There are 3 parts to MCCD that you already from the course earlier:
1 - Constructing a correct sequence of events and identifying the underlying cause-of-death
2 - Selecting the correct ICD-10 code
3 - Filling the death certificate correctly
What you already and what is !
knew
new
knew
Given that there is a disease (COVID) now, the thing you need to update your knowledge is:
1 - Become familiar with a new category of codes that WHO has temporarily kept aside for emergency situations like this
new
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WHO has provided a new ICD code for Coronavirus Disease 2019 (COVID-19) – U07.1
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The WHO has also provided a second code, U07.2, for clinical or epidemiological diagnosis of COVID-19 where a laboratory confirmation is not available
Let us consider first set of scenarios
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Person with symptoms (3 days of fever and dry cough and 1 day of breathlessness) and who had recently attended a mass gathering presented to a hospital; here, he had a nasal swab done and was hospitalized
Patient 1
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The report came as COVID positive
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The patient quickly deteriorated to have a pneumonia and then within few days developed sepsis and then died
How will you proceed with certification and coding?
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Person with symptoms (3 days of fever and dry cough and 1 day of breathlessness) who had prolonged contact with a known COVID patient came to the hospital; here, she had a nasal swab done and was hospitalized
Patient 2
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The report came as COVID positive
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The patient quickly deteriorated to have a pneumonia and then within few days developed adult respiratory distress syndrome in the ICU and then died
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This patient also had other pre-existing co-morbidities and also reported that this COPD was not responding to his usual medicines
How will you proceed with certification and coding?
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Step 3 - Fill in a death certificate with the appropriate diagnoses and codes in both cases
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Step 1- Construct biological sequence of events to identify Underlying, Intermediate and Immediate Cause of Death
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Step 2 - Assign appropriate ICD code
| Underlying CoD |
|---|
| Intermediate CoD |
|---|
| Immediate CoD |
|---|
Patient 1
| COVID, virus identified |
|---|
| Pneumonia |
|---|
| Sepsis |
|---|
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Step 1- Construct biological sequence of events to identify Underlying, Intermediate and Immediate Cause of Death
Patient 1
COVID should be the underlying cause-of-death
To assign an ICD code; see the new U category of codes for COVID
| Underlying CoD |
|---|
| Intermediate CoD |
|---|
| Immediate CoD |
|---|
Patient 2
| COVID, virus identified |
|---|
| Pneumonia |
|---|
| Adult Respiratory Distress Syndrome |
|---|
-
Step 1- Construct biological sequence of events to identify Underlying, Intermediate and Immediate Cause of Death
Patient 2
COVID should be the underlying cause-of-death
To assign an ICD code; see the new U category of codes for COVID
As we have learnt earlier in the MCCD course, the co-morbidities should be listed in Part II as a contributory cause
Now let us consider the second set of scenarios
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A known case of Ca-breast and a past history of ischaemic heart diseases was admitted in the hospital
Patient 3
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She was diagnosed to have metastatic disease of brain, bone and kidneys
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Meanwhile, she also underwent a test for COVID (with no relevant contact history or fever or chest symptoms) and was found to be positive
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She died in the ward due to her extensive metastatic disease
How will you proceed with certification and coding?
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A pregnant woman was brought to the hospital with obstructed labour followed by uterine rupture and then prolonged haemorrhage
Patient 4
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Meanwhile, she also underwent a test for COVID (with no relevant contact history or fever or chest symptoms) and was found to be positive
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She died in the ward due to obstetric hemorrhage
How will you proceed with certification and coding?
| Underlying CoD |
|---|
| Intermediate CoD |
|---|
| Immediate CoD |
|---|
Patient 3
| Carcinoma breast |
|---|
| XXXXXX |
|---|
| Metastasis - multiple |
|---|
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Step 1- Construct biological sequence of events to identify Underlying, Intermediate and Immediate Cause of Death
Patient 3
COVID will not be the underlying cause-of-death but a contributory cause to be entered in part II
To assign an ICD code; see the appropriate chapter, block and sub block
| Underlying CoD |
|---|
| Intermediate CoD |
|---|
| Immediate CoD |
|---|
Patient 4
| Obstructed labour |
|---|
| Rupture uterus |
|---|
| Postpartum hemorrhage |
|---|
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Step 1- Construct biological sequence of events to identify Underlying, Intermediate and Immediate Cause of Death
Patient 4
COVID will not be the underlying cause-of-death but a contributory cause to be entered in part II
In a pregnant woman with obstetric complications and COVID only as a contributory illness, the obstetric CoD should be the underlying CoD
Filling death certificate…if lab confirmation for COVID is
unavailable
Clinicians may also suspect COVID in some of their patients because of the typical illness, but lab testing and confirmation may be delayed or unavailable. In such cases, they can use another code offered by W.H.O. This is described in next set of slides
| Underlying CoD |
|---|
| Intermediate CoD |
|---|
| Immediate CoD |
|---|
Patient 5
| COVID, virus not identified |
|---|
| Pneumonia |
|---|
| Sepsis |
|---|
-
Step 1- Construct biological sequence of events to identify Underlying, Intermediate and Immediate Cause of Death
Patient 5
Note -
COVID, virus not identified is alternately called as COVID suspect or probable COVID
| Underlying CoD |
|---|
| Intermediate CoD |
|---|
| Immediate CoD |
|---|
Patient 6
| COVID, virus not identified |
|---|
| Pneumonia |
|---|
| Adult Respiratory Distress Syndrome |
|---|
-
Step 1- Construct biological sequence of events to identify Underlying, Intermediate and Immediate Cause of Death
Patient 6
Note -
COVID, virus not identified is alternately called as COVID suspect or probable COVID
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While the W.H.O. has specified codes for the COVID itself, there are no specific codes for the complications caused by COVID
You’ll notice that…
-
So the options are:
a)either to use existing codes from the ICD-10 (or)
b)wait for new codes to be released by W.H.O
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Meanwhile, do remember to place COVID either as an underlying CoD in Part I or as only a contributory cause in Part II
it is important to remember that not all physicians and medical records personnel may be aware of these new U-codes created by the World Health Organization (W.H.O.) for COVID-19 and may therefore be using the old coding convention for the diagnosis of pneumonias or severe acute respiratory illnesses (SARIs)….as seen in examples in the next slide!
However
If Pneumonias/LRIs are not being specifically captured as COVID…
Then, physicians and medical records personnel working in such settings must be using the older coding conventions, as described in the next set of slides
Patient 7
This is the underlying cause-of-death coded using older coding convention
Note that there is no mention of the new U category of ICD code for COVID
Patient 8
This is the underlying cause-of-death coded using older coding convention
Note that there is no mention of the new U category of ICD code for COVID
Patient 9
This is the underlying cause-of-death coded using older coding convention
Note that there is no mention of the new U category of ICD code for COVID
You’ll also notice that…
We are breaking our usual conventions…such as not using abbreviations…but since COVID is widely known now and that it is extreme circumstances such as an on-going pandemic now….this is OK for now!
‘Dying of COVID’ and ‘dying with COVID’
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If a person has COVID listed in Part I, that death is included as ‘dying of COVID’; if a person has COVID listed in Part II, then that person is included as ‘dying with COVID’
COVID-related deaths
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While in normal practice, a cause-of-death is taken only when it is mentioned in the lowest filled line in Part I (and not in Part II), during an epidemic such as the on-going pandemic, it is possible that countries and other jurisdictions will add up all deaths where COVID is mentioned either in Part I or in Part II and then club them all together as COVID-related deaths
COVID-related deaths
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For instance, if there are 1000 death certificates filled with COVID in Part I and another 500 death certificates filled with COVID in Part II and multiple other illnesses in Part I, COVID-related deaths will be taken as 1500 (and not 1000) the logic here being that these 500 deaths wouldn’t have occurred now but for the COVID epidemic [this is because this is a pandemic; otherwise, we wouldn’t be doing this for other diseases]
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In addition to persons dying of/with COVID, it is also important to remember that other avoidable deaths will also be occurring during a pandemic
Other pandemic associated deaths
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these will not be included as COVID deaths but health systems should be prepared for such deaths as well. These should be coded as per usual procedure as suicide or alcohol poisoning or neonatal death, etc.
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Examples of such deaths are shown in the next slide
Other pandemic associated deaths
References
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https:WHO. ICD-10 Version 2019. Available at: https://icd.who.int/browse10/2019/en#/U00-U49 [accessed: 09-Apr-2020]
- Ministry of Health & Family Welfare. Govt of India. COVID-19 India update. Available at: https://www.mohfw.gov.in/ [accessed: 09-Apr-2020]
- Centers for Disease Control and Prevention. National Vital Statistics System. U.S. Department of Health and Human Services. Hyattsville, MD. Available at: https://www.cdc.gov/nchs/data/nvss/vsrg/vsrg03-508.pdf [accessed: 09-Apr-2020]
- Scottish Government. Death certification during an influenza pandemic: Chief Medical Officer guidance. 13 Feb 2017. Available at: https://www.gov.scot/publications/death-certification-during-an-influenza-pandemic-chief-medical-officer-guidance/ [accessed: 09-Apr-2020]
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Lee J. How to understand – and report – figures for ‘Covid deaths’. The Spectator (the 10,000th issue). Available at: https://www.spectator.co.uk/article/how-to-understand-and-figures-for-covid-19-deaths-(accessed 25 Apr 2020)