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Clinical Coding with ICD and ACHI

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					                                         1




Introduction to Clinical Coding with
               ICD-10




             Sue Walker
 National Centre for Classification in
               Health
         Brisbane, Australia
                           2


Sue Walker
Associate Director,
NCCH Brisbane
Queensland University of
  Technology
Kelvin Grove 4059
Australia
Email:
s.walker@qut.edu.au
ncch.brisbane@qut.edu.au
Website:
www.ncch.com.au
                                              3



                Lesson Plan
What is coding?
Why do we code?
Structure and principles of classification
Morbidity coding
Mortality coding
Basic coding steps
General discussion
                                          4




                Objective

 To promote a greater understanding of
 coding, abstracting and documentation
 issues to assist with the production of
 high quality coded morbidity and mortality
 data
                                             5



Module 1: Introduction to ICD-10 Structure
    and Principles of Classification
                                        6


     What is Clinical Coding?


 the translation of diseases, health
  related problems and procedural
  concepts from text to
  alphabetical/numeric codes

 for storage, retrieval and analysis
                                             7



What is a Statistical Classification?

   system of categories or groupings

    codes assigned according to criteria


    statistical classification - limited
    number of mutually exclusive code
    categories; there is not a unique code
    for every concept
                                           8


     Why use a classification?
 allows easy storage, retrieval and
  analysis of data

 allows standard comparisons of
  data between hospitals, states,
  provinces or countries

 allows comparisons of data in the same
  location across time
                                             9

             History of the ICD
1900 - 1st   Bertillon’s Classification of COD 179
                   categories
1910 - 2nd   Bertillon continues revision
1920 - 3rd   Bertillon revises, dies in 1922
1929 - 4th   1928 Mixed Commission created
                   expansion of 1920 rubrics
1938 - 5th   Mixed Commission continues
                   development
1946 - 6th   International WHO takes over
1955 - 7th   Minor amendments only
1965 - 8th   Radical revision – structure
 unchanged
1975 - 9th   4th and 5th character detail
1992 - 10th Major restructuring and
 reorganisation
                                               10




        Family of Classifications

ICD-10 is one of a group of classifications
 used to capture information about health
 status
Known as the World Health Organisation
 Family of International Classifications
 (WHO-FIC)
                                          12


         Overview of ICD-10

• Variable-axis classification
   • Epidemic diseases
   • Constitutional or general diseases
   • Local disease – by site
   • Developmental diseases
   • Injuries
                              13


         Overview of ICD-10
General Structure:

  • 3 Volumes

  • 22 Chapters

  • Alphanumeric codes
                                           14




        Volumes of the ICD-10

 Volume 1     Tabular List, the
  alphanumeric
              listing of diseases and
  disease            groups
 Volume 2     Instructions and guidelines
 Volume 3     Alphabetical index,
              comprehensive listing of all
               conditions in the Tabular list
                                            15

          Chapters of the ICD-10
   22 Chapters

   Roman Numerals    I – XXII

   Refer to Chapter number NOT code letter
     Some chapters use multiple code letters

     Some code letters are split between

      chapters
                                                 16




     Structure of the core ICD-10 code

The structure of the core 3 character code is:

                     A37


   first character          followed by
      A to Z                   2 digits
                                                        17


            Structure of the ICD-10 code

The structure of the 4 character sub-categories is:


                       A37.1

first character   followed by then a   lastly another
  A to Z           2 digits   point    digit
                                                              18


       Updating your ICD-10 Volumes
Cumulative updates to ICD-10 are available
 at:
 http://www.who.int/classifications/icd/icd10updates/en/index.ht
  ml


Effective from 1st January of year of
 Implementation
ICD-10 2nd Edition includes all updates for
 implementation up to and including 2003
Have your books been updated?
                                              19




    Module 2: Volume I Tabular List

 Alphanumeric listing of all codes in the
 classification, organised into chapters

 Includes coding instructions, notes,
 punctuation and hints
   These can be found at the start of each
    chapter or at block, category or
    subcategory level
                                             20


     Tabular list at chapter level
   Most chapters associated with body
    systems
    eg cardiovascular, respiratory

   Special disease chapters
    eg infectious and parasitic diseases,
     neoplasms, congenital anomalies,
     perinatal conditions
                                              21

       Tabular list at chapter level

 15 of the chapters have a single letter assigned
  to them and use most of the 100 categories
  available

 3 chapters have a smaller range of categories
  assigned to them and share letters

 4 chapters use more than one letter in defining
  the scope of their categories
                                           22



                Exercise 1
 What is the range of 3-character
  categories used in Chapter III?

 Two letters are split between multiple
  chapters. Which are they?

 How many letters does Chapter XX use?

 What letter is used in Chapter XXII?
                                                    23



           Exercise 1 - Answers
 1. What is the range of 3-character categories used
  in Chapter III?
     D50 to D89

 2. Two letters are split between multiple chapters.
  Which are they?
    D - Chapters II and III & H - Chapters VII and VIII

 How many letters does Chapter XX use?
   4 letters - V, W, X, Y

 4. What letters are used in Chapter XXII?
    Only the letter U is used in Chapter XXII
                                     24




Chapters are further divided into:


   Blocks
   Three Character Categories
   Four Character Subcategories
   Some optional characters
                                      25

    Tabular List Conventions
   Inclusion Terms
   Exclusion Terms
   Chapter V Glossary Descriptions
   Dagger and Asterisk
   Parentheses ( )
   Square Brackets [ ]
   Colon :
   Brace }
   Not Otherwise Specified NOS
   Not Elsewhere Classified NEC
   AND in code titles
   Point dash .-
                                             26

             Inclusion Terms

 Usually listed within the three and four
  character categories, may also be at block or
  chapter level
 Examples of the different conditions or
  synonyms for the condition coded to that
  category
 Not a subclassification
 Guide to contents of category, not exhaustive
                                            27



              Exercise 2:


Does the code J35.8 Other chronic
 diseases of tonsils and adenoids include
 Amygdalolith (calculus of tonsil)?
                                                  28


             Exercise 2 - Answer

 Does the code J35.8 Other chronic diseases of
  tonsils and adenoids include Amygdalolith?

              Yes. It is listed as an
                 inclusion term




                 YES         or          NO
                                                29



              Exclusion Terms

 List of conditions that are to be coded
  elsewhere, not to the code being looked at

 The correct code is in parentheses

 e.g. Q74 Other congenital malformations
     of limb(s) excludes polydactyly (Q69.-),
     reduction defect of limb (Q71-Q73),
     syndactyly (Q70.-)
                                           30




                Exercise 3:

Should reduction defects of the feet be
coded within the 3 character category
 Q66?

If not, where should they be coded?
                                                  31



             Exercise 3 - Answer
 Should reduction defects of the feet be coded
 within the 3 character category Q66?
 If not, where should they be coded?

                   No - the exclusion note
                  directs the coder to Q72.-

           YES                      NO
                                              32

   Chapter V Glossary Descriptions

 Indicate the content of categories in
  Chapter V Mental & Behavioural Disorders

 Used because the terminology of mental
  disorders varies greatly

 Not intended for use by coding staff to
  make a diagnosis but to assist clinicians
  to document
                                                33


    Dagger (†) and Asterisk (*) – Dual coding

 Underlying cause or aetiology         †

 Current manifestation                 *

   Dagger code takes precedence
   Asterisk code never used alone
   Better description of the medical care given
   Asterisk categories listed at beginning of
    each chapter
                                            34

    Dagger and asterisk convention
May be found at:
 4th character level – only that 4th
   character has dagger or asterisk
    B26.3† K87.1*
 3rd character level – all fourth
   characters have the dagger or asterisk
    A17† E35*
 Inclusion term level – only certain
   inclusion terms have daggers or
   asterisks
    A18.3
                                             35




               Exercise 4:

How many asterisk categories are there in
Chapter IX, Diseases of the Circulatory
 System?
                                             36


           Exercise 4 - Answer


How many asterisk categories are there in
Chapter IX, Diseases of the Circulatory
 System?



8 asterisk codes - they are listed at the
 beginning of the chapter
                                            37

          Parentheses ( )
 Enclose supplementary words
 Enclose the code for the exclusion term
 Enclose the three character codes of
  categories in a block
 Enclose the dagger code in an asterisk
  category or the asterisk code in a
  dagger term
                                       38




                Exercise 5:

Is N13.0 the correct code for
 hydronephrosis with ureteropelvic
 junction obstruction and infection?

 If not, what is the correct code?
                                                     39

              Exercise 5 – Answer
 Is N13.0 the correct code for hydronephrosis
     with ureteropelvic junction obstruction and
     infection? If not, what is the correct code?
            No - the exclusion note under N13.0
         excludes hydronephrosis that occurs with
           infection. The correct code is N13.6.





                        YES                 NO
                                             40




           Square Brackets [ ]
 For enclosing synonyms, alternative words or
  explanatory phrases

 For referring to notes

 For referring to fourth character subdivisions
  common to a number of categories
                                               41




                   Exercise 6:

What does the note in [ ] tell us for codes
 in the M79 category?
                                               42



           Exercise 6 – Answer


What does the note in [ ] tell us for codes
 in the M79 category?

[See site code at the beginning of this
 chapter]

The coder should the refer the beginning
 of the chapter for optional site codes for
 this category
                                               43

                    Colon :

 Used in lead terms and listings of inclusion and
  exclusion terms when the words in the list need
  an essential modifier to allow assignment of the
  specified code
   Example:
   G71.0 Muscular dystrophy :
           • autosomal recessive
           • benign [Becker]
           • distal
                                               44




                  Brace }

 Used to link a series of terms

 Each term on the left of the brace must be
  modified by at least one of the terms to
  the right of the brace before the specific
  code can be assigned
                                          45




e.g. E10.1 Insulin dependent diabetes mellitus
           with ketoacidosis

     Diabetic:
     •    acidosis        } without mention
     •    ketoacidosis    } of coma
                                                46

      Not Otherwise Specified (NOS)
 Means unspecified or unqualified

 Only used if no other information exists to
  allow assignment of a more specific code

 Example:
    K14.9      Disease of tongue, unspecified
               Glossopathy NOS
                                                 47

    Not Elsewhere Classified (NEC)
 Used as a warning that specific types of
  the condition being coded appear
  elsewhere in the classification

 If more specific information is available, a
  different code may be selected

 Example:
     K73.2      Chronic hepatitis, not
  elsewhere            classified
                                               48

             “AND” in code titles
 "and" stands for "and/or” in code titles

 e.g.      S49.9 Unspecified injury of shoulder
  and       upper arm

 Means that here we can code the following:
      • unspecified injury of shoulder
      • unspecified injury of upper arm
      • unspecified injury of shoulder and upper
        arm
                                               49




                Point Dash .-
 Indicates to the coder that a fourth character
  exists and should be sought at category,
  block or chapter level

          e.g. D59.1 Other autoimmune
  haemolytic          anaemias
        Excludes: haemolytic disease of fetus
          and newborn (P55.-)
                                                     50



               Additional codes

 Note:
 ICD-10 sometimes indicates when coding can
  be made more specific by the addition of another
  code

 instructions such as
     use additional external cause code, if
  desired, to identify cause
     use additional code (B95-B97) to identify
  infectious agent
                                               51


                Specific Notes
 Volume 2, section 4.4.4 contains specific
  guidance for coding each chapter of ICD-10

 The Tabular List refers the coder to these
  notes where they apply to a situation

 The coder should have read the notes before
  assigning a code

 Chapter-specific notes override general
  guidelines and rules
                                             52

   Module 3: Volume III - Alphabetical
                 Index
 Alphabetic listing of conditions that can be
  coded in the Tabular List
 Consists of:
 Introduction

 Section I Index of Diseases & Nature of Injury

 Section II External Causes of Injury

 Section III Table of Drugs and Chemicals
                                                    53

          Structure of Index Entries
 Lead terms
    In bold type, to the far left of each column




 Modifiers
   Non-essential modifiers in parentheses ( )

   Essential modifiers at different levels of

    indentation to the right - refer to different
    sites or circumstances that affect coding,
    each modifier preceded by one or more
    hyphens
   Note: “with” appears before all other
    modifiers
                                              54

               Lead terms

 Usually nouns - the name of the condition
  or disease or an eponym, not the site or
  type

 For example:
           acute pyelonephritis


              modifier        lead term
                                                            55

      Bilateral inguinal hernia with gangrene and
                      obstruction
   Hernia
   - inguinal (direct) (external) (funicular) etc. K40.9
   - - with
   - - - gangrene (and obstruction) K40.4
   - - - obstruction K40.3
   - - bilateral K40.2
   - - - with
    - - - gangrene (and obstruction) K40.1
    - - - obstruction K40.0
    - unilateral K40.9
   - - - with
   - - - - gangrene (and obstruction) K40.4
   - - - - obstruction K40.3
                                                                  56
  Bilateral inguinal hernia with gangrene and obstruction
Hernia                 Lead Term
- inguinal (direct) (external) (funicular) etc. K40.9
- - with        With always listed first
- - - gangrene (and obstruction) K40.4
- - - obstruction K40.3                       Non-essential modifiers
- - bilateral    K40.2
- - - with
- - - - gangrene (and obstruction) K40.1           Essential modifiers
- - - - obstruction K40.0
- - unilateral K40.9
- - - with
- - - - gangrene (and obstruction) K40.4
- - - - obstruction K40.3
                                                       57

 Code numbers follow the terms in the Index
      may   appear as 3 character category
                  Malaria B54
      be subdivided with either the appropriate 4th
       character or a point dash (.-)
                   MacLeod’s syndrome J43.0
                   Diabetes E14.-
 Where the dual system of coding († and *)
  applies, both codes are given in the Index
                 Leukoderma, leukodermia NEC
                 - syphilitic A51.3† L99.8*
                                                   58
Can’t locate a Lead Term? Try some of these
  Disorder        Contact              Counselling
  Disease         Injury               Observation
  Complication    Sequelae             History
  Syndrome               Suicide             Problem
  Pregnancy              Assault             Screening
  Labour          Wound                Vaccination
  Delivery        Legal intervention   Status
  Puerperal       War operations

  Maternal condition affecting fetus or newborn
  Condition in the Fetus affecting the mother
                                           59


                  Note!

 American spelling is used throughout
 Volume 3 with cross-references whenever
 dipthongs appear at the beginning of a
 term
  eg Oesopahg(o) - see Esophag(o) …

English spelling is used in Volume 1
                                           60


                 Exercise 1:

Identify the lead term and the modifier
in the diagnosis:

              Chronic bronchitis
                                           61


           Exercise 1 – Answer


Identify the lead term and the modifier
in the diagnosis:

              Chronic bronchitis

    Bronchitis
        - chronic
                                             62




            A few more to practice
Identify the lead term and the modifier
in the following diagnoses:

    bleeding external hemorrhoids
    prolapsed umbilical cord complicating
         delivery
    post operative wound infection
    meningococcal meningitis
                                              63


 Identify the lead term and the modifier in the
              following diagnoses:

bleeding external hemorrhoids

Hemorrhoids
  - external
  - - bleeding, prolapsed, strangulated or
                     ulcerated I84.4
                                             64

  Identify the lead term and the modifier in the
               following diagnoses:


prolapsed umbilical cord complicating
 delivery (1)

Delivery
   - complicated (by)
   - - prolapse
   - - - cord (umbilical) O69.0
                                             65

Identify the lead term and the modifier in the
             following diagnoses:


prolapsed umbilical cord complicating
 delivery (2)

Prolapse
   - umbilical cord
   - - complicating delivery O69.0
                                              66

 Identify the lead term and the modifier in the
              following diagnoses:


post operative wound infection
Infection
    - postoperative wound T81.4

Infection
    - wound
    - - surgical T81.4
                                             67


Identify the lead term and the modifier in the
             following diagnoses:

meningococcal meningitis

Meningitis
  - meningococcal A39.0 † G01*
                                              68

                   Exercise 2:

 Look up and assign the Index code for the
  following conditions:


    laryngotracheobronchitis

    Hippel’s Disease

    Mumps with orchitis
                                             69

          Exercise 2 – Answers
Look up and assign the index code for the
 following conditions:

   laryngotracheobronchitis J40

   Hippel’s Disease          Q85.8

   Mumps with orchitis B26.0 † N51.1*
                                   70


       Index Conventions

   Parentheses ( )
   Not Elsewhere Classified NEC
   Cross references
   Point dash .-
   Other symbols
                                                                  71

                    Parentheses
 Enclose supplementary words or non
  essential modifiers
    Example: Deafness
    (acquired)(complete)(hereditary)(partial)
 Enclose Cross references
    Example:  Bronchitis
                       - capillary (see also Pneumonia, broncho)
 Enclose notes
       Example:        Bronchitis
                       - catarrhal (15 years of age and above)
 Enclose Morphology codes
    Example: Carcinoma (M8010/3)
                                                          72

       Not Elsewhere Classified NEC
 Indicates that specified variants or types of a disease
  are classified elsewhere and, where appropriate, a
  more precise term should be looked for in the index

 If the specific diagnostic term can not be located in
  the Index, then proceed using the NEC code
  indicating that the condition does not have a unique
  code

 NEC serves as a warning that there may be a better
  code that can be assigned to this documentation
                                               73

              Cross-references
 Cross-references - used to avoid unnecessary
  duplication of terms in the Index

      See - explicit instruction to look at
      another part of the Index – mandatory

     See also - useful guide to synonyms or
      alternative Index entries - not a mandatory
      instruction
                                                        74

                      Point Dash
 Certain codes listed in the Index will be followed by a
  “point dash” or .- indicating that there is a fourth
  character required to complete the code

           Index Example:
           Diabetes mellitus E14.-

 Coders should refer to the Tabular List as indicated by
  the first part of the Index code and assign the fourth
  character as per directions in the Tabular List

           Tabular Example:
           E14 Unspecified Diabetes mellitus
           [See before E10 for subdivisions]
                                                               75

          Other symbols used in Volume III

 † and *
 Dagger and asterisk system to describe aetiology and current
  manifestation - both are recorded, with † listed first

#
 See Table of Neoplasms - code specified sites to malignant
  neoplasm of skin if the type of neoplasm is a squamous cell
  carcinoma or an epidermoid carcinoma and to benign neoplasm
  of skin of these sites if the variety of neoplasm is a papilloma
◊
 See Table of Neoplasms - code as a metastasis from an
  unspecified primary sites if tumour described as carcinoma or
  adenocarcinoma, of any type other than intraosseous or
  odontogenic
                                                    76




                  Important note!
      It is imperative that Volumes I and III be
    used together to locate codes to accurately
    describe each clinical case.

      Coders should not code straight from the
    Alphabetical Index or by browsing through the
    Tabular List.
                                            77

  Module 5: Basic Coding Guidelines
 Identify the type of statement to be coded
  and refer to the appropriate section of the
  alphabetical index (diseases/nature of
  injury, external causes, drugs & chemical,
  procedures)

 Locate the lead term. Read and be guided
  by any note that appears under the lead
  term
                                            78

        Basic Coding Guidelines
   Read any terms enclosed in
    parentheses after the lead term, as
    well as any essential modifiers -
    ensure all parts of the diagnosis are
    considered

   Follow carefully any cross-references
    found in the Index

   Refer to the Tabular List
                                        79


       Basic Coding Guidelines


 Be guided by any notes and inclusion or
  exclusion terms under the selected code,
  chapter, block or category heading


Finally, assign the code!
                                                           80

                       ICD-11
 Creation of new edition of ICD announced by
  WHO in April 2007
 Anyone can contribute by registering at
  http://extranet.who.int/icdrevision

 Technical Advisory Groups (TAGs)
 Draft – international review – re-draft – field trials
  – World Health Assembly in 2014 – available for
  use 2015

 More information: Dr Robert Jakob, Medical
  Officer, WHO Geneva
  Email: jakobr@who.int
                                                   81


Module 6: What is morbidity coding?

  relates to abstraction and coding of details of the
   patient’s diagnoses and procedures during an
   episode of care in a hospital or health care
   institution


  an episode of care is a period of admitted patient
   care between an admission and a discharge or
   death or series of contacts with health
   practitioner regarding the same problem or its
   immediate consequences
                                                     82

          Sources of morbidity data
 Hospital records
 Clinic records
 School medical records
 Death certificates
 Armed services records
 Occupational medical records
 Health surveys
 Ambulatory care records (OPD, emergency department)
 Maternal and child health services records
 Registers for conditions such as congenital anomalies,
  communicable diseases etc.
 Cancer and chronic disease registry records
                                             83




        Uses of morbidity data

   management of health services
   health service planning
   equitable resource allocation
   identification of causes of disease
   evaluation of treatments
   review of public health initiatives or
         programs

                                            84




           Central concepts

   at the end of episode of care, the
    treating clinician should record ALL
    conditions which affected the patient
    and all procedures and operations
    provided during the episode of care

   the main condition should be uniquely
    identified
                                         85




             What to code?

Main condition or principal diagnosis

+/- other or secondary conditions

+/- procedures, operations and
 interventions
                                            86



 WHO definition of main diagnosis or
          main condition
…the diagnosis established at the end of
 the episode of care to be the condition
 primarily responsible for the patient
 receiving treatment or being
 investigated…that condition that is
 determined to have been mainly
 responsible for the episode of health
 care...
                                             87




Secondary diagnosis / Other condition

   a diagnosis that either co-exists with
    the main diagnosis at the time of
    admission, or which appears during
    the episode of care

   comorbidities and complications
                                            88



        What is a comorbidity?


A disease that accompanies the main
 diagnosis and requires treatment and
 additional care, in addition to the
 treatment provided for the condition for
 which the patient was admitted
                                               89



         What is a complication?


A disease that appears during the episode
 of care, due to a pre-existing condition or
 arising as a result of the care received by
 the patient
                                              90



Rules for selection of main diagnosis
          or main condition
 Used when
   the condition selected by the clinician
    is not consistent with the formal
    definition, or
   where no main condition has been
    specified or documented
                                          91



MB1 Minor condition reported as main
            condition
Where a minor, long standing or incidental
 condition is reported as the main
 condition, and a more significant
 condition relevant to the treatment given,
 is recorded as a secondary condition,
 reselect the more significant condition as
 the main diagnosis
                                           92




  Abbreviations used in exercises

MC     Main diagnosis or main condition
OC     Other / secondary conditions
Proc        Procedure or operation
Spec        Specialty
LOS         Length of Stay
                                  93

              Exercise 1:

MC      Gastritis
OC      Carcinoma of intestine
Proc          Colectomy
Length of stay     5 weeks

MC = Carcinoma of intestine

ICD-10 code = C26.0
                                      94

               Exercise 2:
MC      Impacted wisdom tooth
OC      Hypertensive heart disease
            Neuralgia
            Halitosis
Proc        Dental extraction
Spec        Dentistry
LOS         2 days

MC = Impacted wisdom tooth

ICD-10 code = K01.1
                                         95



MB2: Several conditions
recorded as main condition.
 If cannot code conditions together
  using a combination code, and other
  information on the record points to
  one of the conditions as the main
  diagnosis, select that condition

 Otherwise select the first mentioned
  condition
                                        96

              Exercise 3:

MC: Bilateral bunions
OC:     Secondary lesion, lymph node
        Malignant neoplasm of breast
Procedure: Mastectomy
Pathology: adenocarcinoma of breast
          tissue

MC = Malignant neoplasm of breast
ICD-10 code = C50.9
                                          97



           Exercise 4:
MC:          Premature rupture of
  membranes
             Breech presentation
             Anaemia of pregnancy
Procedure:
             Spontaneous Vaginal Delivery

   MC = Premature rupture of membranes
   ICD-10 code = O42.9
                                         98


  MB3: Symptoms as main
  condition
If a symptom or sign is recorded as the
 main diagnosis for a diagnosed condition
 recorded elsewhere, reselect the
 diagnosed condition as the main condition
                                       99


               Exercise 5:

MC:              Abdominal pain
OC:              Acute appendicitis
Procedure:   Appendicectomy

MC = Acute appendicitis
ICD-10 code = K35.9
                                         100


        Exercise 6:

MC:           Faecal incontinence
OC:           Angina
              Crohn’s Disease, large
  intestine
Procedure:
              Partial excision, colon

MC = Crohn’s Disease, large intestine
ICD-10 code = K50.1
                                           101




             MB4: Specificity


      Where more precise information is
    recorded elsewhere in the medical record
    about a main diagnosis which has been
    specified only in general terms, use the
    more specific information to select a
    better code
                                           102



               Exercise 7:

MC:            Congenital heart disease
X ray report: Ventricular septal defect

MC = Ventricular septal defect
ICD-10 code = Q21.0
                                               103



    MB5: Alternative main diagnoses
    Where a symptom or sign is recorded
     as the main diagnosis with an
     indication that it may be due to either
     one condition or another, select the
     symptom as the main condition.

    Where two or more conditions are
     recorded as diagnostic options for the
     main diagnosis, select the first
     condition recorded.
                                         104



  How alternative diagnoses may be
            documented
Headache due to ?stress or ?sinusitis
 Code to headache

Oesophagitis or gastric ulcer
 Code to oesophagitis

?myocardial infarction ?cardiac spasm
  Code to myocardial infarction
                                          105



             Exercise 8:


MC:    Nausea and vomiting due to food
   poisoning or due to appendicitis



MC = Nausea and vomiting
ICD-10 = R11
                                              106


              Exercse 9 :

MC:           Acute cholecystitis or acute
               pancreatitis

MC = Acute cholecystitis
ICD-10 code = K81.0
                                            107

               Exercise 10:
MC:
    Gastroenteritis due to Salmonella or
  gastroenteritis due to Yersinia

MC = Gastroenteritis due to Salmonella
ICD-10 code = A02.0
                                              108


  Main Condition & Other Conditions
Main condition selected by clinician or by
 application of reselection rules

Code the Main condition

Code Other conditions

Even if you are ‘Single Condition Coding’,
 consider all diagnoses as this can assist in
 applying the reselection rules
                                                    109


        Optional Additional Codes
 ICD-10 indicates where the coded data for a
  diagnosis can be made more specific by the
  addition of another code

 Read Section 4.4.2 Volume 2 Optional additional
  codes
                                            110


     Dagger and Asterisk System
ICD uses a Dagger (†) and Asterisk (*) system
  - dual coding to identify the aetiology and
    manifestation of certain diseases

Dagger and Asterisk codes used together
wherever possible

Asterisk codes never coded as a main
diagnosis - always use the dagger code
                                                 111

     External Causes of Morbidity and
                 Injuries

Injuries are classified by:
  their nature (Chapter XIX) S00-T98
  the external cause that led to injury (Chapter
    XX) V00-Y98

The nature of injury code is always the Main
 Condition in morbidity coding
For mortality coding, the underlying cause of
 death is the external cause code
                                               112



          Sequelae or Late Effects


Categories are available to classify a
 condition which itself is no longer present, but
 which is the cause of a current problem
                                                  113


                   Sequelae
 Need two codes
   code for current condition (residual
    condition)
   code for cause of the sequela
    (originating condition, no longer
    present or being treated) – use
    appropriate Sequelae of… category
 Cannot code the originating condition as an acute
  diagnosis because it no longer exists

 other terms used to mean sequela are:
   late effect     due to previous illness
                                            114




             Coding sequelae

e.g. paraplegia in a 50 year old male,
 sequela to childhood poliomyelitis

G82.2 Paraplegia, unspecified (see Note)
B91 Sequelae of poliomyelitis
                                                       115


   Suspected conditions, Symptoms and
          Non-illness situations

 Codes from Chapter XVIII and Chapter XXI should only
  be assigned if the clinician cannot give a definitive
  diagnosis

 The terms “suspected”, “questionable”, “probable” or
  conditions documented with a “?” should be coded to
  the degree of certainty available in the documentation –
  may require a symptom code
                                                116


         A few helpful coding hints

Be guided by the Index – many of the rules and
 guidelines are ‘built into’ Volume 3

Refer to all notes, inclusions and exclusions in
 the Tabular List – Volume 1

Check for further detail and guidance in the
 Instruction Manual - Volume 2
                                               117


             More coding hints


coding should be a joint effort by both clinician
 and coder – need good communication

never use an external cause or morphology
 code as the main diagnosis
                                                118

     Summary of guidelines for coding of
       main and secondary conditions

 MC should be selected by the treating clinician
  at end of episode of care - or, if necessary, by
  coder by applying the rules of reselection

 Once MC is selected, other conditions and
  procedures may be coded according to normal
  coding practice and the policies of the Ministry
  of Health or health care establishment
                                                  119

How clinical information is transmitted
               and coded

 Doctor documents diagnosis/intervention
 Coder abstracts diagnosis/intervention from
  clinical record
 Coder applies rules/conventions of ICD-10
 Coder/clinician consultation may be necessary
 Coder enters codes into computer system or
  onto data submission forms
 Codes submitted to various authorities
                                                      120


 Abstraction – best practice in coding
 Coders read the clinical record

 Coders extract and write down the things that are
  to be coded - this is called abstraction

 Coders use all the documentation in the clinical
  record, not just a discharge summary or front
  sheet

 Coders code a main condition, other conditions
  (if any) and possibly also interventions or
  procedures (if any) depending on the rules of the
  hospital or health institution
                                              121




          Steps in abstracting

1. Read the front sheet of the medical
   record
2. Read the discharge summary, if available
3. Compare the diagnoses – if differences,
   check test results, other reports
4. Read the history and physical
   examination
    ?reason for admission ?comorbidities
                                                   122




           Steps in abstracting
5. Identify procedures to be coded
6. Verify diagnoses and procedures documented
   on front sheet
7. Review entire record – correspondence,
   progress notes, radiology/laboratory reports,
   procedure/anaesthetic reports
8. If uncertain, clarify with treating clinician
9. Code the main condition/diagnosis, secondary
   diagnoses/other conditions, external causes,
   procedures
                                           123




Module 7: Overview of mortality coding

  ICD has its origins in the preparation of
   mortality statistics
  Death certificates are the main source of
   mortality data
  The person certifying the cause of death
   will enter the sequence of events leading
   to the death on the death certificate in
   international format
                                                                                                  124

Completed Medical Certificate of Cause of Death
 I                                                                                   Duration between
 Disease or condition            (a)…Acute on chronic renal failure                  onset and death
                                                                                     …12 days…
 directly leading to             due to or as a consequence of
 death*                                                                              …1 year
 Antecedent causes                 (b)…Glomerulonephritis…..
 Morbid conditions               due to or as a consequence of
 giving rise to the above
 cause, stating the underlying    (c)….Diabetic nephropathy…                         …5 years ……
 condition last                   due to or as a consequence of
                                 (d)…Diabetes Type II…                               …10 years…



 II
 Other significant conditions   Femoral neck fracture, femoral fracture              1 month
                                                                                     ……………………
 contributing to the death,      repair, Post operative; haematoma
                                                                                     ……………………
 but not related to the disease   ………………………………
 or condition causing it        ………………………………
 *This does not mean the mode of dying e.g. heart failure, respiratory failure. It
 means the disease, injury or complication that caused death.
                                             125



                Exercise 1:

Mortality data, in the form of ICD codes,
is mainly used for a particular purpose.
Is it:

1. Analysis of current causes of death ?
2. Management of public health ?
3. Prevention of major causes of death ?
                                                       126

            Exercise 1 - Answer:

 Mortality data, in the form of ICD codes,
 is mainly used for a particular purpose.
 Is it:
 1. Analysis of current causes of death ?
 2. Management of public health ?
 3. Prevention of major causes of death ?

 It is part of the overall process that leads to 3.
  Prevention of major causes of death.

 data analysis  resource management 
  prevention
                                               127



   UNDERLYING CAUSE OF DEATH
         (WHO definition)


 the disease or injury which initiated the
  train of morbid events leading directly to
  death; or

 the circumstances of the accident or
  violence which produced the fatal injury
                                       128


             Exercise 2:


What would be the underlying cause
 of
 death in this case?



     Coma resulting from subdural
     haematoma after a fall at work
                                       129


        Exercise 2 - Answer:


What would be the underlying cause
 of
 death in this case?



     Coma resulting from subdural
     haematoma after a fall at work
                                                 130


    Parts of the International Format for
              Death Certificates

 Part I - is used for diseases related to the
  sequence of events leading directly to the
  death

 Part II - is used for unrelated conditions
  which have no direct connection with the
  events leading to death but which, by their
  nature, contributed to death
                                           131




              Exercise 3:

Where do you think the underlying cause
of death should be entered on the death
certificate shown on the first page
of this module?
                                           132




          Exercise 3 - Answer:

Where do you think the underlying cause
of death should be entered on the death
certificate shown on the first page
of this module?

Lowest used line of Part 1.
                                                 133
 The completed death certificate contains the
 following information:

     I(a)   Direct cause
      T
      (b)   Intervening Cause of (a)
      I
      (c)   Intervening cause of (b)
      M
      (d)   Originating cause of (c)
      E
     II     Other contributory causes

 For example:
      I(a)  Heart failure
       (b)  Carcinomatosis
       (c)  Cancer of the colon
       (d)  -
                                                134

       Valid ICD-10 UCOD Codes
 There are some ICD-10 codes which
    MAY NOT be assigned as UCOD:


  Asterisk (*) codes indicate the current
    manifestation of diseases, it is the
    aetiology or dagger (†) code that will be
    assigned as UCOD
  Z Codes (Z00-Z99) Factors influencing
    health status and contact with health
    services
  A range of other codes from various
    chapters of the ICD-10 – see notes in
    the Tabular list and volume 2
                                                   135


                 Exercise 4:
 Find the following examples.

 B95-B97 Bacterial, viral and other infectious
                  agents
 G97,H95, N99 Post procedural disorders (Note
            the cross reference to Section 4.2.6
                   “Operations” in volume 2)
 O80 - O84 Method of delivery
 S00 - T98 Injury, poisoning and certain other
                   consequences of external
  causes
                                                136

B95-B97 Bacterial, viral and other infectious
                  agents

The note at the Section (B95-B97) states:

Note:     These categories should never
 be used in primary coding. They are
 provided for use as supplementary or
 additional codes when it is desired to
 identify the infectious agent(s) in diseases
 classified elsewhere.
                                                      137

  G97,H95, N99 Post Procedural Disorders
 The UCOD for death resulting from a post procedural
  disorder is coded to the disease for which the
  procedure was performed unless a specific code
  exists
     Eg: Complication of appendectomy = Code to
  K37 Unspecified Appendicitis

 If the certificate does not identify this disease, code
  to the residual category indicated by the name of the
  operation.
      Eg. “Nephrectomy” Code to N28.9 Disorder of
  kidney and ureter, unspecified
                                         138

     O80 - O84 Method of delivery
The note at Section (O80-O84) states:

Note:    Codes O80-O84 are provided for
 morbidity coding purposes. Codes from
 this block should be used for primary
 morbidity coding only if no other
 condition classifiable to Chapter XV is
 recorded. For use of these categories
 reference should be made to the morbidity
 coding rules and guidelines in Volume 2.
                                               139
S00 - T98 Injury, poisoning and certain other
     consequences of external causes.
In deaths due to injury the UCOD is not the
 nature of injury (eg. Fractured skull with
 intracranial injury) but the “External Cause”
 of the injury . (eg; Hit by falling brick, Motor
 Vehicle Accident, Fall down stairs)

Exceptions where G40 –G41.9 Epilepsy and
 Status epilepticus or A35 Other tetanus are
 mentioned on the certificate. The presence of
 these conditions on a certificate will
 “modify” the UCOD.
More on this later…
                                                     140

            Identifying the UCOD
 where there is only one condition entered on the
  certificate, select it as the UCOD
 the UCOD should be entered alone on the lowest
  used line of Part 1 of the certificate
 not all certificates are completed correctly and
  simply selecting this condition does not always
  provide the best UCOD for prevention and public
  health purposes
 to overcome this, WHO has developed a set of
  “Rules for Selection and Modification” of the
  UCOD
 these rules require no clinical knowledge, just
  coding skill
                                                141



Selection of the underlying cause of death:
    use of the MMDS Decision Tables

The ACME Decision Tables are a part of
 the Medical Mortality Data System (MMDS)
They facilitate application of the selection
 and modification rules by describing the
 causal relationships between COD listed
 on the death certificate
Contain 8 tables Table A –F.
                                                   142

  Understanding Causal Relationships
 To apply the WHO Selection Rules we need to
  know which diseases can and which can’t cause
  other diseases
 To interpret these causal relationships we use the
  decision tables contained within the US National
  Center for Health Statistics (NCHS) Medical
  Mortality Data System (MMDS)
 This ensures consistent application of the
  selection and modification rules across
  jurisdictions and assists with comparable cause
  of death data
 We use Table D and Table E of the MMDS
  Decision Tables to determine valid causal
  relationships
                                                 143


            ACME Decision Tables
Table A lists each ICD-10 code that is valid for
 use in both multiple and underlying cause
 coding

Table B lists those codes valid for use in
 multiple cause coding but NOT underlying
 cause coding

Table C lists all ICD-10 codes that are invalid for
 BOTH multiple and underlying cause coding
                                               144


          ACME Decision Tables Cont.

Table D is used to determine the causal
 relationships relevant to application of the
 General Principle and Selection Rules 1 and 2.

Table E is used for application of Selection Rule
 3, Modification Rule A Senility and ill-defined
 conditions, Modification Rule C Linkage and
 Modification Rule D Specificity
                                               145


        ACME Decision Tables Cont.

Table F explains most ambivalent entries found
 in Table D and Table E.

Table G is the list of code conversions for
 ‘created’ ICD-10 categories.

Table H contains the list of codes considered to
 be trivial
                                                 146




           GENERAL PRINCIPLE:

      When more than one condition is
    entered on the certificate, the condition
    entered alone on the lowest used line of
    part I should be selected only if it could
    have given rise to all the conditions
    entered above it

      Table D
                                              147

    Example: GENERAL PRINCIPLE:

 Part I (a) Abscess of lung and
  septicaemia

           (b) Lobar pneumonia

     Select lobar pneumonia (J18.1) as the
    underlying cause as the lung abscess
    and septicaemia could both have been
    the result of the lobar pneumonia
                                                         148


     Using Decision Table D – General Principle

 Example certificate – General Principle

 Part I    a.    Heart failure (I50.9)
      instant
           b.    Acute myocardial infarction (I21.9)
      minutes
           c.    Generalised arteriosclerosis (I70.9)    5
  years
           d.    Hypertension (I10)                      10
  years

 Part II
                                                                149


    Using Decision Table D – General Principle
             - - - I700– I709 - - -       Address (range of
  codes)
     M       A500     – A539              Sub-address (range of
  codes)
             E000     – E059              Sub-address (range of
  codes)
              “““““““““
     M       E890 – E899                  Sub-address (range of
  codes)
             I10      – I150              Sub-address - includes
  I10
             I159                         Sub-address (individual
  code)
             I700     – I709              Sub-address (range of
  codes)

 Hypertension (I10) can cause Atherosclerosis (I70.9)
                                                               150


    Using Decision Table D – General Principle
             - - - I219 - - -             Address
             A000 – A09
         M   A181
             A200 – B89
               “““““““
             I080 – I083        *
             I10 – I359         *         Sub-address - includes
    I10       I400 – I669        *
             I690 – J80         *

 Hypertension (I10) can cause Acute Myocardial Infarction (I21.9)
                                                                  151


    Using Decision Table D – General Principle


                    - - - I440 – I509 - - -          Address
                         A000 – G98
               M         H000 – H959
                         I00 – L599                  Sub-address -
    includes I10 M        L88 – L929
                           “““““““

 Hypertension (I10) can cause Heart Failure (I50.9)
                                                      152


  Using Decision Table D – General Principle

 Therefore:

 Hypertension (I10) can cause all the conditions listed
  above it and is selected as the Tentative Underlying
  Cause of death (TUCOD)
                                                153


      Introducing the Tentative UCOD

The UCOD determined by application of the
 Selection Rules is considered Tentative
 because it may be changed when we apply the
 Modification Rules

Selection and Modification Rules are applied
 and re-applied to the certificate until the Final
 UCOD can be determined
                                           154



               Exercise 5:


Select the underlying cause, applying
 the general principle:

    I (a) Hepatic failure
      (b) Bile duct obstruction
      (c) Carcinoma of head of pancreas
                                           155



         Exercise 5 – Answer:


Select the underlying cause, applying
 the general principle:

    I (a) Hepatic failure
      (b) Bile duct obstruction
      (c) Carcinoma of head of pancreas
                                                156

                    RULE 1
     If the General Principle does not apply
  and there is a reported sequence
  terminating in the condition first entered
  on the certificate, select the originating
  cause of this sequence
     If there is more than one sequence
  terminating in the condition mentioned
  first, select the originating cause of the
  first-mentioned sequence
     Table D
                                                                     157
                      Example 1: RULE 1
Part I (a) Bronchopneumonia             (1st condition entered on
    certificate)


                  (b) Cerebral infarction and hypertensive
                                               heart disease
            (Originating cause of first mentioned sequence)


There are two reported sequences terminating in
  the condition first entered on the certificate.
Select cerebral infarction, the originating cause
  of the first-mentioned sequence is selected.
                                              158




                  RULE 1

Rule 1 is also invoked if the single
 condition entered on the lowest used line
 on the certificate could not have resulted
 in all of the conditions listed above but
 there is a sequence terminating in one of
 the other conditions
                                                                         159
                       Example 2: RULE 1
 Part I (a) Acute myocardial infarction (AMI)
                                      (1st condition entered on
    certificate)

                  (b) Atherosclerotic heart disease
                                    (Originating cause of first mentioned

    sequence)

                  (c) Influenza

     Select atherosclerotic heart disease. This is the
  originating cause of the condition first entered on the
  certificate (AMI).
     Influenza could not have caused the atherosclerotic
  heart disease or the myocardial infarction.
                                                                160


           Using Decision Table D – Rule 1
 Example certificate – Rule 1
 Part I       a. Heart failure (I50.9)
       instant
              b. Portal hypertension (K76.6)                   6
  months
              c. Liver Cirrhosis (K74.6), Alcoholism (F10.2)   2 yrs,
  15 yrs
              d.
 Part II
                                                      161


       Using Decision Table D – Rule 1


 Heart failure     Heart failure        Heart failure
        ↑                          ↑                    ↑
 Portal HTN        Portal HTN           Portal HTN
        ↑                      ↑
 Liver Cirrhosis           Alcoholism
                                                    162


    Using Decision Table D – Rule 1

         - - - I440 – I509 - - -        Address
             A000 – G98
       M     H000 – H959
             I00 – L599            < (K766)
       M     L88 – L929
                                                                               163
         Using Decision Table D – Rule 1
                  - - - K766 - - -
                  M A000 –B99
                     C000 –D539
                     ““““““
                     E100 –E149
                     E500 –E849
                     F100 –F169              < (F102)
                     I050 –I099
                     I110 –I119
                     I130 –I519
                     I81
                     K500 –K519
                     K630 –K639
                     K700 –K718
                     K730 –K760              < (K746)
                  M K761
                     K763
                  ““““““
 Both Liver cirrhosis (K74.6) and Alcoholism (F10.2) can cause Portal Hypertension
  (K76.6).
                                                           164


       Using Decision Table D – Rule 1
 Here we have two sequences terminating in the
  condition first entered on the certificate.

 Heart failure I50.9        Heart failure   I50.9
              ↑        ↑                   ↑       ↑
 Portal HTN     K76.6       Portal HTN      K76.6
              ↑        ↑                   ↑       ↑
 Liver Cirrhosis      K74.6         Alcoholism    F10.2

 When there is more than one sequence……. We select that which is
  first mentioned. Our Tentative UCOD is K74.6 Liver Cirrhosis.
                                165




               Exercise 6:

Select the underlying cause:

I (a) Pericarditis
 (b) Uraemia and pneumonia
                                166




         Exercise 6 – Answer:

Select the underlying cause:

I (a) Pericarditis
 (b) Uraemia and pneumonia
                                                 167




                    RULE 2

      If there is no reported sequence
    terminating in the condition first entered
    on the certificate, select this first-
    mentioned condition

      Table D
                                               168



                Example: RULE 2
 Part I (a) Pernicious anaemia and gangrene of
  foot              X




           (b) Atherosclerosis

     Select pernicious anaemia (D51.0). There is no
    reported sequence terminating in the pernicious
    anaemia, which is the first mentioned condition.
                                                           169


        Using Decision Table D – Rule 2

 Part I    a. Pernicious anaemia (D51.0) and gangrene of foot
  (R02)
           b. Atherosclerosis (I70.9)
           c.
           d.

 Part II
                                                                   170
       Using Decision Table D – Rule 2
 Step 1.      Does the general principle apply?
 Step 2.      Is I709 listed as sub-address under D51.0?
          - - - D510 - - -
     M        A000 –B99
              C160 –D169
     M        C788
              D510
              E530 –E539
              R75
 Atherosclerosis (I70.9) is not listed under code address D510.


 This tells us two things…
                                                                171


       Using Decision Table D – Rule 2
 1. the General Principle does not apply
 2. Neither does Rule 1, because the only sequence terminating in
  the condition first mentioned on the certificate is:

      Pernicious anaemia (D51.0)
             due to
      Atherosclerosis (I70.9)

 We have already tested this relationship in attempting to apply the
  General Principle

 Therefore we apply Rule 2 and select Pernicious anaemia (D51.0) as
  tentative UCOD
                                             172




               Exercise 7:

Select the underlying cause of death:

I (a) Fibrocystic disease of the pancreas
 (b) Bronchitis and bronchiectasis
                                             173




          Exercise 7 – Answer:

Select the underlying cause of death:

I (a) Fibrocystic disease of the pancreas
 (b) Bronchitis and bronchiectasis
                                              174




                    RULE 3

      If the condition selected by the General
    Principle or by Rule 1 or Rule 2 is
    obviously a direct consequence of another
    reported condition, whether in Part I or
    Part II, select this primary condition

      Table E
                                                     175

             Modifying the UCOD
 The clinically based UCOD referred to as the
  Tentative Underlying Cause of Death (TUCOD)
 The TUCOD may be further modified for statistical
  and tabulation purposes
 Rule 3 applies if the TUCOD is the obvious
  consequence of another reported condition
 Modification rules are applied to the TUCOD when
  particular criteria are met
 We use Table E of the MMDS Decision Tables to
  determine if the TUCOD changes as a result of
  rule 3 or meets the required criteria of the six (6)
  Modification Rules
                                            176


          Using Decision Table E

Selection Rule 3

Modification Rules:
 A Senility and other ill-defined conditions
 C Linkage
 D Specificity
                                                   177


               Decision Table E

          - - - I058 - - -     <   Address = Tentative
    UCOD
LMC              I060 –I069        I080 < Combination
LMC              I070 – I079       I081 < Codes
LMP              I080 – I081
DSC              I082              I083 <
SMP              I083
LMP       M      I088
                                                        178


       Using Decision Table E – Rule 3
 Table E Acronyms relevant to Selection Rule 3
 DS: (Direct Sequel) - When the tentative underlying
  cause is considered a direct sequel (DS) of another
  condition on the certificate in Part I because it is
  reported on the same or a lower line as the tentative
  underlying cause, or if it is reported in Part II, the code
  for that other condition is preferred over the code for
  the tentative underlying cause

 DSC: (Direct Sequel Combined) - When the tentative
  underlying cause is considered a direct sequel of
  another condition on the certificate in Part I (must be on
  the same or lower line as tentative underlying cause) or
  in Part II, and the codes for the tentative underlying
  cause and the other condition combine into a third code
                                               179


          Using Decision Table E – Rule 3

Part I      a. Sepsis (A41.9)
            b. Cerebral oedema (G93.6)
             c.
            d.

Part II Intracranial Brain Stem Haemorrhage (I61.3)
                                                       180


        Using Decision Table E – Rule 3

                   - - - G93.9 - - -   <      Address =
    Tentative
DS             A066                    UCOD
DS             A170 –A179
                ““““““
DS             G970 –G979
DS             I600 –I698       < (I61.3)
DS M           J108
                                               181


     Using Decision Table E – Rule 3

Part I     a. Mitral valve failure (I058)
           b.
           c.
           d.

Part II   Aortic and tricuspid insufficiency (I082)
                                                   182


      Using Decision Table E – Rule 3
           - - - I058 - - -             < Tentative
  UCOD
 LMC               I060 –I069    I080
 LMC               I070 – I079   I081
 LMP               I080 – I081
 DSC               I082          I083   < (I058 + I082
  = I083)
 SMP               I083
 LMP       M       I088
 LMC       M       I098          I088
 LMP               I340 –I349
                                               183
                   Example: RULE 3
Part I      (a)    Bronchopneumonia

Part II            Secondary anaemia and chronic
                    lymphatic leukaemia

      Select chronic lymphatic leukaemia (C91.1).
    Bronchopneumonia, selected by the General
    Principle, and secondary anaemia, can both be
    considered direct sequels of chronic lymphatic
    leukaemia
                                       184



             Exercise 8 :


Select the underlying cause of death.

I(a) Nephrectomy

II   Clear Cell carcinoma of kidney
                                       185



         Exercise 8 - Answer:


Select the underlying cause of death.

I(a) Nephrectomy

II   Clear Cell carcinoma of kidney
                                                       186

               Modification Rules
 Rule A - Senility and other ill-defined conditions

 Rule B - Trivial conditions

 Rule C - Linkage

 Rule D - Specificity

 Rule E - Early and late stages of disease

 Rule F - Sequelae
                                                        187
  Rule A - Senility and other ill-defined
              conditions
 Where the selected cause is ill-defined and a condition
  classified elsewhere is reported on the certificate,
  reselect the cause of death as if the ill-defined condition
  had not been reported, except to take account of that
  condition if it modifies the coding. The following
  conditions are considered ill-defined: I46.9 (Cardiac
  arrest, unspecified), I95.9 (Hypotension unspecified), I99
  (Other and unspecified disorders of circulatory system),
  J96.0 (Acute respiratory failure), J96.9 (Respiratory
  failure unspecified), P28.5 (Respiratory failure of
  newborn), R00-R94 or R96-R99 (Symptoms, signs and
  laboratory findings, not elsewhere classified).

 Note that R95 (Sudden Infant Death Syndrome) is not
  regarded as ill-defined.
                                                 188
           Rule A – Table E Acronyms
             Ill-Defined Conditions
       IDDC: Ill-Defined, Due to, Combined

        When the tentative underlying cause is an
    ill-defined condition in the due to position to
    another condition, and the codes for the
    tentative underlying cause and the other
    condition combine into a third code.

                                                   189
         Rule A – Table E Acronyms
                   Senility
SENMC: Senility, Mention, Combined

    When the tentative underlying cause is
  senility (R54), and this condition is reported
  with mention of another condition on the
  certificate, and the codes for the tentative
  underlying cause and the other condition
  combine into a third code.
                                                   190
             Rule A – Table E Acronyms
                       Senility
      SENDC: Senility, Due to, Combined

       When the tentative underlying cause is senility
    (R54), and is reported in a due to position to
    another condition, and the codes for the tentative
    underlying cause and the other condition combine
    into a third code.
                                                         191


                       Example
 Example:
I   (a) Senility (R54) and hypostatic pneumonia (J18.2)
    (b) Rheumatoid arthritis (M06.9)

 Senility is selected as the tentative UCOD by Rule 2

 Refer to Modification Rule A and reselect the Tentative
  UCOD as if Senility had not been mentioned
                                                         192


                         Example

Our certificate now looks like this.

 I(a) Senility (R54) and hypostatic pneumonia (J18.2)
 (b) Rheumatoid arthritis (M06.9)


       With Senility removed from the certificate we reselect
    the Tentative UCOD as Rheumatoid arthritis (M06.9) by
    applying the General Principle.
                                        193




             Exercise 9:

Select the underlying cause of death.

I(a) Myocardial degeneration (I51.5)
 and emphysema (J43.9)
 (b) Senility (R54)
                                        194




        Exercise 9 – Answer:

Select the underlying cause of death.

I(a) Myocardial degeneration (I51.5)
 and emphysema (J43.9)
 (b) Senility (R54)
                                                         195

Rule B - Trivial Conditions – Table H
                Part A
 A.     Where the selected cause is a trivial
    condition unlikely to cause death, and a more
    serious condition (any condition except an ill-
    defined or another trivial condition) is reported,
    reselect the underlying cause as if the trivial
    condition had not been reported.

       When a trivial condition is reported as
    causing any other condition, the trivial condition
    is NOT discarded, i.e. Rule B is not applicable.
                                            196

     Rule B - Trivial Conditions
               Part B

 B. If the death was the result of an
  adverse reaction to treatment of the trivial
  condition, select the adverse reaction.
                                            197

     Rule B - Trivial Conditions
               Part C

 C. When a trivial condition, is reported as
  causing another condition, the trivial
  condition is NOT discarded (i.e. Rule B is
  not applicable)
                                            198




               Exercise 10:

Select the underlying cause of death.

I(a) Ingrowing toenail (L60.0) and acute
 renal failure (N17.9)
                                            199




         Exercise 10 – Answer:

Select the underlying cause of death.

I(a) Ingrowing toenail (L60.0) and acute
 renal failure (N17.9)
                                              200




       Rule C – Linkage – Table E

 Where the selected cause is linked by a
  provision in the classification or in the
  notes for use in underlying cause
  mortality coding, with one or more of the
  other conditions on the certificate, code
  the combination.
                                                  201




               Rule C - Linkage

       Where the linkage provision is only for
    the combination of one condition
    specified as due to another, code the
    combination only when the correct causal
    relationship is stated or can be inferred
    from application of the selection rules.
                                                   202




               Rule C - Linkage


       Where a conflict in linkage occurs, link
    with the condition that would have been
    selected if the cause initially selected had
    not been reported. Make any further
    linkage that is applicable.
                                                            203


   Rule C – Linkage Table E Acronyms
 LMP: Linkage, Mention, Preferred
     When the tentative underlying cause is
  reported with mention of another condition in
  Part I or Part II of the certificate, and the code for
  the other condition is preferred over the code for
  the tentative underlying cause.

 LMC: Linkage, Mention, Combined
     When the tentative underlying cause is
  reported with mention of another condition, in
  Part I or Part II of the certificate, and the codes for
  the tentative underlying cause and the other
  condition combine into a third code.
                                                       204


   Rule C – Linkage Table E Acronyms
 LDP: Due to, Preferred
     When the tentative underlying cause is
  reported in the due to position to another
  condition, and the code for the other condition is
  preferred over the code for the tentative
  underlying cause.

 LDC: Linkage, Due to, Combined
     When the tentative underlying cause is
  reported in the due to position to another
  condition, and the codes for the tentative
  underlying cause and the other condition
  combine into a third code.
                                        205



              Exercise 11:


Select the underlying cause of death

I (a) Cerebral infarction (I63.9)
 (b) Hypertension (I10)
 (c) Atherosclerosis (I70.9)
                                     206



         Exercise 11 – Answer:


Select the underlying cause of death.

I (a) Cerebral infarction (I63.9)
 (b) Hypertension (I10)
 (c) Atherosclerosis (I70.9)
                                            207




     Rule D – Specificity – Table E

       Where the selected cause describes a
    condition in general terms, and a term
    that provides more precise information
    about the site or nature of this condition
    is reported on the certificate, prefer the
    more informative term. This rule will
    often apply when the general term
    becomes an adjective qualifying the more
    precise term.
                                                208


 Rule D – Specificity Table E Acronyms

SDC: Specificity, Due to, Combined

     When the tentative underlying cause is
  reported in the due to position to another
  condition, and can be regarded as an
  adjective modifying this condition, and the
  codes for the tentative underlying cause
  and the other condition combine into a
  third code
                                               209


 Rule D – Specificity Table E Acronyms
SMP: Specificity, Mention, Preferred

       When the tentative underlying cause
    describes a condition in general terms, and a
    condition which provides more precise
    information about the site or nature of this
    condition is reported anywhere on the
    certificate, the code for the more precise
    condition is preferred over the code for the
    tentative underlying cause
                                               210


 Rule D – Specificity Table E Acronyms

SMC: Specificity, Mention, Combined

       When the tentative underlying cause
    describes a condition in general terms, and a
    condition which provides more precise
    information about the site or nature of this
    condition is reported anywhere on the
    certificate, and the codes for the tentative
    underlying cause and the other condition
    combine into a third code
                                         211




             Exercise 12:

Select the underlying cause of death.

I (a)    Pericarditis (I31.9)
 (b)     Uraemia (N19)
                                         212




         Exercise 12 – Answer:

Select the underlying cause of death.

I (a)     Pericarditis (I31.9)
 (b)      Uraemia (N19)

Uraemic pericarditis N18.8
                                           213

    Rule E - Early and late stages of
          disease - durations

    Where the selected cause is an early
  stage of a disease, and a more advanced
  stage of the same disease is reported on
  the certificate, code to the more
  advanced stage.
    This rule does not apply to a
  "chronic" form reported as due to an
  "acute" form unless the classification
  gives special instructions to that effect.
                                        214




              Exercise 13:

Select the underlying cause of death

I(a) Chronic myocarditis
 (b) Acute myocarditis
                                        215




         Exercise 13 – Answer:

Select the underlying cause of death

I(a) Chronic myocarditis
 (b) Acute myocarditis
                                            216




       Rule F – Sequelae - notes
       Where the selected cause is an early
    form of a condition for which the
    classification provides a separate
    "Sequelae of …" category, and there is
    evidence that death occurred from
    residual effects of this condition rather
    than from those of its active phase, code
    to the appropriate "Sequelae of …"
    category.
                                        217




              Exercise 14:

Select the underlying cause of death

I(a) Hydrocephalus
 (b) Tuberculosis meningitis
                                           218




         Exercise 14 – Answer:

Select the underlying cause of death

I(a) Hydrocephalus
 (b) Tuberculosis meningitis

Sequela of Tuberculous meningitis (G09)
                                                 219



    ASSUMPTION OF INTERVENING
             CAUSE

       On some medical certificates, one
    condition may be indicated as due to
    another, but the first one is not a direct
    sequel of the other. In such cases you
    may safely assume the intervening
    causes. You should only assume an
    intervening cause for the purpose of
    interpreting the sequence.
                                         220




              Exercise 15:

Select the underlying cause of death.

I(a) Mental retardation
 (b) Premature separation of
     placenta
                                              221




             Exercise 15 – Answer:
Select the underlying cause of death.

I(a) Mental retardation
 (b) Premature separation of placenta

      It is necessary to assume birth trauma,
    anoxia or hypoxia as a condition intervening
    between mental retardation and the underlying
    cause, premature separation of placenta.
                                            222


        HIGHLY IMPROBABLE
 Sometimes the recorded sequence is
  highly improbable, i.e. non-acceptable
  sequence.

 Note that acute or terminal circulatory
  disease which are reported as being due
  to: malignant neoplasm, asthma or
  diabetes are acceptable as possible
  sequences when they occur in PART I of
  the certificate.
                                                    223

                   Exercise 16:
      Read through the list in volume 2 at 4.2.2

      Decide whether the following sequences
    are acceptable or not:

Tetanus due to malignant neoplasm of the lung

Diabetes due to malignant neoplasm of the
 pancreas
                                                 224

             Exercise 16 – Answer:

      Using the list, decide whether the following
    sequences are acceptable or not:

Tetanus due to malignant neoplasm of the lung
      Highly improbable (b)
Diabetes due to malignant neoplasm of the
 pancreas Acceptable sequence (e)
                                              225




                 DURATION

      The stated time factor in a sequence
    should be considered. This is important
    when you are considering whether one
    condition was caused by another.
                                                  226

                 Exercise 17:
      When can malformation, deformation or
    chromosomal abnormality be considered to be
    congenital?

(a) only when it is stated to be congenital by
 the certifier

(b) when it is clear that the condition existed
 from birth
                                                  227

            Exercise 17 – Answer:
      When can malformation, deformation or
    chromosomal abnormality be considered to be
    congenital?

(a) only when it is stated to be congenital by
 the certifier

(b) when it is clear that the condition existed
 from birth
                                               228

                  SEQUELAE
     The terms sequelae or late effects are used
  to describe a certain group of conditions
  where a considerable amount of time might
  elapse between cause and effect.
     The aetiology or originating condition is
  often no longer present when the late effect
  occurs. Certain categories in ICD-10 have
  been designated for use in coding sequelae as
  the underlying cause of death. See Volume 2
  Section 4.2.4.
                                                229

                  Exercise 18 :

      Which modification rule applies to
    sequelae?

      Does the interval between the original
    disease and its sequelae matter, for the
    purposes of underlying cause coding?
                                                       230

               Exercise 18 – Answer:

      Which modification rule applies to
    sequelae?
      Modification Rule F


      Does the interval between the original
    disease and its sequelae matter, for the
    purposes of underlying cause coding?
       No. Guidance about coding of sequelae for
    mortality purposes is given in most of the appropriate
    categories in the tabular listing.
                                                 231

                  Nature of Injury
       Although the external cause of an injury or
    injuries should be coded as the UCOD, the
    WHO also recommends that the nature of
    injury is also classified.

       When more than one kind of injury to a
    single body region is recorded, and there is no
    clear indication as to which caused death, you
    must apply the General Principle and selection
    rules in the usual way.
                                                        232

                       Malignancy
    When malignancy is given as the underlying
  cause of death four factors must be taken into
  consideration when assigning a code.
    These are the:
                 Site of the neoplasm
                 Morphology of the neoplasm
                 Behaviour of the neoplasm
                 Whether the site is the primary site or
  a               metastasis

        If there are 4 factors associated with recording
    malignant neoplasms as a cause of death then it is not
    surprising that problems can arise with the way the
    certificate has been completed.
                                                    233



Questions about a particular certificate
         or cause of death?
 You can get support from the Mortality Forum!
  Email discussion list for coders who code
  mortality data.

 To send a query to the Mortality Forum, address
  e-mail to:
             mortforum@nordclass.uu.se
 Past discussions in the Mortality Forum are
  posted to the Nordic CollaboratingCentre’s web
  site for the Mortality Forum
                www.nordclass.uu.se


				
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