4.

Rules and guidelines for mortality and morbidity

coding
This section concerns the rules and guidelines adopted by the World Health Assembly regarding the selection of
a single cause or condition for routine tabulation from death certificates and morbidity records. Guidelines are
also provided for the application of the rules and for coding of the condition selected for tabulation.
4.1 Mortality: guidelines for certification and rules for coding
Mortality statistics are one of the principal sources of health information and in many countries they are the
most reliable type of health data.
4.1.1 Causes of death
In 1967, the Twentieth World Health Assembly defined the causes of death to be entered on the medical
certificate of cause of death as “all those diseases, morbid conditions or injuries which either resulted in or
contributed to death and the circumstances of the accident or violence which produced any such injuries”. The
purpose of the definition is to ensure that all the relevant information is recorded and that the certifier does not
select some conditions for entry and reject others. The definition does not include symptoms and modes of
dying, such as heart failure or respiratory failure.
When only one cause of death is recorded, this cause is selected for tabulation. When more than one cause of
death is recorded, selection should be made in accordance with the rules given in section 4.1.5. The rules are
based on the concept of the underlying cause of death.
4.1.2 Underlying cause of death
It was agreed by the Sixth Decennial International Revision Conference that the cause of death for primary
tabulation should be designated the underlying cause of death. From the standpoint of prevention of death, it is
necessary to break the chain of events or to effect a cure at some point. The most effective public health
objective is to prevent the precipitating cause from operating. For this purpose, the underlying cause has been
defined as “(a) the disease or injury which initiated the train of morbid events leading directly to death, or (b)
the circumstances of the accident or violence which produced the fatal injury”.
4.1.3 International form of medical certificate of cause of death
The above principle can be applied uniformly by using the medical certification form recommended by the
World Health Assembly. It is the responsibility of the medical practitioner signing the death certificate to
indicate which morbid conditions led directly to death and to state any antecedent conditions giving rise to this
cause.
The medical certificate shown below is designed to facilitate the selection of the underlying cause of death when
two or more causes are recorded. Part I of the form is for diseases related to the train of events leading directly
to death, and Part II is for unrelated but contributory conditions.
The medical practitioner or other qualified certifier should use his or her clinical judgement in completing the
medical certificate of cause of death. Automated systems must not include lists or other prompts to guide the
certifier as these necessarily limit the range of diagnoses and therefore have an adverse effect on the accuracy
and usefulness of the report.
In 1990, the Forty-third World Health Assembly adopted a recommendation that, where a need had been
identified, countries should consider the possibility of an additional line, (d), in Part I of the certificate.
However, countries may adopt, or continue to use, a certificate with only three lines in Part I where a fourth line
is unnecessary, or where there are legal or other impediments to the adoption of the certificate shown above.
The condition recorded on the lowest used line of Part I of the certificate is usually the underlying cause of
death used for tabulation. However, the procedures described in sections 4.1.4-4.1.5 may result in the selection
of another condition as the underlying cause of death. To differentiate between these two possibilities, the
expression originating antecedent cause (originating cause) will be used to refer to the condition proper to the
last used line of Part I of the certificate, and the expression underlying cause of death will be used to identify the
cause selected for tabulation.
If there is only one step in the chain of events, an entry at line I(a) is sufficient. If there is more than one step,
the direct cause is entered at (a) and the originating antecedent cause is entered last, with any intervening cause
entered on line (b) or on lines (b) and (c). An example of a death certificate with four steps in the chain of events
leading directly to death is:
(a) Pulmonary embolism
(b) Pathological fracture
(c) Secondary carcinoma of femur
(d) Carcinoma of breast
Part II is for any other significant condition that contributed to the fatal outcome, but was not related to the
disease or condition directly causing death.
After the words “due to (or as a consequence of)”, which appear on the certificate, should be included not only
the direct cause or pathological process, but also indirect causes, for example where an antecedent condition has
predisposed to the direct cause by damage to tissues or impairment of function, even after a long interval.
Noting the approximate interval (minutes, hours, days, weeks, months or years) between the onset of each
condition and the date of death helps the certifying doctor to establish the chain of events that led to the death,
and is also useful subsequently in guiding the coder to choose the appropriate code.
In 1990, the World Health Assembly adopted a recommendation that countries should consider the inclusion on
death certificates of questions about current pregnancy and pregnancy within one year preceding death.
4.1.4 Procedures for selection of the underlying cause of death for mortality
tabulation
When only one cause of death is reported, this cause is used for tabulation.
When more than one cause of death is recorded, the first step in selecting the underlying cause is to determine
the originating antecedent cause proper to the lowest used line in Part I of the certificate by application of the
General Principle or of selection rules 1, 2 and 3.
In some circumstances the ICD allows the originating cause to be superseded by one more suitable for
expressing the underlying cause in tabulation. For example, there are some categories for combinations of
conditions, or there may be overriding epidemiological reasons for giving precedence to other conditions on the
certificate.
The next step therefore is to determine whether one or more of the modification rules A to F (see section 4.1.9),
which deal with the above situations, apply. The resultant code number for tabulation is that of the underlying
cause.
Where the originating antecedent cause is an injury or other effect of an external cause classified to Chapter
XIX, the circumstances that gave rise to that condition should be selected as the underlying cause for tabulation
and coded to V01-Y89. The code for the injury or effect may be used as an additional code.
4.1.5 Rules for selection of the originating antecedent cause
Sequence
The term “sequence” refers to two or more conditions entered on successive lines of Part I, each condition being
an acceptable cause of the one entered on the line above it.
Example 1: I (a) Bleeding of oesophageal varices
(b) Portal hypertension
(c) Liver cirrhosis
(d) Hepatitis B
If there is more than one cause of death in a line of the certificate, it is possible to have more than one reported
sequence. In the example below, four sequences are reported:
Example 2: I (a) Coma
(b) Myocardial infarction and cerebrovascular accident
(c) Atherosclerosis Hypertension
The sequences are:
• atherosclerosis (leading to) myocardial infarction (leading to) coma;
• atherosclerosis (leading to) cerebrovascular accident (leading to) coma;
• hypertension (leading to) myocardial infarction (leading to) coma;
• hypertension (leading to) cerebrovascular accident (leading to) coma;
General Principle
The General Principle states that 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.
Selection rules
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.
Rule 2. If there is no reported sequence terminating in the condition first entered on the certificate, select this
first-mentioned condition.
Rule 3. If the condition selected by the General Principle or by Rule l or Rule 2 is obviously a direct
consequence of another reported condition, whether in Part I or Part II, select this primary condition.
4.1.6 Some considerations on selection rules
In a properly completed certificate, the originating antecedent cause will have been entered alone on the lowest
used line of Part I and the conditions, if any, that arose as a consequence of this initial cause will have been
entered above it, one condition to a line in ascending causal order.
Example 3: I (a) Uraemia
(b) Hydronephrosis
(c) Retention of urine
(d) Hypertrophy of prostate
Example 4: I (a) Bronchopneumonia
(b) Chronic bronchitis
II Chronic myocarditis
In a properly completed certificate, therefore, the General Principle will apply. However, even if the certificate
has not been properly completed, the General Principle may still apply provided that the condition entered alone
on the lowest used line of Part I could have given rise to all the conditions above it, even though the conditions
entered above it have not been entered in the correct causal order.
Example 5: I (a) Generalized metastases 5 weeks
(b) Bronchopneumonia 3 days
(c) Lung cancer 11 months
The General Principle does not apply when more than one condition has been entered on the lowest used line of
Part I, or if the single condition entered could not have given rise to all the conditions entered above it.
Guidance on the acceptability of different sequences is given at the end of the rules, but it should be borne in
mind that the medical certifier's statement reflects an informed opinion about the conditions leading to death and
about their interrelationships, and should not be disregarded lightly.
Where the General Principle cannot be applied, clarification of the certificate should be sought from the certifier
whenever possible, since the selection rules are somewhat arbitrary and may not always lead to a satisfactory
selection of the underlying cause. Where further clarification cannot be obtained, however, the selection rules
must be applied. Rule l is applicable only if there is a reported sequence, terminating in the condition first
entered on the certificate. If such a sequence is not found, Rule 2 applies and the first-entered condition is
selected.
The condition selected by the above rules may, however, be an obvious consequence of another condition that
was not reported in a correct causal relationship with it, e.g. in Part II or on the same line in Part I. If so, Rule 3
applies and the originating primary condition is selected. It applies, however, only when there is no doubt about
the causal relationship between the two conditions; it is not sufficient that a causal relationship between them
would have been accepted if the certifier had reported it.
4.1.7 Examples of the General Principle and selection rules
General Principle
When more than one condition is entered on the certificate, select the condition entered alone on the
lowest used line of Part I only if it could have given rise to all the conditions entered above it.
Example 6: I (a) Abscess of lung
(b) Lobar pneumonia
Select lobar pneumonia (J18.1).
Example 7: I (a) Hepatic failure
(b) Bile duct obstruction
(c) Carcinoma of head of pancreas
Select carcinoma of head of pancreas (C25.0).
Example 8: I (a) Cerebral haemorrhage
(b) Hypertension
 (c) Chronic pyelonephritis
(d) Prostatic adenoma
Select prostatic adenoma (N40).
Example 9: I (a) Traumatic shock
(b) Multiple fractures
(c) Pedestrian hit by truck (traffic accident)
Select pedestrian hit by truck (V04.1).
Example 10: I (a) Bronchopneumonia
II Secondary anaemia and chronic lymphatic leukaemia
Select bronchopneumonia. But Rule 3 also applies; see Example 26.
Example 26: I (a) Bronchopneumonia
II Secondary anaemia and chronic lymphatic leukaemia
Select chronic lymphatic leukaemia (C91.1). Bronchopneumonia, selected by the General Principle
(see Example 10), and secondary anaemia can both be considered direct sequels of chronic lymphatic
leukaemia.1

1
Extracted from ICD-10 Second Edition, 2005, 4. Rules and guidelines for mortality and
morbidity coding.