Instructions for Classifying Multiple Causes of Death, 2022 – Section V

SECTION V - EFFECTS OF EXTERNAL CAUSE OF INJURY AND EXTERNAL CAUSES OF INJURY AND POISONING

In ICD-10, the Nature of Injury Chapter (XIX) is part of the main Classification but certain effects of external causes are classified in Chapters I-XVIII. The external cause codes (Chapter XX) are intended for use, where relevant, to identify the external cause of conditions classifiable to Chapters I-XVIII, as well as to Chapter XIX. While not all external causes will have a corresponding code in Chapter XIX, an external cause code is required when a code from Chapter XIX is applicable.

A. External cause code (E-Code) concept

An external cause of injury may be classified to Accidents (V01-X59), Intentional self harm (X60-X84), Assault (X85-Y09), Event of undetermined intent (Y10-Y34), Legal intervention and operations of war (Y35-Y36), Complications of medical and surgical care (Y40-Y84), and Sequela of external causes (Y85-Y89). When unspecified, assume all external cause one-term entities to be accidental unless the External Causes of Injury Index provides otherwise.

The objective in assigning the external cause codes is to combine into the entity being coded any related entries on the record that will permit the assignment of the most specific external cause codes in accordance with the intent of the certifier. After the determination of the most specific external cause code is made, enter this code where it is first encountered on the record. Do not repeat the same external cause code when it is reported on other lines. When more than one external cause is reported, code each external cause code where it is first encountered on the certificate.

The death certificate provides a specific place for information concerning the external cause of injury that is usually entered on the lines below the line labeled “Part II.” However, a description of the external cause is reported frequently in Part I and may be repeated in the space provided for this information.

When the manner of death block is marked as Homicide but the certifier specifies Accident elsewhere on the certificate, code as Accident. The definition of homicide as "death at the hands of another" may lead certifiers to mark Homicide in the checkbox when really the death itself was unintentional. For all other manners of death, if there is more than one reported, code as could not be determined.

When such statements as: “jumped or fell,” “don’t know,” “accident or suicide,” “accident or homicide,” “undetermined,” or “open verdict” are reported, code the external cause as “undetermined.” The “undetermined” categories include self-inflicted injuries, except poisoning, when not specified whether accidental or with intent to harm.

1. Use of Index

ICD-10 provides separate indexing in Volume 3, Section II for the external causes of injury, with frequent references to Volume 1. The External Causes of Injury Index provides a double axis of indexing — descriptions of the circumstances under which the accident or violence occurred and the agent involved in the occurrence. Usually, the “lead terms” in the External Causes of Injury Index describe the circumstances of the injury with a secondary (indented) entry naming the agent involved.

Fall from building W13

Locate the E-code for “fall”:

Fall, falling

- from, off

- - building W13.-

2. Use of Tabular List

After locating the external cause code in the Index, always refer to Volume 1 since certain external cause codes for transport accidents require a fourth character not provided for in the Index. When ICD-10 provides a fourth character subcategory for an external cause code, always code the fourth character.

Fell from boat V929

Locate the E-code for “fall”:

Fall

- from

- - boat, ship, watercraft NEC (with drowning or submersion) V92.-

In Volume 1, the fourth character describes the type of boat. Code the fourth character “9,” unspecified watercraft.

The Classification provides a fourth character for use with categories W00-Y34, except Y06.- and Y07.-, to identify the place of occurrence of the external cause. NCHS uses a separate field for this purpose. Only the three-character category codes are assigned in multiple cause coding.

House fire X00

Locate the E-code for “House fire”:

House Fire (uncontrolled) X00.-

In Volume 1, a fourth character identifying the place of occurrence is required. Assign code 0 (home) to the place of occurrence variable in the field provided for this variable.

3. Place of occurrence of external cause

Enter a one-character place of occurrence code (0-9), for external causes of injury classifiable to W00-Y34, except Y06.- and Y07.-, if the effects of the external cause are classifiable to Chapter XIX. Do not enter a place code for external causes classifiable to any other external cause code. Use only the information reported in the medical certification section of the death certificate or additional information (AI) to determine the place code. Refer to Appendix D for the list of place of occurrence codes.

4. Manner of death (Item 37) on death certificate

a. Affecting multiple cause codes

(1) When separate check boxes for indicating whether an external cause was accidental, suicidal, homicidal, undetermined, or pending investigation appear on the medical certification form, treat the check box entry as a one-term entity.

(2) When “accident,” “pending,” “unknown,” or “undetermined” is written in the “check box” or is one of the items checked and no condition is coded to Chapter XIX, disregard the check box entry for assignment of codes.

(3) When “suicide” or “homicide” is written in the “check box”, or is one of the items checked and no condition is coded to Chapter XIX, assign the appropriate external cause code preceded by Injury NOS, T149.

(4) When “unknown” or “open verdict” is written in the check box and there is a condition(s) coded to Chapter XIX, code the external cause to the appropriate “event of undetermined intent” category.

(5) When “pending,” “pending investigation,” “deferred,” or “unclassified” is reported in the check box and there is a condition(s) coded to Chapter XIX, code the external cause as indexed.

(6) Enter a code for an entry in a check box for “natural cause” only if this is the only codable entry on the certificate or the only other codable entry is “unknown cause” (R97).

b. As a separate variable

Enter an alpha character manner of death code (N, A, S, H, P, or C) in the appropriate data position for any entry in the manner of death check box. Use only the information reported in the manner of death box to assign the code.

Code the manner of death as:

Natural....................................... N

Accident..................................... A

Suicide........................................ S

Homicide.................................... H

Pending Investigation.................. P

Could not be determined.............. C

Blank.......................................... Blank

5. Nature of injury and external cause code lists

Since certain entities state or imply cause (E-code) and effect (N-code), ICD-10 provides both N-codes and E-codes for many terms. Determination must be made whether to code nature of injury code only, external cause code only, or both nature of injury and external cause codes for such terms. Use the following lists as guides in classifying these terms. When ICD-10 provides a nature of injury code for an entity that does not appear on either list, use the nature of injury code only.

The E-code is only coded the first time external information is mentioned. A term requiring a N-code is coded each time it is reported.

Nature of injury code only (N-Code)

Allergy Intoxication when due to a

Anaphylactic reaction drug

Anaphylactic shock Lacerations

Anaphylaxic, anaphylaxis Lack of care

Anoxia Mucus plug

Bezoar Multiple injuries

Burns Polypharmacy (when it means

Cremation drug poisoning)

Crushed Scald

Decapitation Severed

Deceleration injury Sharp force injury

Drug NOS or named drug Smoke

(when it means drug poisoning) Starvation

Drug synergism Trauma NOS (any site)

Exhaustion Traumatic

Fracture Traumatic death

Inattention at birth Traumatic injury (any site)

Incineration Traumatism

Injury NOS (any site) Wound (penetrating)

External cause code only (E-code)

Abandonment Explosive blasts to site(s) Inhalation

Accident, accidental Fall Physical violence

Arson Fight Projectile

Assault Fire Reaction of drug with a

Beaten Flood reported complication

Blow to any site Foreign body Striking any site

Blunt force NOS Heat Suicide, suicidal

Blunt impact NOS Hitting any site

Conflagration Homicide, homicidal

Desertion Hot environment

Excessive heat Hot weather

Explosion Impact

Entities Requiring nature of injury and external cause codes on the same line (N\E Codes)

Abuse (child) (elder) (spousal) Hypothermia

Airway obstruction by foreign Immersion

body Impact injury (any site)

Alcohol intoxication (any term Impact to a site (any)

meaning intoxication) Incised (wound)

Anastomotic leak Ingestion of foreign body

*Asphyxia Inhalation injury (any)

*Aspiration *Inhalation of foreign body

Battered child (syndrome) Lightning (struck by)

Bite Mangled

Blunt blow to a site Mechanical trauma

Blunt force injury (any site) Overdose (of drug or alcohol)

Blunt force to a site (any) Overheated

Blunt impact to a site (any) Overexertion

Blunt injury (any site) Poisoning (by substance)

Blunt trauma (any site) Pulled trigger

Bullet (to site) Puncture, punctured (any site)

Bullet wound Puncture wound

Child neglect Radiation burns

Choking on foreign body Rape

Crushed by specified object Razor cut

Cut Shoot, shooting, shot (to site)

Drowning Shotgun blast (to site)

Electrocution Slash, slashed (any site)

Electrical burns Smothered

Electrical shock Snake bite

Exposure (to element) (cold, heat) Stab

Firearm (any type) (discharge) Sting

Flame burn Strangulation

Foreign body in any site Submersion

Freezing, froze, frostbite Suffocation

Got too hot Sunstroke

Gun went off Suspension, suspended

Gunshot (to site) Swallowed object

Gunshot wound Toxicity (of substance)

Hanging (by neck) Vehicular trauma

Heat exhaustion Weapon wound

Heat stress .22, .32 or any caliber

Heat stroke

(* This does not apply when certain localized effects result from asphyxia, aspiration, or inhalation. Refer to Section V, Part O.)

B. Placement of nature of injury and external cause codes

When a nature of injury code and an external cause code are required for an entity, enter the nature of injury code followed by the external cause code on the same line.

Place I (a) Gunshot wound of chest S219 &W34

9 (b)

(c)

MOD II

Accident

Since “gunshot wound” requires a nature of injury and an E-code, enter on I(a) the nature of injury code for wound of chest followed by the most specific E-code for gunshot, accidental. Code place of occurrence as 9 (unspecified). Code manner of death as A (accident).

When entries requiring nature of injury codes and external cause codes are reported on the same line in Part I, code the first nature of injury code followed by the most specific external cause code; then code any remaining conditions for the line in the order indicated by the certifier.

Place I (a) Laceration of throat S118

9 (b) Dog bite of shoulder, S410 &W54 T111 S119

Code the nature of injury code only for I(a). On I(b), code the nature of injury code for “bite of shoulder” followed by the E-code for dog bite followed by the remaining nature of injury codes for “bite arm and neck.” Code place of occurrence as 9 (unspecified).

Place I (a) Fracture skull S029

9 (b) Fell from window, crushed S280 &W13 S381

I(a) requires a nature of injury code only. I(b) requires both nature of injury and E-code since the external cause and injuries are reported on this line. Code first nature of injury code followed by the external cause code, followed by the remaining nature of injury codes. Code place of occurrence as 9 (unspecified).

Place I (a) Renal failure N19

0 (b) Injury kidney, liver and S370 &W11 S361 S360

Code I(b) injury kidney followed by external cause code for the fall, followed by the remaining injuries. Code place of occurrence as 0 (home).

Place I (a) Cerebral laceration & contusion S062

9 (b) Blow to right temporal area &X599

Code I(a) to the nature of injury code only, and I(b) to the external cause code only. Code place of occurrence as 9 (unspecified).

In Part II, code each entry in the same order as entered on the certificate. For entities requiring both nature of injury and external cause codes, enter the nature of injury code followed by the external cause code. Enter the information recorded in the special spaces that have been provided on the medical certification form for recording information about external causes of injury following any codes that are applicable to Part II.

Place I (a) Crushed chest S280

9 (b) Broken rib S223

(c)

II Fracture hip and arm S720 T10 &W24

43	Run over by a forklift

In Part II, code each entry in the order entered on the certificate. Code place of occurrence as 9 (unspecified).

Place I (a) Subdural hematoma S065

9 II Blunt impact injury to head S099 &Y00

MOD

Homicide

43	Struck on head with a blunt object by another person

Since the entry in Part II requires both nature of injury and external cause codes, enter the nature of injury code followed by the most specific external cause code. Code place of occurrence as 9 (unspecified).

Place I (a) Head wound S019

9 II &W34 S062 S019

MOD

Accident

43	Cerebral laceration, GSW of head

Code external cause code first in Part II since manner of death box requires an external cause code. Code place of occurrence as 9 (unspecified).

C. Use of ampersand

1. Use an ampersand to identify the following

a. The most specific external cause code causing injuries or poisoning.

b. Certain localized effects of poisonous substances (X45-X49) or aspiration (W78,W79, W80) when classifiable to Chapters I-XVIII.

c. Ampersand the E-code for aspiration (W78-W80) anytime it is reported.

Place I (a) Aspiration T179 &W78

0 (b) Vomitus

II Fx Hip Fall at home S720 &W19

Ampersand both the E-code for aspiration and the E-code for fall at home.

Exceptions to c:

1. When reported due to:

• nature of injury codes

• medical and surgical care

• other external causes

2. When a nature of injury code other than T179 is reported as the first condition on the lowest used line in Part I.

Place I (a) Aspiration of vomitus T179 W78

0 (b) Fx hip S720

II Fall at home &W19

Do not ampersand the E-code for aspiration since both Exception 1 and 2 apply.

2. More than one external cause reported

a. In determining the most specific external cause code, consider all of the information reported on the record. If two or more external causes are reported and the nature of injuries and/or the order in which the conditions are reported indicates that one of the external causes led to the condition that terminated in death, precede the code for this external cause by an ampersand. If no determination can be made, precede the code for the first mentioned external cause with an ampersand.

Place I (a) Aspiration of vomitus T179 W78

9 (b) Internal chest injury S279

The order in which the conditions are reported indicates that the fall down stairs led to aspiration; therefore, the ampersand precedes the code for this external cause.

Place I (a) Gunshot wound of head S019 &X95

9 (b) Stab wound of chest S219 X99

MOD II

Homicide

The order in which the external causes are reported does not indicate which event occurred first; therefore, precede the code for the gunshot wound with an ampersand since it is the first external cause reported.

Place I (a) Head trauma S099

9 II Alcohol intoxication, auto accident T519 X45 &V499

Precede the code for the auto accident with an ampersand. Alcohol intoxication did not cause the head trauma.

Place I (a) Positional asphyxia complicating mixed drug (morphine T71 &W84 T402 X44 T424

9 (b) and temazepam) intoxication

MOD II Obesity and obstructive sleep apnea E669 G473 J969 T402 T424

Accident

Positional respiratory compromise after self-administering morphine and temazepam

Code I(a) as indexed, preceding the W84 with an ampersand since it is the first mentioned e-code. Assign the N and E-codes for the named drug poisoning on line I(a). In Part II, code the diseases as indexed and assign the nature of injury codes for the drugs repeated in the How Injury Occurred block.

b. When alcohol intoxication (or any term meaning intoxication) is reported with another external cause other than aspiration, precede the code for the first mentioned external cause with an ampersand.

When alcohol intoxication is reported with drugs, refer to Section V, Part Q, 4, Poisoning by alcohol and drugs.

When alcohol intoxication is reported with exposure or hypothermia, refer to Section V, Part L, 2, Exposure, cold exposure and hypothermia.

Place I (a) Head trauma S099

9 (b) Auto Accident &V499

Precede the code for the auto accident with an ampersand since it is the first external cause reported.

Place I (a) Drowning T751 &W74

9 (b) Alcohol intoxication T519 X45

II Drinking heavily F101

Precede the code for the drowning with an ampersand since it is the first external cause reported. Code Part II as indexed.

Place I (a) Alcohol intoxication and hip fx T519 &X45 S720

9 II Fall while intoxicated W19 T519

Precede the code for the alcohol intoxication with an ampersand since it is the first external cause reported.

Place I (a) Positional asphyxia in the setting of acute ethanol T71 &W84

9 (b)intoxication T510 X45

Precede the code for the positional asphyxia with an ampersand since it is the first external cause reported.

D. Certifications with mention of nature of injury and without mention of external cause

All certifications that have an entry classifiable to Chapter XIX must have an external cause code. When only one type of injury is reported without indication of the external cause and the External Cause Index provides a code for this type of injury, code accordingly. If the External Cause Index does not provide a code for the type of injury, code to Accident, unspecified (X599). When no external cause is reported and the external cause code must be assumed, code the external cause code as the last entry in Part II.

Place I (a) Crushed chest S280

9 II &X599

Code Crushed (accidentally), X599 as indexed.

Place I (a) Fracture of hip and arm S720 T10

9 II &X590

Code Fracture (circumstances unknown or unspecified), X590 as indexed.

Place I (a) Penetrating wound of abdomen S318 S219

9 (b) and chest

II &X599

Code Wound (accidental) NEC, X599 as indexed.

If different types of injuries are reported without indication of the external cause, use the injury reported in the lowest due to position to assign the appropriate external cause code for this injury. If more than one injury is reported on the lowest line, assign the appropriate external cause code for the first mentioned injury.

Place I (a) Brain injury S069

9 (b) Fracture of skull S029

II &X590

Code Fracture (circumstances unknown or unspecified), X590.

Place I (a) Fracture of hip S720

9 (b) Crushing hip injury S770

II &X599

Code Crushed (accidentally), X599.

Place I (a) Cerebral concussion and S060 S062

9 (b) laceration of brain

II &X599

Concussion is not indexed in External Cause Index. Code to Accident, unspecified, X599.

These generalizations do not apply if the place of occurrence of the injury was highway, street, road, or alley. Refer to instructions for transport accidents in Section V, Part J.

Implied site of injury

Relate most injuries of an unspecified site to a condition of a specified site, whether or not qualified as generalized, multiple, or stated plural, following general instructions for relating disease conditions.

Exceptions:

Do not relate

Injury(ies) (generalized) (internal) (multiple)

Trauma(s) (generalized) (internal) (multiple)

Wound(s) (generalized) (internal) (multiple)

Place I (a) Crushed skull with multiple fractures S071 S029

9 II &X599

Code crushed skull followed by multiple skull fractures relating the injury of unspecified site to the site of the injury that is reported on the same line. Since there is no external cause reported, code Crushed (accidentally) as indexed in Part II.

Place I (a) Fractured neck and contusions S129 S109

9 II &X590

Code fractured neck followed by neck contusion relating the injury of unspecified site to the site of the injury that is reported on the same line. Since there is no external cause reported, code Fracture (circumstances unknown or unspecified) as indexed in Part II.

Place I (a) Fracture of hip S720

9 (b) Crushing injury S770

II &X599

Code crushing injury hip since there is only one site reported either on the line above or below the fracture. Since there is no external cause reported, code Crushed (accidentally) as indexed in Part II.

Place I (a) Fracture of skull with generalized trauma S029 T07

9 II &X590

Code the generalized trauma as indexed. Do not relate to the site of the injury reported on the same line with it. Since there is no external cause reported, code Fracture (circumstances unknown or unspecified) as indexed in Part II.

Place I (a) Skull fracture S029

9 (b) Wound T141

II &X599

Code I(b) to Wound as indexed. Do not relate to the site of the fracture reported on the upper line. Since there is no external cause reported, code Wound (accidental) NEC, X599 as indexed in Part II.

E. Conditions qualified as traumatic

1. Some conditions are indexed directly to a nontraumatic category but the Classification also provides a traumatic code. Consider these conditions to be traumatic and code as traumatic:

a. When they are qualified as “traumatic”

b. Or they are reported on the certificate with:

• Injury or trauma (any specified type or site)

• An external cause

• The Manner of Death is Accident, Homicide, Suicide, Pending Investigation or Undetermined

Exception:

Do not apply this instruction if:

• the condition is reported due to a nontraumatic condition

• W78–W80 is the only external cause reported

• poisoning is reported

Place I (a) Pneumothorax S270

6 (b) Fracture rib S223

II &X590

Place of injury- Factory

Since pneumothorax is reported on the certificate with an injury, code pneumothorax as traumatic.

Place I (a) Cerebral hemorrhage S062

9 (b)

(c)

MOD II &X599

Accident

Consider cerebral hemorrhage to be traumatic since Accident is reported in the Manner of Death box.

I (a) Cardiorespiratory failure R092

(b) Intracerebral hemorrhage I619

MOD &nnbsp; II

Accident

Since intracerebral hemorrhage is reported due to a disease condition, code as nontraumatic. Do not enter an E-code for Accident reported in the check box since no condition is coded to Chapter XIX.

Place I (a) Subarachnoid hemorrhage S066

9 (b) Fall &W19

MOD II

Natural

Code subarachnoid hemorrhage as traumatic since it is reported on the certificate with an external cause, disregarding Natural in the Manner of Death box.

Exceptions:

a. Code emphysema, encephalitis, and meningitis to the nature of injury code only when they are stated to be "traumatic" or are reported due to or on the same line with an injury or external cause.

Place I (a) Emphysema T797

9 (b) Injury chest S299

Code I(a) emphysema, traumatic since the condition is reported due to an injury.

Place I (a) Internal injury T148

9 (b) Fall from ladder &W11

II Meningitis G039

Do not code the meningitis as traumatic since it is not reported due to or on the same line with an injury or external cause. Code place of occurrence as 9 (unspecified).

b. Code the following terms to the traumatic category only when stated “traumatic:”

blindness (H540-H549)

epilepsy (G400-G409)

gastrointestinal hemorrhage (any K922)

pneumonia (classifiable to J120-J168, J180-J189, J690, J698)

Place I (a) Pneumonia J189

9 (b) Fracture hip S720

II Fall &W19

Code I(a) pneumonia as indexed since it is not reported as traumatic.

I (a) Traumatic epilepsy T905

(b) Head injury T909

Code epilepsy to the nature of injury code since it is stated traumatic.

c. When the traumatic form of a condition is classified to Chapters I-XVIII, code as traumatic only when stated to be “traumatic”

Place I (a) Cardiac arrest I469

9 (b) Organic brain syndrome F069

(d) Fall &W19

Code organic brain syndrome as indexed since it is not stated “traumatic.”

2. When a condition of a specified site is stated to be traumatic but there is no provision in the Classification for coding the condition as traumatic, code to injury unqualified of the site.

Place I (a) Traumatic cerebral thrombosis S069

9 (b) Fall &W19

Code Injury, cerebral.

3. When a condition that does not indicate a specified site is stated to be traumatic, but there is no provision in the Classification for coding the condition as traumatic code trauma unspecified and the condition separately.

Place I (a) Traumatic coma T149 R402

9 (b) Fall &W19

Code trauma unspecified and coma separately.

4. Traumatic hemorrhage (T148, T149)

Internal 1 Due to or on same line Code the hemorrhage to T148,

hemorrhage with injury (any site) internal injury NOS

NOS

Hemorrhage 2 Due to injury of a Relate the hemorrhage to the

NOS specified site site of the specified injury

3 Due to injury NOS or Code the hemorrhage to T149,

multiple injuries NOS injury NOS

4 Due to injury of multiple Relate the hemorrhage to site

specified sites of the first mentioned specified

injury

5 Due to internal injury Code the hemorrhage to T148,

NOS or internal injuries internal injury NOS

NOS

6 On same line with Relate the hemorrhage to the

injury of site site of the specified injury

7 On same line with Code the hemorrhage to T149,

injury of multiple injury NOS

specified sites

8 On same line with Code the hemorrhage to T148,

internal injury NOS or internal injury NOS

internal injuries NOS

9 Due to and on same Relate the hemorrhage to the

line with injuries of site of the injury that is entered

different specified sites on the same line with

hemorrhage

Instruction

Number

Place I (a) Internal hemorrhage T148 1

9 (b) Crushed thorax S280

(c)

II &X599

Place I (a) Hemorrhage S799 2

9 (b) Fracture of femur S729

(c)

II &X590

Place I (a) Hemorrhage S299 2

9 (b) Laceration of chest S219

(c)

II &X599

Place I (a) Hemorrhage T149

9 (b) Multiple injuries T07 3

(c)

II &X599

Place I (a) Hemorrhage S299

9 (b) Injury of chest, lung and S299 S273 S223 4

II &X599

Place I (a) Contusion chest with S202 S299

9 (b) hemorrhage 6

(c)

II &X599

Place I (a) Laceration of liver, lung, S361 S273 S360 T149

9 (b) & spleen with hemorrhage 7

(c)

II Fracture rt. femur S729 &X599

Place I (a) Cerebral contusion S062

9 (b) with hemorrhage 9

II &X599

F. Assumption of nature of injury code

When an external cause is reported on a certificate without a nature of injury code, assign both a nature of injury and an external cause code. Assume the nature of injury to be Injury NOS, T149 and place it preceding the external cause code.

Place I (a) Respiratory failure J969

9 (b) Fire T149 &X09

I(b) is an external cause code only. Since there is not a nature of injury reported on the certificate, code nature of injury T149 preceding the external code for fire.

Place I (a) Subarachnoid hemorrhage I609

9 (b) Stroke I64

Do not code the hemorrhage on I(a) as traumatic since it is reported due to a nontraumatic condition. I(c) is an external cause code only and there is not a nature of injury reported on the certificate. Code nature of injury T149 preceding the external code for fall.

Place I (a) Struck by falling tree &W20

9 II Head wound S019

I(a) is an external cause code only. Since there is a nature of injury on the certificate, do not code T149 preceding the external code.

Place I (a) Struck by falling tree T149 &W20

9 II Respiratory failure J969

I(a) is an external cause code only. Since there is not a nature of injury on the certificate, code T149 preceding the external code.

Exceptions:

1. When conditions classified to categories A000-R99 are reported due to “second hand smoke”, code the “second hand smoke” to X49.

I (a) Pulmonary emphysema J439

(b) Second hand smoke X49

I (a) Lung cancer C349

(b) Second hand smoke X49

I (a) Cardiac arrest I469

(b) Second hand smoke X49

2. Anthrax is reported with accident, suicide, homicide or undetermined

When anthrax (A220-A229) is reported with accident, suicide or homicide anywhere on the record (including in the check box) or undetermined in the check box only, code the anthrax as indexed and code the external cause code as:

• Accident specified (X58)

• Suicide specified (X83)

• Homicide specified (Y08)

• Undetermined specified (Y33)

Anthrax designated as an act of terrorism is classified to U016.

MOD I (a) Inhalation anthrax A221

H II Y08

Homicide

Code I(a) as indexed under Anthrax, inhalation. Code an E-code only in Part II for homicide based upon the check box entry. Also enter a H for Homicide in the Manner of Death item.

I (a) Anthrax A229

(b) Homicide Y08

Code I(a) as indexed. Code an E-code only on I(b); do not assume an injury code.

3. When conditions in J680-J709 are reported due to an external cause not considered to be medical or surgical care, refer to Section V, Part O, Guides for differentiating between effects of external causes classifiable to Chapters I-XVIII and Chapter XIX.

4. If a pathological fracture and an external event are reported, no assumption of a nature of injury code is required.

G. Multiple injuries (T00-T07 )

When injury (of a site) or specified type of injury (of a site) is:

Stated as Code as indexed under

Bilateral Injury (or specified type of injury), site,

bilateral

Both Injury (or specified type of injury), site,

both

Multiple Injury (or specified type of injury), site,

multiple

Do not consider the plural form of injury or the plural form of a site to indicate multiple. Do not consider “right and left” as bilateral or both.

Examples of injuries:

1. Fracture of both hips T025

Fracture

- hip

- - both T025

2. Fracture of hips S720

Fracture

- hip S720

3. Multiple fractures of ribs S224

Fracture

- rib

- - multiple S224

4. Fractures of ribs S223

Fracture

- rib S223

5. Multiple wounds of lower limb T013

Wound

- limb

- - lower NEC

- - - multiple sites T013

1. Multiple injuries Followed by specified Code T07 and the specified

type(s) of injuries injuries

2. Multiple injuries Followed by specified Code multiple injuries by

site(s) site(s) only

3. Single site Reported on same line Code the specified types of

with multiple types of injuries of the reported site

injuries

4. More than one site Reported on same line Code the specified type of

with multiple types of injury immediately

injuries preceding the reported sites

to the sites code all other

injuries to the NOS code

1. Place I (a) Multiple injuries with T07 S029 S062

9 (b) fracture skull and

II &X599

2. Place I (a) Multiple injuries - head, neck, chest S097 S197 S297

II &X599

3. Place I (a) Fracture, laceration and contusion T12 T131 T130

9 (b) of leg

4. Place I (a) Contusions, lacerations, fracture of trunk T140 T141 T021 T142

9 (b) and extremities

II &X599

H. Burns: multiple degrees of burns/percentage of body surface burned

1. When multiple degrees of burns are reported, with or without mention of sites, code the most severe degree only.

Place I (a) 2^nd and 3^rd degree burns T203 T213

0 (b) of face, chest wall and abdomen

(c)

MOD II &X00

Accident

home

house fire

Code 3^rd degree burns of each site reported.

Place I (a) 2^nd and 3^rd degree burns T303

9 (b)

(c)

II &X09

Code 3^rd degree burns of unspecified body region.

2. When a percentage of burns or a percentage of body (entire, total) burns is reported, code to the percentage.

Place I (a) Burns of 50% of T315

9 (b) body surface

(c)

MOD II &X06

Accident

clothing caught on fire

Code burns involving 50-59% of body surface.

3. When specified degrees of burns are reported with the percentage of body surface involved, code only the percentage of body surface involved.

Place I (a) 30-40%, 2^nd and 3^rd degree burns of body T314

0 (b)

(c)

II House fire &X00

Code burns involving 40-49% of body surface.

When a percentage of burns of specified sites is reported, code to burn of site(s) involved.

Place I (a) Burns, 76% of face, anterior trunk, and T200 T210 T300

8 (b) extremities

(c)

MOD II &X00 T300

Accident

burned in fire in abandoned shack

Code unspecified degree burns of each site reported. In Part II, code burned as burn of unspecified body region, unspecified degree.

I. Specified types and sites of injuries

1. When specified types of injuries of sites are reported, code to site only. Do not use Index entries of “specified type NEC” or “specified NEC” (usually .8) .

Place I (a) Impact injury, upper arm S499 &X599

Indexed as:

Injury

- arm NEC T119

- - upper S499

- - - specified NEC S498

Place I (a) Blunt injury, trunk T099 &X599

Indexed as:

Injury

- trunk T099

- - specified type NEC T098

2. When specified sites of injuries are reported, do not use Index entries of “specified type NEC” or “specified NEC”. Use only if indexed as “specified site NEC” or “specified part NEC.”

Place I (a) Fracture third cervical vertebra S129

9 (b) Fall &W19

Indexed as:

Fracture

- vertebra T08

- - cervical (teardrop) S129

- - - specified NEC S122

Place I (a) GSW right side of neck S118 &W34

Indexed as:

Wound

- neck S119

- - specified part NEC S118

J. Transportation accidents (V01-V99)

The main axis of classification for land transports (V01-V89) is the victim’s mode of transportation. The vehicle of which the injured person is an occupant is identified in the first two characters since it is seen as the most important for prevention purposes.

Definitions and examples relating to transport accidents are in Volume 1, Chapter XX. Refer to these definitions when any means of transportation (aircraft and spacecraft, watercraft, motor vehicle, railway, other road vehicle) is involved in causing death.

For classification purposes, a motor vehicle not otherwise specified is NOT equivalent to a car. Motor vehicle accidents where the type of vehicle is unspecified are classified to V87-V89.

A vehicle not otherwise specified is NOT equivalent to a motor vehicle unless the accident occurred on the street, highway, road(way), etc. Vehicle accidents where the type of vehicle is unspecified are classified to V87-V89.

Additional information about type of transports are given below

(1) Car (automobile) includes blazer, jeep, minivan, sport utility vehicle

(2) Pick-up truck or van includes ambulance, motor home, or truck (farm) (utility)

(3) Heavy transport vehicle includes armored car, dump truck, fire truck, panel truck, semi, tow truck, tractor trailer, 18-wheeler

(4) A special all-terrain vehicle (ATV) or motor vehicle designed primarily for off-road use includes dirt bike, dune buggy, four-wheeler, go cart, golf cart, race car, snowmobile, three-wheeler

(5) Motor vehicle includes passenger vehicle (private), street sweeper

1. Use of the Index and Tabular List

The Classification provides a Table of land transport accidents in Volume 3,

Section II. This table is referenced with any land transport accident if the mode of transport is known. Since the Index does not always provide a complete code, reference to Volume 1, Chapter XX is required.

For V01-V09, the fourth character indicates whether a pedestrian was injured in a nontraffic accident, traffic accident, or unspecified whether traffic or nontraffic accident.

For V10-V79, the fourth character represents the status of the victim, i.e., whether the decedent was driver, passenger, etc. For each means of transportation, there is a different set of fourth characters. Each means of transportation is preceded by its set of fourth characters in Volume 1.

• Car overturned, killing driver V485

In the Index refer to:

Overturning

- transport vehicle NEC (see also Accident, transport) V89.9

Accident

- transport (involving injury to) (see also Table of land transport accidents) V99

In the Table of land transport accidents, select the intersection of:

Under Victim and mode of transport, select
Occupant of:

- car (automobile)

Under In collision with or involved in: select
Noncollision transport accident

The code is V48.-. From Volume 1 the fourth character is 5, driver injured in traffic accident.

• Auto collision with animal V409

In the Index refer to:

Collision (accidental) NEC (see also Accident, transport) V89.9

Accident

- transport (involving injury to) (see also Table of land transport accidents) V99

In the Table of land transport accidents, select the intersection of:

Under Victim and mode of transport, select
Occupant of:

- car (automobile)

Under In collision with or involved in: select
Pedestrian or animal

The code is V40.-. From Volume 1, determine the fourth character is 9, unspecified car occupant injured in traffic accident.

2. Classifying accidents as traffic or nontraffic.

If an event is unspecified as to whether it is a traffic or nontraffic accident, it is assumed to be:

a. A traffic accident when the event is classifiable to categories V02-V04, V10-V82 and V87.

b. A nontraffic accident when the event is classifiable to categories V83-V86. These vehicles are designed primarily for off-road use.

c. Consider category V05 to be unspecified whether traffic or nontraffic if no place is indicated or if the place is railroad (tracks).

d. Consider category V05 to be traffic if place is railway crossing.

e. Consider accidents involving occupants of motor vehicles as traffic when the place is indicated or if the place is railroad (tracks).

I (a) Laceration lung S273

(b)

MOD II

Accident

Truck struck bridge

Driver

Code to occupant of pick-up truck or van injured in collision with fixed or stationary object, driver. When a motor vehicle strikes another vehicle or object, assume the collision occurred on the highway unless otherwise indicated.

I (a) Fractured skull S029

(b)

MOD II &V866

Accident

Farm

Dune buggy overturned-passenger

Code to passenger of all-terrain or other off-road motor vehicle injured in nontraffic accident.

I (a) Drowning T751 &V863

MOD II

Accident

Snowmobile ran off road and went into pond

Code to unspecified occupant of all-terrain or other off road motor vehicle injured in traffic accident. Code as traffic accident since the accident originated on the road.

3. Status of victim

a. General coding instructions relating to transport accidents are in Volume 1, Chapter XX. Refer to these instructions for clarification of the status of the victim when not clearly stated.

I (a) Multiple internal injuries T065

(b) Crushed by car T147 &V031

Code to pedestrian injured in collision with car, pick-up truck or van, traffic. Refer to Volume 1, Chapter XX, instruction 3, Crushed by car. The victim is classified as a pedestrian. Refer to Table of land transport accidents. Victim and mode of transport, pedestrian, in collision (with) car. Refer to Volume 1 for fourth character.

b. In classifying motor vehicle traffic accidents, a victim of less than 14 years of age is assumed to be a passenger provided there is evidence the decedent was an occupant of the motor vehicle. A statement such as “thrown from car,” “fall from,” “struck head on dashboard,” “drowning,” or “carbon monoxide poisoning” is sufficient.

Female, 4 years old

I (a) Fractured skull S029

(b) Struck head on windshield when car &V476

Code to car occupant injured in collision with fixed or stationary object, passenger (V476).

c. When transport accident descriptions do not specify the victim as being a vehicle occupant and the victim is described as:

pedestrian versus (vs) any vehicle (car, truck,

versus (vs) etc.)

any vehicle (car, truck, versus (vs) pedestrian

etc.) versus (vs)

classify the victim as a pedestrian (V0l-V09).

4. Coding categories V01-V89

a. When drowning occurs as a result of a motor vehicle accident NOS, code as noncollision transport accident. The assumption is the motor vehicle ran off the highway into a body of water. If drowning results from a specified type of motor vehicle accident, code the appropriate E-code for the specified type of motor vehicle accident.

I (a) Drowning T751 &V589

MOD II

Accident

Street

Truck accident

Refer to Table of land transport accidents. Code to occupant of truck injured in noncollision transport accident, unspecified.

I (a) Drowning T751 &V435

MOD II

Accident

Street

Driver-2 car collision

Refer to Table of land transport accidents. Code to occupant of car injured in collision with car, driver.

b. When falls from transport vehicles occur, apply the following instructions:

(1) Consider a transport vehicle to be in motion unless there is clear indication the vehicle was not in transit. Refer to Table of land transport accidents, specified type of vehicle reported, noncollision. Refer to Volume 1 for appropriate fourth character.

I (a) Multiple injuries T07

MOD II &V583

Accident

Home

Fell from truck in driveway

Refer to Table of land transport accidents under Victim and mode of transport. Select occupant of pick-up truck, noncollision transport accident, (V58.-). Refer to Volume 1 for fourth character and select 3, unspecified occupant of pick-up truck, nontraffic accident.

(2) Consider statements like these as stationary:

(a) Coded as transports (most often with 4th character .4)

alighting leaving

boarding exiting

entering getting in or out of vehicle

(b) Coded as fall

stationary

parked

not in transit

not in motion

I (a) Head injury S099

MOD II &V784

Accident

Street

Fell alighting from bus

Refer to Table of land transport accidents under Victim and mode of transport. Select occupant of bus, noncollision transport accident, (V78.-). Refer to Volume 1 for fourth character and select 4, person injured while boarding or alighting.

I (a) Head injury S099

MOD II nbsp; &V892

Accident

Street

Fell on curb as he was exiting his daughter’s vehicle

Refer to Table of land transport accidents under Victim and mode of transport. Select occupant of motor vehicle (traffic), noncollision transport accident (V892).

Place I (a) Head injury S099

MOD II &W17

Accident

Street

Fell from parked car

Code as indexed under Fall, from, vehicle, stationary (W17).

5. Additional examples

I (a) Fractures of ribs S223

(b)

(c)

MOD II &V234

Accident

Driver of motorcycle that collided with parked taxicab

Code to motorcycle rider injured in collision with car, pick-up truck or van, driver (V234).

I (a) Third degree burns T303

(b) Auto accident - car overturned &V489

(c)

Code to car occupant injured in noncollision transport accident, unspecified (V489).

I (a) Fracture of ribs S223

(b)

(c)

MOD II &V892

Accident

Street

Vehicle Accident

Code to person injured in unspecified motor vehicle accident, traffic (V892). Code as motor vehicle accident since the accident occurred on the street.

I (a) Blunt force trauma T149 &V230

(b) Motorcycle accident in a field

(c)

MOD II

Accident

Driver of motorcycle vs parked cars

Code to motorcycle rider injured in collision with car, pick-up truck or van, driver, nontraffic (V230).

6. Occupant of special all-terrain or other motor vehicle designed primarily for off-road use, injured in transport accident (V86)

This category includes accidents involving an occupant of any off-road vehicle. The fourth character indicates whether the decedent was injured in a nontraffic or traffic accident. Unless stated to the contrary, these accidents are assumed to be nontraffic.

I (a) Multiple injuries T07

(b) Driver of snowmobile that collided with auto &V860

Code to driver of all-terrain or other off-road motor vehicle injured in traffic accident since the collision occurred with an automobile.

I (a) Injuries of head S099

(b) Fracture both legs T025

Code to driver of all-terrain or other off-road motor vehicle injured in nontraffic accident.

I (a) Head injuries S099

(b) Overturning snowmobile &V869

Code to unspecified occupant of all-terrain or other off-road motor vehicle injured in nontraffic accident.

I (a) Fracture skull S029

(b) ATV accident &V869

Code to unspecified occupant of all-terrain or other off-road motor vehicle injured in nontraffic accident (V869)

7. Scooter (motorized) vs Motor scooter

It is often hard to distinguish between when a scooter should be considered a pedestrian conveyance or a motorcycle.

In most cases, a scooter or motorized scooter refers to a motorized chair for people with immobility issues, code as a pedestrian conveyance. In instances where there is a scooter accident and POI is Home (with no other details provided) code to X599. However, if POI is street (with no other details provided) code to V099.

A motor scooter is a small motorcycle type vehicle, code to motorcycle.

I (a) Cardiopulmonary arrest I469

(b) Severe head injury S099

(c)

MOD II &W18

Accident

Home

Victim fell off of scooter

Code to fall, from, sitting height or position (W18). Code as pedestrian conveyance since scooter (motorized) is listed in Volume 1 under the definition (e) for pedestrian.

I (a) Multiple blunt force injuries T07 &V299

(b) Motor scooter incident

(c)

MOD II

Accident

Highway

Scooter incident

Code to motorcycle rider (any) injured in unspecified traffic accident (V299). Code as a motorcycle since motor scooter is listed in Volume 1 under definition (k) for motorcycle.

I (a) Injuries sustained in auto – motorized scooter collision T149 &V031

(b)

(c)

MOD II Chronic obstructive lung disease and generalized arteriosclerosis J449 I709

Accident

Street

Collision between automobile and motorized scooter, driver

Code to pedestrian injured in collision with car, pick-up truck or van (V031). Code as pedestrian conveyance since scooter (motorized) is listed in Volume 1 under the definition (e) for pedestrian.

I (a) Respiratory failure J969

(b) Pneumonia J189

MOD II Scooter accident &V299

Accident

Street

Moped crash

Code to motorcycle rider (any) injured in unspecified traffic accident (V299). Code as a motorcycle since moped is listed in Volume 1 under definition (k) for motorcycle.

PLACE I (a) Scooter accident T149 &X599

0 (b)

(c)

MOD II

Accident

home

Code to exposure to unspecified factor causing other and unspecified injury(X599). Code as pedestrian conveyance since scooter is listed in Volume 1 under definition(e) for pedestrian.

I (a) Scooter accident T149 &V099

(b)

(c)

MOD II

Accident

street

Code to pedestrian injured in unspecified transport accident(V099). Code as pedestrian conveyance since scooter(motorized) is listed in Volume 1 under the definition(e) for pedestrian.Scooter accidents occurring on the street are assigned to a transport category.

8. Traffic accident of specified type but victim’s mode of transport unknown (V87)
Nontraffic accident of specified type but victim’s mode of transport unknown (V88)

a. If more than one type of vehicle is mentioned, do not make any assumptions as to which vehicle was occupied by the victim unless the vehicles are the same. Instead, code to the appropriate categories V87-V88. Statements such as these do not indicate status of victim:

• Auto (passenger) vs. truck • Passenger car vs. truck

• Car vs. truck, driver • Car vs. truck, driver

• Driver, car vs. truck • Driver-car vs. truck

I (a) Intrathoracic injury S279

(b)

Do not make any assumption as to which vehicle the victim was occupying. Using the Index, code:

Accident

- transport (involving injury to) (see also Table of land transport accidents) V99

- - person NEC (unknown means of transportation) (in) V99

- - - collision (between)

- - - - car (with)

- - - - - two- or three-wheeled motor vehicle (traffic) V87.0

I (a) Multiple injuries T07

(b) Driver - collision of car and bus &V873

(c)

Do not make any assumption as to which vehicle the victim was driving. Using the Index, code:

Accident

- transport (involving injury to) (see also Table of land transport accidents) V99

- - person NEC (unknown means of transportation) (in) V99

- - - collision (between)

- - - - car (with)

- - - - - bus (traffic) V87.3

b. If reported types of vehicles are not indexed under Accident, transport, person, collision, code V877 for traffic and V887 for nontraffic.

I (a) Multiple injuries T07

(b) Bus and pick-up truck collision, driver &V877

(c)

Do not make any assumption as to which vehicle the victim was driving. Collision between bus and pick-up is not indexed under Accident, transport, person, collision. Code V877.

9. Water transport accidents (V90-V94)

The fourth character subdivision indicates the type of watercraft. Refer to Volume 1, Chapter XX, Water transport accidents for a list of the fourth character subdivisions.

I (a) Drowning T751 &V929

(b) Fell over-board

MOD II

Accident

Code drowning, due to fall overboard. Use fourth character “9,” unspecified watercraft.

10. Air and space transport accidents (V95-V97)

For air and space transport accidents, the victim is only classified as an occupant.

Military aircraft is coded to V958, Other aircraft accidents injuring occupant, since a military aircraft is not considered to be either a private aircraft or a commercial aircraft. Where death of military personnel is reported with no specification as to whether the airplane was a commercial or private craft, code V958.

11. Miscellaneous coding instructions (V01-V99)

a. When multiple deaths occur from the same transportation accident, all the certifications should be examined, and when appropriate, the information obtained from one may be applied to all. There may be other information available such as newspaper articles. A query should be sent to the certifier if necessary to obtain the information.

b. When classifying accidents which involve more than one kind of transport, use the following order of precedence:

aircraft and spacecraft (V95-V97)

watercraft (V90-V94)

other modes of transport (V01-V89, V98-V99)

I (a) Multiple fractures and internal injuries T029 T148

(b) Driver of car killed when a private plane &V973

Code to person on ground injured in air transport accident following above order of precedence. Refer to Index under Accident, transport, aircraft, person, on ground.

c. When no external cause information is reported and the place of occurrence of the injury was highway, street, road(way), or alley, assign the external cause code to person injured in unspecified motor vehicle accident occurring on the highway.

I (a) Head injuries and fracture S099 S029

MOD II &V892

Accident

Highway

Code to person injured in unspecified motor vehicle accident, traffic since the accident occurred on the highway.

d. Homicide, suicide or undetermined in manner of death

(1) When “undetermined” is reported in the manner of death box with transport accidents, code the external cause as accidental unless a statement on the certificate clearly establishes an investigation has not determined whether accidental, homicidal, or suicidal.

I (a) Multiple head injuries S097

(b) Car ran off cliff &V489

MOD II

Undetermined

Code I(a) as indexed. Code I(b) as unspecified car occupant injured in noncollision transport accident. Do not code to undetermined since there is no statement that clearly establishes an investigation resulted in an undetermined verdict.

Place I (a) Multiple head injuries S097

8 (b)Car ran off cliff &Y32

MOD II Police report indicates possible suicide or accident. Verdict

C pending.

Undetermined

Code I(a) as indexed. Code I(b) as indexed under Crash, transport vehicle, motor NEC, undetermined since there is a statement, which clearly establishes an investigation of “undetermined intent,” is pending.

(2) When “homicide” is reported in the manner of death box with transport accidents, code the external cause as accidental unless a statement on the certificate clearly establishes an intentional act of homicide occurred. Words like deliberately, intentionally, purposefully or assault can be interpreted as intentional and coded as homicide.

Place I (a) Multiple traumatic injuries T07

8 (b) Decedent run over by vehicle &Y03

several times in parking lot

MOD II

Homicide

Code I(a) as indexed. Code I(b) as indexed under Assault, crashing of motor vehicle. Homicide is coded since there was evidence the victim was repeatedly run over.

I (a) Multiple traumatic injuries T07

(b) Struck by car while walking on side of road &V031

MOD II

Homicide

Hit and run – driver left scene of accident

Code I(a) as indexed. Code pedestrian struck by car on I(b). Do not code as homicide since there is no statement of intentional homicide.

(3) When “suicide” is reported in the manner of death box with transport accidents, code the external cause qualified as suicide.

e. Garbage /dump truck accidents

When accidents involving garbage/dump trucks are reported and information indicates the mechanism of the body or truck bed caused the injuries, assign the E-code based on reported information. Usually, the statement of events will be falling on, struck by, or caught in and external codes W20, W22, or W23 will be used.

Place I (a) Crushed chest S280

4 (b) Dump truck body fell on chest &W20

MOD II

Accident

Street

Code external cause to Struck (by), object, falling, W20.

Place I (a) Fracture skull S029

4 (b) Struck by dump truck body &W22

MOD II

Accident

Street

Code external cause to Struck (by), object, W22.

Place I (a) Crushed chest S280

4 (b) Caught in compactor of garbage &W23

truck

MOD II

Accident

Street

Code external cause to Caught, between, objects, W23.

K. Falls

1. Other fall on same level (W18)

Code W18 if other or additional information is reported about the fall such as:

Fell from standing height

Fell moving from wheelchair to bed

Fell striking head

Fell striking object

Fell to floor

Fell while transferring from chair to bed

Fell while walking

Lost balance and fell

Place I (a) Fracture right hip S720

0 II Lost balance and fell to floor &W18

MOD

Accident

Home

Code external cause to other fall on same level.

2. Unspecified fall (W19)

Code W19, unspecified fall, for terms such as:

Fall

Fell

Fell at a place

Place I (a) Fracture right hip S720

1 II Fell at nursing home &W19

MOD

Accident

Nursing Home

Code external cause to fall, unspecified.

3. Falls with other external events

When fall is reported more information must be obtained in order to assign the most appropriate code. This information will be reported in Part I and Part II of the medical certification, also the place of injury and the description of how injury occurred.

1. Is a vehicle or transport involved?

YES: Refer to coding instructions for categories V01 - V89. This includes reference to table of land transport accidents. This section also includes specific instructions for fall from transport vehicle.

NOTE: fall from animal: see V80-

2. Is a fire involved?

YES: Refer to coding instructions for categories X00 - X09. Review Threats to Breathing, Table 3, Fire.

3. Is machinery in operation involved?

YES: See code categories W28 - W31.

4. Is drowning or submersion in water involved?

YES: Refer to coding instructions for categories W65 - W74. Review Threats to Breathing, Table 1, Drowning and submersion, if applicable.

5. Is struck by a falling object involved?

YES: See code categories W20 - W49

6. Is a human stampede or pushed by a crowd involved?

YES: Code W52

If none of the above, see code categories W00 - W19 for specific codes.

L. Natural and environmental factors

1. Lightning

Code X33 only when the decedent is injured from direct contact with lightning.

Code injuries, such as stroke or shock, due to direct contact with lightning to T750.

Code burn(s) due to lightning to burn(s) (T200-T289, T300-T319).

Place I (a) Shock T750

9 (b) Struck by lightning T750 &X33

Place I (a) Burns T300

0 (b) House fire &X00

When a secondary fire results from lightning, code to the fire. Do not enter a code for lightning.

2. Exposure, cold exposure and hypothermia

When exposure, cold exposure or hypothermia is reported anywhere on the record with another stated or implied external cause, code the nature of injury code (T68-T699, T758) and the E-code for the exposure, cold exposure or hypothermia (X599, X31). Do not modify the nature of injury code for exposure NOS. Ampersand the external cause code for the other event.

Place I (a) Exposure T758 X599

9 (b) Intoxication with hip fx T519 &X45 S720

II X590

Place I (a) Hypothermia with drowning T68 X31 T751 &W74

9 (b)

(c)

Place I (a) Exposure T758 X83

4 (b)

Suicide

Jumped from bridge

Place I (a) Exposure to cold T699 X31

9 (b)

(c)

II MVA &V892

Place I (a) Exposure and hypothermia T758 X31 T68

9 (b) Unconsciousness R402

(c)

MOD II Blunt trauma to head S099 &W18 T758

Accident

Exposed to elements after falling and striking head

Place I (a) Hypothermia T68 X31

9 (b)

(c)

II Alcohol intoxication T519 &X45

3. Storms and Wildfires

Categories X30-X39 include deaths from direct effects of forces of nature.

General Guidelines

- Use these categories for deaths resulting from direct effects of the storm.

- Do not use these categories for deaths resulting from a second event, such as clean-up after a cataclysmic event.

- When hurricane, storm, etc is reported, consider references to power failure, loss of power, lack of air conditioning, etc as part of the storm and not a subsequent accident.

- Code wildfire as X01, Exposure to uncontrolled fire, not in building or structure

Place I (a) Drowned T751 &X37

9 (b) Car which decedent was driving was washed

Code as victim of cataclysmic storm (X37). The drowning was a direct result of the hurricane.

Place I (a) Suffocation T71 &X36

9 (b) Covered by landslide

(c)

Code as victim of avalanche, landslide and other earth movements (X36).

I (a) Ruptured diaphragm S278

(b) Driver of auto which struck &V475

Code as car occupant injured in collision with fixed or stationary object, driver (V475).

Place I (a) Acute respiratory failure J960

9 (b) Severe emphysema T797

Code as death from hurricane (X37). Consider statement of loss of air conditioner power as part of the storm. The external cause code for storm is assigned where first reported on the record.

I (a) Fracture vertebra T08

(b) Contusion spinal cord T093

II Working to restore power from hurricane

Accident

Light pole fell on him

Code as struck by falling object (W20). This is clearly a subsequent accident and not a direct impact of the storm.

Place I (a) Smoke inhalation T598 &X01

9 (b)

MOD (c)

A II Wildfire

Accident

Wildfire

Code as wildfire (X01). Follow the Index as Exposure, fire, uncontrolled, not in building or structure.

Place I (a) Thermal injuries and smoke inhalation T300 &X01 T598

0 (b)

MOD (c)

A II Multiple sclerosis G35

Accident

Home

Unable to leave home – overcome by wildfire

Code as wildfire (X01) since this house fire resulted from the wildfire. Follow the Index as Exposure, fire, uncontrolled, not in building or structure.

M. Firearms and firearm injuries

1. Coding specific types of firearms

The type of firearm involved in a death is identified at the three character level. Use the following guide to identify the type of firearm:

Intentional Undetermined

Type Firearm Accidental Self-harm Assault Intent

Handgun W32 X72 X93 Y22

25 Caliber

32 Caliber

38 Caliber

45 Caliber

357 Magnum

380 Caliber

Pistol

Revolver Saturday night

special

Rifle, shotgun, larger W33 X73 X94 Y23

firearm

25.06 (25 ought 6)

30.6 (30 ought 6)

30/30

308

AK47

M1 (carbine)

M14

M16

Machine gun

Rifle (army) (hunting)

(military)

Shotgun (8, 10, 12, 16, 20,

410 gauge,

buckshot)

Other and unspecified W34 X74 X95 Y24

firearms

9 mm

22 Caliber gun

30 Caliber gun

Airgun

BB gun

Pellet gun

Pellet pistol

Pellet rifle

Very pistol (Flare)

2. External cause code

When reported as Code

“playing with gun” NOS or external cause as accidental (W32-

“cleaning gun” NOS W34)

“playing Russian external cause as handgun accident

roulette” (whether or not stated (W32)

suicide)

Place I (a) Gunshot wound of femur S711 &W34

9 (b) Cleaning gun T141

Code as accidental since reported due to cleaning gun.

Place I (a) Gunshot wound chest S219 &W32

9 (b)Self-inflicted while playing Russian roulette

MOD II

Suicide

Code as handgun accident since Russian roulette is reported.

3. Nature of injury code

When Is reported due to Code

Injury NOS any caliber the nature of injury to wound

bullet

gun went off

pulled trigger

specified firearm

Place I (a) Injury T141

9 (b) Rifle T141 &W33

When reported as Code

Gunshot or bullet entering and/or exiting a site the nature of injury to wound of site(s)

Place I (a) Bullet entering chest & S219 &W34 S212

9 (b) exiting back

When reported as Code

Bullet (to site) the nature of injury to wound (of site(s))

Gunshot (to site)

Shoot, shooting, shot (to site)

Shotgun blast (to site)

Place I (a) Shot in head S019 &W34

4. Other firearm examples

Place I (a) Gunshot wound chest S219 &Y24

9 (b) Self-inflicted

Code as undetermined gunshot since self-inflicted is reported and is unspecified as accidental or intentional.

Place I (a) Gunshot injury chest S219 &W34 S273

9 (b) and lung

Code the nature of injury to wound of sites and external code to accidental gunshot wound

N. Child abuse, battering and other maltreatment (Y070-Y079)

Code to Child battering and other maltreatment (Y070-Y079) if the age of the decedent is under 18 years and the cause of death meets one of the following criteria:

1. The certifier specifies abuse, battering, beating, or other maltreatment, even if homicide is not specified.

Male, 3 years

I (a) Traumatic head injuries S099

(b)

(c)

MOD II &Y079

Homicide

Home

Deceased had been beaten

2. The certifier specifies homicide and injury or injuries with indication of more than one episode of injury, i.e., current injury coupled with old or healed injury consistent with a history of child abuse.

Male, 1-1/2 years

I (a) Anoxic encephalopathy G931

(b) Subdural hematoma S065

MOD II &Y079

Homicide

3. The certifier specifies homicide and multiple injuries consistent with an assumption of battering or beating, if assault by a peer, intruder, or by someone unknown to the child cannot be reasonably inferred from the reported information.

Female, 1 year

I (a) Massive internal bleeding T148

(b) Multiple internal injuries T065

(c)

MOD II Injury occurred by child being struck T149 &Y079

Homicide

Exception:

Deaths at ages under 18 years for which the cause of death certification specifies homicide and an injury occurring as an isolated episode, with no indication of previous mistreatment, should not be classified to Y070-Y079. This excludes from Y070-Y079 deaths due to injuries specified to be the result of events such as shooting, stabbing, hanging, fighting, or involvement in robbery or other crime, because it cannot be assumed such injuries were inflicted simply in the course of punishment or cruel treatment.

Female, 1 year

Place I (a) Hypovolemic shock T794

0 (b) Laceration of heart S268

MOD II Stabbed with kitchen knife by mother T141

Homicide

Home

O. Guides for differentiating between effects of external causes classifiable to Chapters I - XVIII and Chapter XIX

Categories in Chapters I-XVIII and XIX are mutually exclusive. Where provision has been made for coding effects of an external cause to Chapters I-XVIII, do not use a nature of injury code.

The effects of external causes classifiable to Chapters I-XVIII are primarily those associated with drugs, medicaments and biological substances, surgical procedures, and other medical procedures. Refer to Section V, Part R, Complications of medical and surgical care (Y40-Y84).

A limited number of conditions that can result from other external causes, e.g., certain localized effects of fumes, vapors and nonmedicinal chemical substances and respiratory conditions from aspiration of foreign substances are also classified to Chapters I-XVIII. It is intended that Chapters I-XVIII be used to identify the localized effects and the substance be identified by the external cause code in Chapter XX.

To determine if the conditions reported due to external causes, other than drugs, medicaments, and biological substances, surgical procedures, and other medical procedures, are classified to localized effects in Chapters I-XVIII or to the nature of injury in Chapter XIX – look up the stated condition in the Index and scan the listing under this condition for qualifying terms that relate to the reported external cause. For example, to determine whether pneumonia due to aspiration of vomitus should be coded to Chapter X or to Chapter XIX, look up “Pneumonia, aspiration, due to, food (regurgitated), milk, vomit.” This determination cannot be made by looking up “Aspiration.” Where there is provision in the Index for coding a condition due to an external cause to Chapter I-XVIII, take the external cause into account if it modifies the coding.

I (a) Pneumonia &J690

(b) Aspiration of vomitus W78

Code Pneumonia, aspiration, due to vomit. Code “aspiration of vomitus” as an external cause code only.

I (a) Pneumonia &J690

(b) Aspiration W80

Code Pneumonia, aspiration. Code I(b) “aspiration” as an external cause code only.

I (a) Pneumonia &J690

(b) Asphyxia W80

Code Pneumonia, aspiration. Code I(b) external cause code only.

I (a) Pneumonia &J680

(b) Smoke inhalation X00

II House fire

Code Pneumonia, in (due to), fumes and vapors (J680). Code I(b) external cause code only.

I (a) Acute pulmonary edema &J681

(b) Inhaled gasoline fumes X46

Code Edema, pulmonary, acute, due to, chemicals fumes or vapors (J681). Code I(b) external cause code only.

Place I (a) Pneumonia J189

9 (b) Cardiac arrest I469

Code each entity as indexed. Do not code the pneumonia on I(a) due to aspiration of vomitus since it is reported due to another condition.

P. Threats to breathing

Certain effects of external causes can be classified to more than one nature of injury code depending on the type of external cause. Some of these effects are “anoxia,” “asphyxia,” “aspiration,” “choking,” “compression of neck,” “obstruction of a site,” “strangulation,” “stricture of neck,” and “suffocation.”

The most frequently reported external causes which result in these effects are “aspiration, ingestion, and inhalation of objects and substances,” “drowning,” “fires,” “fumes, gases and vapors,” “hanging,” “mechanical strangulation and suffocation,” and “submersion.”

The following pages contain tables that are used as guides in coding these types of external causes and effects.

In general, if the specific external cause is not in Tables 1-5, it will most likely be in Table 6, which contains the most frequently reported external causes which result in asphyxia, suffocation, etc. If not in any of the tables, code the effect as indexed.

Table Title

Table 1 Drowning and submersion

Table 2 *Hanging and mechanical

strangulation (by external means)

Table 3 Fires (includes burns, gases, fumes in

association with burns and fires)

Table 4 Ingestion, inhalation of gases, fumes,

vapors (without fires, burns)

Table 5 Compression chest, crushed chest by

external means

Table 6 Aspiration NOS, ingestion NOS,

inhalation NOS or aspiration, ingestion,

inhalation of substances or objects

(W78, W79, W80)

*NOTE: Interpret mechanical strangulation as strangulation caused by external means to the exterior of the body.

Table 1. Drowning and submersion

Instruction

When

Is reported due to

Code

anoxia

asphyxia

strangulation

suffocation

drowning

submersion

upper line T751 and the appropriate external cause code.

lower line T751

only.

Examples - Corresponding Table and Instruction 1.1

Place I (a) Asphyxia T751 &W69

8 (b) Drowning T751

MOD (c)

A II T751

Accident

Drowned while swimming in river

I (a) Asphyxia T751 &V909

(b) Strangulation T751

MOD (c) Drowning T751

A II

Accident

Lake

Boat Overturned

Place I (a) Anoxia T751 &W70

8 (b) Drowning T751

MOD (c)

A II

Accident

Fell into Lake

Instruction

When

Is reported on the same line with

Code

anoxia

asphyxia

strangulation

suffocation

drowning

submersion

T751 and the appropriate external cause code.

Example - Corresponding Table and Instruction 1.2

Place I (a) Drowning - asphyxia T751 &W69

8 (b)

MOD (c)

A II

Accident

Pond

Table 2. Hanging and mechanical strangulation (by external means)

Instruction

When

Is reported due to

Code

asphyxia

strangulation

suffocation

hanging

mechanical strangulation

(by external means)

compression of neck

upper line T71 and the appropriate external cause code.

lower line T71 only.

Examples - Corresponding Table and Instruction 2.1

Place I (a) Asphyxia T71 &X70

0 (b) Hanging T71

MOD (c)

S II

Suicide

Home

Place I (a) Aspiration of vomitus T179 W78

0 (b) Strangulation T71 &X70

MOD (c) Hanging T71

S II T71

Suicide

Home

Hanged Self

I (a) Asphyxia T71 &V499

(b) Compression of neck T71

Instruction

When

Is reported on the record with

Code

asphyxia

strangulation

suffocation

hanging

mechanical strangulation

(by external means)

compression of neck

the asphyxia, strangulation, suffocation, T71 followed by the appropriate external cause code.

T71 only where the hanging, mechanical strangulation, compression of neck is reported.

Example - Corresponding Table and Instruction 2.2

Place I (a) Suffocation by hanging T71 &X70

9 (b)

MOD (c)

S II T71

Suicide

Hanging by neck

Male 1 month old

Place I (a) Suffocation T71 &W75

9 (b)

MOD (c)

A II

Accident

Co-sleeping with adults

Instruction

When

Is reported due to

Which is reported due to

Code

asphyxia

strangulation

suffocation

asphyxia

strangulation

suffocation

the external means of the mechanical

strangulation

(such as: ligature, rope around neck, sheet )

uppermost line to T71 and the appropriate external cause code.

the next lower line to T71.

lower line blank.

Example - Corresponding Table and Instruction 2.3

Place I (a) Asphyxia T71 &W75

9 (b) Suffocation T71

Instruction

When

Is reported due to

Code

compression

of neck

stricture of

neck

hanging

mechanical strangulation

(by external means)

suffocation

upper line T71 only.

lower line T71 and the appropriate external cause code.

Example - Corresponding Table and Instruction 2.4

Place I (a) Compression of neck T71

9 (b) Hanging T71 &X91

MOD (c)

H II T71

Homicide

Hanging

Instruction

When

Is reported on the record with

Code

compression
of neck
stricture of
neck

hanging
mechanical strangulation
(by external means)
suffocation

compression of neck, stricture of neck to T71 only.

T71 followed by the appropriate external cause code for the hanging, mechanical strangulation, suffocation.

Example - Corresponding Table and Instruction 2.5

Place I (a) Compression of neck T71

9 (b)

MOD (c)

H II Strangulation by cord around neck T71 &X91

Homicide

Table 3. Fires (includes burns, gases, fumes in association with burns and fires)

Instruction

When

Is reported due to

Code

asphyxia
suffocation

ingestion,
inhalation

of gas, fumes, or vapors
(carbon monoxide, products of combustion, smoke)

the asphyxia, suffocation to the nature of injury code for the gas, fumes, vapor and the appropriate external cause code for the fire where required.

lower line to the appropriate nature of injury code for the gas, fumes, vapor.

with

mention of a fire (specified)

Examples - Corresponding Table and Instruction 3.1

Place I (a) Suffocation T599 &X00

0 (b) Inhalation of products of combustion T599

MOD (c)

A II T599

Accident

Inhaled fumes in house fire

Place I (a) Suffocation T598 &X09

9 (b) Smoke inhalation T598

MOD (c) Fire

A II

Accident

Instruction

When

Is reported on the record with

Code

asphyxia
suffocation

ingestion,
inhalation

of gas, fumes, or vapors
(carbon monoxide, products of combustion, smoke)

the asphyxia, suffocation to the nature of injury code for the gas, fumes, vapor and the appropriate external cause code for the fire where required.

the appropriate nature of injury code for the gas, fumes, vapor where reported.

with

mention of a fire (specified)

Example - Corresponding Table and Instruction 3.2

Place I (a) Asphyxia - carbon monoxide T58 &X00

0 (b)

MOD (c)

A II

Accident

Home

House Fire

Instruction When Is reported due to Code

3 asphyxia burns NOS upper line T300 and the

suffocation (any degree) appropriate external cause code

(any percentage)

(any site) lower line as indexed.

Examples - Corresponding Table and Instruction 3.3

Place I (a) Asphyxia T300 &X04

0 (b) Burns of chest and face T210 T200

MOD (c)

A II

Accident

Home

Ignition of kerosene

Place I (a) Suffocation T300 &X00

9 (b) 3° burns T303

MOD (c)

A II

Accident

Burning Bldg.

Instruction

When

Is reported due to

Code

asphyxia

suffocation

fire NOS

specified fire

upper line T300 and the appropriate

external cause code.

lower line blank.

Instruction

When

Is reported on the record with

Code

asphyxia suffocation

fire NOS

specified fire

the asphyxia, suffocation T300, followed by the appropriate external cause code for the fire.

Example - Corresponding Table and Instruction 3.5

Place I (a) Asphyxia, fire in house T300 &X00

0 (b)

(c)

Table 4. Ingestion, inhalation of gases, fumes, vapors (without fires, burns)

Instruction

When

Is reported due to

Code

asphyxia
suffocation

ingestion,
inhalation

of gas,
fumes,
or vapors

upper line to the appropriate nature of injury code for the gas, fumes, or vapor and the appropriate external cause code.

lower line to the appropriate nature of injury code for the gas, fumes, or vapor.

Example - Corresponding Table and Instruction 4.1

Place I (a) Asphyxia T58 &X67

0 (b) Inhalation of carbon monoxide T58

MOD (c)

S II T58

Suicide

Home

Inhaled car exhaust fumes in garage

Place I (a) Asphyxiation T598 &X67

8 (b) Plastic bag over head with helium infusion T598

MOD (c)

S II T598

Suicide

Lot

Placed plastic bag over head. Tube from helium tank inserted under bag.

Instruction

When

Is reported on the same line with

Code

asphyxia
suffocation

ingestion,
inhalation

of gas,
fumes,
or vapors

the appropriate nature of injury code for the gas, fumes, or vapor and the appropriate external cause code.

Example - Corresponding Table and Instruction 4.2

Place I (a) Suffocation by inhalation of propane gas T598 &X47

0 (b)

MOD (c)

A II T598

Accident

Home

Inhaled propane gas

Table 5. Compression chest, crushed chest by external means

Instruction

When

Is reported due to

Code

asphyxia

suffocation

crushed chest

upper line S280 plus the appropriate external cause code.

lower line S280.

Example - Corresponding Table and Instruction 5.1

I (a) Asphyxia S280 &V892

(b) Crushed chest S280

MOD (c) MVA

A II

Accident

Street

MVA

Instruction

When

Is reported due to

Code

asphyxia

suffocation

compression chest

upper line S299 plus the appropriate external cause code.

lower line S299.

Example - Corresponding Table and Instruction 5.2

Place I (a) Suffocation S299 &W30

7 (b) Compression chest S299

MOD (c) Tractor accident

A II

Accident

Farm

Tractor overturned on victim

Table 6. Aspiration NOS, ingestion NOS, inhalation NOS, or aspiration, ingestion, inhalation of substances or objects (W78, W79, W80)

EXCLUDES: Ingestion, inhalation of drugs and poisonous substances

Instruction

When

Is reported due to

Code

asphyxia

aspiration

choking

obstruction of a site

occlusion of a site

strangulation

suffocation

aspiration NOS

ingestion NOS

inhalation NOS

upper line to T17 plus

appropriate fourth character and the appropriate external cause code (W78, W79, W80).

lower line to T17 with appropriate fourth character.

aspiration

ingestion

inhalation

of substances or objects

Examples - Corresponding Table and Instruction 6.1

Place I (a) Strangulation T179 &W79

9 (b) Aspiration of food T179

(c)

Place I (a) Asphyxia T179 &W78

9 (b) Aspiration T179

Place I (a) Choked T179 W80

9 (b) Aspiration of blood T179

II Car vs. Pedestrian &V031

Instruction

When

Is reported due to

Code

asphyxia

aspiration

choking

obstruction of a site

occlusion of a site

strangulation

suffocation

foreign body in a site (such as: blood, food, gum, medicine, mucus, vomitus)

upper line to T17 plus appropriate fourth character and the appropriate external cause code (W78, W79, W80).

lower line to T17 with appropriate fourth character.

Example - Corresponding Table and Instruction 6.2

Place I (a) Obstruction of pharynx T172 &W79

9 (b) Bolus of meat in throat T172

(c)

Instruction

When

Is reported due to

Code

asphyxia

aspiration

choking

obstruction of a site

occlusion of a site

strangulation

suffocation

foreign body NOS

(such as: blood, food, gum, medicine, mucus, vomitus)

upper line to T17 plus appropriate fourth character and the appropriate external cause code (W78, W79, W80).

lower line blank.

Examples - Corresponding Table and Instruction 6.3

Place I (a) Obstruction of trachea T174 &W79

9 (b) Bolus of meat

(c)

Place I (a) Asphyxia T179 &W78

9 (b) Aspiration T179

Instruction

When

Is reported on the same line with

Code

asphyxia

aspiration

choking

obstruction of a site

occlusion of a site

strangulation

suffocation

aspiration NOS

ingestion NOS

inhalation NOS

on the same line, T17 with appropriate fourth character and the appropriate external cause code (W78, W79, W80).

aspiration

ingestion

inhalation

of substances or objects

Example - Corresponding Table and Instruction 6.4

Place I (a) Asphyxia by aspiration of vomitus T179 &W78

9 (b)

(c)

Instruction

When

Is reported on the same line with

Code

asphyxia

aspiration

choking

obstruction of a site

occlusion of a site

strangulation

suffocation

foreign body in a site (such as: blood, food, gum, medicine, mucus, vomitus)

on the same line, T17 with appropriate fourth character and the appropriate external cause code (W78, W79, W80).

Example - Corresponding Table and Instruction 6.5

Place I (a) Choked by peanut obstructing trachea T174 &W79

9 (b)

(c)

Instruction

When

Is reported on the same line with

Code

asphyxia

aspiration

choking

obstruction of a site

occlusion of a site

strangulation

suffocation

foreign body NOS (such as: blood, food, gum, medicine, mucus, vomitus)

on the same line, T17 with appropriate fourth character and the appropriate external cause code (W78, W79, W80).

Examples - Corresponding Table and Instruction 6.6

Place I (a) Choked on chicken bone &nbsnbsp; T179 &W79

9 (b)

(c)

Place I (a) Obstruction airway by bolus of food T179 &W79

9 (b)

(c)

Instruction

When

Is reported due to

Code

aspiration NOS

aspiration of substances

strangulation NOS

strangulation by substances

a disease

upper line T17 plus appropriate fourth character and the appropriate W78, W79, W80 if not previously coded.

lower line as indexed.

Example - Corresponding Table and Instruction 6.7

Place I (a) Aspiration T179 &W80

9 (b) C.V.A I64

(c)

Place I (a) Cerebro vascular accident I64

9 (b) Aspiration T179 &W80

MOD