Instructions for Classifying Multiple Causes of Death, 2021 - 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

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).

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

Use an ampersand to identify the following
The most specific external cause code causing injuries or poisoning.
Certain localized effects of poisonous substances (X45-X49) or aspiration (W78,W79, W80) when classifiable to Chapters I-XVIII.
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:

When reporteddue to:

nature of injury codes
medical and surgical care
other external causes

When a nature of injury code other than T179 is reported as thefirst 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.

More than one external cause reported
In determining the most specific external cause code, considerall 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.

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

Some conditions are indexed directly to a nontraumaticcategory but the Classification also provides a traumatic code. Consider these conditions to be traumatic and code as traumatic:
When they are qualified as “traumatic”
Or they are reported on the certificate with:

Injury or trauma (any specified type or site)
An external cause
TheManner 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 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:

Code emphysema, encephalitis, and meningitis to the nature of injury code only when they are stated to be “traumatic” or are reporteddue 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).

Code the following terms to the traumatic categoryonly 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.

When the traumatic form of a condition is classified to Chapters I-XVIII, code as traumaticonly 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.”

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.

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.

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 inuries 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:

When conditions classified to categories A000-R99 are reported due to “second handsmoke”, 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

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.

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.
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:

Fracture of both hips T025

Fracture

– hip

– – both T025

Fracture of hips S720

Fracture

– hip S720

Multiple fractures of ribs S224

Fracture

– rib

– – multiple S224

Fractures of ribs S223

Fracture

– rib S223

Multiple wounds of lower limb T013

Wound

– limb

– – lower NEC

– – – multiple sites T013

Multiple injuries Followed byspecified Code T07 and the specified

type(s) of injuries injuries

Multiple injuries Followed byspecified Code multiple injuries by

site(s) site(s) only

Single site Reported on same lineCode the specified types of

with multiple types of injuries of the reported site

injuries

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

Place I (a) Multiple injuries with T07 S029 S062

9 (b) fracture skull and

II &X599

Place I (a) Multiple injuries – head, neck, chest S097 S197 S297

II &X599

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

9 (b) of leg

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

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.

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.

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

When specifiedtypes 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

When specifiedsites 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 traffic accident when the event is classifiable to categories V02-V04, V10-V82 and V87.
A nontraffic accident when the event is classifiable to categories V83-V86. These vehicles are designed primarily for off-road use.
Consider category V05 to be unspecified whether traffic or nontraffic if no place is indicated or if the place is railroad (tracks).
Consider category V05 to be traffic if place is railway crossing.
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 overtuned – 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

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.

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).

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

When drowning occursas 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.

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 &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)

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 • Passengercar vs. truck
Car vs. truck, driver • Carvs. 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

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)

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 ifnecessary to obtain the information.
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.

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.

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.

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.

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-

Is a fire involved?

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

Is machinery in operation involved?

YES: See code categories W28 – W31.

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.

Is struck by a falling object involved?

YES: See code categories W20 – W49

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:

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

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

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

| | | | |

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

| | | | |

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)

| | | | |

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

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

| | | | to | |

| | | | ligature rope| T71. |

Example – Corresponding Table and Instruction 2.3

Place I (a) Asphyxia T71 &W75

9 (b) Suffocation T71

| | | | |

| | | | |

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

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)

| | | | | |

| | | | |

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

| | | | | |

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.

| | | | |

| | | | |

| | | | |

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)

| | | | |

| | | | |

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.

| | | | |

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

| | | | |

| | | | |

Example – Corresponding Table and Instruction 5.1

I (a) Asphyxia S280 &V892

(b) Crushed chest S280

MOD (c) MVA

A II

Accident Street MVA

| | | | |

| | | | |

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

| | | | |

| | strangulation | or | |

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

| | | | |

Example – Corresponding Table and Instruction 6.2

Place I (a) Obstruction of pharynx T172 &W79

9 (b) Bolus of meat in throat T172

(c)

| | | | |

| | | | |

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

| | strangulation | or | |

| | | | |

Example – Corresponding Table and Instruction 6.4

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

9 (b)

(c)

| | | | |

Example – Corresponding Table and Instruction 6.5

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

9 (b)

(c)

| | | | |

Examples – Corresponding Table and Instruction 6.6

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

9 (b)

(c)

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

9 (b)

(c)

| | | | |

| | | | |

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 (c) Acute respiratory failure with hypoxemia J960 R090

C II

Could not be determined

Instruction When Is reported due to Code

8 aspiration NOS vomiting upper line T179, W78.

lower line R11.

Example – Corresponding Table and Instruction 6.8

Place I (a) Aspiration T179 &W78

9 (b) Vomiting R11

(c)

| | | | |

| | or | | W80 if not previously |

Examples – Corresponding Table and Instruction 6.9

Place I (a) Aspiration of vomitus T179 W78

0 (b) Strangulation T71 &X70

MOD (c) Hanging T71

S II T71

Suicide Home Hanged Self

Place I (a) Choked T179 W80

9 (b) Aspiration of blood T179

II Car vs. Pedestrian &V031

Place I (a) Aspiration T179 W80

9 (b) Drowning T751 &W74

MOD (c)

A II

Accident

Place I (a) Pneumonia J189

9 (b) Cardiorespiratory arrest I469

MOD (c) Aspiration T179 &Y33

C II

Could not be determined

Since none of the previous instructions apply, assign the e-code for aspiration to the undetermined category.

Q. Poisoning

When poisoning (any) is reported, code nature of injury code and external cause code for the substance.

When poisoning by fumes, gas, liquids, or solids is reported, refer to Index under “Poisoning (acute)” to determine the nature of injury code for the substance.

To determine the external cause code when a poisonous substance is ingested, inhaled, injected, or taken, refer to the description of such circumstances (acts) for example, Ingestion, Inhalation, or Took.

When a condition is reported due to poisoning and the Index provides a code for the condition qualified as “toxic,” use this code. If the Index does not provide a code for the condition qualified as “toxic,” code the condition as indexed.

1. Poisoning by substances other than drugs

Assume poisoning (self- inflicted) by a substance to be accidental unless otherwise indicated.

Place I (a) Aplastic anemia D612

9 (b) Benzene poisoning T521 &X46

Code I(a) Anemia, aplastic, toxic. Code I(b) to nature of injury and external cause code for benzene poisoning from Table of Drugs and Chemicals.

Place I (a) Toxic poisoning T659 &X46

9 (b) Drank turpentine T528

Code I(a), nature of injury code for poison NOS and the most specific external cause code (turpentine) taking into account the entire certificate. Code nature of injury for turpentine on I(b).

a. Carbon monoxide poisoning

Code carbon monoxide poisoning from motor vehicle exhaust gas to noncollision motor vehicle accident (traffic) according to type of motor vehicle involved unless there is indication the motor vehicle was not in transit. Consider statements of “sleeping in car,” “sitting in parked car,” “in parked car” or place stated as “garage” to indicate the motor vehicle was “not in transit.” Assume “not in transit” in self-harm (intentional) and self-inflicted cases.

I (a) Carbon monoxide poisoning T58 &V892

(b)

(c)

II Motor vehicle exhaust gas T58

Code I(a) nature of injury for carbon monoxide and most specific external cause. Code external cause to person injured in unspecified motor vehicle accident, traffic. Refer to Table of land transport accidents under Victim and mode of transport. Select occupant of motor vehicle (traffic), noncollision transport accident. Code nature of injury for exhaust gas in Part II.

Place I (a) Poisoned by carbon monoxide T58 &X47

9 II Sitting in parked car

Code I(a) nature of injury and external cause for carbon monoxide from Table of drugs and chemicals. The external cause includes poisoning by gas, motor exhaust, not in transit.

Place I (a) Carbon monoxide inhalation T58 &X67

5 II Found in garage. Suicide.

Code I(a) nature of injury and external cause for carbon monoxide from Table of drugs and chemicals. The external cause includes intentional self-harm poisoning by gas, motor exhaust, not in transit.

b. Inhalation and sniffing sprays and aerosol substances

When inhalation of sprays, aerosol substances, etc. is reported, code to the appropriate accidental poisoning category for the external cause.

Exceptions:

“Glue sniffing” and “cocaine sniffing” and “huffing” are indexed to mental and behavioral disorders due to psychoactive substance use (F181, F142, F181).

Place I (a) Toxicity T659 &X46

0 (b) Inhalation of aerosol substance T659

(c)

MOD II Breathed “PAM” (freon) in plastic bag T535

Accident Home

Code I(a) nature of injury code for toxicity as indexed. Code external cause to accidental inhalation of freon gas or spray (X46), the specific substance indicated by the certifier. Code nature of injury for aerosol on I(b) and freon in Part II.

c. Intoxication by certain substances or toxic poisoning due to disease

When ammonia intoxication (NH), carbon dioxide intoxication (C0), or toxic poisoning is reported due to a disease, do not code to poisoning. When due to a disease, code ammonia intoxication to R798, carbon dioxide intoxication to R068, and toxic poisoning to R688.

I (a) Ammonia intoxication R798

(b) Cirrhosis of liver K746

Code I(a) as indexed, Intoxication, ammonia, due to disease (R798).

I (a) Carbon dioxide intoxication R068

(b) Chronic pulmonary emphysema J439

Code I(a) as indexed, Intoxication, carbon dioxide, due to disease (R068).

I (a) Toxic poisoning R688

(b) Gastroenteritis A099

Code I(a) as indexed, Poisoning, toxic, from a disease (R688).

d. Condition qualified as “toxic” with poisoning reported

(1) When a condition is qualified as “toxic” and there is indication of poisoning on the certificate, code the external cause code for the poisoning where the “toxic” is reported, followed by the condition code. If the Classification provides a code for the condition qualified as “toxic,” use this code. If no provision is made for qualifying the condition as toxic, code to the unspecified code for the condition.

Place I (a) Toxic nephritis &X48 N144

9 II Organophosphate poisoning, T600

accidental

Code most specific external cause code on I(a) where toxic is reported followed by condition code for toxic nephritis as indexed. Code nature of injury for organophosphate in Part II.

Place I (a) Toxic GI hemorrhage &X49 K922

9 (b) Carbolic acid T540

Code most specific external cause code on I(a) where toxic is reported followed by condition code for GI hemorrhage as indexed. The Classification does not provide a code for GI hemorrhage qualified as toxic. Code nature of injury for carbolic acid on I(b).

Place I (a) Toxic diarrhea &X48 K521

9 II Rat poison T604

Code most specific external cause code on I(a) where toxic is reported followed by condition code for toxic diarrhea as indexed. Code nature of injury for rat poison in Part II.

(2) When a condition is qualified as “toxic” and there is no indication of poisoning on the certificate, code the condition as indexed to the unspecified code.

I (a) Toxic anemia D612

Code toxic anemia as indexed since there is no indication of poisoning on the certificate.

2. Poisoning by drugs

When the following statements are reported, see Table of Drugs and Chemicals and code as accidental poisoning unless otherwise indicated.

Interpret all these statements to mean poisoning by drug and code as poisoning whether or not the drug was given in treatment:

Drug taken inadvertently

Lethal (amount) (dose) (quantity) of a drug

Overdose of drug

Poisoning by a drug

Toxic effects of a drug

Toxic reaction to a drug

Toxicity (of a site) by a drug

Wrong dose taken accidentally

Wrong drug given in error

Place I (a) Cardiac arrest I469

9 (b) Digitalis toxicity T460 &X44

Code digitalis toxicity to digitalis poisoning. Code nature of injury and external cause code for digitalis poisoning on I(b). Do not ampersand a disease condition when poisoning from a drug occurs while the drug is being administered for medical reasons.

Place I (a) Shock R578

9 (b) Insulin overdose T383 &X44

Code I(a) shock, toxic since reported due to poisoning. Code insulin overdose to insulin poisoning. Code nature of injury and external cause code for insulin poisoning on I(b). Do not ampersand a disease condition when poisoning from a drug occurs while the drug is being administered for medical reasons.

Interpret the terms

(1) “intoxication by drug” to mean poisoning by drug unless indicated or stated to be due to drug therapy or as a result of treatment for a condition (refer to Section V, Part R, 1, (6), “Intoxication by drug” due to drug therapy).

Place I (a) Respiratory failure J969

9 (b)Drug intoxication T509 &X44

II Ingested undetermined T509

amount of drugs

Code “drug intoxication” to poisoning when there is no indication the drug was given for therapy. Code I(b) nature of injury and external cause code for drug poisoning. Code nature of injury code for drug NOS in Part II.

(2) intentional with drug poisoning as Suicide. If the manner of death is reported as something other than Suicide, code as undetermined. If, however, the manner of death is marked Natural, Blank, or Pending Investigation code as Suicide.

Place I (a) Sudden cardiac arrest I469

9 (b) Intentional drug overdose T509 &X64

II Morbid obesity, obstructive sleep apnea, hypertension E668 G473 I10

Natural

Code I(a) as indexed. Code the nature of injury and external cause code for drug nos as suicide on line I(b) since intentional is reported with drug poisoning and the manner of death box is marked Natural. Code Part II conditions as indexed.

When poisoning by drug NOS is reported in Part I and a specified drug is reported in Part II, code the external cause code to the specified drug.

Place I (a) Took overdose of drug T509 &X41

9 II Overdose of barbiturates T423

Code “took overdose of drug” as accidental unless otherwise specified. Code I(a) nature of injury for drug NOS and external cause code to the specified drug reported in Part II. Code nature of injury for barbiturates in Part II.

When a condition is qualified as “toxic” or “drug induced”and there is indication of drug poisoning on the certificate, code the external cause code for the drug poisoning where the “toxic” or “drug induced” is reported, followed by the condition code. If the Classification provides a code for the condition qualified as “toxic”, “due to drug” or “drug induced,” use this code. If no provision is made for qualifying the condition as “toxic”, “due to drug” or “drug induced,” whichever applies, code to the unspecified code for the condition. Code the nature of injury code for poisoning by the specified drug. NOTE: Depending on how the record is reported, the placement of the N & E may vary. See examples below.

Place I (a) Toxic hemolytic anemia &X41 D594

9 (b) Levodopa toxicity T428

Code most specific external cause on I(a) where toxic is reported followed by condition code for toxic hemolytic anemia as indexed. Code nature of injury for levodopa on I(b).

Place I (a) Drug induced hemolytic anemia &X41 D592

9 (b) Levodopa toxicity T428

Code most specific external cause on I(a) where drug induced is reported followed by condition code for Anemia, hemolytic due to, drugs as indexed. Code nature of injury for levodopa on I(b).

Place I (a) Drug induced hypotension &X44 I952

9 II Drug induced hypotension T509 I952

MOD

Accident

Code external cause on I(a) where drug induced is reported followed by condition code for drug induced hypotension as indexed. Code nature of injury for drug NOS in Part II.

Place I (a) Drug induced hypotension T509 &X44 I952

9 II

MOD

Accident

Code nature of injury and external cause on I(a) where drug induced is reported followed by condition code for drug induced hypotension as indexed. Since there are no other drugs reported, the nature of injury code is placed on line (a).

When a condition is qualified as “toxic” and there is no indication of drug poisoning on the certificate, code the condition as indexed.

When a condition is qualified as “drug induced” and there is no mention of drug poisoning on the certificate, code as a complication of drug therapy.

Poisoning by combination of drugs (X40-X44)

(1) When poisoning by a combination of drugs is stated or indicated to be accidental, intentional self-harm (suicide), or undetermined code as follows:

(a) When poisoning by a combination of drugs classified to the same external cause code is reported, use that external cause code.

Place I (a) Doxepin and barbiturate overdose T430 &X41 T423

Code external cause code to X41 since both doxepin and barbiturates are indexed to this code. Code nature of injury for each drug reported.

Place I (a) Doxepin and prozac overdose T430 &X61 T432

MOD

Suicide

Code external cause code to X6l since both doxepin and prozac are indexed to this code. Code nature of injury for each drug reported.

(b) When poisoning from a single drug is reported in Part I with a combination of drugs in Part II, code the external cause code for the drug reported in Part I. Code the nature of injury for each drug reported.

Place I (a) Acute barbiturate intoxication T423 &X41

9 II Took unknown amount of T423 T390

MOD barbiturates and aspirin

Accident

Code external cause code to X41, accidental poisoning by barbiturates, the single drug reported in Part I. Code nature of injury for barbiturates on I(a) and for barbiturates and aspirin in Part II.

(c) When poisoning by a combination of drugs classified to different external cause codes is reported and (b) does not apply, use the following external cause codes when the manner of death is reported as:

Accident Code X44, Accidental poisoning by and exposure to other and unspecified drugs, medicaments and biological substances.

Intentional self- Code X64, Intentional self-poisoning by and exposure

harm to other and unspecified drugs, medicaments and

(Suicide) biological substances.

Undetermined Code Y14, Poisoning by and exposure to other and unspecified drugs, medicaments and biological substances, undetermined intent.

NOTE: This does not apply to chemicals such as carbon monoxide and acetone.

Place I (a) Drug intoxication T509 &X44

9 (b) Digitalis, cocaine T460 T405

The external cause code for accidental poisoning by digitalis is X44 and for cocaine is X42. Since the drugs are assigned to different external cause codes, code X44, Accidental poisoning by and exposure to other and unspecified drugs, medicaments and biological substances. Code nature of injury for each drug reported.

Place I (a) Drug toxicity T509 &X64

9 (b) Overdose of salicylates T390 T423

MOD II Overdose of drugs T509

Suicide

The external cause code for intentional self-harm (suicide) by salicylates is X60 and for seconal, X61. Since the drugs are assigned to different external cause codes, code X64, Intentional self poisoning by and exposure to other and unspecified drugs, medicaments and biological substances. Code nature of injury for each drug reported.

Place I (a) Darvon and promazine T404 &Y14 T433

9 (b) intoxication

MOD II Drug intoxication T509

Undetermined

The external cause code for poisoning of undetermined intent by darvon is Y12 and for promazine, Y11. Since the drugs are assigned to different external cause codes, code Y14, Poisoning by and exposure to other and unspecified drugs, medicaments and biological substances, undetermined intent. Code nature of injury for each drug reported.

3. Percentage of drug(s) in blood

When a percentage (%) of any drug(s) in the blood, code the nature of injury code for the drug if there is mention of drug poisoning elsewhere on the record.

When a complication is reported due to a percentage (%) of any drug(s), code as a complication of drug therapy unless otherwise indicated.

When a percentage (%) of any drug(s) in the blood without mention of drug poisoning or a complication, do not enter a code for the drug.

Place I (a) Gunshot wound brain S069 &X74

9 II .05 mg. barbiturates in blood

MOD

Suicide

Since there is no mention of poisoning or a complication of the barbiturates, do not enter a code for the percentage of drug in the blood.

4. Poisoning by alcohol and drugs

When alcoholism or alcohol poisoning (any F10-, R780, R826, R893, T510-T519) is reported in Part I with drug poisoning in Part I, code the alcohol to the appropriate code (F10-, R780, R826, R893, T510-T519), the nature of injury code for the drug and code the appropriate external cause code for the drug preceded by an ampersand. If alcohol poisoning is reported, code the external cause code for alcohol also, but do not precede this code with an ampersand. Interpret the following statements to mean poisoning by alcohol and drugs and code the appropriate E-code for alcohol poisoning:

Alcohol and drug interaction

Alcohol and drug synergism

Combination of alcohol and drugs

Combined action alcohol and drugs

Combined effects of alcohol and drugs

Mixed effects of alcohol and drugs

Synergistic effects of alcohol and drugs

Place I (a) Combined effects of alcohol T519 X45 T509 &X44

9 (b) and drugs

MOD II Ingested alcohol and drugs F109 T509

Accident

Interpret I(a) as alcohol poisoning and drug poisoning. Code the nature of injury and external cause for the alcohol and drugs. Precede the E-code for the drugs with an ampersand. In Part II, code the ingested alcohol as indexed. Code nature of injury for drugs as last entry.

Place I (a) Alcohol ingestion F109

9 (b) Barbiturate intoxication T423 &X41

Code I(a) alcohol ingestion as indexed and code the nature of injury and external cause for barbiturate intoxication on I(b).

Place I (a) Alcoholism F102

9 II Alcohol and barbiturate T519 X45 T423 &X41

MOD intoxication

Accident

Code alcoholism as indexed in Part I. Code the nature of injury and external cause for the alcohol and barbiturate intoxication in Part II. Precede the E-code for the drug with an ampersand.

Place I (a) Barbiturate toxicity T423 &X61

9 II Barbiturate and T423 T519 X65

MOD alcohol intoxication

Suicide

Code I(a) nature of injury for barbiturate T423 and external cause code X61 for suicidal barbiturate toxicity. Precede the E-code for barbiturate with an ampersand. Code the nature of injury and external cause for barbiturate and alcohol intoxication as indexed Part II.

Place I (a) Poisoning by alcohol T519 &X45

9 II Toxic levels of heroin and T401 X44 T424

flunitrazepam

Code I (a) nature of injury for alcohol, T519 and external cause X45. Precede the E-code for alcohol with an ampersand. Code the nature of injury and external cause for the heroin and flunitrazepam in Part II.

5. Intoxication (acute) NOS

When intoxication (acute) NOS is reported, code the nature of injury code for alcohol as indexed and the appropriate external cause for alcohol poisoning.

When intoxication (acute) NOS is reported “due to” drugs or poisonous substances, code the intoxication to the nature of injury code for the first substance reported in the “due to” position.

Exception:

Intoxication (acute) NOS “due to” drug(s) with indication the drug was being given for therapy.

Place I (a) Intoxication T519 &X45

Code intoxication as indexed to T519 and code the external cause code for alcohol poisoning X45. Precede the external cause code with an ampersand.

Place I (a) Acute intoxication T404

9 (b) Darvon & alcohol poisoning T404 &X62 T519 X65

MOD II

Suicide

Code I(a) T404, the nature of injury code for darvon since this is the first substance reported in the “due to” position. Code I(b) to the nature of injury and external cause code for darvon poisoning and alcohol poisoning. Precede the external cause code for darvon poisoning with an ampersand. Do not ampersand external cause code for alcohol poisoning.

Place I (a) Intoxication T58

9 (b) Carbon monoxide inhalation T58 &X47

MOD II

Accident

Code I(a) T58, the nature of injury for the substance (carbon monoxide) reported in “due to” position. Code I(b) to the nature of injury and external cause code for carbon monoxide inhalation. Precede the external cause code with an ampersand.

NOTE: See Appendix H for additional drug examples.

R. Complications of medical and surgical care (Y40-Y84)

Code any complication, abnormal reaction, misadventure to patient, or other adverse effect that occurred as a result of or during medical care except obstetrical procedures to the appropriate category in Chapters I-XIX, but take into account the medical care if it modifies the code assignment. Assign the appropriate external cause (E-code) pertaining to the medical care regardless of whether the complication is classified to Chapters I-XVIII or to Chapter XIX.

The E-code distinguishes between:

Drugs, medicaments and biological substances causing adverse effects in therapeutic.
Misadventures to patients during surgical and medical care (Y60-Y69).
Surgical and other medical procedures as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure (Y83-Y84).

Use of ampersand (More than one instruction may apply)

Always precede the condition that necessitated the medical or surgical care with an ampersand the first time it is reported. Generally, the first condition on the lowest used line will be the reason for medical care.

I (a) Pneumonia J958

(b) Surgery Y839

(d) Lung cancer &C349

Precede the external cause (Y40-Y84) with an ampersandif the complication is classified to Chapter XIX (T80-T88).

I (a) Pulmonary embolism T817

(b) Surgery &Y839

Precede the first complication with an ampersandif the complication is classified to Chapter I-XVIII and the condition requiring medical or surgical care is NOT reported.

I (a) Renal failure &N19

(b) Drug therapy Y579

If the medical or surgical care was administered for an injury, precede the code for the external cause of the injury with an ampersand.

I (a) Pneumonia J958

Place (b) Surgery Y839

9 (c) Fracture of hip S720

(d) Fall &W19

If two or more conditions for which the medical or surgical care could be administered are reported and the reason for treatment cannot be determined, precede the first condition with an ampersand.

I (a) Pneumonia J958

(b) Surgery Y839

II Lung cancer, gastric ulcer &C349 K259

If the medical care was administered for diagnostic purposes, precede the code for the condition that was found or confirmed by the diagnostic finding with an ampersand the first time it is reported.

I (a) Cerebral edema G978

(b) Cerebral arteriogram Y848

1. Drugs, medicaments and biological substances causing adverse effects in therapeutic use (Y40-Y59)

Complications of drugs

Although almost any condition reported due to drug therapy is regarded as a complication, there are a few diseases that are not considered complications.

The drug therapy (Y40-Y59) is not coded when there is no evidence of a complication.

Interpret “due to drug therapy” as a condition(s) on an upper line with drug therapy as the first condition on the next lower line.

(1) The following are not regarded as complications of drug therapy.

(a) These conditions due to drug therapy:

Infectious and parasitic diseases A000-A309, A320-A329, A360-A399, A420-

A449, A481-A488, A500-A690, A692-B199,

B250-B349, B500-B942, B949

(EXCEPT: Antineoplastic drugs Y431-Y433;

Immunosuppressive agents Y434)

B200-B24

Neoplasms C000-D45, D47-D489

Diabetes E10-E14 (EXCEPT: Steroids Y425, Y427)

Hemophilia D66-D682

Alcoholic disorders E244, E52, F101-F109, G312, G405, G621,

G721, I426, K292, K700-K709, K852,

K860, L278, R780, R826, R893

Rheumatic fever or rheumatic heart I00-I099

disease

Arteriosclerosis and arteriosclerotic

conditions

Influenza J09-J118

Hernia K400-K469

Congenital malformations Q000-Q999

This is not an all inclusive list.

I (a) Lung cancer C349

(b) Drug therapy

Since lung cancer is not considered a complication of drug therapy, no code is assigned for I(b).

I (a) Pancytopenia D619

(b) Lung cancer chemotherapy C349

Do not code the chemotherapy since there is no reported complication. Lung cancer is the first condition on the next lower line.

(b) Any condition stated as congenital, familial, hereditary, idiopathic or conditions with a duration that predates the drug therapy.

I (a) Congenital cardiomyopathy I424

(b) Drug therapy

Do not code the drug therapy since conditions stated as congenital cannot be considered as complications.

I (a) Nephritis 6 months N059

(b) Drug therapy 2 months

Reject 1

Do not code the drug therapy on I(b). The nephritis cannot be considered as a complication since it occurred prior to the drug therapy.

(2) Code any condition classifiable to Chapters I-XVIII that could result from a drug, medicament, or biological substance (including anesthesia) known or presumed to have been properly administered to the appropriate category in these chapters.

If the Classification provides a code for the condition reported as “due to drug” or “drug induced,” use this code. If no provision is made for the condition reported as “due to drug” or “drug induced,” code to the unspecified code for the condition.

When a condition classifiable to Chapters I-XVIII is reported due to a drug reaction (named drug) NOS, e.g., insulin reaction, code the condition as indexed and code the drug reaction to the external cause code.

Classify only those complications that cannot be assigned to Chapters I-XVIII to Chapter XIX (T80.-, T88.-).

I (a) Respiratory and cardiac arrest &R092 I469

(b) Local anesthesia reaction Y483

Code the conditions reported on I(a) as complications of local anesthesia since the local anesthesia is presumed to have been properly administered. Precede the first complication with an ampersand. Since a complication is reported, assign only an external cause on I(b) indicating Adverse effect in therapeutic use.

I (a) Drug reaction T887 &Y400

(b) Penicillin

Code the drug reaction on I(a) to nature of injury and external cause since no specified complication is reported. Precede the E-code with an ampersand. Do not enter a code for penicillin on I(b) since it was coded on I(a).

I (a) Encephalitis &G040

(b) Measles vaccination Y590

Code the encephalitis as a complication of the measles vaccine since the measles vaccine is presumed to have been properly administered. Encephalitis is indexed following vaccination or other immunization procedure. Precede the complication (G040) with an ampersand. Code the measles vaccination toY590, Adverse effect in therapeutic use.

I (a) Pulmonary embolism I269

(b) Estrogen to control excessive Y425 &N920

Code the pulmonary embolism as a complication of the estrogen since the estrogen is presumed to have been properly administered. Code the estrogen as Adverse effect in therapeutic use and excessive menses as indexed. Precede the code for excessive menses with an ampersand to indicate the condition requiring treatment.

(3) Unless there are indications to the contrary, assume the drug, medicament, or biological substance was used for medical care purposes and was properly administered in correct dosage. Do not make this assumption if:

The drug was one which is not used for medical care purposes, e.g., LSD or heroin,

It was an analgesic, sedative, narcotic or psychotropic drug (or combination thereof) or drug NOSAND the certifier indicated the death was due to an “accident” “suicide” or it occurred under “undetermined circumstances ,”

One or more of these drugs was taken in conjunction with alcohol

Code to poisoning (refer to Section V, Part Q, 2, Poisoning by drugs).

Place I (a) Respiratory failure J969

9 (b) Ingestion of mixed sedatives T426 &X41

MOD

Accident

Code I(a) as indexed. Code I(b) nature of injury and external cause code for accidental poisoning by mixed sedatives. Code as poisoning since the drug is a sedative and the certifier indicated the death was due to an accident. Precede the E-code with an ampersand.

Place I (a) Cerebral anoxia G931

9 (b) Ingestion of barbiturates T423 &X41

II Had been drinking F109

Code I(a) as indexed. Code I(b), accidental ingestion of barbiturates since the drug is a sedative and it was taken in conjunction with alcohol. Precede the E-code with an ampersand. Code Part II as indexed.

(4) When the condition for which the drug is usually administered is reported elsewhere on the certificate, code this condition as indexed, preceded by an ampersand to identify the condition requiring treatment.

I (a) Hemorrhage K922

(b) Ulcer of stomach K259

II Scleroderma &M349

The ulcer of the stomach is the complication of the cortisone therapy. Code the E-code for cortisone on I(c). Since cortisone is used in treatment of scleroderma, precede this condition with an ampersand.

When a complication occurs as the result of a drug being given in treatment and the condition requiring the drug is not reported elsewhere on the certificate, do not assume a disease condition.

When a complication classifiable to Chapters I-XVIII occurs as the result of a drug being administered in therapeutic use and the condition requiring the treatment is not reported, place an ampersand preceding the code for the complication.

I (a) Renal failure &N19

(b) Ingested antidiabetic drug Y423

The renal failure on I(a) is the complication of the antidiabetic drug. Code the E-code for antidiabetic drug on I(b). Do not assume a disease condition requiring therapy even though antidiabetic drug is one used in the treatment of diabetes. Precede the complication with an ampersand.

(5) “Drug induced” complications

When a condition is stated to be “drug induced,” consider the condition to be a complication of drug therapy, unless otherwise indicated. Code as follows:

(a) If the complication is classified to Chapter I-XVIII, code the E-code for the drug, followed by the code for the complication.

I (a) Drug induced aplastic anemia Y579 D611

II Carcinoma of lung &C349

Code I(a) Y579, complication of an unspecified drug, and the “drug induced aplastic anemia” as indexed. Ampersand the carcinoma of lung as the condition requiring treatment.

I (a) Drug induced polyneuropathy Y579 &G620

Code I(a) Y579, complication of an unspecified drug, and the “drug induced polyneuropathy” as indexed. Place an ampersand preceding the code for the complication.

(b) If the complication is classified to Chapter XIX, code the nature of injury code for the complication followed by the E-code for the drug. Place an ampersand preceding the E-code.

I (a) Chloramphenicol induced reaction T887 &Y402

(b) Septicemia &A419

Code I(a) as a complication of the drug (named). Code the nature of injury for the complication followed by the E-code for the named drug. Place an ampersand preceding the E-code and the septicemia to indicate the condition requiring treatment.

(6) “Intoxication by drug” due to drug therapy

When “intoxication by drug” is reported or indicated to be treatment for a condition or due to drug therapy, consider these to be complications of drug therapy, not poisoning.

I (a) Cardiac arrest I469

(b) Digitalis intoxication T887 &Y520

Code the digitalis intoxication as drug therapy since it is indicated as treatment for a condition by its position on the record. Code the intoxication as indexed under Intoxication, drug, correct substance properly administered and the E-code for digitalis.

(7) Gastric Hemorrhage as a Complication of Steroids, NSAIDS, Aspirin

When gastric hemorrhage is reported as the first condition on the lowest used line in Part I, and aspirin, steroids or NSAIDS are reported elsewhere on the certificate, consider the gastric hemorrhage as a complication of drug therapy and code as indexed. Code the appropriate e-code for the drug to the adverse effect in therapeutic use (Y40-Y59). If reported, ampersand the condition for which the drug was administered.

(8) Combined effects of two or more drugs

When a complication is reported due to the combined effects of two or more drugs, code the complication as indexed. On the next lower line, code the appropriate E-code (Y400-Y599). To determine the appropriate E-code, refer to the column for “Adverse effect in therapeutic use” in the Table of drugs and chemicals. (refer to Section V, Part R, 1 (3) when coded as poisoning)

(a) When the drugs are classified to different fourth characters of the same three-character category, code the appropriate E-code with the fourth character for “other.”

I (a) Cardiac arrest I469

(b) Valium and sleeping pills Y478

Code I(b) to the appropriate E-code for the combined effects of two drugs in therapeutic use classified to the same three-character category.

(b) When the drugs are classified to different three-character categories, code the E-code to Y578, “Other drugs and medicaments.”

I (a) Congestive heart failure I500

(b) Cor pulmonale &I279

II Hemorrhage from anticoagulant R5800 Y578

and aspirin

Code Y578, the appropriate E-code for combined effect of two drugs in therapeutic use classified to different three-character categories.

(9) Complications of chemotherapy

(a) When a complication of chemotherapy is reported, code the complication as indexed and Y579 unless a malignancy is reported on the certificate. When the complication is classified to Chapters I-XVIII and the reason for the chemotherapy is not reported, precede the complication with an ampersand.

I (a) Aplastic anemia &D611

(b) Chemotherapy Y579

Code I(a), aplastic anemia due to drugs (D611) and code I(b) Y579, adverse effect of unspecified drug in correct usage. Precede the complication with an ampersand.

(b) When a complication of chemotherapy is reported with mention of a malignancy on the certificate, consider the chemotherapy to be antineoplastic drugs and code E-code Y433.

I (a) Purpura D692

(b) Chemotherapy Y433

Code I(a) as indexed. Consider the chemotherapy on I(b) as antineoplastic drugs and code Y433. Ampersand the leukemia as the condition requiring treatment.

(10) Complications of immunosuppression

Immunosuppression can be drug therapy or a complication of drug therapy. Code immunosuppression as drug therapy unless reported due to a drug, then code as a complication of the drug (D849). If the drug is not reported elsewhere on the certificate, code Y434 for the immunosuppressive drug.

I (a) Pneumonia and sepsis J189 A419

(b) Immunosuppression D849

(d) &C719

Since the immunosuppression is due to chemotherapy, consider as a complication. Ampersand the carcinoma of brain as the condition requiring treatment.

I (a) Immunosuppression D849

(b) Vancomycin Y408

Since the immunosuppression is due to a drug, consider as a complication. Ampersand the acute bacterial endocarditis as the condition requiring treatment.

I (a) Infection B99

(b) Immunosuppression for Y434

Consider the infection as a complication of drug therapy (immunosuppression) on I(b). Ampersand the carcinoma of prostate as the condition requiring treatment.

I (a) Cardiorespiratory arrest I469

(b) Sepsis A419

(d) Rheumatoid vasculitis &M052

Consider the sepsis as a complication of drug therapy (immunosuppression) on I(c). Ampersand the rheumatoid vasculitis as the condition requiring treatment.

I (a) Sepsis A419

(b) Immunosuppression Y427

II Steroid therapy

Consider the sepsis as a complication of drug therapy (immunosuppression) on I(b). Code external cause code to steroids, the immunosuppressive drug reported elsewhere on the certificate. Code and ampersand Disease, kidney, as the condition for which the renal transplant was performed and the condition requiring the immunosuppressive drug.

I (a) Respiratory arrest R092

(b) Septicemia A419

II Renal transplant &N289

Consider the septicemia as a complication of drug therapy (immunosuppression) on I(c). In Part II, code and ampersand Disease, kidney, as the condition for which the renal transplant was performed and the condition requiring the immunosuppressive drug.

I (a) Bacteremia A499

(b) Immunosuppression Y434

(c)

II Idiopathic thrombocytopenia purpura &D693

Consider the bacteremia as a complication of drug therapy (immunosuppression) on I(b). Ampersand the idiopathic thrombocytopenia purpura as the condition requiring treatment.

I (a) Cardiac arrest I469

(b) ASHD I251

(c)

II DM, AS, immunosuppression E149 I709

Do not enter a code for the immunosuppression since there is not a reported complication.

(11) Drugs administered for one year or more

When a complication is reported due to a drug being administered for one year or more, consider the drug was given on a continuing basis. Code as a current complication; do not code as sequela.

I (a) Hypercorticosteronism E242

(b) Steroids – 6 years Y427

Consider the steroids as being administered on a continuing basis for six years. Code as a current complication of the drug. Code I(a) Hypercorticosteronism, correct substance properly administered (E242).

2. Surgical procedures as the cause of abnormal reaction of the patient or later complication (Y83)

a. Complications of surgical procedures

Although almost any condition reported due to surgery is regarded as a complication of surgery, there are a few diseases that are not considered complications. The surgical procedure (Y83) is not coded when there is no evidence of a surgical complication.

Interpret “due to surgery” as a condition(s) on an upper line with a surgical procedure as the first condition on the next lower line.

(1) The following are not regarded as complications of surgical procedures:

(a) These conditions reported due to surgery:

Infectious and parasitic diseases A000-A309, A320-A329, A360-A399,

A420-A449, A481-A488, A500-A690,

A692-B349, B500-B978

Neoplasms C000-D489

Hemophilia D66, D67, D680, D681, D682

Diabetes E10-E14

Alcoholic disorders E52, E244, F101-F109, G312, G405,

G621, G721, K860, I426, K292, K700-

K709, K852,L278, R780, R826, R893

Rheumatic fever or I00-I099

rheumatic heart disease

Hypertensive diseases I11-I139, I150, I159

Coronary artery disease

Coronary disease I251

Ischemic cardiomyopathy I255

Chronic or degenerative I514

myocarditis

Arteriosclerosis and

arteriosclerotic conditions except

those classified

to I219

Calculus or stones of any

type or site

Influenza J09-J118

Hernia except ventral K400-K429

(incisional) K440-K469

Diverticulitis K570-K579

Rheumatoid arthritis M050-M089

Collagen diseases M300-M359

Congenital malformations Q000-Q999

This is not an all inclusive list.

I (a) Myocardial infarction I219

(b) Arteriosclerosis I709

Since arteriosclerosis is not accepted as a complication of surgery, do not code the surgery.

I (a) Diabetic gangrene E145

(b) Leg amputation

Do not code the leg amputation (surgery) since there is no indication of a surgical complication.

I (a) Pneumonia J189

(b) Brain tumor removal D432

Do not code the removal since there is no complication. Brain tumor is the first condition on the next lower line.

(b) Do not accept conditions with a duration which predates the surgery

I (a) MI 2 weeks I219

(b) Surgery 2 days

Reject 1

Do not code the surgery on I(b). Since the MI occurred before the surgery was performed it cannot be a complication.

(2) When a condition reported due to a named surgical (operative) procedure can be considered as a complication or abnormal reaction, code as follows:

STEP 1: Determine if the complication is in the Index qualified by the named surgery reported

I (a) Lymphedema I972

(b) Postmastectomy Y836

Code I(a) using Step 1

Lymphedema

– postmastectomy I97.2

I (a) Hemorrhage T828

(b) Coronary artery bypass graft &Y832

Code I(a) using Step 1

Hemorrhage

– due to or associated with

– – device, implant or graft

– – – heart NEC T82.8

“Coronary” is not indexed, but is located in the heart; therefore, heart can be used in place of coronary.

NOTE: Before continuing to STEP 2 (below), it is important to determine the nature of the named surgery.

I (a) Hemorrhage T828

(b) Cardiac revascularization &Y832

Revascularization is defined as the re-establishment of adequate blood supply to a part, by means of a vascular graft. Code I(a) as indexed:

Hemorrhage

– due to or associated with

– – device, implant or graft

– – – heart NEC T82.8

STEP 2: If the Index does not qualify the complication with the named surgery, determine if the complication is indexed under Complications (from) (of), surgical procedure.

I (a) Hemorrhage T810

(b) Postlaminectomy &Y836

The Index does not qualify hemorrhage as postlaminectomy. Code I(a) as indexed:

Complications (from) (of)

– surgical procedure

– – hemorrhage or hematoma (any site) T81.0

Code I(b), as indexed under Complication, laminectomy.

I (a) Intestinal obstruction K913

(b) Colostomy Y833

Code I(a) as indexed

Complications (from) (of)

– surgical procedure

– – intestinal obstruction K91.3

Code I(b), surgery, as indexed under Complications, colostomy. Code I(c), ulcerative colitis, as indexed and precede with an ampersand indicating the reason for the surgery.

STEP 3: If the Index does not qualify the complication with the named surgery nor is the complication indexed under Complications (from) (of), surgical procedures, determine if the named surgery is indexed under Complications (from) (of).

I (a) Stroke T828

(b) Coronary artery bypass &Y832

The Index does not qualify stroke with coronary artery bypass nor is stroke indexed under Complications, surgical procedures; therefore, code I(a) using Step 3:

Complications (from) (of)

– coronary artery (bypass) graft

– – specified NEC T82.8

Stroke is neither an infection nor an inflammation nor mechanical; therefore, select “specified NEC.”

I (a) MI T828

(b) Postfemoral bypass graft &Y832

Code I(a) as indexed

Complications (from) (of)

– graft

– – femoral artery (bypass) – See Complications, graft, arterial

Complications (from) (of)

– graft

– – arterial

– – – specified NEC T82.8

Code I(b), Y832, as indexed under Complication, graft. Precede the E-code (Y832) by an ampersand.

I (a) Cerebral embolism T858

(b) Bypass &Y832

Code I(a) as indexed

Complications (from) (of)

– bypass (see also Complications, graft)

Complications (from) (of)

– graft

– – specified NEC T85.8

Code I(b), Y832, as indexed under Complications, bypass. Precede the E-code (Y832) by an ampersand.

I (a) Anemia T858

(b) Gastrointestinal bypass &Y832

Code I(a) as indexed

Complications (from) (of)

– bypass (see also Complications, graft)

Complications (from) (of)

– graft

– – intestinal tract

– – – specified NEC T85.8

Code I(b), Y832, as indexed under Complications, bypass. Precede the E-code (Y832) by an ampersand. Code I(c), Diverticulitis, K579, as indexed. Precede the code (K579) by an ampersand to indicate the reason for surgery.

(3) When a condition that is

(a) reported due to a named surgery cannot be assigned a code using STEP 1- STEP 3 or

(b) reported due to a surgery (operation) (of a site) NOS, and can be considered as a complication or abnormal reaction, code as follows:

STEP 4: Determine if the complication is in the Index, qualified:

(a) as reported

(b) with any term meaning “due to” surgery (see Section II, Part C, 2, a, “Due to” written in or implied)

(d) as postoperative or postsurgical

(e) as postprocedural

(f) during or resulting from a procedure, so stated

(g) resulting from a procedure, so stated

I (a) Pulmonary insufficiency following &J952

(b) Surgery Y839

Code I(a) as reported using Step 4 (a)

Insufficiency

– pulmonary

– – following

– – – surgery J952

Precede the code J952 by an ampersand. Code I(b), surgery, Y839, as indexed under Complication, surgical operation NEC.

I (a) Hypothyroidism E890

(b) Thyroid surgery Y839

Code I(a) using Step 4 (b). Refer to “due to” list in Section II, Part C, 2, a, “Due to” written in or implied.

Hypothyroidism

– due to

– – surgery E890

Thyroid surgery is equivalent to surgery NOS.

I (a) Cardiac insufficiency T818

(b) Surgery &Y839

Code I(a) using Step 4 (c)

Insufficiency

– cardiac

– – complicating surgery T818

Code I(b), surgery, Y839, as indexed under Complication, surgical operation NEC. Precede the E-code (Y839) by an ampersand.

I (a) Pneumonia &J958

(b) Surgery Y839

Code I(a) using Step 4 (d). Indexed as Pneumonia (see also Pneumonitis).

Pneumonitis

– postoperative J958

Precede the code J958 by an ampersand. Code I(b), surgery, Y839, as indexed under Complication, surgical operation NEC.

I (a) Renal failure &N990

(b) Surgery Y839

Code I(a) using Step 4 (e)

Failure

– renal

– – postprocedural N99.0

Precede the code N990 by an ampersand. Code I(b), surgery, Y839, as indexed under Complication, surgical operation NEC.

I (a) Cerebral anoxia &G978

(b) Surgery Y839

Code I(a) using Step 4 (f)

Anoxia

– cerebral

– – during or resulting from a procedure G97.8

Precede the code G978 by an ampersand. Code I(b), surgery, Y839, as indexed under Complication, surgical operation NEC.

I (a) Anoxic brain damage &G978

(b) Surgery Y839

Code I(a) using Step 4 (g)

Damage

– brain

– – anoxic

– – – resulting from a procedure G97.8

Precede the code G978 by an ampersand. Code I(b), surgery, Y839, as indexed under Complication, surgical procedure NEC.

STEP 5: If the Index does not provide for the complication qualified with any of the terms defined in the previous steps, determine if the complication is indexed under Complications (from)(of), surgical procedure.

NOTE: If a “named” surgery is reported, this step has already been completed in Step 2.

I (a) Hyperglycemia &E891

(b) Surgery Y839

Code I(a) as indexed

Complications (from) (of)

– surgical procedure

– – hyperglycemia E89.1

Precede the code E891 by an ampersand. Code I(b), surgery, Y839, as indexed under Complication, surgical operation NEC.

NOTE: Do not apply Step 6 when assigning a complication code for conditions classified to R00-R99.

STEP 6: If the Index does not provide for the complication as above, determine if:

(a) the site of the complication is in the Index under Complications (from) (of), surgical procedure

(b) the system in which the complication occurred (based upon the code assigned in the Index) is in the Index under Complications (from)(of), surgical procedure.

I (a) MI T818

(b) Surgery &Y839

Code I(a) using Step 6 (a)

Complications (from)(of)

– surgical procedure

– – cardiac T81.8

The site of a myocardial infarction is the muscle tissue of the heart which is synonymous with cardiac. Code I(b), surgery, Y839, as indexed under Complication, surgical operation NEC. Precede the E-code with an ampersand.

I (a) Uremia &N998

(b) Surgery Y839

Code I(a) using Step 6 (b)

Complications (from) (of)

– surgical procedure

– – genitourinary

– – – specified NEC N99.8

Uremia NOS is indexed to N19 which indicates this condition is a specified disease in the genitourinary system.

I (a) Mesenteric embolism K918

(b) Gallbladder surgery Y839

Code I(a) using Step 6 (b)

Complications (from)(of)

– surgical procedure

– – digestive system

– – – specified NEC K91.8

Mesenteric embolism is indexed to K550 which indicates that this condition is a specified disease in the digestive system.

STEP 7: When a reported complication cannot be classified to a system which is indexed, code to T818, other complications of procedures, not elsewhere classified.

I (a) Anemia T818

(b) Surgery &Y839

Anemia is not indexed as due to surgery or as postoperative. Anemia is a disease of the blood-forming organs and neither the term nor the body system is indexed under Complication (from) (of), surgical procedure.

Code I(a) as indexed

Complications (from)(of)

– surgical procedure

– – specified NEC T81.8

Code I(b), surgery, Y839, as indexed under Complication, surgical operation NEC. Precede the E-code with an ampersand.

I (a) Cardiac arrest I469

(b) Brain death T818

Code line I(b) using Step 7. Brain death is not a codable condition but can be a complication of surgery.

Complications (from) (of)

– surgical procedure

– – specified NEC T818

Code I(c) surgery, Y839, as indexed under Complication, surgical operation NEC. Precede the E-code with an ampersand.

b. Condition necessitating surgery

(1) When a complication of surgery is reported and the underlying condition which necessitated the surgery is stated or implied, place an ampersand (&) preceding this condition to indicate the reason for surgery.

I (a) Pulmonary embolism T817

(b) Surgery for &Y839

Code the pulmonary embolism as the complication, Y839 for the surgery, and precede the code for gangrene with an ampersand to identify the reason for surgery. Precede the surgery code with an ampersand since the complication is coded to Chapter XIX.

(2) When the condition necessitating the surgery is not stated or implied and the complication is classifiable to Chapters I-XVIII, place an ampersand preceding the code for the complication.

I (a) Renal failure &N990

(b) Surgery Y839

Code I(a), renal failure, N990, as the complication of the surgery (Y839) on I(b). Precede the N990 with an ampersand since it is classified to Chapter I-XVIII and the reason for the surgery is not reported.

(3) Do not ampersand a condition necessitating surgery unless a complication of the surgical procedure is coded.

I (a) ASHD I251

II SP mastectomy, Cancer of breast C509

Do not precede the reason for surgery, C509 with an ampersand since no complication of the mastectomy is reported.

(4) When the condition that necessitated the surgery is not reported, but the organ or site is implied by the operative term, code disease of the organ or site.

I (a) Septic complications of open heart surgery I519

Even though no complication is reported, the reason for treatment can still be assigned. Code Disease, heart since the surgery was of the heart.

Exception:

Appendectomy

Code appendicitis (K37) when appendectomy is the only operative procedure reported. If appendectomy is reported with other abdominal or pelvic surgery, assume the appendectomy to be incidental to the other surgery and do not code K37.

Use the following codes when these surgical procedures are reported and the condition necessitating the surgery is not reported:

Aorta (with any other vessel NEC) bypass or graft…………………… I779

Aorta coronary bypass or graft……………………………………………. I251

Atrio-ventricular shunt……………………………………………………… G919

Bariatric surgery……………………………………………………………… E668

Billroth (I or II)…………………………………………………………….. K3190

Brock valvulotomy………………………………………………………….. Q223

Cardiac revascularization…………………………………………………… I251

Carotid endarterectomy…………………………………………………….. I679

Choledochoduodenostomy…………………………………………………. K839

Cholecystectomy…………………………………………………………….. K829

Cholelithotomy……………………………………………………………….. K802

Colostomy…………………………………………………………………….. K639

Coronary artery bypass graft (CABG)……………………………………. I251

Coronary endarterectomy………………………………………………….. I251

Coronary revascularization…………………………………………………. I251

Endarterectomy (artery) (aorta)………………………………………….. I779

Femoral bypass………………………………………………………………. I779

Femoral-popliteal bypass…………………………………………………… I779

Gastrectomy………………………………………………………………… K3190

Gastric stapling……………………………………………………………….. E668

Gastroenterostomy………………………………………………………….. K929

Gastro-intestinal surgery NOS…………………………………………….. K929

Gastrojejunostomy………………………………………………………….. K929

Gastrojejunectomy………………………………………………………….. K929

Herniorrhaphy……………………………………………………….. code hernia

Hip fixation…………………………………………………………………….. S720

Hip pinning…………………………………………………………………….. S720

Hip prosthesis………………………………………………………………… M259

Hip replacement…………………………………………………………….. M259

Hysterectomy………………………………………………………………… N859

Ileal conduit…………………………………………………………………… N399

Ileal loop………………………………………………………………………. N399

Iliofemoral bypass……………………………………………………………. I779

Lobectomy-when indicating lung………………………………………… J9840

Mammary artery(internal) implant……………………………………….. I251

Nephrectomy…………………………………………………………………. N289

Revascularization of heart………………………………………………….. I251

Revascularization, myocardial…………………………………………….. I251

T and A…………………………………………………………………………. J359

Thoracoplasty…………………………………………………………………. J989

Tonsillectomy…………………………………………………………………. J359

Ureterosigmoid bypass…………………………………………………….. N399

Ureterosigmoidostomy……………………………………………………… N399

Vein stripping………………………………………………………………….. I839

Ventricular peritoneal shunt……………………………………………….. G919

Vineberg operation…………………………………………………………… I251

When the condition that necessitated the surgery is not reported, do not assume a disease condition for surgical procedures such as:

amputation pelvic exenteration

arteriovenous shunt portocaval shunt

chordotomy radical neck dissection

craniotomy rhizotomy

cystostomy sympathectomy

D & C tracheotomy

gastrostomy tracheostomy

laminectomy tubal ligation

laparotomy vagotomy

lobectomy NOS vasectomy

lobotomy vas ligation

If one of these types of procedures is the only entry on the certificate, code R99.

When the following complications of surgery are reported and the reason for the surgery is not reported, use the following codes as the reason the surgery was performed:

Reason for Surgery
Code

Postsurgical hypothyroidism E079

Postsurgical hypoinsulinemia K869

Postsurgical blind loop syndrome K639

Other and unspecified

postsurgical malabsorption K639

I (a) Postsurgical blind loop syndrome Y839 K912 &K639

When a complication is reported due to:

“Surgery” with the underlying condition that necessitated the surgery stated, code:

the complication to Chapters I-XIX, the surgery to the appropriate external cause code (Y83-) preceded by an ampersand, if required, and the underlying condition necessitating the surgery preceded by an ampersand.

I (a) Hemorrhage T810

(b) Surgery &Y839

Code I(a) as postoperative hemorrhage (T810). Code the external cause code for the surgical procedure and precede by an ampersand. Code C349, cancer of lung and precede by an ampersand to identify the stated underlying condition for which surgery was performed.

I (a) Pulmonary hemorrhage R048

(b) Lung cancer &C349

II Pneumonia due to surgery for J958 Y839 R048

pulmonary hemorrhage

Code line I(a) and (b) as indexed. Precede cancer of lung with an ampersand to indicate the underlying reason for which surgery was performed. Since the first entry in Part II, pneumonia, is reported due to surgery, code as a complication of surgery.

“Surgery” with the condition which necessitated the surgery not stated and only one condition for which surgery could have been performed is reported, code:

the complication to Chapters I-XIX, the surgery to the appropriate external cause code (Y83-) preceded by an ampersand, if required. Since only one condition for which the surgery could have been performed is reported, code the condition and precede with an ampersand to identify the reason for the surgery.

I (a) Mesenteric thrombosis K918

(b) Surgery Y839

II ASHD &I251

Code mesenteric thrombosis as the complication of the surgery and code Y839 for the surgery. Since ASHD is the only condition on the certificate for which surgery could have been performed, precede the code for this condition by an ampersand.

“Surgery” with the condition which necessitated the surgery not stated and two or more conditions for which surgery could have been performed are reported, code:

the complication to Chapters I-XIX and the surgery to appropriate external cause code (Y83-) preceded by an ampersand, if required. Ampersand the first mentioned condition for which the surgery could have been performed.

I (a) Wound dehiscence T813

(b) Surgery &Y839

II Cancer of lung, gastric ulcer &C349 K259

Code I(a), wound dehiscence, T813, as the complication of the surgery and code I(b), surgery, Y839. Code Part II as indexed and precede the code for cancer of lung by an ampersand since it is the first mentioned condition for which the surgery could have been performed.

“Surgery” without indication of the condition which necessitated the surgery, code:

the complication to Chapters I-XIX, and the surgery to appropriate external cause code (Y83-) only. If the complication is classifiable to Chapters I-XVIII, precede the code for the complication with an ampersand.

I (a) Shock & hemorrhage T811 T810

(b) Surgery &Y839

Code I(a), shock and hemorrhage, T811 T810, both as complications of the surgery. Code I(b), surgery, Y839 and precede the code by an ampersand.

Surgical procedure such as aneurysmectomy, cholelithotomy, hemorrhoidectomy or herniorrhaphy which indicates the condition for which the surgery was performed, code:

the complication to Chapters I-XIX, the surgery to the appropriate external cause code (Y83-) preceded by an ampersand, if required, and code the condition implied by the surgery following the external cause code for the surgery. Place an ampersand preceding the code for the condition.

I (a) CHF I978

(b) Cholelithotomy Y838 &K802

Code I(a), CHF (congestive heart failure), as the complication of surgery. Code I(b), cholelithotomy, Y838 K802. Cholelithotomy indicates cholelithiasis (K802) was the condition for which surgery was performed. Precede K802 by an ampersand.

Surgical procedure that indicates an organ or site with one related condition for which the surgery could have been performed, code:

the complication to Chapters I-XIX, the surgery to the appropriate external cause code (Y83-) preceded by an ampersand, if required. Code the condition for which surgery could have been performed and precede with an ampersand.

I (a) MI T818

(b) Gastrectomy &Y836

II Bleeding gastric ulcer &K254

Code I(a), MI, as the complication of the surgery. Code I(b), gastrectomy, Y836, as indexed and precede with an ampersand. Code Part II, bleeding gastric ulcer, as indexed and precede with an ampersand to indicate it was the condition for which surgery was performed.

I (a) Cardiac arrest T828

(b) CABG &Y832

II Heart disease &I519

Code I(a), cardiac arrest, as the complication of the surgery. Code I(b), CABG, Y832 as indexed and precede with an ampersand. Code Part II, heart disease, as indexed and precede with an ampersand to indicate it was the condition for which surgery was performed.

Surgical procedure that indicates an organ or site without a related condition for which the surgery could have been performed, code:

the complication to Chapters I-XIX, the surgery to the appropriate external cause code (Y83-) preceded by an ampersand, if required, and code disease of the organ or site following the external cause code for the surgery. Place an ampersand preceding the code for the condition.

I (a) Cardiac arrest I469

(b) Pneumonia J958

Code I(a), cardiac arrest, as indexed. Code I(b), pneumonia, as the complication of the surgery. Code I(c), pancreatectomy, as indexed, and since the surgery indicates a disease of the pancreas, code this as the reason for surgery. Precede K869 by an ampersand.

Prophylactic or nontherapeutic surgery, code

the complication to Chapters I-XIX, and the surgery to the appropriate external cause code (Y83-) preceded by an ampersand, if required. Do not assume or ampersand a disease condition. When the complication is classifiable to Chapters I-XVIII, precede the code for the complication with an ampersand.

I (a) Sepsis A419

(b) Infection T814

Code I(a), sepsis, as indexed. Code I(b), infection, as the complication of the nontherapeutic surgery. Code I(c) as a specified type of surgical operation.

c. Conditions qualified as postoperative

(1) When the following postoperative terms or a synonymous term qualifies a condition, determination must be made as to whether the condition is a surgical complication or the condition for which the surgery was performed.

p.o postoperative status postop

post-named surgery status p.o. status postoperative

(postgastrectomy) status post-named surgery status post surgery

postop (status post gastrectomy)

(2) The following conditions are common complications of surgery. Code these conditions as postoperative complications when preceded by or followed by one of the postoperative terms except when it is stated elsewhere on the certificate as the reason the surgery was performed.

abscess hemorrhage, hematoma sepsis

adhesions infarction septicemia

aspiration infection septic shock

atelectasis occlusion shock

bowel obstruction peritonitis thrombophlebitis

cardiac arrest phlebitis, phlebothrombosis thrombosis

embolism pneumonia wound infection

fistula pneumothorax

gas gangrene renal failure (acute)

hemolysis,
hemolytic
infection

This list is not all inclusive.

(3) When “postoperative,” “postop,” “status postoperative,” etc., qualifies (preceding or following) a complication:

(a) If the complication is classified to Chapters I-XVIII, code the external cause code followed by the code for the complication.

I (a) Pneumonia postgastrectomy Y836 J958 &K3190

Code pneumonia as the complication of surgery when reported as “postoperative” or a synonymous term. Since the reason for surgery is not stated, code disease stomach and precede by an ampersand to indicate the reason for surgery.

I (a) Postgastrectomy dumping syndrome Y836 K911

(b)

Code I(a), Y836, as indexed under Complication, gastrectomy, and K911, as indexed under Syndrome, dumping. Code I(c) C169, as indexed under Neoplasm, stomach, malignant. Place an ampersand (&) preceding C169 to identify the underlying reason for surgery.

I (a) Pulmonary edema J958

(b) P.O. bowel obstruction Y839 K566

II Surgery for bowel obstruction K566

Code I(a), pulmonary edema, as the complication of surgery. Code I(b) to surgery Y839 and code bowel obstruction as indexed K566 since it is stated as the reason for surgery. Code I(c), cancer of cecum, as indexed and precede the code by an ampersand to indicate the underlying reason for surgery. Part II, do not enter a code for surgery since P.O. was reported on line (b) and a surgery code was entered there. Code bowel obstruction as indexed.

(b) If the complication is classified to Chapter XIX, code the nature of injury code followed by the external cause code.

I (a) Sepsis and anuria A419 R34

(b) P.O. peritonitis T814 &Y839

Code peritonitis as the complication as indexed under Peritonitis, postprocedural, T814. Code Y839 for the procedure. Peritonitis is considered to be a complication of surgery when reported as “postop” and not reported as the reason for surgery. Place an ampersand preceding the surgery code and the cancer of colon to identify the underlying reason for surgery.

I (a) Cardiac arrest I469

(b) Peritonitis, postop T814 &Y839

Code I(a) as indexed. Code I(b), peritonitis, as the complication, T814 and Y839 for the procedure. Peritonitis is considered a complication of surgery when reported as “staus postop” and not reported as the reason for surgery. Precede the E-code with an ampersand. Code I(c), cholelithiasis, as indexed and precede the code by an ampersand to indicate the condition necessitating surgery.

I (a) MI postgastrectomy T818 &Y836

II Gastric ulcer surgery &K259

Code I(a), M.I. postgastrectomy, T818 Y836. M.I. is considered to be a complication of surgery when reported as “postoperative” and not reported as the reason for surgery. Precede the E-code with an ampersand. Code Part II, gastric ulcer, K259 as indexed and precede the code by an ampersand to indicate the condition necessitating surgery. Do not enter a code in Part II for surgery since gastrectomy was reported on I(a) and the code was entered there.

I (a) Postoperative embolism T817 &Y836

(b) Appendectomy

Code I(a), postoperative embolism, as indexed to T817 and Y836 as indexed under Complication, appendectomy. Precede the E-code with an ampersand. Code I(c), acute appendicitis, as indexed and precede the code by an ampersand to identify the underlying condition that necessitated surgery.

I (a) Heart failure I509

(b) ASHD &I251

II Thrombophlebitis, postoperative T817 &Y839

Code I(a) and I(b) as indexed. Code Part II, thrombophlebitis, postoperative, T817 Y839. Precede the E-code (Y839) by an ampersand. Thrombophlebitis is considered to be a complication of surgery when reported as “postoperative” and not reported as the condition that necessitated surgery. Precede the code on I(b), I251 (ASHD), by an ampersand to indicate the underlying condition necessitating surgery.

I (a) Pneumonia J189

(b) P.O. infection (wound) T814 &Y839

Code I(a) as indexed. Code I(b), p.o. infection (wound), T814 Y839. Precede the E-code with an ampersand. Infection is considered to be a complication of surgery when reported as “postop” and not reported as the reason for surgery. Code I(c), intestinal obstruction, K566 and precede the code by an ampersand to indicate the condition necessitating surgery.

I (a) Postoperative complication T819 &Y839

(b) Open heart surgery

Code I(a) as indexed under Complications, postoperative. Code the external cause code where the surgery is first reported, in the second position on I(a). Precede the E-code with an ampersand. Code I(c), heart disease, as indexed and precede the code by an ampersand to indicate the condition necessitating surgery.

(c) When “postoperative intestinal obstruction” (any K560-K567) is reported and no condition which could have necessitated the procedure is reported:

(i) Code the postoperative intestinal obstruction as the condition which necessitated the surgical procedure if another condition is reported due to the postoperative obstruction.

I (a) Peritonitis T814

(b) Postoperative bowel &Y839 &K566

Code I(a), peritonitis, as the complication of surgery. Code I(b), postoperative bowel obstruction Y839 K566. Precede the E-code with an ampersand. Precede the K566 with an ampersand to indicate the condition necessitating surgery.

(ii) Code the postoperative intestinal obstruction to K913 as the complication if no other condition is reported due to postoperative obstruction.

I (a) Postoperative ileus Y839 &K913

Code I(a) Y839 K913. Precede K913 by an ampersand. Consider the postoperative ileus to be the complication since no other condition is reported due to this condition.

NOTE:

(4) Status post – When status post (s/p) qualifies a condition, disregard the statement of status post and code the condition as indexed. This applies whether or not surgery is mentioned elsewhere on the certificate.

I (a) Cardiogenic shock R570

(b) Myocardial infarction I219

Code each condition as indexed. No code is entered for the surgery since no complication is reported. Assume the ischemic heart disease was the reason the CABG was performed.

I (a) S/P cardiac arrest I469

(b) Arteriosclerosis I709

II S/P gastrectomy, cancer stomach C169

Code each condition as indexed. No code is entered for the surgery since no complication is reported.

I (a) Status post MI I219

(b) ASHD I251

Code the MI as indexed.

d. Complication as first entry on lowest used line in Part I

(1) When one of the conditions listed below is reported as the first entry on the lowest used line in Part I with surgery (any) reported on same line or in Part II, code this condition as a complication of surgery.

Do not apply this instruction:

(a) When the surgery is stated to have been performed 28 days or more prior to death.

(b) When the condition on the lowest used line predates the surgery.

Acute renal failure

Aspiration

Atelectasis

Bacteremia

Cardiac arrest (any I469)

Disseminated intravascular coagulopathy (DIC)

Embolism (any site)

Gas gangrene

Hemolysis, hemolytic infection

Hemorrhage NOS

Infarction (any site)

Infection NOS

Occlusion (any site)

Phlebitis (any site)

Phlebothrombosis (any site)

Pneumonia (J120-J168, J180-J189, J690, J698)

Pneumothorax

Pulmonary insufficiency

Renal failure (acute) NOS

Septicemia (any A400-A419)

Shock (R570-R579)

Thrombophlebitis (any site)

Thrombosis (any site)

I (a) Pneumonia J958

(b)

(c)

II Diabetic gangrene, amputation &E145 Y835

Code pneumonia as a complication of the amputation since it is the first entry on the lowest used line in Part I and surgery, not indicated to have been performed 28 days or more prior to death, is reported in Part II.

I (a) Pneumonia J189

(b) Pulmonary embolism, gastrectomy T817 &Y836

(c)

II Cancer of stomach &C169

Code pulmonary embolism as a complication of gastrectomy since it is the first entry on the lowest used line in Part I and gastrectomy, not stated to have been performed 28 days or more prior to death, is reported on the same line as the embolism.

Date of death 09/17/96

I (a) Pleural effusion J90

(b) Pulmonary embolism & pneumonia T817 J189

(c)

II &Y839

Operation block

/ 9/15/96 /

NOTE: When a date is entered in the operation block, code as if surgery was performed on that date.

Code I(a) as indexed. Code pulmonary embolism as the complication of surgery since this condition is the first condition on the lowest used line in Part I and surgery was performed less than 28 days prior to death.

I (a) Cardiogenic shock R570

(b) Hypovolemic shock T828

II Dialysis shunt hemorrhage; renal failure T828 &Y832 &N19

Code line I(a) as indexed. Code Hypovolemic shock as a complication of the dialysis shunt since it is the first entry on the lowest used line in Part I and dialysis shunt, not stated to have been performed 28 days or more prior to death, is reported in Part II. Hemorrhage reported in Part II is also a complication.

I (a) Pulmonary infarction I269

(b)

(c)

II Cardiac catheterization

Cardiac catheterization is not classified as a surgical procedure; therefore, do not code the pulmonary infarction as a complication.

(2) When any of the conditions listed below are reported as the first entry on the lowest used line in Part I and abdominal or pelvic surgery is reported on the same line or in Part II, code complication as indexed and the surgery to appropriate external cause code (Y83-) where it is indicated on the record by the certifier.

Peritonitis

Intestinal obstruction (K560-K567)

I (a) Pneumonia J189

(b) Peritonitis K659

II Colostomy – ulcerative colitis Y833 &K519

Code intestinal obstruction on I(c) as a complication of the surgery reported in Part II, since the surgery was abdominal and there is no indication that this procedure was performed 28 days or more prior to death.

(3) When any of the conditions listed below are reported as the first entry on the lowest used line in Part I and surgery of the same site or region is reported on the same line or in Part II, code complication as indexed and the surgery to appropriate external cause code (Y83-) where it is indicated on the record by the certifier.

Hemorrhage of a site

Fistula of site(s)

I (a) Pneumonia J189

(b) Gastrointestinal hemorrhage T810

II Gastrectomy for stomach cancer &Y836 &C169

Code gastrointestinal hemorrhage as a complication of the surgery reported in Part II since the surgery was of the same region and there is no indication that surgery was performed 28 days or more prior to death.

(4) When conditions listed in paragraph d(1), (2), and (3) are reported as the first entry on the lowest used line in Part I and surgery stated to have been performed 28 days or more prior to death is reported on the same line or in Part II, code condition as indexed. Do not code as a complication of the surgery.

I (a) Congestive heart failure I500

(b) Shock R579

II Surgery performed 6 wks. ago for colon cancer C189

Code all conditions on this record as indexed. Do not code acute renal failure as a complication of surgery since the surgery was performed 28 days or more prior to death.

(5) When adhesions are reported as the first entry on the lowest used line in Part I and surgery stated to have been performed less than one year prior to death is reported on same line or in Part II, code adhesions to K918 and code the surgery to appropriate E-code (Y83-).

I (a) Septic shock A419

(b) Peritonitis K659

II Surgery – 6 mos. ago for ca. of colon Y839 &C189

Code adhesions on I(c) as a complication of surgery and code the external cause code for the surgery as the first entry in Part II. Code the condition for which surgery was performed and precede by an ampersand.

(6) When adhesions are reported as the first entry on the lowest used line in Part I and surgery stated to have been performed one year or more prior to death is reported on same line or in Part II, code adhesions to K918, Other postprocedural disorders of the digestive system and code the surgery to Y883, sequela of surgery.

I (a) Renal failure N19

(b) Intestinal obstruction K566

II Surgery – 16 months ago for diverticulitis Y883 &K579

Code adhesions on I(c) as a complication of the surgery reported in Part II. Since this surgery was performed more than 1 year ago, code Y883 for the sequela of surgery. Code diverticulitis as the condition for which surgery was performed.

e. Ill-defined condition as first entry on lowest used line in Part I

When an ill-defined condition classifiable to the following codes:

I461 (Sudden cardiac death, so described)

I959 (Hypotension, unspecified)

I99 Except occlusion and infarction (Other and unspecified disorders of circulatory system)

J960 (Acute respiratory failure)

J969 (Respiratory failure, unspecified)

P285 (Respiratory failure of newborn)

R000-R568, R590-R948, R960-R99 (Symptoms, signs, and abnormal clinical and laboratory findings, not elsewhere classified) is reported as the first entry on the lowest used line in Part I with surgery reported on the same line or in Part II, proceed:

(1) Code the ill-defined condition, then code the remaining conditions as if the ill-defined condition had not been reported.

I (a) Senility and MI R54 T818

II Gastrectomy &Y836 &K3190

Code senility on I(a) R54 as indexed. Then code MI as if senility had not been reported. MI is coded as the complication of the surgery reported in Part II. Gastrectomy indicates a disease of the stomach. Precede both the code for the surgery and the code for Disease, stomach, with an ampersand.

I (a) Renal failure N990

(b) Cause unknown R97

II Mastectomy Y836 &N649

Code cause unknown on I(b) as indexed, then code renal failure as the complication of the surgery reported in Part II as if cause unknown had not been reported. Code Part II, mastectomy, Y836 N649. Code Disease, breast as the condition necessitating the mastectomy and precede it by an ampersand.

Exceptions:

Code each entry as indexed when:

The first entry on the And a condition classifiable

lowest line in Part I is to one of the following

classifiable to codes is reported on the

same line or in Part II

I461 A520 I260-I4290

B24 I510-I518

B332 M349

I010-I099 P293

I110-I119 Q200-Q269

I130-I139

J960 E841

E849

J969 E841

E849

R000 Tachycardia, unspecified I010-I099 I470-I519

I110-I119 J380-J399

I130-I461

R002 Palpitations I010-I099 I130-I461

I110-I119 I470-I519

R010 Benign and innocent I010-I099 I130-I461

cardiac murmurs

R011 Cardiac murmur, I110-I119 I470-I519

unspecified

R012 Other cardiac sounds

R02 Gangrene NEC A480 E135 K410

E100-E104 E136 K412

E105 E137 K413

E106 E139 K419

E107 E140-E144 K420

E109 E145 K429

E110-E114 E146 K430

E115 E147 K439

E116 E149 K440

E117 I702 K449

E119 I709 K450

E120-E124 I730-I739 K458

E125 K352-K389 K460

E126 K400 K469

E127 K402

E129 K403

E130-E134 K409

R030 Elevated blood pressure I10-I139

reading, without

diagnosis of hypertension

The first entry on the And a condition classifiable

lowest line in Part I is to one of the following

classifiable to codes is reported on the

same line or in Part II

R040 Epistaxis C300-C319C783 I10

C910-C959 J00-J019

D023 J068-J069

D140 J300-J311

D385 J320-J348

J393-J399

R041 Hemorrhage from throat C090-C148 D141

C320-C329 D370

C783 D380

C798 J00

C910-C959 J020-J040

D000 J042-J069

D020 J311-J312

D104-D109 J350-J399

R042 Hemoptysis A162-A1690 D141-D143

R048 Hemorrhage from other C320-C349 D380-D381

sites in respiratory C780 J040-J22

passages C783 J370-J387

C910-C959 J393-J989

D020-D022

R05 Cough F453 J111

J101 J1110

J1010 R042

R060 Dyspnea A162-A1690 D381-D383

B909 D385-D386

C33-C399 J40-J989

C780-C783 P221

D142-D159

The first entry on the And a condition classifiable

lowest line in Part I is to one of the following

classifiable to codes is reported on the

same line or in Part II

R061 Stridor J385

R062 Wheezing A162-A1690 D381-D383

B909 D385-D386

C33-C399 J40-J989

C780-C783 P221

D142-D159

R064 Hyperventilation F453

R066 Hiccough F453

R090 Asphyxia T360-T659

R104 Other and unspecified R100

abdominal pain R193

R11 Nausea and vomiting J1010 J118

J108 K250-K289

J1110 K800-K820

R17 Unspecified jaundice B150-B199 C787-C788

C220-C259 K700-K839

R18 Ascites C160-C269 C796

C56 C80-C969

C784 K740-K746

C787-C788

R233 Spontaneous ecchymoses D690-D699

The first entry on the And a condition classifiable

lowest line in Part I is to one of the following

classifiable to codes is reported on the

same line or in Part II

R250 Abnormal head movements G110-G119

R251 Tremor, unspecified G20-G259

R252 Cramp and spasm G400-G419

R253 Fasciculation G510

R258 Other and unspecified G800-G839

abnormal involuntary

movements

R260 Ataxic gait A521

R261 Paralytic gait

R262 Difficulty in walking,

not elsewhere classified

R268 Other and unspecified

abnormalities of gait

and mobility

R270 Ataxia, unspecified A521

A523

G110-G119

R278 Other and unspecified A521

lack of coordination G110-G119

R290 Tetany E200-E209

R291 Meningismus J1010 J1110

J108 J118

R298 Other and unspecified G800-G839

symptoms and signs

involving the nervous and

musculoskeletal systems

The first entry on the And a condition classifiable

lowest line in Part I is to one of the following

classifiable to codes is reported on the

same line or in Part II

R300 Dysuria C600-C689 D280-D309

R301 Vesical tenesmus C790-C791 D390-D419

R309 Painful micturition, C796 N000-N999

unspecified C798 Q600-Q649

D060-D061

R31 Unspecified hematuria B508 D060-D061

B54 D280-D309

C600-C689 D390-D419

C790-C791 N000-N999

C796 Q600-Q649

C798

R32 Unspecified urinary C600-C689 D280-D309

incontinence C790-C791 D390-D419

R33 Retention of urine C796 N000-N999

C798 Q600-Q649

D060-D061

R34 Anuria and oliguria C600-C689 D280-D309

C790-C791 D390-D419

C796 N000-N999

C798 Q600-Q649

D060-D061 T795

R35 Polyuria C600-C689 D280-D309

R36 Urethral discharge C790-C791 D390-D419

R390 Extravasation of urine C796 N000-N999

R391 Other difficulties with C798 Q600-Q649

micturition D060-D061

R392 Extrarenal uremia

R398 Other and unspecified

symptoms and signs

involving the urinary

system

The first entry on the And a condition classifiable

lowest line in Part I is to one of the following

classifiable to codes is reported on the

same line or in Part II

R400 Somnolence E100 E147

R401 Stupor E107 E15

E110 K729

E117 S020-S024

E120 S026-S029

E127 S060-S099

E130 T902

E137 T905-T909

E140

R402 Coma, unspecified E100 E132-E136

E101 E137

E102-E106 E139

E107 E140

E109 E141

E110 E142-E146

E111 E147

E112-E116 E149

E117 E15

E119 E160-E162

E120 K729

E121 S020-S024

E122-E126 S026-S029

E127 S060-S099

E129 T902

E130 T905-T909

E131

R529 Pain, unspecified G547

R568 Other and unspecified A35

convulsions G400-G419

O100-O11

O13-O16

The first entry on the And a condition classifiable

lowest line in Part I is to one of the following

classifiable to codes is reported on the

same line or in Part II

R590 Localized enlarged B270-B279

lymph nodes C810-C969

R591 Generalized enlarged B24 B589

lymph nodes B270-B279 C810-C969

B588

R599 Enlarged lymph nodes, B270-B279

unspecified C810-C969

R600 Localized edema E43 N000-N058

R601 Generalized edema E877 N059

R609 Edema, unspecified E43

E877

N000-N058

R628 Other lack of expected B24

normal physiological E45

development E46

R630 Anorexia F500

R631 Polydipsia E232

N251

R64 Cachexia B24

E41

E46

R730 Abnormal glucose E100-E162

tolerance test E891

R780 Finding of alcohol in F101-F109

blood

The first entry on the And a condition classifiable

lowest line in Part I is to one of the following

classifiable to codes is reported on the

same line or in Part II

R788 Finding of other A000-A079

specified substances, A090-A499

not normally found in J13-J159

blood J180-J189

R798 Other specified abnormal E100 E127

findings of blood E101 E129

chemistry E102-E106 E130

E107 E131

E109 E132-E136

E110 E137

E111 E139

E112-E116 E140

E117 E141

E119 E142-E146

E120 E147

E121 E149

E122-E126

R799 Abnormal finding of E101 E127

blood chemistry, E107 E131

unspecified E111 E137

E117 E141

E121 E147

R80 Isolated proteinuria C900 N000-N079

D511 N170-N19

D649 N250-N289

R81 Glycosuria E100-E149

E748

R823 Hemoglobinuria B508

B54

D595-D596

The first entry on the And a condition classifiable

lowest line in Part I is to one of the following

classifiable to codes is reported on the

same line or in Part II

R824 Acetonuria E101 E127

E107 E131

E111 E137

E117 E141

E121 E147

R826 Abnormal urine levels of F101-F109

substances chiefly

nonmedicinal as to source

R893 Abnormal findings in F101-F109

specimens from other

organs, systems and

tissues

I (a) Pneumonia J189

(b) Coma R402

II Surgery for diabetic gangrene E145

Code I(a) and I(b) as indexed. Coma is reported as the first condition on the lowest used line, but diabetic gangrene is reported in Part II. Therefore, pneumonia cannot be coded as a complication of surgery. Do not enter a code for surgery since no complication is reported.

I (a) Aspiration pneumonia J690

(b) Jaundice R17

II Cholecystectomy for gallstones K802

Code I(a) and I(b) as indexed. Jaundice is reported as the first condition on the lowest used line with gallstones reported in Part II. Therefore, aspiration pneumonia cannot be coded as a complication of surgery. Code Part II, K802 (gallstones). Do not enter a code for the cholecystectomy since no complication was reported.

I (a) Sepsis A419

(b) Gangrene, pneumonia, and R02 J189 I709

II Surgery

Code I(a) and I(b) as indexed. Gangrene is reported as the first condition on the lowest used line, but arteriosclerosis is reported on the same line; therefore, pneumonia cannot be a complication of surgery. Do not enter a code for surgery since no complication is reported.

f. Relating condition for which surgery was performed to the site of the surgery

(1) When a condition of unspecified site is reported with surgery of a defined site, code the condition of unspecified site to the defined site.

I (a) Aneurysm I719

II Operation for aortic aneurysm I719

Code I(a), aneurysm of unspecified site to aortic aneurysm, I719, since the surgery is of a defined site. Code aortic aneurysm in Part II. Do not enter a code for the surgery since there is no reported complication.

I (a) Pneumonia J958

(b) Esophagectomy due to cancer Y836

Code I(c), cancer of unspecified site to esophageal cancer C159, since the surgery is of a defined site.

(2) When a condition of a site is reported with surgery of a more defined part of the site, code the condition to the more specified site.

I (a) Carcinoma colon C186

II Left colectomy

Code I(a), carcinoma colon to carcinoma left colon, C186, since the surgery is of a more specified part of the colon. Do not enter a code for the surgery since there is no reported complication.

I (a) Valvular heart disease I059 I069

II Status post mitral and aortic valve repair

Code I(a) valvular heart disease of unspecified valve to disease, mitral and aortic valves since the surgery is of specified valves. Do not enter a code for the surgery since there is no reported complication.

(3) When a condition of a site is reported with surgery for the same condition of unspecified or a less defined part of the site, code the condition to the most defined site.

I (a) Cancer of head of pancreas C250

II Pancreatectomy for cancer C250

Code I(a), cancer head of pancreas, C250. Code Part II as cancer of head of pancreas since elsewhere a more defined site was reported of the condition for which surgery was performed. Do not enter a code for the surgery since there is no reported complication.

(4) Do not apply these instructions when more than one condition or a condition of multiple specified sites which could have necessitated the surgery is reported.

I (a) Cardiac arrest I469

(b) Respiratory arrest R092

II Findings of operation: Carcinoma C80

Code I(a), I(b) and I(c) as indexed and according to neoplasm instructions. Code Part II, carcinoma, C80. Do not code the carcinoma to a more defined site since multiple specified sites are reported for which the surgery could have been performed. Do not enter a code for the surgery since there is no reported complication.

g. Complications of amputation and amputation stump

When a complication (stated or implied) occurs as a result of an amputation, code the complication to Chapters I-XIX. When the complication is classifiable to Chapters I-XVIII and the condition that necessitated the amputation is not reported, precede the code for the complication with an ampersand.

I (a) Renal failure &N990

(b) Below knee amputation of leg Y835

Code I(a), renal failure, N990 as the complication of surgery. Code I(b), below knee amputation of leg, Y835. Precede the N990 with an ampersand since it is classified to Chapter XIV and the condition that necessitated the amputation is not reported.

When there is a complication of an amputation stump, code the complication to T873-T876 or to the appropriate code in Chapters I-XVIII. (Do not use T873-T876 for “stump” of internal organs).

I (a) Infected amputation stump T874 &Y835

(b) Osteosarcoma of leg &C402

Code I(a), infected amputation stump T874 Y835. Precede the E-code, Y835, by an ampersand. Code I(b), osteosarcoma of leg, C402. Precede C402 by an ampersand to indicate the condition that necessitated the amputation.

3. Complications of medical procedures other than surgical (Y84)

Medical procedures are any type of nonsurgical procedures used in the treatment of diseases or injuries. Although almost any condition reported due to medical procedures is regarded as a complication, there are a few diseases that are not considered complications. Do not code the conditions listed under 2. a. (1) (a) and (b) in Section V, Part R as complications of medical procedures. The medical procedure (Y84) is not coded when there is no evidence of a complication. If the reason for the medical procedure is not reported, do not assume a disease condition.

Interpret “due to medical procedures” as a condition(s) on an upper line with a medical procedure as the first condition on the next lower line.

When a condition is reported due to a named medical procedure other than a surgical operation or is modified by a named procedure and can be considered as a complication(s) or adverse effect, code as follows:

STEP 1: Determine if the complication is in the Index qualified by the specific procedure reported.

I (a) Kidney blockage &N990

(b) Postcystoscopic procedure Y848

Code I(a) as indexed using Step 1

Block

– kidney

– – postcystoscopic or postprocedural N99.0.

Code I(b) Y848 as indexed under Complication, procedures other than surgical operation, specified NEC. Precede N990 with an ampersand.

STEP 2: If the Index does not qualify the complication with the specified procedure, determine if the procedure is indexed under Complications (from) (of).

I (a) Urinary tract infection T835

(b) Post-indwelling urinary catheter &Y846

Code I(a) using Step 2

Complications (from) (of)

– catheter (device)

– – urinary (indwelling)

– – – infection or inflammation T83.5

Select infection or inflammation since urinary tract infection is an infectious condition.

Code I(b) Y846 as indexed under Complication, catheter, catheterization (urinary). Precede the E-code with an ampersand.

I (a) Pulmonary embolism T838

(b) Catheter &Y846

Code I(a) using Step 2

Complications (from) (of)

– catheter (device)

– – specified NEC T83.8

Select specified since pulmonary embolism is a specified complication.

Code I(b) Y846 as indexed under Complication, catheter, catheterization (urinary). Precede the E-code with an ampersand.

When the Index does not provide for the term as specified in STEP 1 and STEP 2, code the complication as if procedure NOS was reported instead of the named medical procedure as defined in the following instructions:

NOTE: Before continuing to STEP 3, it is important to determine the nature of the named procedure.

When a condition that is

(1) reported due to a named procedure cannot be assigned a code using STEP 1 or STEP 2 or

(2) reported due to a procedure other than surgical operation NOS or therapy NOS, and can be considered as a complication(s) or adverse effect, code as follows:

STEP 3: Determine if the complication is in the Index, qualified:

(a) as reported

(b) with any term meaning “due to” procedure or medical care (see Section II, Part C, 2, a, “Due to” written in or implied)

I (a) Renal failure &N990

(b) Paracentesis Y844

Code I(a) as indexed using Step 3 (c)

Failure

– renal

– – postprocedural N99.0

Code I(b) Y844 as indexed under Complication, paracentesis. Precede N990 with an ampersand.

STEP 4: If the Index does not provide a code for the complication in Steps 1-3, determine if:

(a) the site of the complication is in the Index under Complications (from) (of)

– medical procedure

(b) the system in which the complication occurred (based upon the code assigned in the Index) is in the Index under

Complications (from) (of)

– medical procedure

Complications (from) (of)

– postprocedural

I (a) Cardiac arrest T818

(b) Therapy &Y849

Code I(a) using Step 4 (a)

Complications (from) (of)

– medical procedure

– – cardiac T81.8

Select cardiac since this is the site of the complication.

Code I(b) Y849 as indexed under Complication, procedures other than surgical operation. Precede the E-code and the condition requiring treatment with an ampersand.

I (a) Pulmonary edema &J958

(b) Endotracheal tube Y848

Code I(a) using Step 4 (b)

Complications (from) (of)

– medical procedure

– – respiratory

– – – specified NEC J95.8

Select respiratory, specified since pulmonary edema is classified to J81, a specified disease in the respiratory system.

Code I(b) Y848 as indexed under Complication, procedures other than surgical operation, specified NEC. Precede J958 with an ampersand.

I (a) Stroke I64

(b) Cerebral embolism T817

Code I(b) using Step 4 (b)

Complications (from) (of)

– medical procedure

– – circulatory T81.7

Select circulatory since cerebral embolism is classified to I634, a specified disease in the circulatory system.

Code I(c) Y848 as indexed under Complication, procedures other than surgical operation, specified NEC. Precede the E-code with an ampersand.

STEP 5: When a reported specified complication cannot be classified to a system that is indexed, code T818, Other complications of procedures, not elsewhere classified.

I (a) Shock R579

(b) Coagulation disorder T818

Coagulation disorder is not indexed as due to a procedure or as postprocedural. This condition is classified to D689, a disease of the blood-forming organs. Neither the term nor the body system is indexed under Complications (from) (of), medical procedure.

Code I(b) using Step 5

Complications (from) (of)

– procedure

– – specified T81.8

Select specified since coagulation disorder is a specified complication.

Code I(c) Y848 as indexed under Complication, procedures other than surgical operation, specified NEC. Precede the E-code with an ampersand.

4. Complications of procedures involving administration of drugs, radiation, and instruments

Many procedures (e.g., angiogram, barium enema, pyelogram) involve the administration of drugs and the use of x-ray or radioactive substances and various instruments. When complications of these procedures are reported, determine, if possible, which specific part of the procedure caused the complication. Assign the appropriate codes for the complication and the procedure. When the complication is classified to Chapters I-XVIII and the reason for the procedure is not reported, precede the code for the complication with an ampersand. If the reason for the medical care is not reported, do not assume a disease condition.

I (a) Pulmonary embolism T828

(b) Cardiac catheterization &Y840

Code I(a) as the complication of the catheterization. Code I(b) as indexed, Y840 and precede with an ampersand. Code I(c) as indexed and precede with an ampersand to indicate the reason for the procedure.

I (a) Barium impaction of intestine Y575 K564

(b) Barium enema

Code the barium on I(a) to adverse effect in therapeutic use, Y575, since it was the drug that caused the impaction. Code the complication, impaction, as indexed, Impaction, intestine, K564. Do not enter a code on I(b) for barium since it was coded on I(a). Code I(c) as indexed and precede with an ampersand to indicate the reason for the procedure.

I (a) Anaphylactic shock T886

(b) Contrast medium (aortogram) &Y575

II Dissecting aortic arch aneurysm &I710

Code I(a) as the complication of the contrast medium. Indexed as Shock, anaphylactic, correct substance properly administered. Code I(b) contrast medium as adverse effect in therapeutic use, since the drug caused the anaphylactic shock. Code Part II as indexed and precede with an ampersand to indicate the reason for the procedure.

I (a) Peritonitis K659

(b) Hemorrhage of colon K918

(d) Diverticulitis &K579

Code I(a) as indexed. Code I(b) as the complication of the administration of the enema. Code I(c) barium enema, Y848, since the hemorrhage most likely resulted from the administration of the enema rather than the barium. Code I(d) as indexed and precede with an ampersand to indicate the reason for the procedure.

I (a) Cerebral hemorrhage T817

(b) Cerebral arteriogram &Y848

Code I(a) as the complication of the arteriogram. Code I(b) cerebral arteriogram, Y848, since the hemorrhage resulted from the procedure and precede with an ampersand. Do not assume a disease condition for the cerebral arteriogram.

When a complication results from the administration of anesthesia, code the complication as indexed and code the appropriate external cause code (Y480-Y485) (refer to Section V, Part R, 1,Drugs, medicaments and biological substances causing adverse effects in therapeutic use).

I (a) Cardiac failure I509

(b) Anesthesia for prostate surgery Y484

Code I(a) as indexed and as the complication of the anesthesia. Code I(b) anesthesia to adverse effect in therapeutic use, Y484, since it was the anesthesia that caused the heart failure. Code I(c) N429, disease prostate, as the reason for surgery and precede with an ampersand.

I (a) Cardiac failure T818

(b) Prostate surgery under anesthesia &Y839

Code I(a) as indexed under Failure, heart, complicating surgery. Code I(b) prostate surgery as indexed. Code I(c) as indexed and precede with an ampersand to indicate the reason for surgery.

5. Complications of radiation during medical care (Y842)

When a complication results from exposure to radiation, except radio-frequency radiation, infrared heaters or lamps and visible or ultraviolet light sources, consider as exposure of patient to radiation during medical care unless there is information on the certificate that indicates otherwise. Code complications of radiation during medical care as follows:

Complications qualified as “radiation,” “radiation-induced,” “due to radiation,” or “following radiation”

(1) Coding the complication

(a) If the Index provides a code for the complication qualified by one of these terms, use that code.

(b) If the Index does not provide a code for the complication qualified by one of these terms, code the complication as indexed without the qualifier.

(2) Placement of codes

(a) If the complication is qualified as “radiation” or “radiation-induced” and classified to Chapters I-XVIII, code the external cause code followed by the code for the complication.

(b) If the complication is qualified as “radiation” or “radiation-induced” and classified to Chapter XIX, code the nature of injury code followed by the external cause code.

Code the external cause code to Y842, (Radiological procedure and radiotherapy).
Use of ampersand

(1) If the reason for the radiation therapy is reported, precede this condition with an ampersand.

(2) If the reason for the radiation therapy is not reported and a malignant neoplasm is reported, precede the neoplasm with an ampersand.

(3) If the reason for the radiation therapy is not reported and the complication is classified to Chapters I-XVIII, precede the complication with an ampersand.

I (a) Pulmonary edema J81

(b) Radiation pneumonitis Y842 J700

(d) &C509

Code I(b) to the external cause as indexed where the radiation is first reported followed by the code for the complication. Pneumonitis is the complication of the radiation and is indexed, Pneumonitis, radiation. Precede the code for cancer of breast with an ampersand to indicate the reason for the radiation.

I (a) Carcinomatosis C80

(b) Oat cell carcinoma &C349

(c)

II X-ray fibrosis – lung Y842 J701

Code Part II to the external cause as indexed followed by the code for the complication. Fibrosis of lung is the complication and is indexed, Fibrosis, lung, following radiation. Code I(b) as indexed and precede with an ampersand to indicate the reason for the radiation.

I (a) Pneumonia J700

(b) Radiation Y842

Pneumonia is the complication of the radiation reported on I(b). Code I(a) as indexed, Pneumonia, radiation. Code the external cause as indexed on I(b). Code I(c) as indexed and precede with an ampersand to indicate the reason for the radiation.

I (a) Debility R53

(b) Radiation therapy Y842

Debility is the complication of the radiation reported on I(b). Code I(a) as indexed since the Classification does not provide a code for radiation debility. Code the external cause as indexed on I(b). Code I(c) as indexed and precede with an ampersand to indicate the reason for the radiation.

I (a) Radiation-induced acute Y842 J700

(b) bronchitis

II Carcinoma of trachea &C33

Code I(a) to the external cause as indexed, followed by the code for the complication. Acute bronchitis is the complication and is indexed Bronchitis, acute, due to radiation. Code Part II as indexed and precede with an ampersand to indicate the reason for the radiation.

I (a) Alopecia L581

(b) Radiation Y842

II Hodgkin granuloma &C817

Alopecia is the complication of the radiation reported on I(b). Code I(a) as indexed under Alopecia, X-ray. Code the external cause as indexed on I(b). Code Part II as indexed and precede with an ampersand to indicate the reason for the radiation.

I (a) Peritonitis K659

(b) Intestinal fistula &K632

Intestinal fistula is the complication of the radiation reported on I(c). Code I(b) as indexed since the Classification does not provide a code for radiation intestinal fistula. Code the external cause as indexed on I(c). Precede the complication (intestinal fistula) with an ampersand since it is classified to Chapters I-XVIII and the reason for the radiation was not reported.

When radiation fibrosis is reported without a site or of a site not indexed, code the fibrosis to T66, Complications, radiation.

I (a) Cerebral anoxia G931

(b) Carcinoma of tongue &C029

II Radiation fibrosis, upper airway obstruction T66 &Y842 J988

Code Part II Complications, radiation for the fibrosis and the external cause as indexed. Code the nature of injury followed by the external cause. Place an ampersand preceding the E-code and the condition on I(b) to indicate the reason for the radiation.

I (a) Radiation pelvic fibrosis T66 &Y842

(b) Carcinoma of uterus &C55

Code I(a) Complications, radiation for the pelvic fibrosis and the external cause as indexed. Code the nature of injury followed by the external cause. Place an ampersand preceding the E-code and the condition on I(b) to indicate the reason for the radiation.

6. Misadventures to patients during surgical and medical care (Y60-Y69)

Except for poisoning, overdose of drug and wrong drug given in error, code most misadventures (accidents or errors) to patients during surgical and medical care to Complications of surgical and medical care (T800-T889) in the nature of injury chapter and to Y600-Y69 in the external cause chapter. Code burns from local applications or irradiation to burns in the nature of injury chapter and to Y600-Y69 in the external cause chapter. Code trauma from instruments during delivery to Chapter XV and do not use an external cause. A limited number of conditions attributable to misadventure to patient (Y600-Y69) in the external cause code, e.g., serum hepatitis, are classified to Chapters I-XVIII.

Indications of Misadventures

Hemorrhage (of a site) Stated as intraoperative or

during medical and surgical

Rupture (of a site) care

Cut or cutting (of a site) Reported as postoperative,

Perforation (of a site) intraoperative, during or due

Puncture (of a site) to medical and surgical care

Laceration (of a site)

Burns (of a site) From local applications or

irradiation

Serum hepatitis From blood transfusions

Fracture (thoracic area) From cardiopulmonary resuscitation

From Heimlich maneuver

This list is not all inclusive.

When a misadventure to patient during surgical and medical care (classifiable to Y600-Y69) is reported and the condition which necessitated the surgical or medical care is stated or implied, precede the code for this condition with an ampersand. Apply the instructions for Condition necessitating Surgery in Section V, Part R, 2, b.

I (a) Hemorrhage during T810

(b) craniotomy &Y600

Code I(a) Complication, surgical procedure, hemorrhage. Since “during” is stated, interpret I(b) as a misadventure and code Misadventure, hemorrhage, surgical operation. Code I(c) as indexed and precede with an ampersand to indicate the reason for surgery.

I (a) Perforation of colon T812

(b) Colostomy &Y600 &K639

Code I(a) Perforation, surgical. Interpret I(b) as a misadventure and code Misadventure, perforation, surgical operation. Since the surgery indicates a disease of the colon, code this as the reason for surgery. Precede K639 with an ampersand

I (a) Cardiac tamponade I319

(b) Perforation of auricle by cardiac catheter T812 &Y605

II Therapeutic misadventure T889

The perforation occurred during a cardiac catheterization. Code I(b) as accidental perforation of organ during a procedure, and accidental perforation during a heart catheterization. Code Part II as indexed, Misadventure (prophylactic) (therapeutic).

I (a) Peritonitis K659

(b) Accidental perforation of T812 &Y607

II Self-administered tap water enema

I(b) is a reported misadventure occurring during medical care. Code T812, accidental perforation during a procedure and Y607, accidental perforation during the administration of an enema.

I (a) Serum hepatitis B169

(b) Blood transfusion Y640

Serum hepatitis is a misadventure occurring during a blood transfusion. Code I(a) B169, serum hepatitis, and I(b) Y640, Contaminated medical or biological substance transfused or infused. Code I(c) as indexed and precede with an ampersand to indicate the reason for the transfusion.

I (a) Burns T300

(b) Radiation therapy &Y632

Code I(a) T300, radiation burns. Code I(b) Y632, Overdose of radiation given during therapy. Code I(c) as indexed and precede with an ampersand to indicate the reason for the radiation.

I (a) Rib fracture T818

(b) Cardiopulmonary resuscitation &Y658

Rib fracture due to cardiopulmonary resuscitation is considered a misadventure. Code I(a) Complications, medical procedure, specified NEC T818. Code I(b) Misadventure, specified type Y658. Code I(c) as indexed and precede with an ampersand to indicate the reason for cardiopulmonary resuscitation.

I (a) HIV B24

(b) Blood transfusion

Code I(a) and I(c) as indexed. No code for I(b) since there are no complications reported. Do not consider HIV (any B20-B24) as a misadventure occurring during a blood transfusion.

S. Sequela of injuries, poisonings, and other consequences of external causes

A sequela is a late effect, an after effect, or a residual of a nature of injury or external cause. The Classification provides categories T900-T983 for sequela of nature of injury codes and Y850-Y899 for sequela of external causes. There are separate instructions for determining if the nature of injury or the external cause should be coded as sequela. If either the nature of injury or the external cause requires a sequela code, both the nature of injury and the external cause must be coded to a sequela category.

1. Sequela of injuries, poisoning, and other consequences of external causes (T900-T983)

Use these categories for the classification of injuries and poisonings (conditions in S00-T88) if:

A statement of sequela of the condition in S00-T88 is reported unless the interval between date of injury and date of death is less than 1 year.

I (a) Sequela of hip fracture T931

(b)

(c)

II &Y86

Code I(a) to T931 since it is stated as a sequela of hip fracture. Code Part II as sequela of accident NEC.

The condition in S00-T88 is stated to be ancient, by history, healed, history, history of, late effect of, old, remote, regardless of reported duration, or the interval between onset of this condition and death is indicated to be 1 year or more, whether or not the residual (sequela) effect is specified.

Date of death 12/1/98

I (a) Old head injury T909

MOD II &Y86

Accident Farm Date of injury 9/3/98 Tractor overturned

Code I(a) old head injury to Sequela, injury, head since it is stated as old. Interpret “tractor overturning on farm” as contact with agricultural machinery. Code Part II accident – tractor overturned to sequela of other accidents since it resulted in an injury stated as old.

A condition with a duration of 1 year or more that was due to the condition in S00-T88 is reported.

I (a) Paralysis 16 mos. T941

(b) Spinal cord injury T913

Code I(a) paralysis to sequela of traumatic paralysis since it is reported due to trauma and has a duration of 1 year or more. Code I(b) spinal cord injury to Sequela, injury, spinal, cord since it caused a condition of 1 year or more. Code I(c) auto accident, to Sequela, motor vehicle accident.

More than one nature of injury or a nature of injury and an external cause are reported on the same line with a duration of 1 year or more, apply the duration to each condition.

I (a) Head injury and skull fracture Years T909 T902

(b)

II Fall &Y86

Code both conditions on I(a) as sequela. Do not disregard the duration since there is more than one injury on same line.

I (a) Gunshot wound head Years T901 &Y86

Code both head wound and gunshot as sequela. Apply duration to nature of injury and external cause.

2. Sequela of external causes (Y850-Y899)

Y850 Sequela of motor vehicle accident (includes V01-V89)

Y859 Sequela of other and unspecified transport accidents (includes V90-V99)

Y86 Sequela of other accidents (excludes W78-W80)

Y870 Sequela of intentional self-harm

Y871 Sequela of assault

Y872 Sequela of events of undetermined intent

Y880 Sequela of adverse effects caused by drugs, medicaments, and biological substances in therapeutic use

Y881 Sequela of misadventures to patients during surgical and medical procedures

Y882 Sequela of adverse incidents associated with medical devices in diagnostic and therapeutic use

Y883 Sequela of surgical and medical procedures as the cause of abnormal reaction of the patient, or of later complication, without

mention of misadventure at the time of the procedure

Y890 Sequela of legal intervention

Y891 Sequela of war operations

Y899 Sequela of unspecified external cause

Use the preceding categories with the appropriate fourth characters for the classification of external causes of injury (V010-Y849) if:

A statement of sequela of the external cause is reported unless the interval between date of external cause and date of death is less than 1 year.

I (a) Paralysis, sequela of T941 &Y86

(b) fall down steps

Code I(a) to sequela of traumatic paralysis and sequela of fall down the steps.

An injury that is stated to be ancient, by history, healed, history, history of, late effect of, old, remote, or a delayed union that was due to the external cause is reported.

I (a) Pneumonia J189

MOD (b) Debility R53

A (c) Nonunion of hip fracture M841

II Inanition R64 Y86

Accident Fell at home

Code I(c) as indexed. Code sequela of fall last in Part II since the fall resulted in nonunion of the fracture.

I (a) ASHD I251

II Old fractured hip T931 &Y86

Code I(a) ASHD as indexed. Code Part II old fractured hip, T931 Y86, since the injury was specified as old.

If the external cause is stated to be ancient, by history, history, history of, old, remote, regardless of reported duration, or the interval between onset of the external cause and death is indicated to be 1 year or more.

I (a) Old fall, fractured hip 6 months T931 &Y86

(b)

(c)

MOD II T931

Accident Fell and fractured hip 6 months ago

Code as sequela since the external cause is stated as “old.”

A condition with a duration of 1 year or more that was due to the external cause is reported.

I (a) Subdural hematoma 1 year T905

(b) Fall &Y86

Code I(a) subdural hematoma, T905, since it is reported to be of 1 year or more duration. Code I(b) fall, Y86, since it resulted in a condition of 1 year or more duration.

I (a) Esophageal stricture years K222

(b) Ingestion of lye T97 &Y870

II Suicide attempt

Code I(a) esophageal stricture as indexed. Code I(b) ingestion of lye, T97 Y870, since it resulted in a condition of 1 year or more duration.

The interval between the time of occurrence of the external cause and death is indicated to be 1 year or more,whether or not the residual (sequela) effect is specified.

Date of death 11/1/96

I (a) Bronchopneumonia J180

MOD II Contusion brain T905 &Y850

Accident Street Date of injury 5/20/95 Bicycle (operator) vs. truck

Code I(a) bronchopneumonia as indexed. Code sequela of nature of injury and external cause since the date of injury is 1 year or more prior to death.

I (a) Cardiac arrest I469

(b) Pacemaker failure weeks T983 &Y883 &I519

Code I(a) cardiac arrest as indexed. Code I(b) pacemaker failure to sequela T983 and Y883 since duration of implanted pacemaker is 3 years. Code I519, Disease, heart since pacemaker indicates a heart disease. Precede I519 with an ampersand as reason for the surgery. Do not enter a code on I(c).

The complication of the external cause classified to Chapters I-XVIII and the external cause is reported on the same line and the duration is 1 year or more.

I (a) Radiation enteritis 3 years Y883 K520

(b) Lung cancer &C349

Code I(a) as a sequela of radiation therapy. Do not disregard the duration. Precede the code for the lung cancer with an ampersand to indicate the reason for medical care.

Page last reviewed: March 24, 2021

Content source: National Center for Health Statistics

Instructions for Classifying Multiple Causes of Death, 2021 - Section V

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

A. External cause code (E-Code) concept

1. Use of Index

2. Use of Tabular List

3. Place of occurrence of external cause

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

5. Nature of injury and external cause code lists

B. Placement of nature of injury and external cause codes

C. Use of ampersand

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

E. Conditions qualified as traumatic

F. Assumption of nature of injury code

G. Multiple injuries (T00-T07 )

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

I. Specified types and sites of injuries

J. Transportation accidents (V01-V99)

1. Use of the Index and Tabular List

2. Classifying accidents as traffic or nontraffic.

3. Status of victim

4. Coding categories V01-V89

5. Additional examples

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

7. Scooter (motorized) vs Motor scooter

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)

9. Water transport accidents (V90-V94)

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

11. Miscellaneous coding instructions (V01-V99)

K. Falls

1. Other fall on same level (W18)

2. Unspecified fall (W19)

3. Falls with other external events

L. Natural and environmental factors

1. Lightning

2. Exposure, cold exposure and hypothermia

3. Storms and Wildfires

M. Firearms and firearm injuries

1. Coding specific types of firearms

2. External cause code

3. Nature of injury code

4. Other firearm examples

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

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

P. Threats to breathing

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)

Q. Poisoning

1. Poisoning by substances other than drugs

a. Carbon monoxide poisoning

b. Inhalation and sniffing sprays and aerosol substances

c. Intoxication by certain substances or toxic poisoning due to disease

d. Condition qualified as “toxic” with poisoning reported

2. Poisoning by drugs

3. Percentage of drug(s) in blood

4. Poisoning by alcohol and drugs

5. Intoxication (acute) NOS

R. Complications of medical and surgical care (Y40-Y84)

1. Drugs, medicaments and biological substances causing adverse effects in therapeutic use (Y40-Y59)

2. Surgical procedures as the cause of abnormal reaction of the patient or later complication (Y83)

a. Complications of surgical procedures

b. Condition necessitating surgery

c. Conditions qualified as postoperative

d. Complication as first entry on lowest used line in Part I

e. Ill-defined condition as first entry on lowest used line in Part I

f. Relating condition for which surgery was performed to the site of the surgery

g. Complications of amputation and amputation stump

3. Complications of medical procedures other than surgical (Y84)

4. Complications of procedures involving administration of drugs, radiation, and instruments

5. Complications of radiation during medical care (Y842)

6. Misadventures to patients during surgical and medical care (Y60-Y69)

S. Sequela of injuries, poisonings, and other consequences of external causes

1. Sequela of injuries, poisoning, and other consequences of external causes (T900-T983)

2. Sequela of external causes (Y850-Y899)

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)