver in Part II.

I (a) Cancer of brain C793

(b) Cancer of lung C349

Code I(a) secondary cancer of brain since brain is on the list of common sites. Code I(b) primary cancer of lung because the only other site mentioned is on the list of common sites.

If one or more of the common sites of metastases, excluding lung, is reported and one or more site(s) or one or more morphological type(s) is mentioned on the certificate, none specified as primary, code the common site(s) secondary and the other site(s) or morphological type(s) primary.

I (a) Cancer of stomach C169

(b) Cancer of liver C787

Code I(a) primary cancer of stomach and code I(b) secondary cancer of liver since liver is on the list of common sites and stomach is not.

I (a) Liver cancer C787

(b) Bladder cancer C679

Code I(a) secondary neoplasm of liver since liver is on the list of common sites of metastases. Code I(b) and I(c) as primary.

I (a) Peritoneal cancer C786

II Mammary carcinoma C509

Code I(a) secondary peritoneal cancer since peritoneum is on the list of common sites. Code Part II primary carcinoma of breast.

I (a) Brain carcinoma C793

II Melanoma of scalp C434

Code I(a) secondary brain carcinoma since brain is on the list of common sites. Code Part II melanoma of scalp.

NOTE: If a malignant neoplasm of lymphatic, hematopoietic, or related tissue (C81-C96) is reported in one part and one of the common sites is mentioned in the other part, code the common site primary.

I (a) Brain cancer C793

(b) Lymphoma C859

Code I(a) secondary brain cancer since brain is on the list of common sites and is reported in the same part with a neoplasm indexed to C859.

I (a) Brain cancer C719

II Lymphoma C859

Code I(a) primary brain cancer. Brain is on the list of common sites of metastases, but it is reported in one part and a neoplasm indexed to C859 is reported in the other part.

If lung is mentioned in the same part with another site(s), not on the list of common sites, or one or more morphological type(s), code the lung as secondary and the other site(s) primary.

I (a) Lung cancer C780

(b) Stomach cancer C169

Code secondary lung cancer on I(a) and code primary stomach cancer on I(b) since both are in the same part.

I (a) Lung cancer C780

(b) Leukemia C959

Code secondary lung cancer on I(a) and code leukemia on I(b) since both are in the same part.

I (a) Bladder carcinoma C679

II Lung cancer, breast cancer C780 C509

Code I(a) primary bladder carcinoma and code primary breast cancer in Part II. Code secondary lung cancer in Part II. Lung is in the same part with another site.

If lung is mentioned in one part, and one or more site(s), not on the list of common sites, or one or more morphological type(s) is mentioned in the other part, code the lung as primary and the other site(s) or other morphological type primary.

I (a) Stomach cancer C169

II Lung cancer C349

Code primary stomach cancer on I(a) and code primary lung cancer in Part II. Lung is mentioned in one part and the other site is mentioned in the other part.

I (a) Leukemia C959

II Lung cancer C349

Code leukemia on I(a) and code primary lung cancer in Part II. Lung is mentioned in one part and the other morphological type is mentioned in the other part.

8. Metastatic neoplasms

The adjective “metastatic” is used in two ways–sometimes meaning a secondary neoplasm from a primary elsewhere and sometimes denoting a primary that has given rise to metastases. Neoplasms qualified as metastatic are always malignant, either primary or secondary. In order to avoid confusion, use the following to determine whether to code a metastatic neoplasm as primary or secondary.

Malignant neoplasm described as “from” or “metastatic from” a specified site should be interpreted as primary of that site and all other sites should be coded as secondary unless stated as primary whether in Part I or Part II.

I (a) Metastatic teratoma from ovary C80

(b) C56

Interpret as: I (a) Metastatic teratoma

(b) Primary ovary cancer

Then, code I(b) to primary malignant neoplasm of ovary since it states metastatic from ovary. Code I(a) to C80, malignant neoplasm, unspecified site.

I (a) Metastatic cancer from kidney C80

(b) C64

Interpret as: I (a) Metastatic cancer
(b) Primary kidney cancer

Then, code I(b) to primary malignant neoplasm of kidney since it states metastatic from kidney. Code I(a) to C80, malignant neoplasm, unspecified site.

I (a) Carcinomatosis C80

(b) Metastatic from bowel C260

II Carcinoma of rectum C785

Code I(b) primary neoplasm of bowel. Code the site in Part II as secondary.

Malignant neoplasms of morphological type C80 of unspecified site described “to a site” or “metastatic to a site” should be interpreted as secondary of that site(s).

I (a) Metastatic carcinoma to the rectum C785

Code to secondary malignant neoplasm of rectum. The word “to” indicates that the rectum is secondary.

I (a) Metastatic carcinoma to lungs and liver C780 C787

Code I(a) secondary neoplasm of lungs and liver since the record states “metastatic to.”

I (a) Metastatic carcinoma to lungs and liver C780 C787

(b) Bladder carcinoma C679

Code I(a) secondary neoplasm of lungs and liver since it states “metastatic to” and code I(b) primary malignant bladder carcinoma.

Malignant neoplasms described as “from a site to a site” should be interpreted as primary of the site stated “from” and secondary of all other sites unless stated primary whether in Part I or Part II

I (a) Metastatic cancer from bowel to liver C787

(b) C260

Code I(a) secondary liver neoplasm. Interpret metastatic cancer from bowel to be a statement of primary and code I(b) primary cancer of bowel.

I (a) Metastatic cancer from liver to abdomen C798

(b) C229

Code secondary malignant neoplasm of abdomen on I(a) and primary malignant neoplasm of liver on I(b).

I (a) Malignant neoplasm of bone from leg C795

(b) C765

Code I(a) secondary bone neoplasm. Interpret metastatic neoplasm of bone from leg to be a statement of primary and code I(b) primary malignant neoplasm of leg.

Malignant neoplasm described as (of) a site to a site should be interpreted as primary of the site preceding “to a site” and all other sites should be coded as secondary unless stated as primary, whether in Part I or Part II.

I (a) Cancer of breast C509

(b) Metastatic to mediastinum C781

Code I(a) to primary malignant neoplasm of breast and I(b) to secondary malignant neoplasm of mediastinum since it is reported as “metastatic to.” Enter the codes on the lines where reported.

I (a) Metastatic liver cancer to the brain C229 C793

II Esophageal cancer C788

Code liver cancer as primary since it is the site preceding “to a site” and code other sites as secondary.

If the morphological type of neoplasm classifiable to one of the following categories: C40, C41, C43, C44, C45, C46, C49, C70, C71, and C72 is described as “to a site” or “metastatic to a site,” code the morphological type of unspecified site and code the site that follows as secondary.

I (a) Metastatic osteosarcoma to brain C419 C793

Code to malignant neoplasm of bone since this is the unspecified site of osteosarcoma. Code secondary brain neoplasm.

Consider any form of the following terms as synonymous with “metastases or metastatic to” when these terms follow or are reported as due to a malignant neoplasm classifiable to C00-C76, C80, C81-C96.

Extension

Infiltration in,

Invasion into, of,

Involvement or to another site

Metastatic

Secondaries

Spread

I (a) Ca of stomach with invasion C169 C780

of lung

Code cancer of stomach primary and invasion of lung as secondary.

I (a) Carcinoma of bladder with C679 C791

(b) infiltration into the ureter

Code carcinoma of bladder as primary and code secondary carcinoma of ureter since it is the site following “infiltration into.”

The terms “metastatic” and “metastatic of” should be interpreted as follows:

(1) If one site is mentioned and this is qualified as metastatic, code to malignant primary of that particular site if the morphological type is C80 and the site is not a common site of metastases, excluding lung.

I (a) Metastatic carcinoma of C259

pancreas

Code primary malignant neoplasm of pancreas since one site is reported and it is not a common site.

I (a) Metastatic cancer of lung C349

Code to primary malignant neoplasm of lung since no other site is mentioned.

(2) If no site is reported but the morphological type is qualified as metastatic, code to primary site unspecified of the particular morphological type involved. Do not use “metastatic” to qualify a malignant neoplasm, stated or presumed to be primary, of lymphoid, hematopoietic, and related tissue, classifiable to C81-C96 as secondary.

I (a) Metastatic melanoma C439

Code as indexed. Melanoma is a morphological type of neoplasm and is indexed to C439.

I (a) Metastatic Hodgkin Disease C819

Code a morphological type of neoplasm that is classified to C81-C96 as indexed regardless of whether qualified as metastatic.

(3) Site-specific neoplasms reported as metastatic

(a) When a site specific neoplasm is qualified as metastatic, code as indexed.

I (a) Metastatic hypernephroma C64

Code as indexed. Hypernephroma is a site specific neoplasm and is indexed to C64.

I (a) Metastatic meningioma C709

Metastatic meningioma is a malignant site specific morphological type of neoplasm. Code as indexed under Meningioma, malignant.

(b) If there is a conflict between the code for a site specific neoplasm and the stated site, code the site specific neoplasm as indexed and consider the stated site to be qualified as secondary and code accordingly. Enter the code for the secondary site on the same line with and immediately following the code for the site specific neoplasm.

I (a) Metastatic renal cell carcinoma C64 C780

(b) of lung

Code the site specific neoplasm, renal cell carcinoma followed by the code for secondary neoplasm of lung.

I (a) Metastatic hepatoma of brain C220 C793

Code the site specific neoplasm, hepatoma as indexed followed by the code for secondary brain neoplasm.

(4) If a single morphological type and a site, other than a common site, code to the specific category for the morphological type and site involved.

I (a) Metastatic melanoma of arm C436

Code to malignant melanoma of skin of arm (C436), since in this case the ill-defined site of arm is a specific site for melanoma, not a common site of metastases classifiable to C76.

I (a) Metastatic sarcoma of stomach C169

Code as indexed.

(5) If a single C80 morphological type is qualified as metastatic and the site mentioned is one of the common sites of metastases except lung, code to secondary malignant neoplasm of the site mentioned. If the single site is lung, qualified as metastatic, code to primary of lung.

I (a) Metastatic cancer of peritoneum C786

Code to secondary cancer of peritoneum since peritoneum is on the list of common sites of metastases and the morphological type of neoplasm is classified to C80.

I (a) Metastatic cancer of lung C349

Code to primary malignant neoplasm of lung, C349, since no other site is mentioned.

(6) If a single morphological type, other than C80 type, is qualified as metastatic and the site mentioned is one of the common sites of metastases except lung, code the unspecified site for the morphological type. Code the common site as secondary and as a second entry on the same line.

I (a) Metastatic rhabdomyosarcoma of C499 C771

(b) hilar lymph nodes

Code to unspecified site for rhabdomyosarcoma and code the lymph nodes as secondary.

I (a) Metastatic sarcoma of lung C349

Code to malignant neoplasm of lung since lung is not considered a common site for this instruction.

Exception: Metastatic mesothelioma or Kaposi sarcoma

If site IS indexed under “Mesothelioma” or “Kaposi’s sarcoma,” assign that code.

I (a) Metastatic mesothelioma of liver C457

Code site as indexed under mesothelioma.

I (a) Metastatic mesothelioma of mesentery C451

Code as indexed under mesothelioma.

If site is NOT indexed under “Mesothelioma” or “Kaposi’s sarcoma” and site reported is NOT a common site of metastases – assign code for specified site NEC.

I (a) Metastatic mesothelioma of kidney C457

Code mesothelioma specified site NEC. Kidney is not a common site of metastases.

If site is NOT indexed under “Mesothelioma” or “Kaposi’s sarcoma” and site reported IS a common site of metastases – assign code for unspecified site and secondary code for common site.

I (a) Metastatic mesothelioma of C459 C779

(b) lymph nodes

Code the morphological type as the first entry followed by the code for the site not indexed under mesothelioma.

I (a) Metastatic Kaposi’s of brain C469 C793

Code the morphological type and code brain as secondary. Brain is on the list of common sites of metastases.

I (a) Kaposi’s sarcoma of brain C467

This instruction does not apply since Kaposi’s sarcoma is not qualified as metastatic. Code Kaposi’s sarcoma, specified site, since not qualified as metastatic.

(7) When morphological types of neoplasms classifiable to C40, C41, C43, C44, C45, C46, C47, C49, C70, C71, and C72 without mention of a site are jointly reported with the same morphological type of neoplasm with mention of a site, code the morphological type of unspecified site as indexed.

I (a) Metastatic rhabdomyosarcoma C499

(b) Rhabdomyosarcoma kidney C64

Code to unspecified site of rhabdomyosarcoma on I(a) and code rhabdomyosarcoma kidney as indexed.

More than one malignant neoplasm qualified as metastatic.

(1) If two or more sites with a morphology of C80, not on the list of common sites of metastases, are reported and all are qualified as “metastatic” code as follows:

(a) If the sites are in the same anatomical system code each site as primary.

C150-C269 Digestive system

C300-C399 Respiratory system

C400-C419 Bone and articular cartilage of limbs, other, and unspecified sites

C490-C499 Connective and soft tissue

C510-C579 Female genital organ

C600-C639 Male genital organ

C64-C689 Urinary organ

C690-C699 Eye and adnexa

C700-C729 Central nervous system

C73 -C759 Thyroid and other endocrine glands

I (a) Metastatic stomach carcinoma C169

(b) Metastatic pancreas carcinoma C259

Code both sites primary since they are a C80 morphological type, are in the same organ system, and neither is on the list of common sites of metastases.

(b) If the sites are in different anatomical systems, code each as secondary.

I (a) Metastatic carcinoma of stomach C788

(b) Metastatic carcinoma of bladder C791

Code secondary neoplasm of each site listed. Stomach and bladder are in two different anatomical systems.

(2) If two or more morphological types are qualified as metastatic, code to malignant neoplasms, each independent of the other.

I (a) Metastatic adenocarcinoma of bowel C260

(b) Metastatic sarcoma of uterus C55

Code to primary neoplasm of each site since adenocarcinoma and sarcoma are of different morphological types.

I (a) Metastatic cancer of pleura C782

(b) Metastatic melanoma of back C435

Code I(a) to secondary neoplasm of pleura since pleura is on the list of common sites of metastases. Code I(b) to melanoma of back (C435) from the site list under melanoma.

(3) If a morphology implying site and an independent anatomical site are both qualified as metastatic, code to secondary malignant neoplasm of each site.

I (a) Metastatic colonic and renal cell C785 C790

carcinoma

Code both sites as secondary.

(4) If more than one site with a morphology of C80 is mentioned code as follows:

(a) If all but one site is qualified as metastatic and/or appear on the list of common sites of metastases, including lung, code to primary neoplasm of the site that is not qualified as metastatic or not on the list of common sites of metastases, irrespective of the order of entry or whether it is in Part I or Part II. Code all other sites as secondary.

I (a) Metastatic carcinoma of stomach C788

(b) Carcinoma of gallbladder C23

Code primary carcinoma of gallbladder since it is the only site not specified as metastatic. Assign a primary code on I(b) and secondary codes on I(a) and I(c).

I (a) Metastatic carcinoma of stomach C788

(b) Metastatic carcinoma of lung C780

II Carcinoma of colon C189

Code I(a) and I(b) secondary and code primary carcinoma of colon in Part II since this is the only malignant neoplasm not qualified as metastatic, even though it is in Part II.

I (a) Cancer of kidney C64

(b) Metastatic cancer of prostate C798

Code I(a) primary cancer of kidney since the only other site on the record is qualified as metastatic. Code I(b) secondary cancer of prostate since it is qualified as metastatic.

I (a) Metastatic cancer of ovary C796

II Cancer of colon C189

Code I(a) secondary and code part II primary. There are two sites reported and one is qualified as metastatic while the second site is not reported metastatic.

(b) If all sites are qualified as metastatic and/or are on the list of common sites of metastases, including lung, code to secondary malignant neoplasm of all reported sites.

I (a) Metastatic cancer of stomach C788

(b) Metastatic cancer of breast C798

Code secondary neoplasm of each site listed. All sites are reported as metastatic.

I (a) Metastatic carcinoma of ovary C796

(b) Carcinoma of lung C780

Code to secondary malignant neoplasm of each site. Lung is on the list of common sites of metastases and ovary and pancreas are both reported as metastatic.

I (a) Metastatic stomach cancer C788

(b) Lung cancer C780

Code to secondary malignant neoplasm of each site. Lung is on the list of common sites of metastases and stomach cancer is reported as metastatic.

I (a) Carcinoma of spine C795

(b) Metastatic lung cancer C780

Code to secondary malignant neoplasm of each site. Spine is on the list of common sites of metastases and lung is reported as metastatic.

I (a) Metastatic carcinoma of abdomen C798

(b) Metastatic carcinoma of colon C785

Code both sites as secondary since both are qualified as metastatic.

I (a) Metastatic brain carcinoma C793

(b) Metastatic lung carcinoma C780

Code both sites as secondary malignant neoplasm since both are qualified as metastatic.

(c) If one site is qualified as metastatic and there are other sites specified as “secondary”, “metastases”, “metastasis”, “spread”, or a statement of “metastasis NOS” or “metastases NOS”, code the site qualified metastatic as primary and all other sites secondary, whether in Part I or Part II. If, however, lung is mentioned in one part and the metastatic neoplasm in the other part, code lung primary.

I (a) Metastatic breast cancer with brain metastases C509 C793

II Lung cancer C349

Code I(a) as primary cancer of breast since there is a statement of metastases on the record. Code brain metastases as secondary since metastases are always secondary. Code Part II as primary lung cancer since it is reported in a different part from the metastatic neoplasm.

(5) When a metastatic malignant neoplasm is reported on a record with a malignant neoplasm of the same site whether stated as metastatic or not, code both primary.

I (a) Metastatic gastric carcinoma C169

(b) Gastric carcinoma C169

Code primary gastric carcinoma on I(a) and code primary gastric carcinoma on I(b).

(6) If two or more sites with a morphology of C40, C41, C43, C44, C45, C46, C47, C49, C70, C71, and C72 are reported and all sites are qualified as metastatic, add an additional code to identify the morphological type of neoplasm. Code the morphological type of neoplasm to the unspecified site category, i.e., to “9.” Enter this code on the same line with and preceding the code for the first mentioned secondary site.

I (a) Metastatic leiomyosarcoma arm, C499 C798 C788 C793

stomach and brain

Code leiomyosarcoma, the morphological type of neoplasm, to C499 and code the reported sites as secondary neoplasms since all three sites are qualified as metastatic.

I (a) Metastatic sarcoma of stomach and C499 C788 C784

small intestine

Code the sarcoma, the morphological type of neoplasm, to C499 and code the reported sites as secondary neoplasms.

I (a) Metastatic squamous cell carcinoma of head and neck C449 C798

Since the reported sites are marked with a # sign in the Index, code the morphological type to malignant neoplasm of skin, C449, and code the reported sites as secondary neoplasms.

I (a) Metastatic squamous cell carcinoma of head C449 C798

(b) Metastatic squamous cell carcinoma of neck C798

Since the reported sites are marked with a # sign in the Index, code the morphological type to malignant neoplasm of skin, C449, and code the reported sites as secondary neoplasms. Enter C449 for the morphological type as first code on I (a) preceding the first secondary site. Enter only the secondary code on line b.

9. Primary site unknown

Consider the following terms as equivalent to “primary site unknown

? Origin (Questionable origin)

? Primary (Questionable primary)

? Site (Questionable site)

? Source (Questionable source)

Undetermined origin

Undetermined primary

Undetermined site

Undetermined source

Unknown origin

Unknown primary

Unknown site

Unknown source

When the statement, “primary site unknown,” or its equivalent, appears anywhere on the certificate with a site specific neoplasm or a neoplasm classifiable to C81-C96, code the neoplasm as though the statement did not appear on the certificate.

I (a) Renal cell carcinoma C64

(b) Primary site unknown

Code renal cell carcinoma (C64) as though the statement “primary site unknown” was not on the certificate.

I (a) Reticulum cell sarcoma C833

II Undetermined source

Code reticulum cell sarcoma (C833) as though the statement “undetermined source” was not on the certificate.

When primary site unknown or its equivalent appears on the certificate with a morphological type of neoplasm classifiable to C40, C41, C43, C44, C45, C46, C47, C49, C70, C71, and C72, add an additional code to identify the morphological type of neoplasm. Code the morphological type of neoplasm to the unspecified site category. This additional code should be entered on the same line with and preceding the code for the first mentioned secondary site.

I (a) Generalized metastases C80

(b) Melanoma of back C439 C798

Code I(b) melanoma, unspecified site, followed by the code for the secondary site reported.

When “primary site unknown,” or its equivalent, appears on the certificate with neoplasms classified to morphological type C80, (classifiable to C00-C76), code all reported sites as secondary and precede the first neoplasm code with C80.

I (a) Secondary carcinoma of liver C80 C787

(b) Primary site unknown

Code secondary liver carcinoma preceded with C80.

I (a) Carcinoma of stomach C80 C788

(b) Primary site unknown

Code secondary stomach carcinoma preceded with C80.

I (a) Carcinoma of stomach C80 C788

(b) Primary site of carcinoma unknown C80

Code I(a) secondary carcinoma of stomach preceded with C80. Code I(b) C80 for carcinoma since the term carcinoma is repeated.

I (a) Cancer of intestines, stomach, C80 C785 C788 C798

(b) and abdomen

Code all sites as secondary; precede the first code with C80.

When “primary site unknown” or its equivalent appears on the certificate and a doubtful expression such as presumed or probably is reported qualifying a specific site(s), interpret the primary to be the site(s) following the doubtful qualifying expression and code as primary.

I (a) Cancer, unk primary, presumed lung C349

(b) Primary site unknown

Code primary lung cancer.

10. Primary examples

When a morphological type of C80, not qualified as metastatic, is reported with a
site stated to be primary, code primary of the site.

I (a) Carcinoma, breast primary C509

Code primary malignant neoplasm of breast.

When a morphological type of C80 is qualified as metastatic and reported with a site stated to be primary, code C80 and primary of the site.

I (a) Metastatic cancer (primary bladder) C80 C679

Code C80 and primary cancer of the bladder.

I (a) Mestastatic cancer probably breast primary C80 C509

Code C80 and primary cancer of the breast.

11. Implication of malignancy

Mention on the certificate that a neoplasm has produced metastases (secondaries) means it must be coded as malignant, even though this neoplasm without mention of metastases would be classified to some other section of Chapter II.

Code neoplasms indexed to D00-D09 (in situ neoplasms), D10-D36 (benign neoplasms), or D37-D48 (neoplasms of uncertain or unknown behavior) to a primary malignant neoplasm category in C00-C76 (whether or not on the list of common sites of metastases and even if modified by qualifiers such as benign) if reported anywhere on the record with the following conditions:

Metastases NOS and metastases of a site

I (a) Breast tumor with metastases C509 C80

Code I(a) to primary malignant neoplasm of breast and code metastases NOS. Code breast tumor as malignant neoplasm of breast since it is reported with metastases NOS.

I (a) Brain metastasis C793

(b) Lung tumor C349

Code I(a) secondary neoplasm of brain and I(b) primary malignant neoplasm of lung since the lung tumor is reported with metastases of a site.

I (a) Lung cancer with metastasis C349 C80

II Hypertension, Benign spinal cord tumor I10 C720

Code I(a) to primary malignant neoplasm of lung and code metastasis NOS. Code benign spinal cord tumor as malignant neoplasm of spinal cord since it is reported with metastases NOS.

Any neoplasm indexed to C77-C79 in Volume III

I (a) Lymph node cancer C779

(b) Carcinoma in situ of breast C509

Code the carcinoma in situ of breast as primary malignant neoplasm of breast since it is reported with a neoplasm that is indexed to C779. Malignant neoplasm of lymph node is indexed to secondary neoplasm.

A common site of metastases (excluding lung) qualified by the word “metastatic.”

I (a) Metastatic liver cancer C787

(b) Small intestine tumor C179

Code I(a) as secondary neoplasm of liver and code primary malignant neoplasm of small intestine on I(b), since the small intestine tumor is reported with a common site of metastases qualified by the word “metastatic.”

If a, b, or c do not apply, code the neoplasm in D00-D09, D10-D36, D37-D48 as indexed.

12. Sites with prefixes or imprecise definitions

Neoplasms of sites prefixed by “peri,” “para,” “supra,” “infra,” etc. or described as in the “area” or “region” of a site, unless these terms are specifically indexed, should be coded as follows: for morphological types classifiable to one of the categories C40, C41, C43, C44, C45, C46, C47, C49, C70, C71, and C72, code to the appropriate subdivision of that category; otherwise, code to the appropriate subdivision of C76 (other and ill-defined sites).

I (a) Fibrosarcoma in the region of the leg C492

Code I(a) fibrosarcoma in the region of the leg to the appropriate subdivision of the category, malignant neoplasm of connective and soft tissue of lower limb.

I (a) Carcinoma in lung area C761

Since the morphological type of the term “carcinoma” is C80, code I(a), carcinoma in lung area, to the appropriate subdivision of C76 (other and ill-defined sites).

13. Malignant neoplasms described with “either/or”

Malignant neoplasms of more than one site described as “or” and both sites are classified to the same anatomical system, code the residual category for the system. If the sites are in different systems, and are in the same morphological category, code to the residual category for the morphological type.

I (a) Cancer of kidney or bladder C689

Code C689, malignant neoplasm of other and unspecified urinary organs.

I (a) Cancer of gallbladder or kidney C80

Code to C80, malignant neoplasm without specification of site since there is more than one site qualified by the statement “or” and the sites are in different systems.

I (a) Osteosarcoma of lumbar vertebrae C419

(b) or sacrum

Code to malignant neoplasm of bone unspecified (C419). Both sites separated by the “or” are indexed to bone.

14. Mass or lesion with malignant neoplasms

When mass or lesion is reported with malignant neoplasms, code mass or lesion as indexed.

I (a) Lung mass R91

(b) Carcinomatosis C80

Code mass as indexed. Do not consider as malignant mass.

I (a) Metastatic lung carcinoma C349

II Lung lesion J984

Code lung lesion as indexed.

B. Rheumatic heart diseases

1. Heart diseases considered to be described as rheumatic

When rheumatic fever (I00) or any heart disease that is specified as rheumatic is reported anywhere on the death certificate, consider conditions listed in categories I300-I319, I339, I340-I38, I400-I409, I429, and I514-I519 to be described as rheumatic unless there is indication they were due to a nonrheumatic cause.

I (a) Myocarditis I090

(b) Rheumatic heart disease I099

Consider “myocarditis” to be described as “rheumatic” since reported with a heart disease specified as rheumatic.

I (a) Cardiac tamponade I092

(b) Rheumatic endocarditis I091

(c)

Consider “cardiac tamponade” to be described as “rheumatic” since reported with a heart disease specified as rheumatic.

When rheumatic fever and a heart disease are jointly reported, enter a separate code for the rheumatic feveronly when it is not used to qualify a heart disease as rheumatic. This applies whether or not the heart disease is stated or classified as rheumatic.

I (a) Heart disease I099

(b) Rheumatic fever

Consider “heart disease” to be described as “rheumatic.” Do not enter a separate code for rheumatic fever since it is used to qualify the heart disease as rheumatic.

I (a) Rheumatic heart disease I099

(b) Rheumatic fever

Code “rheumatic heart disease” as indexed. Do not enter a separate code for rheumatic fever since the heart disease is qualified as rheumatic.

I (a) Cardiac arrest I469

(b) Rheumatic fever I00

Cardiac arrest is not one of the conditions considered to be described as rheumatic when reported with rheumatic fever. Code each condition as indexed.

When a condition listed in category I50.- is indicated to be due to rheumatic fever and there is no mention of another heart disease that is classifiable as rheumatic, consider the condition in I50.- to be described as rheumatic.

I (a) Heart failure I099

(b) Rheumatic fever

Since there is no other heart disease classified as rheumatic, use the rheumatic fever to qualify the heart disease on I(a) as rheumatic.

I (a) Heart failure I509

(b) Rheumatic heart disease I099

Since there is a heart disease qualified as rheumatic reported on the record, code heart failure, I509.

2. Distinguishing between active and chronic rheumatic heart disease

Rheumatic heart diseases are classifiable to I010-I019, Rheumatic fever with heart involvement, or to I050-I099, Chronic rheumatic heart diseases, depending upon whether the rheumatic process was active or inactive at the time of death.

When rheumatic fever or any rheumatic heart disease is stated to be active, recurrent, or recrudescent, code all rheumatic heart diseases as active. Conversely, code all rheumatic heart diseases as inactive if rheumatic fever or any rheumatic heart disease is stated to be inactive.

I (a) Endocarditis I011

(b) Active rheumatic fever

Code I(a), active rheumatic endocarditis since the rheumatic fever is stated as active. Leave I(b) blank.

I (a) Heart failure I509

(b) Inactive rheumatic heart disease I099

(c)

Code I(a) as indexed since another heart disease classified as rheumatic is reported. Code I(b) as indexed since stated as inactive.

When there is no statement of active, recurrent, recrudescent, or inactive, code all heart diseases that are stated to be rheumatic or that are considered to be described as rheumatic as activeif any of the following instructions apply:

(1) The interval between onset of rheumatic fever and death was less than one year.

I (a) Endocarditis – 6 months I011

(b) Rheumatic fever – 9 months

(2) One or more of these heart diseases (listed in Section IV, Part B, 1, a) is stated to be acute or subacute.

NOTE: This does not mean rheumatic fever stated to be acute or subacute.

I (a) Acute myocarditis I012

(b) Rheumatic heart disease I019

I (a) Rheumatic heart disease I099

(b) Acute rheumatic fever

(3) One of these heart diseases is pericarditis.

I (a) Pericarditis I010

(b) Rheumatic heart disease I019

(4) At least one of these heart diseases is “carditis,” “endocarditis” (any valve), “heart disease,” “myocarditis,” or “pancarditis” with a stated duration of less than one year.

I (a) Endocarditis – 9 months I011

(b) Rheumatic heart disease I019

(5) At least one of these heart diseases is “carditis,” “endocarditis” (any valve), “heart disease,” “myocarditis,” or “pancarditis” without a duration and the age of the decedent was less than 15 years.

Age: 10 years

I (a) Rheumatic heart disease I019

(b) Rheumatic fever

In the absence of the previous mentioned indications of an active rheumatic process, consider all heart diseases that are stated to be rheumatic or that are considered to be described as rheumatic as inactive and code to categories I050-I099.

Age: 75 years

I (a) Rheumatic heart disease I099

(b) Rheumatic fever

Code I(a) as indexed, there is no indication the rheumatic process was active. Leave line I(b) blank.

3. Valvular diseases jointly reported

When diseases of the mitral, aortic, and tricuspid valves, not qualified as rheumatic, are jointly reported, whether on the same line or on separate lines, code the disease of all valves as rheumatic unless there is indication to the contrary.

I (a) Mitral insufficiency and aortic stenosis I051 I060

(b)

Code both valvular diseases as rheumatic since there is no indication to the contrary.

I (a) Aortic insufficiency I061

(b) Mitral endocarditis with I059 I051

Code the diseases of both valves as rheumatic since there is no indication to the contrary.

I (a) Mitral endocarditis c I059 I051 I050

(b) insufficiency and stenosis

Code the diseases of both valves as rheumatic since there is no indication to the contrary.

I (a) Mitral valve disease I059 I051 I48

(b) with insufficiency and

II Aortic stenosis I060

Code the diseases of both valves as rheumatic since there is no indication to the contrary.

I (a) Valvular heart disease with mitral I091 I050 I060

(b) and aortic stenosis

Code the disease of all valves as rheumatic since there is no indication to the contrary.

When mitral insufficiency, incompetence, or regurgitation is jointly reported with mitral stenosis NOS (or synonym), code all these mitral conditions as rheumatic unless there are indications to the contrary.

I (a) Mitral insufficiency with mitral stenosis I051 I050

Code the mitral insufficiency as rheumatic since it is reported with mitral stenosis and there is no indication to the contrary.

I (a) Endocarditis with mitral stenosis and mitral insufficiency I38 I050 I051

Code the endocarditis as nonrheumatic. Code the mitral insufficiency as rheumatic since it is reported with mitral stenosis and there is no indication to the contrary.

4. Valvular diseases not indicated to be rheumatic

In the Classification, certain valvular diseases, i.e., disease of mitral valve (except insufficiency, incompetence, and regurgitation without stenosis) and disease of tricuspid valve are included in the rheumatic categories even though not indicated to be rheumatic. This classification is based on the assumption that the vast majority of such diseases are rheumatic in origin. Do not use these diseases to qualify other heart diseases as rheumatic. Code these diseases as nonrheumatic if reported due to one of the nonrheumatic causes on the following list.

I (a) Pericarditis I319

(b) Mitral stenosis I050

Although mitral stenosis is classified to a rheumatic category, do not use it to qualify the pericarditis as rheumatic.

When valvular heart disease (I050-I079, I089 and I090)not stated to be rheumatic is reported due to:

A1690 C73-C759 E804-E806 J030

A188 C790-C791 E840-E859 J040-J042

A329 C797-C798 E880-E889 J069

A38 C889 F110-F169 M100-M109

A399 D300-D301 F180-F199 M300-M359

A500-A549 D309 I10-I139 N000-N289

B200-B24 D34-D359 I250-I259 N340-N399

B376 D440-D45 I330-I38 Q200-Q289

B379 E02-E0390 I420-I4290 Q870-Q999

B560-B575 E050-E349 I511 R75

B908 E65-E678 I514-I5150 T983

B909 E760-E769 I700-I710 Y400-Y599

B948 E790-E799 J00 Y883

C64-C65 E802 J020

Code nonrheumatic valvular disease (I340-I38) with appropriate fourth character.

I (a) Mitral stenosis and aortic stenosis I342 I350

(b) Hypertension I10

Code I(a) as separate one-term entities to nonrheumatic mitral and aortic stenosis since they are reported “due to” a nonrheumatic condition.

I (a) Mitral insufficiency I340

(b) Goodpasture syndrome & RHD M310 I099

Code I(a) to nonrheumatic mitral insufficiency since it is reported “due to” a nonrheumatic condition. Apply this instruction even though rheumatic heart disease is entered as the second entry on I(b).

Consider diseases of the aortic, mitral, and tricuspid valves to be nonrheumatic if they are reported on the same line due to a nonrheumatic cause in the previous list. Similarly, consider diseases of these three valves to be nonrheumatic if any of them are reported due to the other and that one, in turn, is reported due to a nonrheumatic cause in the previous list.

I (a) Mitral disease I349

(b) Aortic stenosis I350

Classify both valvular diseases as nonrheumatic. The mitral disease is reported due to the aortic disease which is, in turn, reported due to a nonrheumatic cause.

I (a) Congestive heart failure I500

(b) Mitral stenosis I342

Code the mitral stenosis as nonrheumatic since the certifier indicated it was due to a nonrheumatic cause.

I (a) Aortic and mitral insufficiency I351 I340

(b) Subacute bacterial endocarditis I330

Code the valvular diseases as nonrheumatic since they are reported due to a nonrheumatic cause.

C. Pregnancy, childbirth, and the puerperium (O00-O99)

1. General information

Conditions classifiable to categories O00-O99 are limited to deaths of females of childbearing age. Some of the maternal conditions are also the cause of death in newborn infants. Always refer to the age and sex of the decedent before coding a condition to O00-O99.

Obstetric deaths are classified according to time elapsed between the obstetric event and the death of the woman:

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

O970-O979 Death from sequela of obstetric causes (death occurring one year or more after delivery)

The standard certificate of death contains a separate item regarding pregnancy. Any positive response to one of the following items should be taken into consideration when coding pregnancy related deaths:

✚ Pregnant at time of death

✚ Not pregnant, but pregnant within 42 days of death

✚ Not pregnant, but pregnant 43 days to 1 year before death

If one of the options from the previous list is marked and the decedent is greater than 44 years old, code as pregnancy record only when there is a condition reported which indicates the person was pregnant either at the time of death or pregnant 43 days to 1 year before death.

Additionally, if the third option is checked, but there is a maternal condition reported with a duration that indicates the pregnancy was within 42 days of death, disregard the checkbox and prefer the duration.

The following are valid single character codes used in the separate checkbox item regarding pregnancy on some variations of the standard death certificate. These codes are to be taken into consideration when coding pregnancy related deaths.

1 – Not pregnant within the past year

2 – Pregnant at the time of death

3 – Not pregnant, but pregnant within 42 days of death

4 – Not pregnant, but pregnant 43 days to 1 year before death

7 – Not on certificate

8 – Not applicable

9 – Unknown

Consider the pregnancy to have terminated 42 days or less prior to death unless a specific length of time is written in by the certifier. Take into consideration the length of time elapsed between pregnancy and death if reported as more than 42 days.

Maternal deaths are subdivided into two groups:

Direct obstetric deaths (O00-O97): those resulting from obstetric complications of the pregnant state (pregnancy, labor and puerperium), from interventions, omissions, incorrect treatment, or from a chain of events resulting from any of the above.

Indirect obstetric deaths (O98-O99): those resulting from previous existing disease or disease that developed during pregnancy and which was not due to direct obstetric causes, but which was aggravated by physiologic effects of pregnancy.

When coding pregnancies, code any direct obstetric cause to O00-O97 and any indirect obstetric cause to O98-O99.

2. Checkbox only

If the only indication of pregnancy is in the checkbox, do not convert any reported conditions to maternal categories (O00-O99).

Female, 34 years

I (a) Rheumatic heart disease I099

(b)

Pregnancy: Pregnant at time of death

Code I(a) as indexed since the only indication of pregnancy is in the checkbox.

Female, 34 years

I (a) Right heart failure I500

(b) Pulmonary hypertension I272

Pregnancy: Not pregnant, but pregnant 43 days to 1 year before death

Code I(a) and I(b) as indexed since the only indication of pregnancy is in the checkbox.

Female, 34 years

I (a) Pulmonary embolism I269

(b) Right heart failure I500

Pregnancy: Not pregnant, but pregnant within 42 days of death

Code I(a) and I(b) as indexed since the only indication of pregnancy is in the checkbox.

3. Pregnancy or childbirth without mention of complication

Do not assign a separate code for “pregnancy” or “delivery” if any other condition is reported other than laboratory evidence of human immunodeficiency virus [HIV] (R75) and /or nature of injuries and external causes (S000-Y899).

Female, 39 years

Place I (a) Asphyxia by hanging T71 &X70

9 (b)

MOD II 1st trimester pregnancy O95

Suicide

Code I(a) to nature of injury and external cause. Code pregnancy in Part II to Pregnancy, death from (O95) since the only other reported condition is classified to a nature of injury and external cause.

When pregnancy or delivery is theonly entry on the certificate, apply the following instructions:

(1) Code to category O95 if death occurred 42 days or less after termination of pregnancy or when there is no indication of when the pregnancy terminated.

Female, 28 years

I (a) Pregnancy O95

Code “pregnancy” to Pregnancy, death from (O95) since it is the only entry on the certificate.

(2) Code to category O969 if death resulted from direct or indirect obstetric
causes that occurred more than 42 days but less than one year after termination of the pregnancy.

Female, 28 years

I (a) Childbirth – 3 months O969

Code childbirth to death from any obstetric cause occurring more than 42 days but less than one year after delivery.

(3) Code to category O979 if death occurred 1 year or more after termination of pregnancy.

Female, 28 years

I (a) Pregnancy – 1 year O979

Code to death from sequela of an obstetric cause.

4. Pregnancy with an external event reported

When an external event is reported with pregnancy or a maternal related condition, code conditions reported due to the external as indexed and do not convert to a maternal category, whether or not the maternal checkbox is marked. For conditions not reported due to the external event, apply the maternal instructions.

Female, 34 years

Place I (a) Anoxic brain injury G978

9 (b) CPR due to cardiopulmonary arrest Y848

MOD (c) Acute cocaine intoxication I469

A (d) T405 &X42

II Asthma, pregnancy, status post C-section O995 O759 T405

Pregnancy: Not pregnant, but pregnant within 42 days of death

Accident Self-administered cocaine

Code anoxic brain injury and cardiopulmonary arrest to appropriate non-maternal code since both are reported due to external causes. Convert the remaining conditions to the appropriate maternal category since they are not reported due to an external, and a maternal condition is reported in Part II.

Female, 34 years

I (a) Anoxic brain injury G978

(b) CPR due to cardiopulmonary arrest Y848

(d)

II Asthma, C-section O995 O759

Pregnancy: Not pregnant, but pregnant within 42 days of death

Code I (a) anoxic brain injury to appropriate non-maternal code since reported due to CPR an external. Convert the remaining conditions to the appropriate maternal category since they are not reported due to an external, and a maternal condition is reported in Part II.

Female, 24 years

Place I (a) Cardiorespiratory arrest I469

9 (b) Fentanyl overdose T404 &X42

MOD (c)

A (d)

II Remote history of opiate abuse O993 T404

Pregnancy: Pregnant at time of death

Accident Fentanyl overdose

Code I (a) cardiorespiratory arrest to appropriate non-maternal code since reported due to poisoning, an external. Code the poisoning as indexed. Convert the opiate abuse in Part II to the appropriate maternal category since not reported due to an external, and the pregnancy checkbox indicates Pregnant at time of death.

Female, 24 years

Place I (a) Fentanyl overdose T404 &X42

9 (b)

MOD (c)

A (d)

II O95

Pregnancy: Pregnant at time of death

Accident

Code I (a) poisoning as indexed. Since the only other codes on the record are externals, assign O95 in Part II for the checkbox entry Pregnant at time of death.

5. Pregnancy with abortive outcome (O000-O089)

Code allcomplications of conditions listed in categories O000-O029 to the appropriate subcategory of O08 and also code O000-O029 as indexed. To determine the appropriate subcategory for O08, refer to the Index under Abortion, complicated by and select appropriate fourth character from last column.

Female, 28 years

I (a) Septicemia O080

(b) Tubal pregnancy O001

Code I(a) Abortion, complicated by, septicemia (O080) and I(b) Pregnancy, tubal (O001).

Female, 20 years

I (a) Shock O083

(b) Ectopic pregnancy O009

Code I(a) Abortion, complicated by, shock (O083) and I(b) Ectopic, pregnancy (O009).

Code allcomplications of conditions listed in categories O03-O07 to the appropriate subcategory of O08 and also code O03-O07 with fourth character “9.” To determine the appropriate subcategory for O08, refer to the Index under Abortion, complicated by and select appropriate fourth character from last column.

Female, 22 years

I (a) Pulmonary embolism O082

(b) Spontaneous abortion O039

Code I(a) Abortion, complicated by, pulmonary embolism (O082) and I(b) Abortion, spontaneous (O039).

When conditions in categories O00-O07 are reported in Part I or Part II of the death certificate with:

(1) a direct obstetric complication classifiable to category O08, code the complication to category O08 with the appropriate fourth character. Also code O00-O02 as indexed or O03-O07 with fourth character “9.”

Female, 31 years

I (a) Cardiac arrest O088

(b) Abortion O069

Code I(a) Abortion, complicated by, cardiac arrest, a direct obstetric complication and I(b) Abortion NOS.

(2) an indirect obstetric complication classifiable to categories O98-O99, code the O98-O99. Also code the O00-O02 as indexed or O03-O07 with fourth character “9.”

Female, 25 years

I (a) Abortion O069

II Rheumatic heart disease O994

Code I(a) Abortion NOS (O069). Code Pregnancy, complicated by rheumatic heart disease (O994), an indirect obstetric cause.

(3) both a direct and an indirect obstetric complication, code the direct complications to O08 with the appropriate fourth character and the indirect complications to O98-O99. Also code the O00-O02 as indexed or O03-O07 with fourth character “9.”

Female, 33 years

I (a) Renal failure O084

(b) Abortion O069

II Anemia O990

Code I(a) Abortion, complicated by, renal failure. Direct complications of abortions are classified to category O08 with the appropriate fourth character. Code I(b) Abortion NOS. Code Part II Pregnancy, complicated by, anemia, an indirect obstetric complication.

6. Other complications of pregnancy, childbirth and puerperium (O00-O99)

If death occurred more than 42 days but less than 1 year after termination of pregnancy, code all direct and indirect obstetric complications to O960-O969.

Female, 28 years

I (a) Cardiomyopathy O960

(b) Childbirth 3 months

Code cardiomyopathy as a direct obstetric cause occurring more than 42 days but less than 1 year after childbirth.

Female, 28 years

I (a) Intracerebral hemorrhage O961

(b) Childbirth 3 months

Code intracerebral hemorrhage as an indirect obstetric cause occurring more than 42 days but less than 1 year after childbirth.

If death occurred 1 year or more after termination of pregnancy, code all direct and indirect obstetric complications to O970-O979.

Female, 28 years

I (a) Cardiomyopathy O970

(b) Childbirth 1 year

Code to O970, Death from sequela of direct obstetric causes. Cardiomyopathy is a direct obstetric cause. Do not enter a code on I(b) for childbirth.

Female, 28 years

I (a) Intracerebral hemorrhage O971

(b) Childbirth 1 year

Code to O971, Death from sequela of indirect obstetric cause. Intracerebral hemorrhage is an indirect obstetric cause. Do not enter a code on I(b) for childbirth.

Code all complications of pregnancy, childbirth, and the puerperium to categories O00-O75, O85-O92, O96-O99. When delivery is mentioned on the certificate, consider complications to be of delivery unless otherwise specified.

(1) When both direct and indirect obstetric causes are reported on the same certificate code as indexed to appropriate code in Chapter XV.

(2) When a complication is reported and not indexed to a direct or indirect obstetric code, assign the complication to O98-O99 with the appropriate fourth character. Refer to Volume I for correct code assignment.

Female, 35 years

I (a) Thrombosis 1 hr O229

(b) Pregnancy 8 mos

II Obesity O992

Code I(a) to Pregnancy, complicated by, thrombosis. Do not enter a code on I(b) for pregnancy. Code Part II to Pregnancy, complicated by, endocrine diseases NEC as indexed. Obesity is an endocrine disorder.

Female, 29 years

I (a) Acute anemia O990

(b) Massive postpartum hemorrhage O721

Code I(a) to Anemia, complicating pregnancy, childbirth or the puerperium, an indirect obstetric cause. Code I(b) to Hemorrhage, postpartum, a direct obstetric cause. Do not enter a code on I(c) for delivery NOS.

Female, 21 years

I (a) Gram negative sepsis O988

(b) Congenital anomalies of ureters O998

II 30 weeks pregnant

Code I(a) to Pregnancy, complicated by, septicemia, an indirect obstetric cause. Code I(b) to Pregnancy, complicated by, congenital malformation, an indirect obstetric cause. Do not enter a code in Part II for pregnancy.

Female, 28 years

I (a) Aspiration pneumonia O995

(b) Delivery

II Rubella in first trimester O985

Code the indirect causes, aspiration pneumonia and rubella to the appropriate code in Chapter XV. Do not enter a code for delivery on I(b).

7. Delivery reported with anesthetic death or anesthesia

When delivery (normal) NOS is reported withanesthetic death, code O748 only. When reported with anesthesia, code O749 only.

Female, 29 years

I (a) Anesthetic death O748

(b) Delivery

Code I(a) to O748, other complications of anesthesia during labor and delivery. Do not enter code on I(b) for delivery.

Whenanesthetic death is reported with a complication(s) of delivery or puerperium, code O748 and the code(s) for complication(s) of pregnancy, delivery, or puerperium.

Female, 26 years

I (a) Anesthetic death O748

(b) Obstructed labor O669

Code Delivery, complicated by, anesthetic death on I(a). Code I(b) as indexed.

Whenanesthesiais reported with a complication(s) of delivery or puerperium, code O749 and the code(s) for complication(s) of pregnancy, delivery, or the puerperium.

Female, 28 years

I (a) Prolonged labor O639

(b) Anesthesia – delivery O749

Code prolonged labor as a complication of delivery. Code “anesthesia-delivery” to O749.

Female, 34 years

I (a) Cardiac arrest O742

(b) Anesthesia O749

Code I(a) cardiac arrest as a complication of anesthesia. Code the anesthesia on I(b) to O749. Code I(c) as indexed.

8. Operative delivery

Code anoperative delivery such as cesarean section or hysterectomy to O759.
Codereported complications of the operative delivery to complications of obstetric surgery (O754).
Code conditions reported due tocomplications of operative delivery as indexed under complication of delivery and/or the puerperium.

Female, 18 years

I (a) Cardiac arrest O742

(b) Anesthesia during C-section O749

(d) O459

Code I(a) cardiac arrest as a complication of anesthesia. Code O749 for the anesthesia. There is no complication of the C-section; therefore, code the C-section to O759. Code premature separation of placenta as indexed on line I(d).

Female, 27 years

I (a) Pulmonary embolism O882

(b) Pelvic thrombosis O754

Code I(a) Puerperal, embolism (pulmonary). Code I(b) as a complication of the operative delivery. Code I(c) Delivery, cesarean, as indexed.

Female, 39 years

I (a) Pneumonia O995

(b) Peritoneal hemorrhage O754

Code I(a) O995, an indirect obstetric cause. Pneumonia is reported due to the complication and coded as complicating delivery. Code I(b) as a complication of the operative delivery. Code I(c) Delivery, cesarean, as indexed.

Female, 30 years

I (a) Pneumonia 24 hr O995

(b) Pulmonary embolism 3 days O754

II O759

Operation Block: C-section

Code I(a) an indirect obstetric cause. Code I(b) as a complication of the operative delivery reported in Part II. Code Part II cesarean section as indexed.

Female, 28 years

I (a) Pneumonia O754

(b) C-section O759

II O759 O321

Operation Block: C-section for breech presentation

Code I(a) as a complication of the operative delivery. Code cesarean section on I (b) as indexed. Code cesarean section and breech presentation as indexed in Part II.

D. Congenital conditions

The Classification does not provide congenital and acquired codes for all conditions. When no provision is made for a distinction, disregard the statement or implication of congenital or acquired and code the NOS code.

Female, 45 years

I (a) Patent ductus arteriosus – acquired Q250

(b) Pneumonia J189

Code I(a) to Q250 since patent ductus arteriosus does not have an acquired code.

Male, 33 years

I (a) Gastric hemorrhage K922

(b) Gastric ulcer – congenital K259

Code I(b) to K259 since gastric ulcer does not have a congenital code.

Male, 33 years

I (a) Cardiorespiratory failure R092

(b) Hypoxic ischemic encephalopathy – at birth I678

Code I(b) to I678 since it does not have a congenital code.

When a condition specified or implied as “congenital” is reported “due to” another condition not specified as congenital, code both conditions as congenital.

Male, 2 months

I (a) Peritonitis – birth P781

(b) Intestinal obstruction Q419

Code the condition on I(b) as congenital.

Code hydrocephalus (G91.0, 1, 2, 8, 9) (any age) to Q039 (congenital hydrocephalus) when it is reported with another cerebral or other central nervous system condition (Q00-Q07, Q280-Q283) which is classified as congenital.

Male, 3 months

I (a) Cerebral anoxia G931

(b) Hydrocephalus & hypoplasia Q039 Q061

Code hydrocephalus NOS to Q039 since the hypoplasia of spinal cord is classified as congenital.

Male, 3 months

I (a) Cerebral anoxia G931

(b) Hydrocephalus Q039

II Meningomyelocele Q059

Code the hydrocephalus NOS to Q039 since the meningomyelocele is classified as congenital.

E. Conditions of early infancy (P000-P969)

When reported on certificate of infant, code the following entries as indicated:

Birth weight of 2 pounds (999 gms) or under……………………………… P070

Over 2 pounds (1000 gms) but not more than

5 ½ pounds (2499 gms)……………………………………. P071

10 pounds (4500 gms) or more…………………………… P080

Gestation of Less than 28 weeks…………………………………………. P072

28 weeksbut less than 37 weeks…………………………. P073

42 or more completed weeks……………………………… P082

Premature labor or delivery NOS………………………………………………………… P073

Female, 3 hours

I (a) Respiratory distress syndrome P220

(b) Prematurity P073

II 26 weeks gestation P072

Code Gestation, less than 28 weeks to P072.

Male, 8 hours

I (a) Respiratory failure P285

(b) Prematurity, 23 weeks P073 P072

Code I(b) as two separate conditions. Code prematurity as indexed P073 and code P072 for “23 weeks.” The 23 weeks is an implied length of gestation.

When a multiple birth or low birth weight is reported on an infant’s death certificate outside of Part I or Part II, code this entity as the last entry in Part II.

Male, 29 minutes – Twin A

I (a) Immature P073

(b) Weight 1,500 grams – twin P071 P015

II Atelectasis P281 P015

Code “twin” as the last entry in Part II.

Male, 5 minutes

4 lbs. I (a) Immaturity of lung P280

(b)

(c)

II P071

Code P071 for “4 lbs.” as last entry in Part II.

When “termination of pregnancy” or “abortion” (legal)other than criminal is the only reported cause of an infant death, code P964. Do not code P964 if any other codable entry is reported.

Female, 3 minutes

I (a) Legal abortion P964

Since “legal abortion” is the only entry on the certificate, code P964, as indexed.

When a condition classifiable to P703-P720, P722-P749 is the only cause(s) reported on a newborn’s death, code P969. If reported with other perinatal conditions, code as indexed.

Male, 7 days

(a) Hypomagnesemia P969

(b)

(c)

Code the hypomagnesemia to P969, even though it is indexed to P712 since it is the only cause of death reported.

Female, 2 weeks

(a) Hypoglycemia P704

(b) Maternal diabetes P701

Code I(a) as indexed since reported with another perinatal condition.

F. Sequela

A sequela is a late effect, an after effect, or a residual of a disease, nature of injury or external cause. ICD-10 provides sequela codes for the following conditions:

B900-B909 Sequela of tuberculosis

B91 Sequela of acute poliomyelitis

B92 Sequela of leprosy

B940-B949 Sequela of other and unspecified infectious and parasitic diseases

E640-E649 Sequela of malnutrition and other nutritional deficiencies

E68 Sequela of hyperalimentation

G09 Sequela of inflammatory diseases of central nervous system

I690-I698 Sequela of cerebrovascular disease

O970-O979 Death from sequela of obstetric causes

T900-T983* Sequela of injuries, of poisoning, and of other consequences of external causes

Y850-Y859* Sequela of transport accidents

Y86* Sequela of other accidents

Y870-Y872* Sequela of intentional self-harm, assault and events of undetermined intent

Y880-Y883* Sequela with surgical and medical care as external cause

Y890-Y899* Sequela of other external causes

* See Section V, Part S for instructions for coding sequela of injuries and external causes.

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

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

When there is evidence death resulted from residual effects rather than the active phase of conditions for which the Classification provides a sequela code, code the appropriate sequela category. Code specified residual effects separately. Apply the following instructions to the sequela categories.

1. B900-B909 Sequela of tuberculosis

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

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

I (a) Pulmonary fibrosis J841

(b) Sequela of pulmonary tuberculosis B909

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

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

I (a) Arrested pulmonary tuberculosis B909

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

When there is evidence of active tuberculosis of a site with inactive (ancient, arrested, by history, cured, healed, history, history of, old, quiescent, remote) tuberculosis of adifferent site, code both.
When there is evidence of active and inactive (ancient, arrested, by history, cured, healed, history, history of, old, quiescent, remote) tuberculosis of thesame site, code active tuberculosis of the site only.

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

I (a) Respiratory failure J969

(b) Pneumonia J189

Code pulmonary tuberculosis as active. Do not use duration of the tuberculosis to indicate sequela.

2. B91 Sequela of acute poliomyelitis

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

A statement of a late effect or sequela of acute poliomyelitis is reported.

I (a) Sequela of acute poliomyelitis B91

Code sequela of acute poliomyelitis as indexed.

A chronic condition or a condition with a duration of one year or more that was due to the acute poliomyelitis is reported.

I (a) Paralysis – 1 year G839

(b) Acute poliomyelitis B91

Code sequela of acute poliomyelitis, since the paralysis has a duration of 1 year.

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

I (a) Old polio B91

Code old polio.

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

I (a) Poliomyelitis B91

(b)

(c)

I (a) ASHD I251

(b)

(c)

II Poliomyelitis B91

I (a) Paralysis G839

(b) Polio B91

(c)

I (a) Poliomyelitis with B91 G839

(b) paralysis

(c)

3. B92 Sequela of leprosy

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

A statement of a late effect or sequela of the leprosy is reported.
A chronic condition or a condition with a duration of one year or more that was due to leprosy is reported.

4. B940 Sequela of trachoma

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

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

I (a) Late effects of trachoma B940

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

I (a) Healed trachoma B940

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

I (a) Conjunctival scar H112

(b) Trachoma B940

5. B941 Sequela of viral encephalitis

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

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

I (a) Late effects of viral encephalitis B941

Code sequela of viral encephalitis as indexed.

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

I (a) Chronic brain syndrome F069

(b) Viral encephalitis B941

Code sequela of viral encephalitis, since a resultant chronic condition is reported.

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

I (a) St. Louis encephalitis 1 yr B941

Code sequela of viral encephalitis, since a duration of 1 year is reported.

I (a) Old viral encephalitis B941

Code sequela of viral encephalitis, since it is stated “old.”

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

I (a) Paralysis G839

(b) Viral encephalitis B941

Code sequela of viral encephalitis since paralysis is reported due to the viral encephalitis.

6. B942 Sequela of viral hepatitis

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

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

7. B948 Sequela of other specified infectious and parasitic diseases
B949 Sequela of unspecified infectious and parasitic diseases

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

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

A statement of a late effect or sequela of the infectious or parasitic disease is reported.
The infectious or parasitic disease is stated to be ancient, arrested, by history, cured, healed, history, history of, inactive, old, quiescent, or remote, whether or not the residual (late) effect is specified, unless there is evidence of activity of the disease.
A chronic condition or a condition with a duration of one year or more that was due to the infectious or parasitic disease is reported.

I (a) Reye syndrome 1 yr G937

(b) Chickenpox B948

I (a) Chronic brain syndrome F069

(b) Meningococcal encephalitis B948

I (a) Acute and chronic UTI N390

(b) Clostridium difficile colitis B948

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

8. E640-E649 Sequela of malnutrition and other nutritional deficiencies

Use Sequela Code For Categories

E640 E40-E46

E641 E500-E509

E642 E54

E643 E550-E559

E648 E51-E53 E610-E638

E56-E60

E649 E639

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

A statement of a late effect or sequela of malnutrition and other nutritional deficiencies (E40-E639) is reported.

I (a) Cardiac arrest I469

(b) Sequela of malnutrition E640

A condition with a duration of one year or more is qualified as rachitic or that was due to rickets (E55.-) is reported.

I (a) Scoliosis 3 years M419

(b) Rickets E643

9. E68 Sequela of hyperalimentation

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

A statement of a late effect or sequela of the hyperalimentation is reported.
A condition with a duration of one year or more that was due to hyperalimentation is reported.

10. G09 Sequela of inflammatory diseases of central nervous system

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

A statement of a late effect or sequela of the condition in G000-G009, G030-G049, G060-G069, G08 is reported.
A condition with a duration of one year or more that was due to the condition in G000-G009, G030-G049, G060-G069, G08 is reported.
The condition in G000-G009, G030-G049, G060-G069, G08 is stated to be ancient, by history, history, history of, old, remote, or the interval between onset of this condition and death is indicated to be one year or more, whether or not the residual (late) effect is specified.
Brain damage, cerebral fungus, CNS damage, epilepsy, hydrocephalus, mental retardation, paralysis (G810-G839) is reported due to a condition in G000-G009, G030-G049, G060-G069, G08.

I (a) Hydrocephalus G919

(b) Meningitis G09

11. I690-I698 Sequela of cerebrovascular disease

Use this category for the classification of cerebrovascular disease (conditions in I600-I64, I670-I671, I674-I679) if:

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

I (a) Sequela of cerebral infarction I693

Code sequela of cerebral infarction as indexed.

A condition with a duration of one year or more that was due to one of these cerebrovascular diseases is reported.

I (a) Hemiplegia 1 year G819

(b) Intracranial hemorrhage I692

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

The condition in I600-I6400, I670-I671, I674-I679 is stated to be ancient, by history, history, history of, old, remote, or the interval between onset of this condition and death is indicated to be one year or more, whether or not the residual (late) effect is specified.

I (a) Brain damage G939

(b) Remote cerebral thrombosis I693

Code sequela of cerebral thrombosis since the cerebral thrombosis is reported as remote.

I (a) Old intracerebral hemorrhage I691

Code sequela of intracerebral hemorrhage since the intracerebral hemorrhage is stated as old.

I (a) Cerebrovascular occlusion 6 yrs I693

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

I (a) History of CVA 9 mos I694

Code sequela of CVA since “history of” CVA is reported.

The condition in I600-I6400, and I670-I671, I674-I679 is reported with paralysis (any) stated to be ancient, by history, history, history of, old, remote, or the interval between onset of this condition and death is indicated to be one year or more whether or not the residual (late) effect is specified.

I (a) CVA with old hemiplegia I694 G819

Code sequela of CVA since it is reported with hemiplegia stated as old.

12. O970-O979 Sequela of obstetric cause

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

A statement of a late effect or sequela of the obstetric cause is reported.
A chronic condition or a condition with a duration of one year or more that was due to the obstetric cause is reported.

G. Ill-defined and unknown causes

1. Sudden infant death syndrome (R95)

Includes:

Cot death

Crib death

SDII, SID, SIDS, SUD, SUDI, SUID Causing death at ages under 1 year

Sudden (unexpected) (unattended) (unexplained)

death (cause unknown) (in infancy) (syndrome)
infant death (syndrome)

Excludes:

The listed conditions causing death at ages one year or over (R960)

Female, 6 months

I (a) Sudden death R95

Male, 3 weeks

I (a) Sudden death, cause unknown R95

(b) R97

Female, 3 months

I (a) SIDS, pneumonia R95 J189

2. Other sudden death and other unspecified cause (R960-R961, R98-R99)

Code R960-R961, R98-R99 only when:

A term(s) classifiable to one of these codes is the only entry (or entries) on the death certificate.
The only other entry on the death certificate is classifiable to R97 (cause unknown).

Female, 2 years

I (a) Sudden death R960

(b) Crib death R960

When more than one term classifiable to two or more of these categories is reported, code only one in this priority: R960, R961, R98, R99.

(1) Instantaneous death (R960)

Includes:

Cot death

Crib death

SDII, SID, SIDS, SUD, SUDI, SUID Causing death at age 1 year or over

Sudden (unexpected) (unattended) (unexplained)

death (cause unknown) (in infancy) (syndrome)
infant death (syndrome)

Excludes:

The listed conditions causing death at ages under one year (R95).

Male, 3 years

I (a) Sudden death, cause unknown R960

(b) R97

Female, 2 years

I (a) SIDS, pneumonia J189

(2) Death occurring in less than 24 hours from onset of symptoms, not otherwise explained (R961)

I (a) Died—no sign of disease R961

(3) Unattended death (R98)

I (a) Found dead R98

(b) Investigation pending

I (a) Found dead at foot of steps R98

(b) Natural causes

(4) Ill-defined and unspecified cause of mortality (R99)

Includes:

Bone(s) found

Dead on arrival (DOA)

Diagnosis deferred

Died without doctor in attendance

Inquest pending

Natural cause(s)

Natural causes, cause unknown

Natural causes uncertain

Natural causes undetermined

Natural causes unknown

Natural causes unspecified

Natural disease undetermined

No doctor

Pending examination (any type)

(pathological) (toxicological)

Pending investigation (police)

Skeleton

Uncertain natural causes

Undetermined natural causes

Undetermined natural disease

Undiagnosed disease

Unknown natural causes

Unspecified natural causes

Excludes:

Unknown cause (R97)

NOTE: When a term from the preceding list is reported immediately preceding or following a term from the Unknown Cause (R97) list, assign R99 only.

I (a) DOA R99

(b) Cause unknown R97

I (a) No doctor R99

(b) Pending investigation R99

I (a) Cause unknown R97

(b) Pending pathological examination R99

I (a) Natural causes, cause unknown R99

3. Unknown cause (R97)

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

Use this category for the classification of the listed termsexcept when the term in R97 is reported

(1) On the same line with and preceding a condition qualified as “possible,” “probable,” etc.

(2) In “Describe How Injury Occurred” (Item 43) of the death certificate.

In such cases, do not enter a code for the term in R97.

I (a) G. I. hemorrhage K922

(b) Cause unknown R97

I (a) Unknown cause R97

I (a) Intestinal obstruction K566

(b) Unknown, possibly cancer C80

I (a) Amyloidosis E859

(b) Chronic ulcerative colitis K519

(c)

II Cirrhosis of liver, cause unknown K746 R97

Place I (a) Cardiac arrest I469

9 (b) Hip fracture S720

MOD (c) Fall &W19

A II

Accident 43 Unknown

If the term in R97 is reported in Part I on the same line with and following the condition to which it applies, enter the code for unknown cause on the next due to line whether or not “cause unknown” is in parentheses beside the condition in Volume 3. Code the conditions on each of the remaining lines in Part I, if there are any, as though they had been reported on the succeeding line(s).

Female, 3 months

I (a) SIDS, cause unknown R95

(b) R97

I (a) Unknown cause R97

(b) Found dead R98

I (a) Unknown R97

(b) Known to have had ASHD I251 J42

I (a) Gastric ulcer, cause unknown K259

(b) Rheumatoid arthritis R97

Page last reviewed: May 14, 2021

Content source: National Center for Health Statistics

Instructions for Classifying Multiple Causes of Death, 2020 – Section IV

SECTION IV – CLASSIFICATION OF CERTAIN ICD CATEGORIES

A. Malignant neoplasms (C00-C96)

1. Neoplasms stated to be secondary

2. Malignant neoplasms with primary site indicated

3. Site specific neoplasms

4. Other morphological types of neoplasms

5. Independent (primary) sites

6. Metastases

7. Multiple sites

8. Metastatic neoplasms

9. Primary site unknown

10. Primary examples

11. Implication of malignancy

12. Sites with prefixes or imprecise definitions

13. Malignant neoplasms described with “either/or”

14. Mass or lesion with malignant neoplasms

B. Rheumatic heart diseases

1. Heart diseases considered to be described as rheumatic

2. Distinguishing between active and chronic rheumatic heart disease

3. Valvular diseases jointly reported

4. Valvular diseases not indicated to be rheumatic

C. Pregnancy, childbirth, and the puerperium (O00-O99)

1. General information

2. Checkbox only

3. Pregnancy or childbirth without mention of complication

4. Pregnancy with an external event reported

5. Pregnancy with abortive outcome (O000-O089)

6. Other complications of pregnancy, childbirth and puerperium (O00-O99)

7. Delivery reported with anesthetic death or anesthesia

8. Operative delivery

D. Congenital conditions

E. Conditions of early infancy (P000-P969)

F. Sequela

1. B900-B909 Sequela of tuberculosis

2. B91 Sequela of acute poliomyelitis

3. B92 Sequela of leprosy

4. B940 Sequela of trachoma

5. B941 Sequela of viral encephalitis

6. B942 Sequela of viral hepatitis

7. B948 Sequela of other specified infectious and parasitic diseases B949 Sequela of unspecified infectious and parasitic diseases

8. E640-E649 Sequela of malnutrition and other nutritional deficiencies

9. E68 Sequela of hyperalimentation

10. G09 Sequela of inflammatory diseases of central nervous system

11. I690-I698 Sequela of cerebrovascular disease

12. O970-O979 Sequela of obstetric cause

G. Ill-defined and unknown causes

1. Sudden infant death syndrome (R95)

2. Other sudden death and other unspecified cause (R960-R961, R98-R99)

3. Unknown cause (R97)

7. B948 Sequela of other specified infectious and parasitic diseases
B949 Sequela of unspecified infectious and parasitic diseases