General process and procedures for assigning, classifying ...



Professor Barker

Updated: September 13, 2020

General process and procedures for assigning, classifying, coding and counting "cause of death" from

the bedside to tabulation in the NCHS,CDC official counts on

Chris Barker, Ph.D. Adjunct Associate Professor of Biostatistics

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Professor Barker

Updated: September 13, 2020

Contents

Covid19 as a cause of death.................................................................................................................................................... 3 Reporting a cause of death. ................................................................................................................................................ 4 CDC cause of death reporting process................................................................................................................................ 4

Nosology ................................................................................................................................................................................. 4 ICD coding ........................................................................................................................................................................... 4 ICDxx considerations for Underlying vs Immediate cause of death ................................................................................... 5 Cause of Death Form........................................................................................................................................................... 5

CDC caveat emptor. Do not compare deaths across states.................................................................................................... 7 Comparing deaths from different states ............................................................................................................................ 7 There is an important detail about the covid19 coding and influenza ............................................................................... 7 Why are pneumonia and influenza deaths included in this report? .................................................................................. 7 History of the coding of Cause of Death, John Graunt 1662 Bills of Mortality Birth of Epidemiology............................ 7 QANON conspiracy theory and Republican Senator Ernst ................................................................................................. 7

Roll-up: Consistency of Cause of death coding for California, CDC, NCHS, NDI and NVSS ..................................................... 8 Hypothetical example: Immediate vs. Underlying Cause of Death .................................................................................... 8 ICD coding example............................................................................................................................................................. 8 White House requires cause of death data to bypass CDC................................................................................................. 8

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Professor Barker

Updated: September 13, 2020

Covid19 as a cause of death

There are claims of miscounting covid19 deaths. It's not a minor issue. There are a lot of unreasonable conspiracy theories associated with counting or mis-counting covid19

It's time to consider how doctors report and CDC officially counts and reports counts of "cause of death".

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Professor Barker

Updated: September 13, 2020

Reporting a cause of death.

After a patient dies in the hospital the attending physician fills out the cause of death form. A person that dies at home may have the cause of death form filled out by the coroner. There may also be a "pronouncing physician" or a "certifying physician" - more below.

CDC cause of death reporting process

First there is a "bottom up" process of reporting. The hospital attending or coroner determines the "cause of death" abbreviated COD (more below). That is forwarded to the local department of public health, then to the state department of public health, then to the NCHS (national center for health statistics) which includes the CDC.

Nosology



There are often some manual steps in coding cause of death (aside from the efforts by the attending doctor or coroner). The "manual " coding described on the CDC website is typically processed by people called "nosologists".

CDC has an excellent description of Nosology



The major news here about covid19 is that per the CDC

...Furthermore, all deaths with COVID-19 are manually coded....

The "manual coding" is performed by the "nosologists".

ICD coding

After the doctor fills out the cause of death form, end of story. Right?

Nope.

What is coding? After the attending MD or coroner are done, Deaths are further coded (more below) on the COD form. In addition, the nosologists (or a "coder" assigns an international code (a number to each cause of death. This is the "ICD" code. ICDxx is regularly updated and the xx is the version, currently version 10. For covid its ICD10 is ICD?10 code U07.1. Note the ICD can be updated as often as every year, and one should notice the ICD version. The ICD does undergo incremental updates. A more detailed discussion of ICD codes.



and downloaded to



ICD is the "international classification of disease" (for short) and the official long name "International Statistical Classification of Diseases and Related Health Problems" . ICD is an international "dictionary" and WHO adopted it. hospitals /doctors typically hire or contract with "ICD coders" who can do the coding, for example before sending a claim to an insurance company.

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Professor Barker

Updated: September 13, 2020

ICDxx considerations for Underlying vs Immediate cause of death

...Coronavirus disease deaths are identified using the ICD?10 code U07.1. Deaths are coded to U07.1 when coronavirus

disease 2019 or COVID-19 are reported as a cause that contributed to death on the death certificate. These can include

laboratory confirmed cases, as well as cases without laboratory confirmation. If the certifier suspects COVID-19 or

determines it was likely (e.g., the circumstances were compelling within a reasonable degree of certainty), they can

report COVID-19 as "probable" or "presumed" on the death certificate (5, 6). COVID-19 is listed as the underlying cause

on the death certificate in 94% of deaths (see Table 1)....

Cause of Death Form

Note the terminology "underlying" cause of death. In the world of cause of death coding, the death certificate can list several causes of death. One of them is the "immediate cause of death" another is the "underlying cause of death". if any others, those can be "contributing" cause of death. an (as big as I could find) image of a death certificate





? Extracted the death certificate image from preceding





and a nice not too technical writeup of cause of death "COD" coding



Excerpting from table I of the COD form, let me highlight the "immediate" and the "underlying" cause of death.

Entries on the Cause of Death form

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Professor Barker

Updated: September 13, 2020

The foregoing is small print. Excerpted here.

? Immediate cause of death: The final disease or injury causing the death. ? Intermediate cause of death: A disease or condition that preceded and caused the immediate cause of death. ? Underlying cause of death: A disease or condition present before, and leading to, the intermediate or ? immediate cause of death. It can be present for years before the death. ? Manner of death: The circumstances leading to death--accident, homicide, suicide, unknown or ? undetermined, and natural causes. ? Medical examiner: A physician, acting in an official capacity within a particular jurisdiction, charged ? with the investigation and examination of persons dying suddenly, unexpectedly, or violently, or whose death

resulted from, or presents, a potential public health hazard. The medical examiner is not always required to be a specialist in death investigation or pathology. Most systems employing physicians as part time medical examiners encourage them to obtain training for medical examiners such as that offered by the National Association of Medical Examiners. ? Coroner: A coroner is a public official, appointed or elected, in a particular geographic jurisdiction, whose official duty is to make inquiry into deaths in certain categories. In some jurisdictions, the coroner is a physician, but in many localities, the coroner is not required to be a physician nor be trained in medicine. ? Pronouncing physician: The one who determines the decedent is legally dead. Not all states require a death to be pronounced by a physician. ? Certifying physician: The one who certifies the cause of death ? The foregoing is the process and procedure. The CDC website describes additional complicating factors, such as a "lag " in reporting. Counts of covid deaths are not updated instantaneously. ? CDC notes, excerpting

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Professor Barker

Updated: September 13, 2020

Previous analyses of provisional data completeness from 2015 suggested that mortality data is approximately 27%

complete within 2 weeks, 54% complete within 4 weeks, and at least 75% complete within 8 weeks of when the death

occurred (8). Pneumonia deaths are 26% complete within 2 weeks, 52% complete within 4 weeks, and 72% complete

within 8 weeks (unpublished). Data timeliness has improved in recent years, and current timeliness is likely higher than

published rates,

CDC caveat emptor. Do not compare deaths across states.

This may be surprising given that the death counts by state appear nearly daily in the news. Again, excerpting from CDC

Comparing deaths from different states

Death counts should not be compared across states. Data timeliness varies by state. Some states report deaths on a daily basis, while other states report deaths weekly or monthly. Furthermore, health departments and state vital record offices may be affected by COVID-19 related response activities, which could further delay death certificate reporting. Currently, 63% of US deaths are reported within 10 days of the date of death, but there is variation within states. Twenty states report over 75% of deaths within the first 10 days, while three states report fewer than 1% of deaths within 10 days.

There is an important detail about the covid19 coding and influenza Again, excerpting from CDC .

Why are pneumonia and influenza deaths included in this report? Pneumonia and influenza deaths are included to provide context for understanding the completeness of COVID-19 mortality data and related trends. Deaths due to COVID-19 may be misclassified as pneumonia or influenza deaths in the absence of positive test results, and pneumonia or influenza may appear on death certificates as a comorbid condition. Additionally, COVID-19 symptoms can be similar to influenza-like illness, thus deaths may be misclassified as influenza. Thus, increases in pneumonia and influenza deaths may be an indicator of excess COVID-19-related mortality. Additionally, estimates of completeness for pneumonia and influenza deaths may provide context for understanding the lag in reporting for COVID-19 deaths, as it is anticipated that these causes would have similar delays in reporting, processing, and coding.

History of the coding of Cause of Death, John Graunt 1662 Bills of Mortality Birth of Epidemiology

The birth of cause of death coding and epidemiology is considered as 1662 and the Bills of Mortality written by John Graunt. Every student in a graduate program in public health learns at least once about Graunt. A link here.



QANON conspiracy theory and Republican Senator Ernst

I wrote a blog piece for debunking conspiracy theory floating around that hospitals were "up" or "down" coding cause of death so they could get larger ($$$) reimbursement. This was 100% false. I believe some of the QAnon conspiracy people believe the coding of cause of death for Covid19 has been due to reimbursement reasons. The Senator from Iowa publicly cited the conspiracy theory.





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Professor Barker

Updated: September 13, 2020

Roll-up: Consistency of Cause of death coding for California, CDC, NCHS, NDI and

NVSS

The cause of death (on a standard form) is coded by the attending physician or coroner, or medical examiner. There is a list ) of other people who can complete the cause of death form. That is on the CDC website and includes the "pronouncing physician". The CDC document also describes the requirement for consistency in coding of causes of death among several large databases (NCHS, National Vital Statistics System, etc.). Note he CDC guidance clearly states the physician be contacted about the cause of death coding (page 13).



Hypothetical example: Immediate vs. Underlying Cause of Death

A (not the only) key distinction is between the "underlying cause of death" and the "immediate cause of death". For example, a completely hypothetical situation where a person who just got a covid19 test but walked out of the hospital before getting the test result and not aware the test was positive. The person walks across a busy intersection and is crushed by a car speeding through the intersection. The person is determined to be dead at the scene.

ICD coding example The Immediate cause of death is getting smashed by a car (there is an official ICD10 code ) -V89- for that.

IN my very hypothetical the underlying cause of death is the covid19. Here is a link to the complete CDC instructions for coding underlying cause of death.. See page 2 of attached ("medical certification")

Generally, CDC will use cause of death as coded by nosologists. My assumption is that cause of death is determined at bedside by attending or by coroner, and possibly a nosologists is involved at the county or state level (in Sacramento SDPH and California CDPH). In California (LA) a cause of death certificate is a legal document. Note that in LA the "medical registrar" (page 4) reviews and can require revision to the cause of death certificate. I presume CDC or NCHS has nosologists on staff to assist with coding.

White House requires cause of death data to bypass CDC

Note that the White house to bypass CDC the data analyses prepared by CDC to a vendor without taking competitive bids. If or when we see the consequences of this terrible decision are not clear. The CDC has instructions and examples of coding cause of death for covid19 (page 4)

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