Overview of Mortality Coding and its

usage inMEDICAL CERTIFICATION OF

CAUSE OF DEATH

BYBYSHIV KUMARSHIV KUMAR

DRG(MCCD) OFFICE OF THE RGIDRG(MCCD) OFFICE OF THE RGI

Background

1961 Conference on Improvement of Vital Statistics endorsed the gradual introduction of scheme on Medical Certification of Cause of Death only in limited areas with support by legal sanction (as subsequently provided in the Registration of Birth and Death Act of 1969).

Introduction of MCCD MEDICAL CERTIFICATION OF CAUSE OF DEATH

(MCCD) under Civil Registration System was initiated by the office of the RGI during the Third Five Year Plan. It was operational in many states in the beginning of 70s.

It provides data on deaths by age and sex in respect of 18 major groups, 66 categories and 197 sub-categories of causes (includes few single causes) as per National list based on ICD-9 till 1998.

National list based on ICD-10 is comprised of 20 Major Groups, 69 categories and 194 sub-categories of causes is prepared by ORGI and been adopted since 1999.

Medical Certification of Cause of Death under Civil Registration System has got statutory backing under sections 10(2) and 10(3) of the Registration of Births & Deaths Act, 1969.

The Act also incorporates a clause about the confidentiality of the information on cause of death, forbidding to disclose this in any extract provided from the registration records.

Under Section 23(3) of the RBD Act, any Medical Practitioner who neglects or refuses to issue a certificate under section 10(3) and any person who neglects or refuses to deliver such certificate shall be punishable with fine, which may extend to fifty rupees.

Legal Provisions

Cause of death A cause of death is disease, abnormality, injury or poisoning that contributed directly or indirectly to death.

Underlying cause of death

a) The disease or injury which initiated the train of events leading directly to death;

orb) The circumstances of the accident or

violence which produced the fatal injury.

Form of medical certificateForm of medical certificate Sixth Decennial International Conference held in Sixth Decennial International Conference held in

April 1948 at Paris endorsed the:April 1948 at Paris endorsed the:

1)1) Selection of Selection of Underlying cause of death as Underlying cause of death as main cause of deathmain cause of death for tabulation of for tabulation of mortality data; andmortality data; and

2)2) Tabulation list of mortality & morbidityTabulation list of mortality & morbidity

The standard format of the certificate is The standard format of the certificate is incorporated in the rules made by the State incorporated in the rules made by the State Government. Government.

The format of the certificate proper (medical The format of the certificate proper (medical part) conforms to the standard prescribed by part) conforms to the standard prescribed by (WHO) :(WHO) :

CAUSE OF DEATH Interval between onset & death approx.

I. Immediate cause: State the disease. Injury or complication which caused death, not the mode of dying such as heart failure, asthenia, etc. Antecedent cause : Morbid conditions, if any, giving rise to the above cause, stating the underlying conditions last. II. Other significant conditions contributing to the death, but not related to the diseases or conditions causing it.

(a). . . . . . . . (due to (or as a consequence of ) (b) . . . . . . . . . . . . . (due to (or as a consequence of) (c) . . . . . . . . . . . . .. . . . . . . . . . . . . . . . .

International FormatInternational Format

Form 4 for hospital deaths1. Name of the Hospital2. Name of the deceased3. Sex( Male/Female)4. Age at death5. Cause of Death 1(a) Immediate cause of death 1(b) Antecedent cause of death 1(c) Underlying cause of death6. Internal between onset and

deaths7. Manner of death (1. Natural, 2. Accident 3. Suicide, 4. Homicide, 5. Pending

investigation)8. How did the injury occur?9. Whether death related to

pregnancy?

Form 4A for Non-hospital deaths1. Name of the deceased

2. Sex( Male/Female)

3. Age at death

4. Cause of Death

1(a) Immediate cause of death

1(b) Antecedent cause of death

1(c) Underlying cause of death

5. Internal between onset and deaths

6. Whether death related to pregnancy?

 

Revised Form of Medical Certificate in the revamped system of civil registration w.e.f

1.1.2000

Implementation of MCCD

Implemented in all States/Uts except:

Newly created States: Uttranchal and Jharkhand

Union Territories of Dadra & Nagar Haveli and Daman & Diu

Coverage of MCCDRECOMMENDATIONS OF 1980 WORKSHOP ON

MCCD:

First phase: The scheme was to cover teaching hospitals at State Headquarter towns to gain experience of problems that may arise in introducing the scheme;

 

Second phase: Specialized hospitals and district and sub-divisional hospitals;

 

Third phase: Private hospitals, other public hospitals and Primary Health Centres (PHCs) ; and

 

Final phase: Private physicians practicing modern medicine.

States/UTS Existing Covered ReportedAndhra Pradesh @

3133 1652 314

Arunachal Pradesh

262 262 262

Goa 136 136 136

Gujarat @ 2528 4 4

Haryana @ 80 56 50

Himachal Pradesh @

63 2 2

Karnataka @ 293 369 (207 PH)

367

Kerala @ 2107 162 162

Madhya Pradesh 363 399 265

Maharashtra 3115 3115 405

Manipur 17 17 17

Meghalaya @ 9 9 9

Coverage of hospitals in 1998

States/UTS Existing Covered ReportedNagaland 34 34 34

Orissa 273 73 72

Punjab 220 208 208

Rajasthan 253 253 253

Sikkim @ 1 1 1

Tamil Nadu 408 334 334

Tripura 29 16 16

A & N Islands @ 10 4 4

Delhi 332 157 157

Lakshdweep 2 2 2

Pondicherry 29 22 22

TOTAL All Hospitals

13,697 7,277 3,096

@: Operational in urban hospitals.

22 States/Uts reported data on medically certified 22 States/Uts reported data on medically certified deaths during 1999: deaths during 1999:

About 15.4% of the total registered deaths.About 15.4% of the total registered deaths.

About 41.3% of urban registered deaths.About 41.3% of urban registered deaths.

More than 50% of the urban registered deaths:More than 50% of the urban registered deaths: In In Arunachal Pradesh, Goa, Maharashtra, Manipur, Arunachal Pradesh, Goa, Maharashtra, Manipur, Meghalaya, Orissa, Tamil Nadu, A & N Islands, Delhi Meghalaya, Orissa, Tamil Nadu, A & N Islands, Delhi and Pondicherry and Pondicherry

More than 100% Urban registered deaths:More than 100% Urban registered deaths: In In Arunachal Pradesh, Goa and Manipur due to inclusion Arunachal Pradesh, Goa and Manipur due to inclusion the rural deaths.the rural deaths.

More than 50% of total registered deaths:More than 50% of total registered deaths: In In Arunachal Pradesh, Goa, Manipur, Delhi and Arunachal Pradesh, Goa, Manipur, Delhi and Pondicherry.Pondicherry.

Medically certified deaths during 1999

Mortality codingMortality coding

Coding: It is the assignment of a code for a diagnostic statement, related health conditions, or cause of death as identified by the health care.

Classification of diseases: It can be It can be defined as a system of categories to defined as a system of categories to which morbid entities are assigned which morbid entities are assigned according to established criteria.according to established criteria.

International Classification of Diseases International Classification of Diseases (ICD) is used for coding cause of mortality.(ICD) is used for coding cause of mortality.

Purpose & applicability of ICDPurpose & applicability of ICD

ICD permits the systematic recording, ICD permits the systematic recording, analysis, interpretation and analysis, interpretation and comparison of mortality and morbidity comparison of mortality and morbidity data collected in different countries or data collected in different countries or areas and at different times.areas and at different times.

It translates diagnoses of diseases and It translates diagnoses of diseases and other health problems from words into other health problems from words into an numeric/alphanumeric code, which an numeric/alphanumeric code, which permits easy storage, retrieval and permits easy storage, retrieval and analysis of the data.analysis of the data.

Simple situation

Part-I (a) Peritonitis(b) Perforation of

Duodenum(c) Duodenal ulcer

2 days3 days6 months

ICD codes

Part-II

Carcinoma of bronchus

Complicated situation:Complicated situation:A lady aged 23 years was admitted to a hospital. She had H/O suicidal burn- because of pouring of kerosene and burnt herself. O/E patient had 78% burn (superficial & deep). She developed septicemia and died after 3 days of admission.

Part-Part-II

(a)(a) Septicemic shockSepticemic shock

(b)(b) Burn 78% (Deep & Burn 78% (Deep & superficial)superficial)

(c)(c) Intentional self-harm byIntentional self-harm by

fire and flamesfire and flames

3 days3 days

3 days3 days

By 3 By 3 days days backback

ICD ICD codecodess

Part-Part-IIII

NILNILManner of death1. Natural, 2. Accident, 3 . Suicide,

4. Homicide, 5. Pending investigation

Special Tabulation Lists for Special Tabulation Lists for Mortality and MorbidityMortality and Morbidity

ICD-10 provides four special tabulation lists for mortality and one list for morbidity: List 1-General mortality-condensed list List 1-General mortality-condensed list (103 causes);(103 causes); List 2-General mortality-selected list List 2-General mortality-selected list (80 (80

causes);causes); List 3- Infant and child mortality-condensed List 3- Infant and child mortality-condensed

list list (67 causes);(67 causes);

List 4- Infant and child mortality-selected listList 4- Infant and child mortality-selected list(51 causes);(51 causes); and and

Tabulation list for morbidity Tabulation list for morbidity (298 causes)(298 causes)

The ICD-10 tabulation lists are not being adopted as such instead national list based on ICD is used for tabulation of mortality.

In National list major group, category and sub-category terms are used in place of Chapter, Block and three/four character category.

National list based on ICD-9 has been used up to the year 1998.

National list based on ICD-10 has been adopted from the year 1999 onwards.

Characteristics of National list based on ICD-9 Characteristics of National list based on ICD-9 and ICD-10and ICD-10National list based on ICD-National list based on ICD-99

National list based on ICD-National list based on ICD-1010

Major Groups-17Major Groups-17

Plus Plus E code- E code- Supplementary Supplementary Classification of External Classification of External Causes of Injury & Causes of Injury & PoisoningPoisoning

Major Groups-19Major Groups-19

PlusPlus Major Group XX- Major Group XX- External Causes of External Causes of Mortality & MorbidityMortality & Morbidity

Categories-56Categories-56

(Group of three-digit (Group of three-digit categories)categories)

Categories-58Categories-58

(Group of three-character (Group of three-character categories)categories)

Sub-categories-192Sub-categories-192

1.1. Group of 3 –digit / 4 –Group of 3 –digit / 4 –digit categories, digit categories,

2.2. 3 –digit/4 -digit single 3 –digit/4 -digit single category category

Sub-categories-185Sub-categories-185

1.1. Group of 3 –character/ Group of 3 –character/ 4–character categories, 4–character categories,

2.2. 3 –character /4 -3 –character /4 -character single character single category category

Deaths by type of medical attention during 1998

QMP(A)12.5%

QMP(O)5.7%

Institutional Deaths26.9%

Deaths not Attended by Medical Practitioners

54.9%

Leading causes of deaths during 1999

OTHERS18.8%

X7.7%

XVI7.5%

XIX13.0%

XVIII14.6%

I14.6%

IX23.8%

Others: It include Major Cause Groups II, III, IV, V, VI, VII, VIII, XI, XII, XIII, XIV, XV and XVII

Leading Causes of Deaths during 1991 to 1999 – All India

Major Causes of Deaths

1991

1992

1993

1994

1995

1996

1997

1998

1999

Circulatory Circulatory systemsystem

21.21.11

21.21.22

21.521.5 21.21.99

21.421.4 21.621.6 22.22.11

25.225.2 23.23.88

Infectious and Infectious and parasitic diseasesparasitic diseases

17.17.00

16.16.77

17.317.3 16.16.77

16.216.2 16.316.3 15.15.77

16.416.4 14.14.66

Symptoms, signs Symptoms, signs and ill-defined and ill-defined conditionsconditions

14.14.55

14.14.22

12.612.6 13.13.44

14.614.6 14.314.3 14.14.44

12.312.3 14.14.66

Injury & poisoningInjury & poisoning 11.11.22

11.11.11

11.211.2 11.11.77

12.112.1 12.412.4 12.12.11

12.112.1 13.13.00

Certain conditions Certain conditions originating in the originating in the perinatal periodperinatal period

8.78.7 9.19.1 9.29.2 8.58.5 8.28.2 7.97.9 8.88.8 7.97.9 7.57.5

Respiratory Respiratory systemsystem

8.18.1 7.77.7 7.77.7 7.47.4 7.37.3 7.57.5 7.17.1 7.37.3 7.77.7

Total all 6 major Total all 6 major causescauses

80.80.66

80.80.00

79.579.5 79.79.66

79.879.8 80.080.0 80.80.22

81.281.2 81.81.22

Trends in leading causes of death

0.0

5.0

10.0

15.0

20.0

25.0

30.01

98

5

19

86

19

87

19

88

19

89

19

90

19

91

19

92

19

93

19

94

19

95

19

96

19

97

19

98

19

99

Year

Perc

enta

ge d

eath

s

CirculatorySystem

Infectious &Parasitic

Symptoms,signs and illdefined

Injury &Poisoning

Certainconditionoriginating

Respiratorysystem

Level and Coverage of causes of deaths in Level and Coverage of causes of deaths in India and United StatesIndia and United States

United States- 1997United States- 1997 India-1998India-1998

Coverage: All States &District of Columbia

23 States/UTs

Level of Causes of deaths: 99% (23,14,245)

14.9% (4,98,586)

Certificates are filled by:Funeral Directors,Attending Physicians,Medical Examiners,Coroners

Attending Physicians,Medical Examiners,

Top ten causes of deaths in US in 1997

31.4

23.3

6.9

4.7

4.1

1.9 2.3 3.

7

2.7

1.3

1.1

1.1

19.6

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

Causes of deaths

Perc

enta

ge d

eath

s

Top causes of deaths in India during 1998

19.8

7.3

6.9

4.7

3.6

3.2

3.0

2.9

2.7

2.2

1.9

1.9

1.6

1.3

1.2

1.0

0.9

0.6

0.6

0.0

5.0

10.0

15.0

20.0

25.0

Disease

s of H

eart (1

)

Tuberc

ulosis

Accidents

and a

dvers

e effe

cts (5

)

Cerebro

vasc

ular d

iseas

es (3)

Slow feta

l gro

wth, fe

tal m

alnutri

tion &

imm

aturity

Septicaemia

Malig

nant n

eoplasm

s (2)

Pneumonia (6)

Hypoxia

, birt

h asphyx

ia & o

ther

resp

irato

ry co

nditions

Diabetes m

ellitus (

7)

Anaemias

Chronic

obstructi

ve p

ulmonary

dise

ases (

4)

Chronic

liver

dise

ases &

cirrh

osis

(10)

Diarrhoea, d

ysentry

& ga

stoente

ritis

Nephritis,

nephrotic

syndr

ome &

nephrosis

(9)

Menin

gitis

Malar

ia

Suicide (8

)

Viral h

epatiti

s

Causes of deaths

Perc

enta

ge d

eath

s

MCCD provides cause-specific mortality profiles and is a key indicator for analyzing the health trends of the population in a scientific manner.

The information is of considerable use to public health planners, administrators, medical professionals and research workers.

The information is made use of in the

assessment of the effectiveness of public health programme.

It is feedback for better health planning and management as well as for deciding priorities of health and medical research programme.

Usefulness of MCCD

T T H H AA N N KK SS