ICD-11

International
Classification
of Diseases
for
Mortality and
Morbidity Statistics

Eleventh Revision

Reference Guide
0 ICD-11 Reference Guide
0.1 Copyright page
International Classification of Diseases, Eleventh Revision (ICD-11)
© World Health Organization 2022
Some rights reserved. This work is available under the Creative Commons Attribution-
NoDerivatives 3.0 IGO license (CC BY-ND 3.0 IGO; [Link]
nd/3.0/igo/).
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This PDF version of ICD-11 was generated to support the user preference for viewing ICD-11
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Suggested citation
International Classification of Diseases Eleventh Revision (ICD-11). Geneva: World Health
Organization; 2022. License: CC BY-ND 3.0 IGO.
Mappings or crosslinks between other classifications and terminologies and ICD-11 and/or
translations are not covered by the ICD-11 license and are subject to a separate written
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ICD-11 Reference Guide 1

delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent
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Correct use of ICD-11
Please refer to the reference guide for the correct use of ICD-11
([Link]
For coding the API must be used. For use of the API or coding tool, (see [Link]
To prevent the dilution of ICD’s purpose to provide a definitive standard for identifying
health information, ICD-11 may not be used for the purpose of developing or promoting a
different standard.
The use of ICD-11 in software products is subject to the following license:
[Link] Under the terms of this license, users may
not:
• reproduce ICD-11 in part or whole and distribute it under a different name or without
attribution;

• reproduce and distribute ICD-11 in part or whole without the ICD-11 codes;

• reproduce ICD-11 in part or whole without the ICD-11 URIs (not applicable for print
publications).

Mappings or crosslinks between other classifications and terminologies and ICD-11 and/or
translations are not covered by the ICD-11 license and are subject to a separate written
agreement from WHO.
Adding data fields to ICD-11 concepts is permitted, provided such additions are clearly
identified as additions that do not originate from WHO.
Suggestions for changes to ICD-11 should be submitted as a proposal to the ICD-11
maintenance platform ([Link]
0 ICD-11 Reference Guide
0.1 Copyright page
0.2 How to use this Reference Guide
0.3 Table of Acronyms and Abbreviations

2 ICD-11 MMS
0.4 Glossary
1 Part 1 - An Introduction to ICD-11
1.1International Classification of Diseases (ICD)
1.1.1 Intended uses
1.1.2 Classification
1.1.3 ICD in the context of the WHO Family of International Classifications (WHO-FIC)
1.1.4 WHO-FIC: Reference Classifications
[Link] International Classification of Functioning, Disability & Health (ICF)
[Link] The International Classification of Health Interventions (ICHI)
[Link] WHO-FIC: Derived classifications
[Link] Related classifications
1.1.5 ICD use in health information systems
[Link] Use of ICD–11 in a digital setting and with web services
[Link] Use of ICD–11 in an analogue paper-based setting
[Link] Electronic version
1.1.6 Links with other Classifications and Terminologies
[Link] Integrated use with Terminologies
[Link] Functioning in ICD and joint use with ICF overview
1.2 Structure and taxonomy of the ICD
1.2.1 Taxonomy
[Link] Content model and definition of disease
1.2.2 ICD Chapter structure
1.2.3 Guiding principles for classification of special concepts
1.2.4 General features of ICD-11
[Link] Code structure
[Link] Uniform resource identifiers
[Link] Block codes
[Link] Stem codes
[Link] Extension codes and postcoordination

ICD-11 Reference Guide 3

[Link] Other general features
1.2.5 Foundation Component and Tabular lists of ICD–11
[Link] Precoordination and Postcoordination in ICD-11
[Link] Multiple parenting
1.2.6 Language independent ICD entities
1.3 Main uses of the ICD: Mortality
1.3.1 What is coded: Causes of death
1.4 Main uses of the ICD: Morbidity
1.4.1 What is coded: patient conditions
1.5 Traditional Medicine
1.6 ICD maintenance
1.6.1 Guiding principles of authoring process
1.6.2 Improving user guidance
1.6.3 Introduction to the ICD–11 Update Process
1.6.4 National Modifications for morbidity coding
2 Part 2 - Using ICD-11
2.1 Basic coding and reporting guidelines
2.2 Tabular List, Special Tabulation Lists, Qualifiers, and Modifiers
2.3 Index
2.4 Reference Guide
2.5 Browser and coding tool
2.6 Coding step by step – clinical term
2.7 ICD–11 conventions
2.7.1 Inclusions
2.7.2 Exclusions
[Link] ‘Code also’ and ‘Use additional code, if desired’ instructions
2.7.3 ‘NEC’ and ‘NOS’
[Link] ‘NEC’
[Link] ‘NOS’

4 ICD-11 MMS
2.7.4 ‘Certain’
2.7.5 Residual categories – ‘Other’ and ‘Unspecified’
2.7.6 Use of ‘And’ and ‘Or’
2.7.7 ‘Due to’ and ‘Associated with’
2.7.8 Spelling, parentheses, grammar and other conventions
2.7.9 General features
2.8 Stem codes
2.9 Extension codes
2.10 Precoordination and postcoordination
2.10.1 Adding detail – postcoordination and cluster coding with multiple stem codes and
extension codes
2.10.2 Combining stem codes and extension codes, and how to order these in a complex
code cluster
2.10.3 Diagnosis Timing - ‘Present on admission’ vs. ‘Developed after admission’
2.11 Functioning section
2.11.1 Functioning assessment
[Link] WHO DAS 2.0: features and use cases
[Link] WHO DAS 2.0: representation and coding structure
2.11.2 Generic functioning entity
[Link] Functioning entities: features and use cases
[Link] Functioning entity: representation and coding structure
2.12 Electronic recording and reporting
2.13 Foundation Component and Tabular lists
2.14 Main uses of the ICD: Mortality
2.15 Mortality statistics
2.15.1 What is tabulated: Underlying cause of death
2.15.2 Data source: The international form of Medical Certificate of Cause of Death (MCCD)
2.15.3 Routine use and special cases
[Link] Routine cause of death reporting systems
[Link] Verbal autopsy

ICD-11 Reference Guide 5

2.16 Basic concepts
2.16.1 Terminal cause of death
2.16.2 Causal relationship and sequence
2.16.3 Starting point
2.16.4 Duration
2.16.5 First-mentioned sequence
2.16.6 Underlying cause of death (UCOD)
2.16.7 Priority underlying condition
2.16.8 Modification
2.17 Coding instructions for mortality
2.17.1 Basic coding and multiple cause coding guidelines
2.17.2 Selecting the underlying cause of death
2.17.3 Find the starting point (Steps SP1 to SP8)
2.17.4 Step SP1 – Single cause on certificate
2.17.5 Step SP2 – First condition on the only line used
2.17.6 Step SP3 – First condition on the lowest used line causing all entries above
2.17.7 Step SP4 – Starting point of the first-mentioned sequence
2.17.8 Step SP5 – Terminal cause of death when no sequence
2.17.9 Step SP6 – Obvious cause
2.17.10 Step SP7 – Ill-defined conditions
2.17.11 Step SP8 – Conditions unlikely to cause death
2.18 Check for modifications of the starting point (Steps M1 to M4)
2.18.1 Step M1 – Special instructions
2.18.2 Step M2 – Specificity
2.18.3 Step M3 – Recheck Steps SP6, M1 and M2
2.18.4 Step M4 - Instructions on medical procedures, main injury, poisoning, and maternal
deaths
2.19 Special instructions on selecting the underlying cause of death
2.19.1 Special instructions on accepted and rejected sequences (Steps SP3 and SP4)
[Link] Conflicting durations

6 ICD-11 MMS
[Link] Infectious diseases due to other conditions
Cholera and certain infectious diseases due to other conditions
Typhoid and certain infectious disease due to other conditions
HIV due to other conditions
Infectious diseases not listed above due to other conditions
[Link] Malignant neoplasms due to other conditions
[Link] Congenital or constitutional haemorrhagic condition due to other conditions
[Link] Anaphylaxis due to external causes
[Link] Diabetes due to other conditions
[Link] Rheumatic fever due to other conditions
[Link] Hypertension due to other conditions
[Link] Certain ischaemic heart disease due to other conditions
[Link] Atherosclerosis due to other conditions
[Link] Developmental anomalies due to other conditions
[Link] Unintentional cause of morbidity or mortality due to other conditions
[Link] Suicide due to other conditions
[Link] Obstetric conditions due to other conditions
2.19.2 Special instructions on obvious cause (Step SP6)
[Link] Complications of HIV
Infectious diseases and HIV
Malignant neoplasms and HIV
Immune deficiency and HIV
Pneumonia and HIV
Cachexia and HIV
[Link] Enterocolitis due to Clostridium difficile
[Link] Sepsis
[Link] Complications of diabetes
[Link] Dehydration
[Link] Dementia

ICD-11 Reference Guide 7

[Link] Disorders of intellectual development
[Link] Heart failure and unspecified heart disease
[Link] Embolism
[Link] Oesophageal varices
[Link] Pneumonia
[Link] Pulmonary oedema
[Link] Nephritic syndrome
[Link] Pyelonephritis
[Link] Acute renal failure
[Link] Primary atelectasis of newborn
[Link] Premature rupture of membranes and oligohydramnios
[Link] Haemorrhage
[Link] Aspiration and inhalation
[Link] Surgery and other invasive medical procedures
[Link] Common secondary conditions
[Link] Secondary peritonitis
2.19.3 Special instructions on linkages and other provisions (Step M1)
[Link] Special instructions on Chapter 01 Certain infectious or parasitic diseases
Human immunodeficiency virus disease
[Link] Special instructions on Chapter 02 Neoplasms
[Link] Special instructions on Chapter 03 Diseases of the blood or blood-forming organs
[Link] Special instructions on Chapter 04 Diseases of the immune system
[Link] Special instructions on Chapter 05 Endocrine, nutritional or metabolic diseases
[Link] Special instructions on Chapter 06 Mental, behavioural or neurodevelopmental
disorders
[Link] Special instructions on Chapter 07 Sleep-wake disorders
[Link] Special instructions on Chapter 08 Diseases of the nervous system
[Link] Special instructions on Chapter 09 Diseases of the visual system
[Link] Special instructions on Chapter 10 Diseases of the ear or mastoid process
[Link] Special instructions on Chapter 11 Diseases of the circulatory system

8 ICD-11 MMS
[Link] Special instructions on Chapter 12 Diseases of the respiratory system
[Link] Special instructions on Chapter 13 Diseases of the digestive system
[Link] Special instructions on Chapter 14 Diseases of the skin
[Link] Special instructions on Chapter 15 Diseases of the musculoskeletal system or
connective tissue
[Link] Special instructions on Chapter 16 Diseases of the genitourinary system
[Link] Special instructions on Chapter 17 Conditions related to sexual health
[Link] Special instructions on Chapter 18 Pregnancy, childbirth or the puerperium
[Link] Special instructions on Chapter 19 Certain conditions originating in the perinatal
period
[Link] Special instructions on Chapter 20 Developmental anomalies
[Link] Special instructions on Chapter 21 Symptoms, signs or clinical findings, not
elsewhere classified
[Link] Special instructions on Chapter 22 Injury, poisoning or certain other consequences
of external causes
[Link] Special instructions on Chapter 23 External causes of morbidity or mortality
[Link] Codes not to be used for underlying cause of death
[Link] Codes not to be used if the underlying cause is known or other specific conditions
apply
2.19.4 Special instructions on surgery and other medical procedures (Step M4)
[Link] Reason for the surgery or procedure stated
[Link] Reason for the surgery or procedure not stated, complication reported
[Link] Reason for the surgery or procedure not stated, no complication reported
[Link] Medical devices associated with adverse incidents due to external causes
2.19.5 Special instructions on main injury in deaths from external causes (Step M4)
2.19.6 Special instructions on poisoning by drugs, medications and biological substances
(Step M4)
[Link] The drug most likely to have caused death is specified
[Link] The drug most likely to have caused death is not specified
[Link] Identification of the drug most likely to have caused death
2.19.7 Special instructions on maternal mortality (Step M4)
2.20 Coding instructions for mortality: multiple cause coding and other specific instructions

ICD-11 Reference Guide 9

2.21 Mortality Rules – Knowledgebase
2.21.1 Uncertain diagnosis
[Link] Either … or
[Link] One condition, either one site or another
[Link] One site or system, either one condition or another condition
[Link] Either one condition or another, different anatomical systems
[Link] Either disease or injury
2.21.2 Effect of connecting terms
[Link] Connecting terms implying a causal relationship
‘Due to’ written or implied by a similar term
‘Resulting in’ written or implied by a similar term
[Link] Connecting terms not implying a causal relationship
‘And’ written or implied by a similar term first or last on a line
‘And’ written or implied by a similar term but not first or last on a line
Diagnostic terms that do not stop at the end of the line
2.21.3 Duration of conditions
[Link] Single duration stated for multiple conditions
[Link] Modifying temporality of conditions by stated duration
2.21.4 ‘Code also’ instructions in mortality use case
2.21.5 Malignant neoplasms
Using the coding tool for neoplasms
[Link] Behaviour: malignant, in situ, benign, uncertain or unknown behaviour
The term itself indicates behaviour
Other information on the certificate indicates behaviour
[Link] Malignant neoplasms: primary or secondary?
Common sites of metastases
Malignant neoplasm reported as primary
Other indication of primary malignant neoplasm
Malignant neoplasm reported as secondary

10 ICD-11 MMS
Other indication of secondary malignant neoplasm
[Link] More than one primary malignant neoplasm
[Link] Site not clearly indicated
[Link] Primary site unknown
[Link] ‘Metastatic’ cancer
Malignant neoplasm ‘metastatic from’ a specified site
Malignant neoplasm ‘metastatic to’ a specified site
Malignant neoplasm metastatic of site A to site B
‘Metastatic’ neoplasm of a specific histopathology
‘Metastatic’ malignant neoplasm on the list of common sites of metastases
‘Metastatic’ malignant neoplasm not on the list of common sites of metastases
‘Metastatic’ malignant neoplasm, some on the list of common sites of metastases and
some not
2.21.6 Sequelae
[Link] Conditions considered to be sequelae
[Link] Sequelae of tuberculosis
[Link] Sequelae of trachoma
[Link] Sequelae of viral encephalitis, diphtheria or other specified infectious diseases
[Link] Sequelae of malnutrition or certain specified nutritional deficiencies
[Link] Late effects of Chapter 22 and Chapter 23
[Link] Sequelae of leprosy
[Link] Sequelae of poliomyelitis
2.21.7 Consistency between sex of patient and diagnosis
2.21.8 Specific instructions on other ICD categories
[Link] Acute or chronic rheumatic heart diseases
[Link] Obstetric death of unspecified cause, Obstetric deaths 42 days–1 year after
delivery, sequelae of obstetric causes
[Link] Deaths due to Certain conditions originating in the perinatal period
Fetus or newborn affected by maternal factors or by complications of pregnancy, labour or
delivery
[Link] Special instructions on fetal deaths

ICD-11 Reference Guide 11

[Link] Developmental anomalies
[Link] Multiple injuries in the same body region and Injuries involving multiple body
regions
[Link] Complications of surgical and medical care
[Link] Intent of external causes
Undetermined intent
[Link] Coding of transport injury events
[Link] Factors influencing health status or contact with health services
[Link] Infectious agents reported alone on a death certificate
2.22 Mortality digital end to end solution (forms, tools and training modules)
2.23 Main uses of the ICD: Morbidity
2.23.1 ICD use in clinical care
2.23.2 ICD use for epidemiological purposes
2.23.3 ICD use in quality and patient safety
[Link] The quality and safety use case for ICD–11
[Link] Reporting on indicators of quality of care and patient safety
[Link] Functionality:
[Link] Additional information:
[Link] Recommendations for use and interpretation of coded data
[Link] ICD use for research purposes
[Link] ICD use in primary care
[Link] ICD use in Casemix groupings
2.23.4 What is coded: Patient conditions
[Link] Main condition
[Link] Multiple conditions contributing to need for admission
[Link] Other conditions
2.23.5 Health care practitioner documentation guidelines for morbidity coding
[Link] Documentation guidelines involving the term ‘Multiple’-For Single condition
reporting
[Link] Specificity and detail

12 ICD-11 MMS
[Link] Unconfirmed diagnoses
[Link] Documentation of a ruled out condition
[Link] Contact with health services for reasons other than illness
[Link] Conditions due to external causes
[Link] Documentation of sequelae
2.23.6 Coder guidelines for selecting ‘main condition’ and ‘other conditions’ for coding
purposes
[Link] MB1 - Several conditions recorded as ‘main condition’
[Link] MB2 - Condition recorded as ‘main condition’ is presenting symptom of diagnosed,
treated condition
[Link] MB3 - Signs and symptoms recorded as ‘main condition’ with alternative conditions
recorded as the cause
2.23.7 Coding using postcoordination in morbidity
[Link] Coder rule for use of extension codes
2.23.8 Coding from health care practitioner documentation of ‘causal relationships’
2.23.9 Coding of suspected conditions or symptoms, abnormal findings and non-illness
situations
2.23.10 Coding using combination categories
2.23.11 Coding using external causes of morbidity
2.23.12 Coding of acute and chronic conditions recorded as main condition
2.23.13 Coding of injuries or harm arising from surgical or medical care
2.23.14 Coding of adverse events and circumstances in health care that do not cause actual
injury or harm
2.23.15 Coding of chronic postprocedural conditions
2.23.16 Coding ‘History of’ and ‘Family history of’
2.23.17 Coding a “ruled out” condition
2.23.18 Coding of conditions documented as sequela (late effect)
2.23.19 Standards and coding instructions for injury events
[Link] Descriptions related to transport injury events
[Link] Classification and coding instructions for unintentional injury caused by transport
2.23.20 Conceptual model for quality and patient safety

ICD-11 Reference Guide 13

[Link] Overview of code-set in ICD–11 for quality and patient safety
[Link] Causation in the context of quality and safety
[Link] Chronic postprocedural conditions
[Link] Adverse events and circumstances in health care that do not cause actual injury or
harm
[Link] Recommendations for data capture and organisation
2.23.21 Chapter-specific notes
[Link] Chapter 1: Infectious and parasitic diseases
[Link] Chapter 2: Neoplasms
[Link] Chapter 3: Diseases of the blood or blood-forming organs
[Link] Chapter 5: Endocrine, nutritional or metabolic diseases
[Link] Chapter 6: Mental, behavioural or neurodevelopmental disorders
[Link] Chapter 8: Diseases of the nervous system
[Link] Chapter 9: Diseases of the visual system
[Link] Chapter 10: Diseases of the ear or mastoid process
[Link] Chapter 11: Diseases of the circulatory system
[Link] Chapter 15: Diseases of the musculoskeletal system or connective tissue
[Link] Chapter 18: Pregnancy, childbirth or the puerperium
[Link] Chapter 21: Symptoms, signs or clinical findings, not elsewhere classified
[Link] Chapter 22: Injury, poisoning or certain other consequences of external causes
[Link] Chapter 23: External causes of morbidity or mortality
[Link] Chapter 24: Factors influencing health status or contact with health services
2.23.22 Traditional Medicine Conditions - Module 1 (TM1)
2.23.23 Use in Traditional Medicine
2.23.24 Coding instructions for Traditional Medicine conditions - Module 1 (TM1)
2.24 General statistical recommendations
2.24.1 Data quality
2.24.2 Specificity versus ill-defined codes
2.24.3 Problems of a small population
2.24.4 ‘Empty cells’ and cells with low frequencies

14 ICD-11 MMS
2.24.5 Precautions needed when tabulation lists include subtotals
2.24.6 Ethical Aspects
2.24.7 Avoidance of Potential Harm
2.24.8 Security of Privacy – Confidentiality
2.25 Recommendations in relation to statistical tables for international comparison
2.25.1 The recommended Special tabulation lists
2.25.2 International morbidity reporting
[Link] Minimum data set and markup for postcoordination
2.25.3 Presentation of statistical tables
[Link] Tabulation of causes of death
[Link] Injury mortality
2.25.4 Standards and reporting requirements for mortality in perinatal and neonatal periods
[Link] Terms used in perinatal and neonatal mortality
[Link] Definitions in perinatal and neonatal mortality
Fetal death, spontaneous abortion, stillbirth, live birth, neonatal death
Artificial termination of pregnancy
[Link] Other terminologies used in recording and presentation of perinatal or neonatal
mortality
Fetal death (i.e. regardless of gestational age; lower limit, if any, should be stated)
Stillbirth (i.e. 22 or more completed weeks)
Period of gestation
Birthweight
Neonatal death
Total birth
[Link] Certification of stillbirth and live births in the neonatal period
The international form of medical certificate of cause of death and additional details
Level of details for recording
[Link] Reporting criteria for fetal death, stillbirth and live birth
Criteria for international reporting
[Link] Statistical presentation of perinatal, neonatal, infant or under-five mortality

ICD-11 Reference Guide 15

Groupings of gestational age groups for fetal death under 22 weeks, stillbirth and neonatal
mortality statistics
Groupings of birthweight for fetal death under 22 weeks, stillbirth and neonatal mortality
statistics
Groupings by chronological age in neonatal mortality statistics
[Link] Under-five mortality
[Link] Infant mortality
2.25.5 Standards and reporting requirements related for maternal mortality
[Link] Maternal death
[Link] Late Maternal death
[Link] Comprehensive maternal death
[Link] Direct and indirect obstetric deaths
[Link] Death occurring during pregnancy, childbirth and puerperium
[Link] Recording requirements of maternal mortality
[Link] International reporting of maternal mortality
[Link] Numerator, denominator, and ratios of published maternal mortality
3 Part 3 - New in ICD-11
3.1 ICD-11 new conventions and terminology
3.1.1 Short Description
3.1.2 Additional Information
3.1.3 Code Structure
3.2 Chapter Structure of ICD-11
3.2.1 Chapter 01 – Certain infectious or parasitic diseases
[Link] Chapter 01 – Structure of chapter 01
[Link] Chapter 01 – Rationale for chapter 01
[Link] Antimicrobial resistance
3.2.2 Chapter 02 – Neoplasms
[Link] Chapter 02 – Structure of chapter 02
[Link] Chapter 02 - Rationale for Chapter 02
3.2.3 Chapter 03 – Diseases of the blood or blood-forming organs

16 ICD-11 MMS
[Link] Chapter 03 – Structure of chapter 03
[Link] Chapter 03 – Rationale for chapter 03
3.2.4 Chapter 04 – Diseases of the immune system
[Link] Chapter 04 – Structure of chapter 04
[Link] Chapter 04 – Rationale for chapter 04
3.2.5 Chapter 05 – Endocrine, nutritional or metabolic diseases
[Link] Chapter 05 – Structure of Chapter 05
[Link] Chapter 05 – Rationale for Chapter 05
3.2.6 Chapter 06 – Mental, behavioural or neurodevelopmental disorders
[Link] Chapter 06 – Structure of Chapter 06
[Link] Chapter 06 – Rationale for Chapter 06
3.2.7 Chapter 07 – Sleep–wake disorders
[Link] Chapter 07 – Structure of Chapter 07
[Link] Chapter 07 – Rationale for Chapter 07
3.2.8 Chapter 08 – Diseases of the nervous system
[Link] Chapter 08 – Structure of Chapter 08
[Link] Chapter 08 – Rationale for Chapter 08
3.2.9 Chapter 09 – Diseases of the visual system
[Link] Chapter 09 – Structure of Chapter 09
3.2.10 Chapter 10 - Diseases of the ear or mastoid process
[Link] Chapter 10 – Structure of Chapter 10
3.2.11 Chapter 11 – Diseases of the circulatory system
[Link] Chapter 11 – Structure of Chapter 11
[Link] Chapter 11 – Rationale for Chapter 11
3.2.12 Chapter 12 – Diseases of the respiratory system
[Link] Chapter 12 – Structure of Chapter 12
[Link] Chapter 12 – Rationale for Chapter 12
3.2.13 Chapter 13 – Diseases of the digestive system
[Link] Chapter 13 – Structure of Chapter 13

ICD-11 Reference Guide 17

[Link] Chapter 13 – Rationale for Chapter 13
3.2.14 Chapter 14 – Diseases of the skin
[Link] Chapter 14 – Structure of Chapter 14
[Link] Chapter 14 – Rationale for Chapter 14
3.2.15 Chapter 15 – Diseases of the musculoskeletal system or connective tissue
[Link] Chapter 15 – Structure of Chapter 15
[Link] Chapter 15 – Rationale for Chapter 15
3.2.16 Chapter 16 – Diseases of the genitourinary system
[Link] Chapter 16 – Structure of Chapter 16
[Link] Chapter 16 – Rationale for chapter 16
3.2.17 Chapter 17 – Conditions related to sexual health
[Link] Chapter 17 – Structure of Chapter 17
[Link] Chapter 17 – Rationale for Chapter 17
3.2.18 Chapter 18 – Pregnancy, childbirth or the puerperium
[Link] Chapter 18 – Structure of Chapter 18
[Link] Chapter 18 – Rationale for Chapter 18
3.2.19 Chapter 19 – Certain conditions originating in the perinatal period
[Link] Chapter 19 – Structure of Chapter 19
3.2.20 Chapter 20 – Developmental anomalies
[Link] Chapter 20 – Structure of Chapter 20
[Link] Chapter 20 – Rationale for Chapter 20
3.2.21 Chapter 21 – Symptoms, signs or clinical findings, not elsewhere classified
[Link] Chapter 21 – Structure of Chapter 21
[Link] Chapter 21 – Rationale for Chapter 21
3.2.22 Chapter 22 – Injury, poisoning or certain other consequences of external causes
[Link] Chapter 22 – Structure of Chapter 22
[Link] Chapter 22 – Rationale for Chapter 22
3.2.23 Chapter 23 – External causes of morbidity or mortality
[Link] Chapter 23 – Structure of Chapter 23

18 ICD-11 MMS
[Link] Chapter 23 – Rationale for Chapter 23
3.2.24 Chapter 24 – Factors influencing health status or contact with health services
[Link] Chapter 24 – Structure of Chapter 24
[Link] Chapter 24 – Rationale for Chapter 24
3.2.25 Chapter 25 – Codes for special purposes
[Link] Chapter 25 – Structure of Chapter 25
3.2.26 Chapter 26 - Supplementary Chapter Traditional Medicine Conditions - Module 1
3.2.27 Section V – Supplementary section for functioning assessment
3.2.28 Chapter X - Extension Codes
3.3 Multiple Parenting
3.4 The Content Model
3.5 Language independent ICD entities
3.6 Innovation to mortality coding in ICD-11
3.7 Innovation to morbidity coding in ICD-11
3.8 Functioning section
3.9 General features of ICD–11
3.10 Traditional Medicine conditions - Module 1 (TM1)
3.11 Preparations for the Eleventh Revision
3.12 Annex A: ICD-11 Updating and Maintenance
3.12.1 Background
3.12.2 Updating Cycle
[Link] Types of proposals for ICD-11-MMS maintenance
3.12.3 Proposal completeness
3.12.4 Proposal Timelines
3.12.5 Proposal Workflow
3.12.6 Changes that cannot be done during the normal updating process
3.12.7 Applicability and Intellectual Property
3.13 Annex B: History of the development of the ICD
3.13.1 Early history

ICD-11 Reference Guide 19

3.13.2 Adoption of the International List of Causes of Death
3.13.3 The Fifth Decennial Revision Conference
[Link] International Lists of Diseases
3.13.4 Previous classifications of diseases for morbidity statistics
3.13.5 United States Committee on Joint Causes of Death
3.13.6 Sixth Revision of the International Lists
3.13.7 The Seventh and Eighth Revisions
3.13.8 The Ninth Revision
3.13.9 The Tenth Revision
3.13.10 The WHO Family of International Classifications
3.13.11 Updating of ICD between revisions
3.13.12 Major Steps in the ICD-11 Revision
3.13.13 Preparations for the Eleventh Revision
3.13.14 References for history of ICD
3.14 Annex C: Annexes for Mortality Coding
3.14.1 International form of medical certificate of cause of death
3.14.2 Quick reference guide for the International form of medical certificate of cause of
death (MCCD flyer)
3.14.3 Suggested additional details of perinatal deaths
3.14.4 Workflow diagram for mortality coding
3.14.5 Priority ranking of Nature-of-Injury codes
3.14.6 List of ill-defined conditions
3.14.7 List of conditions that can cause HIV disease
3.14.8 List of conditions that can cause diabetes mellitus
3.14.9 List of conditions to be considered obvious consequences of surgery and other
invasive medical procedures
[Link] List of conditions to be considered direct consequences of surgery
[Link] List of conditions to be considered direct consequences of other invasive medical
procedures
3.14.10 List of conditions unlikely to cause death
3.14.11 List of categories limited to, or more likely to occur in, female persons

20 ICD-11 MMS
3.14.12 List of categories limited to, or more likely to occur in, male persons
3.14.13 Collection of instructions with coding examples related maternal mortality
3.14.14 Target list of causes of death for verbal autopsy
3.15 Annex D: Differences between ICD-10 and ICD-11
3.15.1 Chapter 01 – Differences between ICD–10 and ICD–11 in Chapter 01
3.15.2 Differences between ICD–10 and ICD–11 in Chapter 02
3.15.3 Differences between ICD–10 and ICD–11 in Chapter 03
3.15.4 Differences between ICD–10 and ICD–11 in Chapter 04
3.15.5 Differences between ICD–10 and ICD–11 in Chapter 05
3.15.6 Differences between ICD–10 and ICD–11 in Chapter 06
3.15.7 Chapter 07 is a new addition to ICD–11 and was not found in past editions
3.15.8 Differences between ICD–10 and ICD–11 in Chapter 08
3.15.9 Differences between ICD–10 and ICD–11 in Chapter 09
3.15.10 Differences between ICD–10 and ICD–11 in Chapter 10
3.15.11 Differences between ICD–10 and ICD–11 in Chapter 11
3.15.12 Differences between ICD–10 and ICD–11 in Chapter 12
3.15.13 Differences between ICD–10 and ICD–11 in Chapter 13
3.15.14 Differences between ICD–10 and ICD–11 in Chapter 14
3.15.15 Differences between ICD–10 and ICD–11 in Chapter 15
3.15.16 Differences between ICD–10 and ICD–11 in Chapter 16
3.15.17 Chapter 17 is a new addition to ICD–11 and was not found in past editions
3.15.18 Differences between ICD–10 and ICD–11 in Chapter 18
3.15.19 Differences between ICD–10 and ICD–11 in Chapter 19
3.15.20 Differences between ICD–10 and ICD–11 in Chapter 20
3.15.21 Differences between ICD–10 and ICD–11 in Chapter 21
3.15.22 Differences between ICD–10 and ICD–11 in Chapter 22
3.15.23 Differences between ICD–10 and ICD–11 in Chapter 23
3.15.24 Differences between ICD–10 and ICD–11 in Chapter 24
3.15.25 Differences between ICD–10 and ICD–11 in Chapter 25

ICD-11 Reference Guide 21

3.16 Annex E: Referred Value Sets

0.2 How to use this Reference Guide

This Reference Guide for ICD-11 is divided into three parts. While each part will contain
information valuable for your understanding and use of ICD-11, each has been created to be
relevant to your primary purpose for coming to the Guide.
If you are looking to gain a general, broad understanding of ICD-11, with little or no prior
experience with ICD, we suggest you start with Part 1.
If you are looking to understand how codes are created, and the details of the organisation
behind ICD-11, we suggest you start with Part 2.
If you are already familiar with ICD, particularly if you have used ICD-10, we suggest you
start with Part 3 to see what is new (and what has not changed) in ICD-11.

22 ICD-11 MMS
0.3 Table of Acronyms and Abbreviations
Acronym In Full
AMR Antimicrobial Resistance
ATC/DDD The Anatomical Therapeutic Chemical Classification with Defined Daily
Doses
DRG Diagnostic Related Group
DSAP Duration Stated, developed After Procedure
DSM-(5 or Diagnostic and Statistical Manual of Mental Disorders (fifth edition)
V)
ICD The International Classification of Diseases and Related Health Problems
ICD-O The International Classification of Disease for Oncology
ICECI The International Classification of External Causes of Injury
ICF The International Classification of Functioning, Disability, and Health
ICHI The International Classification of Health Interventions
ICNP The International Classification of Nursing Practice
ICPC The International Classification of Primary Care
INN International Non-proprietary Names
ISO9999 International Standards Organization for Technical aids for persons with
disabilities
MMS Mortality and Morbidity Statistics
NEC in an ICD category, indicates Not Elsewhere Classified
NOS in an ICD category, indicates Not Otherwise Specified
OCPR Other Cause of Procedure Required
PCL Primary Care Low Resources Settings
SMoL Startup Mortality List
TAG Topic Advisory Group
TM Traditional Medicine
URI Uniform Resource Identifier
WHODAS The World Health Organization Disability Assessment Scale
WHO-FIC The World Health Organization - Family of International Classifications
WM Western Medicine
WONCA World Organization of National Colleges, Academies, and Academic
Associations of General Practice/Family Practitioners
0.4 Glossary

ICD-11 Reference Guide 23

Term Description
Activity limitations The level of functioning an individual may have in executing
activities.
Body functions The physiological functions of body systems (including
psychological functions).
Body structures The anatomical parts of the body such as organs, limbs, and their
components.
Casemix A system that groups patients using information about the patient,
their diagnoses, procedures, complexity, and needs. Used for
resource allocation.
Causal relationship A relationship that exists if a condition is caused by another
(coding) condition (e.g. on the same death certificate or in a morbidity
coding situation where one condition or factor causes another
condition).
Classification An exhaustive set of mutually exclusive categories to aggregate
data at a pre-prescribed level of specialisation for a specific
purpose.
Cluster A cluster are postcoordinated entities that are joined using either a
forward slash (/) or ampersand (&).
Content Model A structured framework that captures the knowledge that
underpins the definition of an entity.
Derived Classifications, often tailored for use at the national or international
classification level, or for use in a specialty, based upon reference classifications.
Dual coding The process used in situations where clinical terms are coded in to
two different classification systems or versions for purposes of
comparison, transition, mapping, casemix grouping or
understanding the implications of change from one system to
another.
Duration (coding) The time-period between the onset of the disease and the time
admission for care or death.
Environmental The physical, social, and attitudinal environment in which people
factors live and conduct their lives.
Extension code Extension codes are lists of additional information that can be
added to a stem code when users and settings are interested in
reporting more detail. Extension codes are not mutually exclusive
and should not be used alone in the context of statistical
classification but must be added to a stem code. Extension codes
may be used alone in another context, e.g. for device
documentation. Not all extension codes can be used with every
stem code. Extension codes can never appear in the first position in
a cluster.

24 ICD-11 MMS
 Term Description
Foundation A large collection of terms and their relationships, which describe
Component health and health-related domains. Underlying data base content
that holds all necessary information to generate print versions of
the Tabular list and the alphabetical index as well as additional
information that is needed to generate specialty linearisations of
ICD-11 and country specific modifications. The mention of a term or
entity in the foundation exclusively serves ontological purposes and
indexing. Mention of a term or entity in the foundation does not
mean approval or endorsement of a particular condition.
Impairments The problems in body function or structure such as a significant
deviation or loss.
Integrated coding Full use of all chapters of ICD-11 (including, codes from Western
Medicine and Traditional Medicine (TM1) chapters) for
classification of clinical terms.
Modification rule When coding for mortality from death certificates, the procedure
by which an ICD code for the starting point is replaced by another
code, due to special instructions.
Precoordination Stem codes which contain all pertinent information about a
documented clinical concept in a pre-combined fashion.
Postcoordination The use of multiple codes (i.e. stem codes and/or extension codes)
together to fully describe a documented clinical concept.
Postcoordination is permitted by a matter of principle with all
codes, as long as at least one stem code is used.
Primary parent A higher level entity that covers the full range or scope of another
entity.
Reference Classifications that cover the main parameters of the health system
classifications – disease (ICD), disability, functioning, and health (ICF), and health
interventions (ICHI).
Secondary parents The ability to connect a specific entity within the classification to
more than one parent.
Sequence (coding) In the context of mortality coding, a set of conditions reported line
by line with a causal relationship between each element.
Starting point In the context of mortality coding, normally the condition or event
(coding) reported that started the sequence of acceptable causal
relationships ending with the terminal cause of death, or when a
death certificate is correctly completed, the condition reported on
the lowest used line in Part 1 of the death certificate.
Stem code Codes in the Tabular list of ICD-11 that can be used alone. Stem
codes may be entities or groupings of high relevance in any of the
use cases or clinical conditions that should always be described as
one single category. Stem codes are designed to ensure that in use
cases that require only one code per case, meaningful information
is collected.

ICD-11 Reference Guide 25

 Term Description
Terminal cause of The first condition entered on the first used line of Part 1 of the
death (coding) death certificate. Also known as immediate cause of death.
Underlying cause The disease or injury which initiated the train of morbid events
of death leading directly to death, or the circumstances of the unintentional
injury or violence which produced the fatal injury.
Verbal autopsy A method used to ascertain the cause of a death based on an
interview with next of kin or other caregivers where no physician
can evaluate the deceased.

1 Part 1 - An Introduction to ICD-11

1.1International Classification of Diseases (ICD)
The International Classification of Diseases and Related Health Problems (ICD) is a tool for
recording, reporting and grouping conditions and factors that influence health. It contains
categories for diseases and disorders, health related conditions, external causes of illness or
death, anatomy, sites, activities, medicines, vaccines and more.
The purpose of the ICD is to allow the systematic recording, analysis, interpretation and
comparison of mortality and morbidity data collected in different countries or regions and
at different times.
ICD-11 has been designed to serve semantic interoperability of individual data, reusability of
recorded data, for use cases other than health statistics, including decision support,
resource allocation, reimbursement, guidelines and more.
The role of the WHO in maintenance and implementation support of ICD is described in the
WHO constitution. In addition, implementation and use of the most recent revision of ICD in
all member states are legally mandated by the WHO International Nomenclature
Regulations and reiterated with revisions of ICD adopted by the World Health Assembly.
This includes an updating mechanism between revisions and the ongoing development and
implementation of the family of diseases- and health-related classifications (WHO-FIC). The
ICD as the core classification linked to other related classifications, specialty versions and
terminologies.
In health information systems, data needs to be reusable for epidemiological analysis,
resource allocation or research, as well as for individual level uses like health
documentation, decision support, or reimbursement. ICD provides highly detailed
information, far beyond the level of statistical categories, using unique identifiers. This way
for example rare diseases, special findings or individual medicines can be recorded and
reported.
The ICD is used to translate diagnoses of diseases and other health problems into
alphanumeric codes, allowing storage, retrieval, and analysis of the data. The ICD is the
international standard diagnostic classification for all general epidemiological and many
health management purposes. These purposes include analysis of general health situations
in population groups, monitoring of incidence and prevalence of diseases, and examining

26 ICD-11 MMS
other health problems in relation to other variables, such as the characteristics and
circumstances of the affected individuals. ICD is also suitable for studies of financial aspects
of a health system, such as billing or resource allocation.
The ICD has evolved over the past 150 years from an International List of Causes of Death to
a comprehensive classification and terminology system. The ontology-based design of ICD-
11 and the migration of its sibling classifications ICF and ICHI to the same ontological
infrastructure has enabled the full integration of terminology and classification in a common
platform. In that way lossless clinical documentation is possible (coding all the necessary
details), statistical aggregation is an integrated feature, end-to-end digital solutions are
provided and links to other terminologies for other uses are enabled.
The ICD is used to allocate the majority of global health resources. Users of the ICD include
physicians, nurses, other health care providers, researchers, health information
management professionals, coders, health information technology workers, analysts,
policymakers, insurers, patient organisations, and many more.
The ICD is used in various settings at different levels of detail. It therefore includes an
information framework that contains a fully specified set of health concepts and their
characteristics and relationships from which appropriate code sets can be selected. The
ICD11 ensures consistency with traditional use cases of earlier ICD versions, because it has
been built with the past revisions in mind. Past data analyses based on older versions of ICD
can be linked to analyses of data based on ICD11.
The ICD can therefore be used to record, classify and use otherwise data recorded under
headings such as cause of death, diagnosis, reason for admission, conditions treated,
additional diagnoses, risk factors and reason for consultation, which appear on a wide
variety of health records and documents from which statistics are derived.
1.1.1 Intended uses

The ICD has been designed to address the needs of a broad range of use cases, such as:
causes of death, morbidity, epidemiology, casemix (Diagnosis-Related Groups (DRG)),
quality and patient safety, primary care, functioning assessment, research, prevention,
substance (medication) or device safety, specific surveillance like antimicrobial resistance
(AMR), cancer registration, injury research, as well as ensuring semantic interoperability for
clinical documentation, decision support and guidelines or recommendations.
Detailed information and instructions for users on the different use cases are available in
other sections of the guide, relating to mortality use and different morbidity uses. Where
innovative uses of ICD are envisaged, it is recommended to consult with the WHO to make
best use of the flexibility and features of ICD-11.
1.1.2 Classification

A classification is ‘an exhaustive set of mutually exclusive categories to aggregate data at a

pre-prescribed level of specialisation for a specific purpose’ (ISO 17115). A classification
involves the categorisation of relevant concepts for the purposes of systematic recording or
analysis. The categorisation is based on one or more logical rules. The purpose of a health
classification varies. For example, it may be used in the analysis of cause of death

ICD-11 Reference Guide 27

(mortality), morbidity, or human functioning. Low frequency concepts tend to be grouped
but rare concepts may be individually classified.
Coding is the process of assigning a code from a classification to represent a clinical concept
for a specific purpose. Coding rules must be incorporated in the classification to achieve
consistency of coding and comparability of coded data over time and place. Classifications
are complementary to terminologies, since they are designed to be used for standardised
coding of information for statistical purposes.
ICD-11 is combining the elements of classification and terminology and is designed to be
linked to other terminologies that may provide additional detail or serve different purposes.
Coding in ICD-11 can draw on statistical codes and on Uniform Resource Identifiers (URIs).
1.1.3 ICD in the context of the WHO Family of International Classifications (WHO-FIC)

The WHO Family of International Classifications (WHO-FIC) comprises classifications that

have been endorsed by the WHO to describe various aspects of health and the health
system in a consistent manner.
The WHO-FIC provides standardised building blocks for health information systems and
consists of three broad groups: Reference classifications, Derived classifications, and Related
classifications.
The Reference and the Derived classifications are based on the Foundation Component,
which is a large collection of concepts (with synonyms and preferred terms) and their
relationships, which describe health and health-related domains.
Terms and entities related to diseases and health-related problems are organised into the
ICD, those pertaining to functioning into the ICF, and those related to interventions into ICHI
(International Classification of Health Interventions). Terms from the Foundation
Component may be used in more than one Reference classification.
Derived Classifications draw on terms that may come from one or more of the Reference
Classifications. Within the WHO-FIC Family, Related classifications are regarded as
complementary to the Reference and Derived classifications. Related classifications have
their own sets of terms, but can also share terms as part of the WHO-FIC Family.

28 ICD-11 MMS
Figure 1: Relationships between the WHO Family of International Classifications (WHO-FIC)
and Related Classifications, the Foundation Component, and shared terms.
The purpose of the WHO-FIC is to assist the development of reliable statistical and other
data systems at local, national, and international levels, with the aim of improving health
status and health care. Health related information might sometimes require additional
detail to that contained in the ICD. A group or ‘family’ of health relevant classifications
covers these needs both by classification of domains different from those of the ICD and
provision of more details for specific uses, e.g. cancer registration. The WHO-FIC designates
a suite of integrated classification products that share similar features and can be used
singularly or jointly to provide information on different aspects of health and health care
systems. For example, the ICD as a reference classification is mainly used to capture
mortality and morbidity information. Functioning is classified in the International
Classification of Functioning, Disability and Health (ICF) and health interventions in the
International Classification of Health Interventions (ICHI).
The WHO-FIC provides a conceptual framework of information dimensions which are
related to health and health management. In this way, it provides a common language that
improves communication and permits comparisons of data within countries, across
countries, health care disciplines, services, and time. The WHO and the WHO-FIC Network
(including collaborating centres, Non-governmental Organisations (NGOs), and selected
experts) ([[Link]
([Link] strive to build the
Family of International Classifications based on sound scientific and taxonomic principles,
ensure that it is up-to-date, culturally appropriate and internationally applicable, and meet
the needs of its different users by focusing on the multi-dimensional aspects of health.

ICD-11 Reference Guide 29

1.1.4 WHO-FIC: Reference Classifications

Reference classifications cover the main parameters of the health system, such as death and
disease (ICD), disability, functioning, and health (ICF) and health interventions (ICHI). WHO-
FIC reference classifications are a product of international agreements. They have achieved
broad acceptance and official agreement for use and are approved and recommended as
standards for international reporting on health. They may be used as models for the
development or revision of other classifications. The three Reference classifications are:
1. International Classification of Diseases and Health Related Problems (ICD)
2. International Classification of Functioning, Disability & Health (ICF)
3. International Classification Health Interventions (ICHI)
The Reference Classifications are based on the same Foundation Component and share sets
of Extension Codes.

[Link] International Classification of Functioning, Disability & Health (ICF)

The ICF is the WHO’s framework for measuring health and functioning/disability at both the
individual and population levels. While the ICD classifies diseases and causes of death, the
ICF classifies health and health-related domains. ICD and ICF together provide a framework
to capture the full picture of health.
The ICF classifies health and health-related states in two parts. Part one deals with
functioning and disability, described from the perspectives of the body, the individual, and
society. It is composed of two components: Body functions and structures, and Activities
and participation. Part two covers contextual factors and also has two components:
Environmental factors and Personal factors, since an individual’s functioning occurs in a
context. Work is proceeding on the development of a classification of personal factors to be
included in the contextual factors.
Functioning is a generic term for body functions (e.g. memory), body structures
(e.g. occipital lobe), and activities and participation (e.g. walking, engaging in paid work). It
denotes the positive aspects of the interaction between an individual (related to the
individual’s health) and that individual’s contextual factors (environmental and personal
factors).
Disability is an umbrella term for impairments, activity limitations and participation
restrictions. It denotes the negative aspects of the interaction between an individual (with a
health condition) and that individual’s contextual factors (environmental and personal
factors). Disabilities are envisioned as a continuum and therefore the ICF and the codes
within it do not confer an international binary status of disabled/not disabled. Levels of
disability can be used descriptively in clinical settings when formulating a case. Program and
policy decision-makers can apply the ICF and specify their own standards for the level of
disability as eligibility criteria that are relevant for specific purposes.
ICF includes other relevant descriptions:

30 ICD-11 MMS
 • Body functions are the physiological functions of body systems (including mental
functions).
• Body structures are anatomical parts of the body such as organs, limbs and their
components.
• Impairments are problems in body function or structure such as a significant
deviation or loss.
• Activity is the execution of a task or action by an individual.
• Activity limitations are difficulties an individual may have in executing activities.
• Participation is involvement in a life situation.
• Participation restrictions are problems an individual may experience in involvement
in life situations.
• Environmental factors make up the physical, social and attitudinal environment in
which people live and conduct their lives.
ICF includes codes for Body Functions (b), Body Structures (s), Activities and Participation
(d), and Environmental Factors (e).
ICF codes are only complete with the presence of a qualifier, which denotes the level of
health (i.e. severity of the problem from ‘no problem’ to ‘complete problem’). Without
qualifiers, codes have no inherent meaning. The ICF acknowledges that every human being
can experience a decrement in health and thereby experience some disability. Disabilities
can be temporary and may be brief (such as staying home from work for a few days with the
flu); they can also be chronic or permanent and may fluctuate in severity over time.
Personal factors are included in the ICF model of functioning and disability, but have not
been classified in ICF because of the large social and cultural variants associated with them.
The taxonomy has not been operationalized further due to challenges related to
establishing cross-cultural applicability, resource constraints, and ethical considerations.

[Link] The International Classification of Health Interventions (ICHI)

ICHI includes interventions across all functional sectors of the health system, covering acute
care, primary care, rehabilitation, assistance with functioning, prevention, public health, and
ancillary services. Interventions delivered by all types of providers have been included. The
importance of describing and classifying health interventions has long been understood. An
International Classification of Procedures in Medicine (ICPM) was published by WHO in 1978
but was not maintained. ICHI is much broader than the former ICPM because it includes the
full range of health interventions. Development of ICHI began in 2007, as a joint effort of the
WHO Family of International Classifications (WHO-FIC) Network and WHO, based on the
experience gathered with the development of several national classifications of health
interventions.
Table 1: Descriptions and terms used in creation of ICHI.

ICD-11 Reference Guide 31

 Axes Inclusions Example
The Target axis contains the entities Anatomy, Human function, stomach, activities
on which the action is carried out. Person or client, Group or of daily living
population
The Action axis is defined as a deed Investigation, Treating, biopsy, vaccination
which is done by an actor to a target Managing, Informing,
during a health care intervention. Assisting, Preventing
The Means axis contains the entities Approach: the process by open, endoscopic
describing the processes and which the target of the
methods by which the action is action is accessed
carried out.
Technique used as part of radiation, magnetic
the action resonance
Method describing how law enforcement,
the action is undertaken method of
transport.

The content of the axes has been restricted to attributes that are common to many
interventions. In particular:
• Devices have not been included as an axis because most interventions do not involve
a device and devices change rapidly, however devices may be included as extension
codes
• Drugs or other substances administered through an intervention are classified
elsewhere (e.g. ICD, The Anatomical Therapeutic Chemical Classification with
Defined Daily Doses (ATC/DDD), INN).
The coding system comprises a seven-character category structure for the three axes:
• Three letters for the Target
• Two letters for the Action
• Two letters for the Means
ICHI codes comprise valid seven letter combinations of the three axes. For each intervention
included in ICHI, the appropriate seven letter combination is identified. Not every possible
combination of the three axes represents a valid ICHI domain.

[Link] WHO-FIC: Derived classifications

Derived classifications are often tailored for use at the national or international level or for
use in a particular specialty. They are based on reference classifications (i.e. ICD, ICF, ICHI).
Derived classifications may be prepared by:

32 ICD-11 MMS
 • adopting the reference classification structure and classes
• providing additional detail beyond that provided by the reference classification
• rearrangement or by aggregation of items from one or more reference
classifications.
ICD-11 has specialty linearisations that are derived from the common foundation. These
include a version for dermatology, one for primary care and one for mental health. Others
may follow.

[Link] Related classifications

Related classifications are included in the WHO Family of International Classifications to
describe important aspects of health or the health system not covered by reference or
derived classifications. Related classifications are:
• International Classification of Primary Care (ICPC)
• International Classification of External Causes of Injury (ICECI)
• Technical aids for persons with disabilities (ISO9999)
• The Anatomical Therapeutic Chemical Classification with Defined Daily Doses
(ATC/DDD)
• The International Classification for Nursing Practice (ICNP)
1.1.5 ICD use in health information systems

Health information systems include a range of different components for collection, analysis,
and use of health data. Information sources could, for example, be population-based, health
facility-based, or focused on particular diseases. The main population-based sources of
health information are civil registration and vital statistics (CRVS) systems, census data, and
household surveys.
Health facility-related data sources include public health surveillance, health services data
(that may be referred to as health management information systems or routine health
information systems (RHIS)), and health system monitoring data (e.g. human resources,
health infrastructure, financing).
National health accounts (NHA) are designed to provide a comprehensive picture of health
financing. Coding enables the recording of health information in a language independent
way. Standardisation of coding enables both intra- and international data comparison. For
example, ICD coded data can be compared across different sectors of the health system – if
the same coding rules are applied.
Health information systems are increasingly based on digital (electronic) reporting and
coding. ICD–11 is designed to be used in such environments. The content of this Reference
Guide is the only additional document required when coding with ICD-11.
In many places information collection is based on paper reporting in a traditional analogue
way. ICD–11 can also be produced in a printed version for use in paper-based systems if
needed (see [Link]).

ICD-11 Reference Guide 33

[Link] Use of ICD–11 in a digital setting and with web services
ICD-11 is used for coding of diagnoses, in electronic health records or with electronic death
certificates, or in other digital data collections. Special tools like the ICD-11 Coding Tool
facilitate finding specific ICD-11 codes for any of the several dimensions that define an ICD-
11 entity or category. Additional details can be added using multiple codes for one
condition. Retaining the unique identifier of the coded ICD-11 entity allows the same
information to be reused across different translations. WHO has developed ICD web services
([Link] designed to support interoperable machine-to-machine
interaction.

[Link] Use of ICD–11 in an analogue paper-based setting

ICD-11 can be used as an analogue printed version, if needed. Information is reported on
hard copy documents and then coded manually with the ICD-11. It should be noted that
paper-based recording requires manual transcription of the information into electronic
systems and consideration should be given to moving to electronic reporting as early as
possible in the information chain. Paper-based recording may cause problems with
readability and timeliness of coded data. ICD-11 supports many ways of computer assisted
coding including embedding of instructions for code combinations and other possible
plausibility checks. The long-term goal for all users should be coding using ICD-11 in an
electronic environment.
In the print version, the information is divided into 3 volumes, the Tabular list, the
Reference Guide, and the Index. All three are needed to use the ICD correctly.

[Link] Electronic version

In the browser version of the ICD, most information is interlinked and visible in the relevant
context. The WHO provides this version for browsing ICD-11 in multiple languages (linked
from [Link] This tool allows the user to retrieve concepts by searching for
terms, anatomy or any other element of the content model. With the browser, users can
also contribute to the updating and continuous improvement of ICD with comments and
suggestions. Such input is reviewed for consideration for inclusion on an annual basis.
ICD–11 can also be accessed using web services with user specific software. The IT guide to
the ICD provides more details on compatibility requirements can be found on the following
page: [Link] Both the web services and the online browser allow access
and searching of all Tabular lists of the ICD, including for mortality and morbidity statistics,
primary care, or for specialty linearisations for certain specific domains.
1.1.6 Links with other Classifications and Terminologies

ICD coded entities or categories can be used in conjunction with other relevant health
classifications and terminologies to fully document an episode of care, or a case for
research.

[Link] Integrated use with Terminologies

Classification involves grouping information according to logical rules. Terminology allows
the reporting of information at any desired level of detail: for example, body parts, findings,

34 ICD-11 MMS
or other elements that constitute a disease. Only items defined in a terminology can be
reported (i.e. terminologies have no mechanism to report new information that has not
previously been added to the terminology). In contrast, a classification has residual classes
(‘other specified’ and ‘unspecified’) that ensure that all cases can always be classified. In a
terminology, similar to a modern classification, a disease can be defined, for example by
establishing linkages between its elements, such as anatomy or findings. Terminologies
retain the information without emphasising any aspect of the recorded information.
In contrast, classifications allow for identification of ‘relevant parts’ of the content, for
example, for public health purposes. International agreement about these relevant parts
ensures sure that the aggregated information is internationally comparable. The
standardised use of the aggregation logic of a classification and the standardised use of the
detailed information of a terminology aim at the same result: comparability. Transparent
international agreement processes are necessary in both cases, with integration of index
and tabular lists, ICD has moved towards having its own terminology component.
Terminologies and classifications should be considered complementary. ICD-11 Foundation
is the terminological part of ICD-11 derived from the former ICD-10 Index and other sources.
Third party terminologies ideally are linked to the ICD-11 Foundation in 1:1 relationships or
“signposted from ICD-11 foundation in 1:n relationships. These links shall follow the
recommendations by the mapping paper.

[Link] Functioning in ICD and joint use with ICF overview

Historically, the ICD has used certain disability concepts as common disease or disorder
entities, such as: blindness, deafness, learning disability, or paraplegia, as well as certain
disability concepts for other purposes, such as ‘disability as a sequela of injury’, and
‘limitation of activities due to disability’. The ICF was developed after the publication of ICD–
10.
In ICD-11, links with ICF have been created in terms of aligning the concepts of disease and
functioning and facilitating the joint use.
Conceptual alignment between ICD-11 and ICF has taken place in several areas.
• Signs and symptoms in the ICD are aligned with body functions in the ICF, and
‘factors influencing health status’ in the ICD align with contextual factors in the ICF.
• ICD-11 categories related to visual impairment in the Ophthalmology Chapter
(Chapter 09) have been aligned with the respective ICF taxonomy and definitions for
seeing functions.
Additional selected ICF categories are drawn from the component Activities and
Participation and help to describe the functional limitations commonly associated with
specific health conditions in a functioning pattern. The impact of a disease or disorder in the
daily activities of a person may vary depending on the severity of the condition as well as
the contextual factors (e.g. environmental factors) and possible co-morbidities. The ICD
takes an approach that identifies ‘severity’ as a property of the disease/disorder and
describes the impact of the health condition on the daily life of a person with a set of
functioning codes.

ICD-11 Reference Guide 35

An optional functioning section has been embedded in ICD-11 to enable the classification
and measurement of the impact of health conditions in terms of functioning.
The ICD-11 functioning section provides two options for impact assessment and
documentation:
• use of an ICF-based generic assessment instrument (i.e. World Health Organization
Disability Assessment Schedule (WHODAS) 2.0) and the Model Disability Survey
(MDS) to generate an overall and domain specific functioning score. In order to
obtain such scores, WHODAS 2.0 (like other clinical rating scales) has to be used as a
whole (i.e. the full battery of questions). Further instructions on the use of WHODAS
2.0 are provided in the WHODAS Manual.
• use of a short-list of functioning categories derived from ICF Annex 9. These
categories should be used with a generic 5-point qualifier indicating severity for
reporting of functioning in health information systems.
Overall, the linkage between ICD-11 and ICF may assist with the following use cases:
• evaluation for general medical practice (e.g. work in capacity assessment)
• evaluation for social benefits (e.g. disability pension)
• payment or reimbursement purposes
• needs assessments (e.g. for rehabilitation, occupational assistance, long-term care)
• outcome evaluation of interventions
Wherever full functioning reporting is desired and required, the ICF should be used. (see
Section 2.11 for further information)

1.2 Structure and taxonomy of the ICD

The chapter and block structure of the ICD has evolved in 11 iterations of the classification
over 150 years. The authoring of ICD follows a set of rules that ensure the functional and
structural integrity of the classification. The evolution of the ICD carefully balances the need
for categories that match current knowledge while allowing statistical comparability over
space and time.
The chapter structure of ICD reflects major aspects of diseases. Chapters are not intended to
delimit areas of medical expertise or domains of specialties. The link to any specialty or
reimbursement schemes is secondary. The ICD has categories for diseases, disorders,
syndromes, signs, symptoms, findings, injuries, external causes of morbidity and mortality,
factors influencing health status, reasons for encounter of the health system, and traditional
medicine. ICD-11 complements these by allowing capture of additional details such as
anatomy, substances, medications, medical devices, infectious agents, place of injury, and
many more. ICD-11 also comes with a set of rules and explanations for its use and necessary
metadata. Required reporting formats are also included.
The most widespread use of ICD over time and geographically is for cause of death
(mortality) statistics. ICD is also used for classification of clinical documentation, to provide
standardised, language independent information for morbidity use, such as resource
allocation, casemix, patient safety and quality of care, as well as primary care and research.
ICD and its descriptions are also used as a framework in legislation.

36 ICD-11 MMS
1.2.1 Taxonomy

A statistical classification of diseases must be confined to a limited number of mutually

exclusive categories able to encompass the complete range of morbid conditions. The
categories are chosen to facilitate the statistical study of disease phenomena. Every disease
or morbid condition must have a well-defined place in the list of categories. Consequently,
throughout the classification, there are residual categories for other and miscellaneous
conditions that do not have their own unique category or which cannot be allocated to the
more specific categories. However, the ICD-11 Uniform Resource Identifiers (URI) allow
retention of such detail for future analysis. The following measures apply in determining
whether an entity qualifies to become a unique category:
1. Epidemiological evidence: frequency analyses of coded mortality and morbidity data
2. Clinical evidence: disease evidence provided by the medical specialties
3. Granularity: minimum detail reported and useful in mortality or primary care
4. Continuity: preservation of the level of detail pre-existing in ICD
5. Parsimony: the need to limit the number of categories for international mandatory
reporting
A statistical classification can allow for different levels of detail if it has a hierarchical
structure and subdivisions. A statistical classification of diseases should retain the ability to
both identify specific disease entities and to allow statistical presentation of data for
broader groups, thus enabling the attainment of useful and understandable information.
The same general principles apply to the classification of other health problems and reasons
for contact with health care services, which are also incorporated in the ICD. The ICD was
developed as a practical, rather than a purely theoretical classification, in which there are a
number of compromises between classification based on aetiology, anatomical site,
circumstances of onset, or other criteria.
ICD-11 draws extensively on the method of combining several codes to describe a clinical
condition to the desired level of detail. Its electronic architecture allows assignment of
unique identifiers to any condition listed - independently whether the condition is grouped
in a statistical class or whether it represents a class of its own. The two approaches together
allow the option of keeping coding simple where diagnostic detail is limited; and
alternatively adding detail where diagnostic reporting requires a high level of
comprehensiveness and sophistication.

[Link] Content model and definition of disease

Content model
For further information please see 3.4 The Content Model.
Definition of disease
A disease is usually defined using a set of relevant aspects drawn from the pattern below. A
disease is a set of dysfunctions in any body system defined by:

ICD-11 Reference Guide 37

 Property Description
Symptomatology or Known pattern of signs, symptoms, and related
manifestations findings
Aetiology An underlying explanatory mechanism
Course and outcome A distinct pattern of development over time
Treatment response A known pattern of response to interventions
Linkage to genetic factors E.g. genotypes, patterns of gene expression, etc.
Linkage to environmental Factors of the environment that trigger presence of a
factors disease
1.2.2 ICD Chapter structure

The ICD is a variable-axis classification. The structure was developed out of that proposed by
William Farr in the early days of international discussions on classification structure:
epidemic diseases, constitutional or general diseases, local diseases arranged by site,
developmental diseases, injuries.
These groups remain in the chapters of ICD–11. The structure has stood the test of time
and, though in some ways arbitrary, is still regarded as more useful for general
epidemiological purposes than any of the alternatives tested. The conservation of the
structure acknowledges the need for stability while allowing incorporation of additional
sections.
Special groups bring together conditions that would be inconveniently arranged for
epidemiological study if they were to be scattered, for instance in a classification arranged
primarily by anatomical site. These conditions formulate the ‘special groups’ chapters:

Chapter Title
1 Certain infectious or parasitic diseases
2 Neoplasms
3 Diseases of the blood or blood-forming organs
4 Diseases of the immune system
18 Pregnancy, childbirth, or the puerperium
19 Certain conditions originating in the perinatal period
20 Developmental anomalies
22 Injury, poisoning or certain other consequences of external cause

The distinction between the ‘special groups’ chapters and the ‘body systems’ chapters has
practical implications for understanding the structure of the classification, for coding to it,
and for interpreting statistics based on it. It has to be remembered that, in general,
conditions are primarily classified to one of the ‘special groups’ chapters.
Where there is any doubt as to where a condition should be positioned, the ‘special groups’
chapters take priority. This principle is enforced in the ‘excludes’ notes at the beginning of
each chapter in the ICD.

38 ICD-11 MMS
1.2.3 Guiding principles for classification of special concepts
1. Clinical findings are located in Chapter 21 ‘Symptoms, signs or clinical findings, not
elsewhere classified’. (e.g. ‘Abnormal serum enzyme levels’ or ‘Results of function
studies of the circulatory system’)
2. Manifestations of diseases, a relevant point for health intervention, are ‘clinical
manifestations’ located in the body system chapter where they manifest. The
underlying condition has to be coded as well. (e.g. myocarditis)
3. Syndromes, where the aetiology is unknown, are allocated with the most relevant
body system. (e.g. Costen syndrome is in the ‘Digestive’ chapter)
4. The number of categories with ‘due to’ in the title are restricted to certain
exceptions. (e.g. acute bronchiolitis due to respiratory syncytial virus)
5. Very specific, chronic, postprocedural conditions are grouped at the end of the body
system chapter where they manifest. (e.g. lymphoedema due to surgery or
radiotherapy). Residual categories do not exist for these groups.
6. Acute postprocedural complications are identified by combinations of codes from
body system or injury chapters, and external causes chapter (e.g. an unintentional
puncture of an organ during an intervention is classified with a code for the injured
organ (harm), a code describing what surgery caused the injury (cause), and a code
identifying the unintentional puncture as the mode/mechanism of injury.).
7. Categories with mention of ‘multiple’ are restricted to exceptions and require coding
of the different multiple conditions individually (e.g. multiple injuries are to be coded
individually when possible).
8. Categories with mention of ‘sequelae’ are restricted to exceptions. The specific
condition resulting as a sequela needs to be coded along with the underlying cause.
In some instances, they will continue to exist with the label ‘late effects of…’
(e.g. late effects of cerebrovascular disease or late syphilis). ‘Sequelae’ include
residual effects of diseases or disorders, injuries or poisonings specified as such, or
as late effect of, arrested, cured, healed, inactive, old or quiescent condition unless
there is evidence of active disease.
9. Categories with mention of ‘history of’ are limited to exceptions (e.g. personal
history of malignant neoplasms lists only the more frequent anatomical sites).
10. High level groupings need to be meaningful.
11. Residual categories exist only where they are meaningful. (e.g. where conditions are
either congenital or acquired, there is no ‘other’ residual, but there will be an
‘unspecified’ option)
1.2.4 General features of ICD-11

The main structural innovation of ICD–11 is that it is built on a Foundation Component from
which the Tabular lists (such as the classification for morbidity and mortality statistics) are
derived.

[Link] Code structure

The codes of the ICD–11 are alphanumeric and cover the range from 1A00.00 to [Link].
These are referred to as stem codes. The structure of stem codes is described below:

ICD-11 Reference Guide 39

 • The first character of the code always relates to the chapter number. It may be a
number or a letter.
• Codes starting with ‘X’ indicate an extension code (see 2.9).
• There is always a letter in the second position to differentiate ICD-11 codes from the
codes in ICD–10.
• The inclusion of a forced number at the third character position prevents spelling
‘undesirable words’.
• The letters ‘O’ and ‘I’ are omitted to prevent confusion with the numbers ‘0’ and ‘1’.
For example, 1A00 is a code in Chapter 01, and BA00 is a code in Chapter 11.
For example: [Link]
• E corresponds to a ‘base 34 number’ (0-9 and A-Z; excluding O, I);
• D corresponds to ‘base 24 number’ (A-Z; excluding O, I); and
• 1 corresponds to the ‘base 10 integers’ (0-9)
• The first E starts with ‘1’ and is allocated for the chapter. (i.e. 1 is for the first
chapter, 2: chapter 02, … A chapter 10, etc.)
The terminal letter Y is reserved for the residual category ‘other specified’ and the terminal
letter ‘Z’ is reserved for the residual category ‘unspecified’. For the chapters that have more
than 240 blocks, ‘F’ (‘other specified’) and ‘G’ (‘unspecified’) are also used to indicate
residual categories (due to limitations in the coding space).
Throughout the Reference Guide a dash indicates that more detailed codes exist, and should
be used as appropriate. For example
• 8B24 - covers codes from 8B24.0 to 8B24.Z
• CA23.0 - covers CA23.01 to CA23.02

[Link] Uniform resource identifiers

All entities have a Uniform Resource Identifier (URI) which is a string of characters that
uniquely identifies a particular ICD-11 entity. Each entity has a specific place in the hierarchy
of groups and categories.

[Link] Block codes

Higher level entities in ICD-11 (called ‘blocks’) may be used for reporting aggregated
statistics. However, blocks do not have category codes as they are not supposed to be used
in coding. Blocks have their own URIs (e.g. the URI for Neoplasms is
[Link] Blocks may also be referred to by block IDs. The
code structure for block IDs are 11 characters long (e.g. “BlockL1-1A0”).

[Link] Stem codes

Codes in the Tabular list of ICD-11 that can be used alone. Stem codes may be entities or
groupings of high relevance in any of the use cases, or clinical conditions that should always
be described as one single category. Stem codes are designed to ensure that in use cases
that require only one code per case, meaningful information is collected.

40 ICD-11 MMS
[Link] Extension codes and postcoordination
The extension codes are comprised of groups of codes e.g. anatomy, agent, histopathology
and other aspects that may be used to add detail to a stem code. Extension codes are not to
be used alone in the context of statistical classification but must be added to a stem code.
Extension codes may be used in another context, e.g. for device documentation. Not all
extension codes can be used with every stem code. Refer to 2.9.
Postcoordination is a notable new feature in ICD-11 that creates the ability to link core
diagnostic concepts (i.e. stem+stem code concepts) when desired, and/or to add clinical
concepts captured in extension codes to primary stem code concepts. The linked diagnostic
concepts are called a cluster. It should be emphasised that the postcoordination ability
inherent in ICD-11 is one of the significant changes compared with ICD-10. A cluster
describes one clinical concept as described by the health care practitioner. Postcoordination
is by matter of principle permitted with all axes, as long as at least one stem code is used.
API, Browser and coding tool facilitate postcoordination in certain areas. Other areas of
postcoordination have to be coded individually, but may be supported by future updates of
ICD-11, where need arises.

[Link] Other general features

• ICD–11 categories have short descriptions, plus long descriptions labelled ‘additional
information’. The short description is a maximum of 100 words relating to the entity that
states things that are always true about a disease or condition which are necessary to
understand the scope of the rubric. It appears in the Tabular list of the classification. The
long ‘additional information’ is the full description, without length restriction.

• Special tabulation lists (refer to section 2.25) continue to exist in ICD-11, but there are three
additional lists - the Startup Mortality List (SMoL), the list for verbal autopsy, and the list for
infectious diseases by agent. Specialty linearisations allow the representation of content
from the perspective of a specialty, such as dermatology or neurology, through the creation
of subsets, and through the precoordination of more detail, if desired.

1.2.5 Foundation Component and Tabular lists of ICD–11

The Foundation Component is a multidimensional collection of all ICD entities. It is an

underlying database that holds all necessary information to generate print versions of the
tabular list and the alphabetical index, as well as additional information that is needed to
generate specialty linearisations of ICD-11 and country-specific modifications. Entities can
be diseases, disorders, injuries, external causes, signs and symptoms. Some entities may be
very broad, for example ‘injury of the arm’, while others are more detailed, for example
‘laceration of the skin of the thumb’. The Foundation Component also has the necessary
information to use the entities to build a tabular list. The Foundation Component includes
information on where and how a certain entity is represented in a Tabular list, whether it
becomes a grouping, a category with a stem code, or whether it is mentioned as an index
term in a particular category.
Several different Tabular lists can be built from the Foundation Component. Drawing on the
same Foundation Component, a set of tabular lists that builds on the same hierarchical tree
structure can be created – producing congruent tabular lists. The Foundation component
includes instructions on how to combine certain codes in a Tabular list to achieve more

ICD-11 Reference Guide 41

detail in coding. These rules help coders and computer systems to visualise the permitted
code combinations when they are using a Tabular list.
In a Tabular list, entities of the Foundation Component become categories. The categories
are mutually exclusive and jointly exhaustive and linked to a mono hierarchical tree (that is,
they have only one parent). The information related to an entity that has become a category
and has multiple parents is still available from the Foundation Component. This information
can be used to visualise that category in more than one place in the Tabular list, e.g. by
showing them in black font in its place for reference tabulation and in grey font in any other
place for browsing or alternative tabulations. ICD–11 has multiple congruent tabular lists
with varying levels of detail.

[Link] Precoordination and Postcoordination in ICD-11

A health condition may be described to any level of detail, by applying more than one code,
or by ‘postcoordinating’ (i.e. combining):
• two or more stem codes, (e.g. code1/code2)
• stem codes with one or more extension codes. (e.g. stem code&extension
code1&extension code2)
In this manner, the classification can address a large number of clinical concepts with a
limited range of categories.
Stem codes contain all pertinent information in a pre-combined fashion. This is referred to
as ‘precoordination’. When additional detail that pertains to a condition is described by
combining multiple codes, this is referred to as ‘postcoordination’. The combination of
codes is called a cluster. Refer to 2.10.

[Link] Multiple parenting

An entity may be correctly classified in two different places, e.g. by site or by aetiology. For
a disease, such as oesophageal cancer, this would mean that it could be classified to cancers
(malignant neoplasms) or to conditions of the digestive system. In the same way, cerebral
ischaemic conditions could be classified to the vascular system or to the nervous system. A
decision about which place a condition is in depends on international agreement and legacy.
1.2.6 Language independent ICD entities

ICD-11 entities are language independent. The maintenance of the ICD-11 on an

international level is handled in the English language but the content model of ICD–11 is
language independent and allows binding of any desired language to the elements of its
Foundation Component. In this way, an international translation base facilitates translations
or multilingual browsing. (See 3.12 Annex A: ICD-11 Updating and Maintenance)

1.3 Main uses of the ICD: Mortality

Mortality statistics are widely used for medical research, monitoring of public health,
evaluating health interventions, and planning and follow-up of health care. Rules adopted
by the World Health Assembly (WHA) regarding the selection of a single cause or condition,
from death certificates, for routine tabulation of mortality statistics are provided to

42 ICD-11 MMS
standardise production of mortality data. Implementation of the ICD for mortality requires
establishment of an infrastructure for reporting and storing information, design of
information flows, quality assurance and feedback, and training for classification users
working with the input or output of data.
1.3.1 What is coded: Causes of death

The description of a single underlying cause of death, and selected approaches to capture
further information on causes of death also reported on a death certificate, enables the
identification of trends in health for a given population.
Effective public health interventions prevent harm or death by breaking the chain of events
that lead to harm. For this purpose, the underlying cause of death 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’, and is
selected for routine single-cause tabulation of mortality statistics. (See Section 2.20 for
more information.)

1.4 Main uses of the ICD: Morbidity

Morbidity data are used for statistical reporting mostly at national or local levels. While
some of this statistical reporting is conducted within an academic research context, it is
commonly conducted in applied settings to inform health system and public health agency
decision-making. ICD coded data also forms the basis for different casemix systems, such as
different varieties of Diagnosis Related Groups (DRGs). Coded morbidity data can also be
used to inform a variety of clinical guidelines through provision of Foundation Component
information on burden of disease.
1.4.1 What is coded: patient conditions

The definition of main condition relates to the description of an episode of hospital-based

care. The health care practitioner should record and identify as the main condition the one
condition that is determined to be the reason for admission, established at the end of the
episode of health care.
The health care practitioner responsible for the patient’s treatment is also responsible for
documenting the patient’s health conditions. This information should be organised
systematically by using standard recording methods. A properly completed record is
essential for good patient management. It is also an essential prerequisite to the creation of
a valid coded record of patient diagnoses, derived through a coding process from written
information describing the patient’s medical condition. When a sound written record of
patient conditions is available, successful coding of this information in ICD and associated
classifications produces a valuable source of epidemiological and other statistical data on
morbidity and other health care problems. The person transforming the information on the
stated condition to codes (the ‘coder’) may be the health care practitioner or a clinical coder
(who is not responsible for the patient’s treatment). In the latter situation, which is common
among member countries, the coder depends on the adequacy of clinical documentation of
patient conditions by health care practitioners in the medical record. The importance of
clinical documentation by health care practitioners as the starting point for coded health
data cannot be overstated, and needs to be underlined as being a matter of key significance

ICD-11 Reference Guide 43

within countries and internationally. This has implications for education on health
information and clinical documentation within health care practitioner training programs.
(See Section 1.4 for more information.)

1.5 Traditional Medicine

Traditional Medicine (TM) is an integral part of health services provided in many countries.
International standardisation by including Traditional Medicine within the ICD allows for
measuring, counting, comparing, formulating questions and monitoring over time. Although
some countries have had national Traditional Medicine classification systems for many
years, information from such systems has not been standardised or available globally.
It is recommended that coding of cases with ICD-11’s chapter on Traditional Medicine
disorders and patterns (TM1) be used in conjunction with the Western Medicine concepts of
ICD Chapters 1-25.
As with other ICD chapters, the TM1 chapter is not designed to assess TM practice or the
efficacy of any TM intervention. However, as a tool for classifying, diagnosing, counting,
communicating and comparing TM conditions, it assists research and evaluation to assess
the safety and efficacy of TM.
See 3.12 Annex A: ICD-11 Updating and Maintenance for more detailed information.

1.6 ICD maintenance

The ICD maintenance process allows for the updating of the ICD following
evolution in the understanding of diseases, treatments, and prevention. It also ensures
improvements and clarifications coming from daily use of ICD, and requests by Member
States or any other interested party.
A standardised open process has been established to ensure that the proposed updates are
collected, routed, reviewed, and duly considered before being implemented. A proposal and
review mechanism on an online platform makes the process transparent. Workflows ensure
that proposed changes are considered both from a medical and scientific perspective and
from their value and place in a particular use case (See 3.12 Annex A: ICD-11 Updating and
Maintenance).
1.6.1 Guiding principles of authoring process

Allocation of entities in the classification follows a set of rules that serve to maintain the
structural and functional integrity of the classification. The core set of rules listed here is
complemented by additional rules that address special cases or serve to ensure consistent
user guidance. They are listed in order of priority.
1. No changes to the classification, including movement of categories or groups
between chapters, without rationale and documented change in aetiology or
prevention method. (e.g. Chapter 04 - ‘Diseases of the immune system’ was added
as a new chapter as there was sufficient scientific evidence to support this move).
Alternatively, it was suggested to move ‘wounds of skin’ to ‘Diseases of the skin’. The

44 ICD-11 MMS
 wound of the skin, being an injury, remains grouped with injuries because
prevention will focus on the cause of the wound.
2. Conditions are classified predominantly by their aetiology.
– Local manifestations of important ‘aetiologies’ are located in the aetiology
chapter (e.g. Viral hepatitis is in ‘Certain infectious or parasitic disease’).
– Where one condition can be due to multiple different aetiologies, and it is
more relevant to retain the affected body system, it is usually classified with
the body system (e.g. some gastric ulcers are caused by bacteria, but they
remain in the ‘Digestive system’ chapter).
– Where the aetiology of the condition is unknown, it is allocated to the most
relevant organ system (e.g. Costen syndrome is in the ‘Digestive system’
chapter).
– Systemic ‘aetiologies’ are primarily in their relevant aetiology chapter
(e.g. Idiopathic inflammatory myopathy is in “Diseases of the immune
system”).
3. Conditions that could arguably be in two or more places of the classification remain
in their legacy location.
– For example, injuries of the eye are equally important for the eye and their
prevention. Despite the suggestion of including them in the eye chapter, they
remained where they were, in the injury chapter.
– Where aetiology and body system are equally important, the legacy location
remains unchanged (e.g. ocular motor nerve palsies).
4. Keeping a group of subtypes together in one location may override anatomical or
aetiological considerations (e.g. human prion diseases - some have a genetic
component, others a transmissible component).
1.6.2 Improving user guidance

The following rules serve to provide user guidance. Users may expect to find conditions in
certain places when browsing the tree structure. User groups may need to group data or
create subsets for other reasons. The multiple parenting in the Foundation Component
serves to address that issue. 1. Where a condition could be in two or more places, identify
these other places and add them as secondary parents, e.g. malignant neoplasm of the
colon is coded to the neoplasm chapter, but is also shown in the chapter of diseases of the
digestive system. In case a set of conditions needs to be shown in more than one place and
there is no grouping matching that set, create a window (no primary children, no terms, no
residual categories) in the appropriate place. 2. Where a condition could be confused with
another condition bearing a similar name, add an exclusion note. (e.g. ‘Influenza due to
seasonal influenza virus’ has a note ’Exclusion: Haemophilus influenzae [H. influenzae]
meningitis’). 3. Where alternative ways of tabulating data are required, create a special
linearisation list as a second parent (e.g. infectious diseases by agent). The coding scheme of
the individual entries will remain the one used for the full international classification. 4.
Where diseases of certain body systems are spread across different chapters, allow for a
specialty linearisation of the pertinent diseases. The coding scheme of the individual entries
will remain the one used for the full international classification. Currently there are specialty
linearisations for primary care, dermatology, neurology, ophthalmology, and in special cases

ICD-11 Reference Guide 45

such as the International Classification of Disease for Oncology (ICD-O) and the International
Classification of External Causes of Injury (ICECI).
1.6.3 Introduction to the ICD–11 Update Process

Official releases of the ICD-11 classification are produced annually for international use in
mortality and morbidity (This is known as the ‘blue browser’). By contrast, the ICD-11
Foundation Component is continuously updated. A standardised process has been
established to ensure that the proposed updates are collected, routed, reviewed, and duly
considered before being implemented.
The updating is carried out at different levels with different frequencies. Updates that
impact on the four- and five-character codes will be published every five years. Updates at a
more detailed level are published more frequently. Additions to the index are done on an
ongoing basis. Mortality and morbidity rules that have significant impact on statistical
output will be updated in long-term cycles of every 10 years.
Any individual user of the classification can submit a proposal for an update to the ICD. Such
updates can refer to one or more entities of the ICD. They may address the position of
entities in a tabular list, in the Foundation Component, and any element of the content
model. The maintenance platform of ICD-11 (known as the ‘orange browser’) is used for
proposals and comments. Any input to ICD-11 and its components requires proper
referencing of sources, details of scientific evidence, and permission from the owner of any
copyright materials (where applicable).
1.6.4 National Modifications for morbidity coding

The use of ICD in the specific context of the health care system of a country may require
detail that is not currently part of ICD-11, for example, due to specific settings or due to
reimbursement system requirements. Such changes will be subject to the same
international process as are all other changes to ICD and will then become part of the
Foundation Component and eventually of the Mortality and Morbidity Statistics (MMS),
ideally prior to their implementation in the requesting country.
A situation may arise, where a national government or a related national institution needs a
modification to be implemented immediately. In such circumstances, conflicts with the
current Foundation Component must be avoided, and the relevant changes will be subject
to special mechanisms for the international updating process. All countries planning to
produce national modifications must make relevant contractual arrangements with WHO.
This includes regulations on distribution within and outside the respective country and the
resources necessary for the WHO to add such changes to the foundation.
For developing a national modification of ICD-11 the following rules must be adhered to:
1. Ideally, modifications will be agreed by the ICD-11 maintenance bodies before they are
implemented nationally.

2. Modifications should not impact on morbidity and mortality statistics, and should not
conflict with the foundation.

3. Approval of all national modifications will be subject to consideration of whether suitable

additional detail already exists in the foundation.

46 ICD-11 MMS
 4. If a change is made to the international version of ICD-11 the respective national
modification must incorporate the change as soon as possible.

Example
‘Diabetes Type 1’ in the WHO version of ICD-11 is classifed to 5A10. A national modification
may require additional detail to be added to the ICD-11 codes. For example, ‘Diabetes Type
1, uncontrolled’ could be added as a subcategory to 5A10, as 5A10.1 Diabetes Type 1,
uncontrolled. However, when the mechanism of postcoordination provides the necessary
detail, the addition of a new subcategory may not be necessary.

2 Part 2 - Using ICD-11

2.1 Basic coding and reporting guidelines
Coding is the assignment of one or more codes in order to represent the meaning of a
condition in as much detail as required. Before attempting to code, the coder should be
acquainted with the principles of classification and coding. In some instances, using one
code will provide sufficient detail. In other instances, it may be necessary to use several
codes together to express the level of detail required by the use case, setting, or laws.
For coding, it is recommended to use the ICD-11 Smart coding tool that can be used online
and offline. It provides users with a simple automated way to find and select the needed
categories. When the search shows a cluster of codes, rather than a single stem code, the
tool can return the assembled cluster.
Software must not include lists or other prompts to guide the recording or coding, as these
necessarily limit the range of diagnoses and therefore have an adverse effect on the
accuracy and usefulness of the record and report.
There may be an alternative way, to use the print version of ICD-11 but this option is not
recommended as its time consuming and may cause confusion in finding and selecting the
correct codes or code combinations without the hints that the electronic coding tool
provide. In case no electronic environment is available, specific solution can be sought in
collaboration with WHO.

2.2 Tabular List, Special Tabulation Lists, Qualifiers, and Modifiers

The Tabular list is an alphanumeric listing of diseases and disease groups, inclusion and
exclusion notes, and some coding rules. Chapters 1 to 25 of the ICD contain approximately
15 000 entities at the four-, five- or six-character level.
In addition, there is a section on extension codes (2.9) and one on Traditional medicine
(1.5). The Special tabulation lists are presented at the end of the Tabular list. Special
tabulation lists are not designed for coding but are for tabulation and reporting only (2.25).

2.3 Index
The Alphabetical Index is a list of more than 120 000 clinical terms (including synonyms or
phrases). The index is used to find the relevant ICD codes or code combinations for clinical

ICD-11 Reference Guide 47

terms. The mention of a term in the index exclusively serves coding. Mention of a term in
the index does not mean approval or endorsement of a particular condition.

2.4 Reference Guide

The Reference Guide contains an introduction to the context, components, and intended
use of the ICD. It describes the diverse components of ICD-11, provides guidance for
certification, recording, rules for mortality coding (i.e. causes of death statistics) and
morbidity coding (e.g. hospital statistics) and lists for tabulation of statistical data.

2.5 Browser and coding tool

The WHO provides a browser and coding tool (‘blue browser’) for ICD–11 in multiple
languages [Link] This tool allows the user to retrieve concepts by searching for
terms, anatomy or any other element found within the content of ICD-11 (see1.2.5
Foundation Component and Tabular lists of ICD–11).
WHO also provides a maintenance platform (‘orange browser’), (see 3.12 Annex A: ICD-11
Updating and Maintenance). This tool allows the users to contribute to the updating and
continuous improvement of ICD-11. Such input is submitted in the form of a proposal with a
detailed rationale, scientific evidence and peer reviewed references to justify consideration
for inclusion on an annual basis (see 3.12 Annex A: ICD-11 Updating and Maintenance).
For coding, the WHO provides the ICD-11 Smart coding tool, a simple automated way to find
and select the needed categories.
ICD–11 can also be accessed using web services with user-specific software. The IT guide to
the ICD provides more details on compatibility requirements.
Both the web services and the online browser allow access to all Tabular lists of the ICD, for
mortality and morbidity statistics, primary care, or for a specialty linearisation for use in
certain specialised domains.

2.6 Coding step by step – clinical term

The table below compares the coding steps in a paper and an electronic environment. The
essential component of coding is finding a match to the reported clinical term – having a
good dictionary in the relevant language, and verifying the resulting code against additional
rules, are necessary. In an electronic environment programmatically embedded instructions
can verify compliance with the coding rules.

48 ICD-11 MMS
 Electronic Paper
1. Enter the statement or term in the 1. Look up the lead term in the Alphabetical
coding tool Index and applicable secondary terms.
2. Select the matching term, or the one 2. Select the appropriate term, or one
closest to what you are looking for from closest to what you are looking for, from
amongst the displayed options amongst the listed options
3. Verify the result in the tabular list 3. Verify the result in the tabular list
browser view for exclusions, inclusions and (Volume 1) for exclusions, inclusions and
notes given at the level of that category, its notes given at the level of that category, its
grouping levels and at the chapter level. grouping levels and at the chapter level.

The WHO online browser and coding tool are available at [Link]

2.7 ICD–11 conventions

ICD–11 has standard ways of presenting its content. Conventions describe textual content
and also apply to the coding structure.
2.7.1 Inclusions

Within the coded categories there are typically other optional diagnostic terms. These are
known as ‘inclusion terms’ and are given, in addition to the title, as examples of the
diagnostic statements to be classified to that category. They may refer to different
conditions or be synonyms. They are not a sub-classification of the category.
Inclusion terms are listed primarily as a guide to the content of the category, in addition to
the descriptions. Many of the items listed relate to important or common terms belonging
to the category. Others are borderline conditions or sites listed to distinguish the boundary
between one subcategory and another. The lists of inclusion terms are by no means
exhaustive.
Alternative names of diagnostic entities (synonyms) are included and shown in the
electronic coding tool and the Alphabetic Index.
It is sometimes necessary to read inclusion terms in conjunction with titles. This usually
occurs when the inclusion terms describe lists of sites or pharmaceutical products, where
appropriate words from the title (e.g. ‘malignant neoplasm of …’, ‘injury to …’, ‘toxic effects
of …’) need to be understood. General diagnostic descriptions common to a range of
categories, or to all the subcategories in a four-character category, are to be found in the
notes heading ‘Inclusions’, immediately following a chapter, group, or category title.
2.7.2 Exclusions

Certain categories contain lists of conditions preceded by the word ‘Exclusions’. These are
terms which are classified elsewhere. An example of this is 5A60 Hyperfunction of pituitary
gland which excludes Cushing syndrome.
Exclusions serve as a cross reference in ICD and help to delineate the boundaries of a
category.

ICD-11 Reference Guide 49

General exclusions for a range of categories or for all subcategories are found in the notes
heading ‘Excludes’, immediately following a chapter, group or category title.
Multiple parenting in ICD-11 shows categories in the context of siblings that are placed
elsewhere in the classification. This is also an indication of an exclusion and means ‘a sibling
is coded elsewhere’. In the print and the electronic version this is marked with the label
‘code elsewhere’.

[Link] ‘Code also’ and ‘Use additional code, if desired’ instructions

‘Code also’ instructions inform the user about required additional aetiological information
which is mandatory to be coded in a cluster with certain categories because that additional
information is relevant for primary tabulation. The ‘code also’ statement marks the
categories that must be used in conjunction with the indicated second code(s). However, in
some instances aetiology may be unknown although the condition requires treatment in its
own right. In this circumstance, the code may be reported alone.
For example, the category Diabetic cataract indicates ‘code also’ type of diabetes. This
means that in conjunction with the code for ‘diabetic cataract’, the code for the type of
diabetes should be assigned. Both stem codes for the type of diabetes and the diabetic
cataract are always reported in a cluster.
‘Use additional code, if desired’ - instructions inform the user about optional additional
detail that can be coded.
2.7.3 ‘NEC’ and ‘NOS’

[Link] ‘NEC’
The stem ‘not elsewhere classified’, when used in a category title, serve as a warning that
certain specified variants of the listed conditions may appear in other parts of the
classification. For example, NF09 Adverse effects, not elsewhere classified. Codes to which
the NEC description is appended should only be used if one of the other options available in
the classification is not suitable.

[Link] ‘NOS’
The letters NOS are an abbreviation for the term ‘not otherwise specified’, implying that the
documentation that is used for classifying does not provide more detail beyond the term
provided. It implies ‘unspecified’, ‘incompletely specified’ or ‘unqualified’. Sometimes an
unqualified term is nevertheless classified to a rubric for a more specific type of the
condition. This is because, in medical terminology, the most common form of a condition is
often known by the generic name of the condition itself and only the less common types are
qualified. For example, ‘pharyngitis’ is commonly used to mean ‘acute pharyngitis’. These
inbuilt assumptions have been taken into account in order to avoid incorrect classification.
Careful inspection of inclusion terms will reveal where an assumption of cause has been
accounted for. Coders should be careful not to code a term as unqualified unless it is quite
clear that no information is available that would permit a more specific assignment
elsewhere. Similarly, in interpreting statistics based on the ICD, some conditions assigned to
an apparently specified category will not have been so specified on the record that was

50 ICD-11 MMS
coded. When comparing trends over time and interpreting statistics, it is important to be
aware that assumptions may change from one revision of the ICD to another. For example,
before the Eighth Revision, an unqualified aortic aneurysm was assumed to be due to
syphilis (this is no longer the case since the introduction of ICD–10). In ICD-11 in most
instances the ‘NOS’ terminology points to unspecified categories, so that future data
analysis can take care of assumptions regarding the linguistic meaning.
Additional terms permitted in ICD coding:
• Certain
• Other
• Unspecified
• And
• Or
• Due to
• With
• Caused by
• Attributed to
• Secondary to
• Associated with
2.7.4 ‘Certain’

The term ‘certain’ is used where certain entities that could be grouped in a specific location
in the classification are grouped somewhere else outside the current chapter or block. For
example, 8B22 Certain specified cerebrovascular diseases means that only some specified
cerebrovascular diseases are coded here, whereas other specific types of cerebrovascular
disease are located elsewhere in the classification.
2.7.5 Residual categories – ‘Other’ and ‘Unspecified’

ICD-11 coding should always be completed to include the most specific level of detail
possible with the use of one code or multiple codes as described above. There are, however,
circumstances when that is not possible and for that reason the ICD-11 includes categories
titled ‘other’ and ‘unspecified’. In some instances, necessary information to select a specific
category may not be available in the source documentation. When this is the case, the
residual category ‘unspecified’ is selected. Conversely, there are instances where the
information in the source documentation is very specific, but the tabular list does not
include a specific category. In this case, users identify the closest category match, and code
to the residual category titled ‘other’.
2.7.6 Use of ‘And’ and ‘Or’

The words ‘and’ and ‘or’ in ICD–11 are used in their meaning in formal logic. A term that
includes a statement of the kind ‘A and B’ means that both A and B, have to be present in
order to use that category. A term that includes a statement of the kind ‘A or B’ means that
the category may be used if either A or B are present.

ICD-11 Reference Guide 51

2.7.7 ‘Due to’ and ‘Associated with’

‘Due to’ is the preferred term for categories where two conditions are mentioned, and a
causal sequence exists between them. Other terms, such as ‘caused by’ or ‘attributed to’ are
allowable synonyms. The phrase ‘secondary to’ is equivalent and may also be included as a
synonym. ‘Associated with’ is the preferred term for categories where two conditions are
mentioned but there is no causal sequence implied.
2.7.8 Spelling, parentheses, grammar and other conventions

Spelling and grammar of ICD-11 follow the British rules with exceptions and amendments
conforming to WHO spelling rules. The detailed conventions are listed below. The ICD-11
terminology uses the following conventions:
• Terms are listed in their singular form. For example, ‘Superficial injury of scalp’
instead of ‘Superficial injuries of scalp’. There are exceptions when the singular form
doesn’t apply, such as ‘Multiple injuries of head’, and when a term describes a group
of diseases, such as “Benign vascular neoplasms”.
• No use of apostrophes with eponyms. For example, ‘Hodgkin lymphoma’ (instead of
‘Hodgkin’s lymphoma’)
• Entities are described using natural language. For example, ‘myocardial infarction’
(instead of ‘infarction, myocardial’).
• Abbreviations are printed using upper case letters and followed by the complete title
in full. For example, ‘MI – [myocardial infarction]’.
• Parentheses are used in the tabular list to enclose the code to which an exclusion
term refers. For example, 9A01.3 Infectious blepharitis Exclusions:
Blepharoconjunctivitis (9A60.4)
2.7.9 General features

The main structural innovation of ICD–11 is that it is built on a Foundation component from
which the tabular lists (such as the classification for morbidity and mortality statistics) is
derived. See 1.2.5 Foundation Component and Tabular lists of ICD–11.
Table 1: ICD-11 Terminology

52 ICD-11 MMS
 ICD-11 Term Explanation
Foundation Underlying data base content that holds all necessary information to
component generate print versions of the tabular list and the alphabetical index,
as well as additional information that is needed to generate
specialty linearisations of ICD-11 and country specific modifications.
Stem code Stem codes are codes that can be used alone. They are found in the
tabular list of ICD-11 for Mortality and Morbidity Statistics. Stem
codes may be entities or groupings of high relevance, or clinical
conditions that should always be described as one single category.
The design of stem codes makes sure that in use cases that require
only one code per case, a meaningful minimum of information is
collected.
Extension code Extension codes are lists of additional information that can be is
added to a stem code when users and settings are interested in
reporting more detail. Extension codes are not mutually exclusive.
They are not designed to be a classification but may show
hierarchies and can never be used without a stem code in the
context of statistical classification. Extension codes can never
appear in the first position in a cluster. Extension codes may be used
alone in another context, e.g. for device documentation.
Precoordination Stem codes may contain all pertinent information about a clinical
concept in a pre-combined fashion. This is referred to as
‘precoordination’.
Example: BD50.40 Abdominal aortic aneurysm with perforation
Example: CA40.04 Pneumonia due to Mycoplasma pneumoniae
Postcoordination The use of multiple codes (i.e. stem codes and/or extension codes)
together to fully describe a documented clinical concept.
Postcoordination is by matter of principle permitted with all axes, as
long as at least one stem code is used. API, Browser and coding tool
facilitate postcoordination in certain areas. Other areas of
postcoordination have to be coded individually, but may be
supported by future updates of ICD-11, where need arises.
Cluster A cluster is the postcoordinated entities that are joined using either
a forward slash (/) or ampersand (&).
Example:
Diagnosis: Duodenal ulcer with acute haemorrhage
Cluster: DA63.Z/ME24.90
Condition - DA63 Duodenal ulcer, unspecified
Has manifestation (use additional code, if desired) - ME24.90 Acute
gastrointestinal bleeding, not elsewhere classified

ICD-11 Reference Guide 53

 ICD-11 Term Explanation
Primary and The hierarchy of ICD-11 is defined the same as it was in previous
secondary parents versions of ICD. The ability to connect specific diseases and concepts
within the classification to another parent code was introduced to
enable specific extracts of the Tabular list for medical specialties or
for specific use cases.
Example: A code for a malignant neoplasm of the skin is in the
chapter for malignant neoplasms. The primary parent for this code
is a code or a block from this chapter. However, a medical doctor
treating only skin diseases might want to see only codes from the
classification that are relevant for his or her specific clinical purpose.
Therefore, a secondary parent was defined in the skin chapter which
will only show the code in this chapter if the specific extract of
codes for his or her use case is selected.
2.8 Stem codes
ICD–11 stem codes are codes in a particular tabular list that can be used alone. Stem codes
may be entities or groupings of high relevance, or clinical entities that should always be
described as one entity. The design of stem codes makes sure that in use cases that require
only one code per case a meaningful minimum of information is collected.
The stem codes of the ICD-11 are organised in 26 chapters that follow the traditional
pattern of the ICD, relating to aetiology, relevant organ system, maternal status, perinatal
status, external causes, and factors influencing health status.

2.9 Extension codes

Extension codes are provided for use as supplementary or additional codes when it is
desired to identify more detail in classification entities elsewhere. The inclusion of the new
Extension codes in ICD–11 provides capacity for coding qualifying information and are linked
to stem codes. Extension codes have been designed to standardise the way additional
information is added to stem codes, and the adoption of multi-dimensional coding results in
a substantially reduced amount of stem codes. Extension codes may be used alone in other
contexts, e.g. device documentation.
Extension codes are not mutually exclusive. They are not a classification and can never be
used without a stem code for statistical purposes. Extension codes can never appear in the
first position in a classification cluster. One or more extension codes can be linked when
coding a specific condition.
There are two main types of Extension codes:
• Type 1 extension codes allow the user to add detail to a stem code in terms of severity,
temporality, anatomy, histopathology of the condition or other dimensions like substances
and medical devices. For example, if the diagnostic statement reads ‘cervical disc prolapse
C5-C6’ the anatomy extension code XA1X49 Cervical intervertebral disc or space C5-C6 can
be added to the stem code FA80.1 Intervertebral disc degeneration of cervical spine with
prolapsed disc in order to capture the detail of contained in the diagnostic statement.

54 ICD-11 MMS
 • Type 2 extension codes represent diagnosis code descriptors which indicate how the
diagnosis is to be used and/or interpreted. The meaning of the code refers to the same
condition, but the use of type 2 – diagnosis code descriptor extension code alters its
interpretation. For example, for adverse event reporting it is important to code diagnosis
timing in terms of XY6M Present on admission, XY69 Developed after admission, or XY85
Uncertain timing of onset relative to admission.

Overview of the Type 1 Extension codes

• Severity scale value
• Temporality (course of the condition)
• Aetiology
• Topology Scale Value
• Anatomy and topography
• Histopathology
• Dimensions of injury
• Dimensions of external causes
• Consciousness
• Substances
• ICD-O
• Health Devices, Equipment and Supplies
Overview of Type 2 – Extension codes - Diagnosis Code Descriptors
• Discharge diagnosis types
• Diagnosis timing
• Diagnosis timing in relation to surgical procedure
• Diagnosis method of confirmation
• Diagnosis certainty
• Obstetrical diagnosis timing
• Encounter descriptors
• Capacity or context
2.10 Precoordination and postcoordination
Some stem codes contain all pertinent information about a clinical concept in a pre-
combined fashion. This is referred to as ‘precoordination’.
A health condition may be further described to any level of detail, by applying more than
one code, or by ‘postcoordinating’ (i.e. combining codes):
• two or more stem codes, (i.e. code1/code2)
• stem codes with one or more extension codes. (i.e. stem code&extension
code1&extension code2)
A group of codes that have been postcoordinated is called a ‘cluster’. A forward slash (/) or
ampersand (&) is used to show the linkage between postcoordinated codes. In this manner,
the classification can address many clinical concepts with a limited range of categories.

ICD-11 Reference Guide 55

Example
Precoordination of concepts in a single code Condition: 2C25.2 Squamous cell carcinoma of
bronchus or lung has precoordination, both site and pathology are combined in a single
precoordinated stem code.
Example
Postcoordination of concepts combined in a cluster: the condition urinary tract infection
due to Extended spectrum beta-lactamase producing Escherichia coli’ is expressed through a
combination of two linked or postcoordinated stem codes. Condition: GC08.0 Urinary tract
infection, site not specified, due to Escherichia coli Associated with (use additional code, if
desired): MG50.27 Extended spectrum beta-lactamase producing Escherichia coli Cluster
code: GC08.0/MG50.27

Postcoordination axis Description

‘Has causing condition’ - this field is It is mandatory to code the causing
indicating the causing condition that must condition for primary tabulation when it is
be coded when known. The causing known. ‘Has causing condition’ is added to
condition can be compared to the ‘dagger’ categories that are caused by an
code in ICD-10. This option is found at underlying disease. For example,
entities that are typically caused by a range retinopathy has a ‘causing condition’ of
of different conditions and is referred to as diabetes. Causing conditions should be
mandatory postcoordination in the Coding considered required in almost all
tool. situations, and must be used for
conditions that are manifestations.
‘Has manifestation’ - prompts the user to It is optional to code manifestations of a
code any manifestations. Manifestations can disease. For example, diabetes ‘Has
be compared to the ‘asterisk’ codes in ICD- manifestations’ such as retinopathy. This
10. This option is found at entities that can coding should be considered ‘Allowed’ in
develop manifestations. almost all situations. The listed
manifestations are usually a sample of the
ones frequently resulting from the
condition.
‘Associated with’ - when conditions are This field is used when multiple codes are
captured together for a full picture but do required to fully describe a condition. For
not necessarily represent a cause and effect example, ‘Associated with’ is used to link
scenario. the codes for antimicrobial resistance to
the codes for the infection. This coding can
be either ‘Allowed’ or ‘Required’
depending on the situation.

Special cases for postcoordination:

56 ICD-11 MMS
 1. External cause codes are ‘allowed’ to identify the cause of an injury and are
‘associated with’ the injuries.
2. The external cause code to identify a specific drug is ‘allowed’ with entities beginning
with or including the phrase ‘Drug -induced’.
3. External cause codes for the mode and mechanism of health care related harm are
‘associated with’ the codes for the harm.
2.10.1 Adding detail – postcoordination and cluster coding with multiple stem codes
and extension codes

Information about the aetiology and the manifestation of the condition of interest should
be coded. In some instances, the ICD category refers to both (i.e. precoordinated), while in
other instances more than one stem code (and/or extension code) needs to be used in order
to express the relevant detail. This requires postcoordination.
E.g. Acute bleeding duodenal ulcer
Stem Code: DA63.Z Duodenal ulcer, unspecified Has manifestation (use additional code, if desired):
ME24.90 Acute gastrointestinal bleeding, not elsewhere classified Cluster: DA63.Z/ME24.90

However, postcoordination must never be used to replicate the meaning of a condition that
is a precoordinated concept. The precoordinated code should be used.
E.g. Acute RSV bronchiolitis
Code: CA41.0 Acute bronchiolitis due to respiratory syncytial virus Explanation: Since RSV bronchiolitis is
a precoordinated concept in ICD-11, it is incorrect/prohibited to replicate the meaning of the diagnostic
statement using a stem code and extension code (i.e. do not code: [CA41.Z] Acute bronchiolitis,
unspecified&XN275 Human respiratory syncytial virus)

E.g. Fracture, shaft of ulna

Code: NC32.2 Fracture of shaft of ulna Explanation: Since fracture of shaft of ulna is a precoordinated
concept in ICD-11, it is incorrect/prohibited to replicate the meaning of the diagnostic statement using a
stem code and extension code (i.e. do not code: NC32.Z Fracture of forearm, unspecified&XA8U33 shaft of
the ulna)

There may be less obvious cases across the ICD. In an electronic environment,
programmatically embedded instructions will help to avoid this kind of mistake. For
reporting purposes, any correlated codes are linked using a forward slash (/) between stem
codes and an ampersand (&) to separate stem codes with extension codes.
2.10.2 Combining stem codes and extension codes, and how to order these in a complex
code cluster

Stem codes from other parts of ICD and extension codes can be linked together to describe
a clinical concept in detail. They have to be grouped together in data transmission and
evaluation in order to not lose the information conveyed by the joint group of codes. Such a
group of codes is called a cluster. Cluster coding requires use of a specific syntax to indicate
which codes belong together when postcoordination is used. This syntax has to comply with
the following rules:
1. If only one stem code is coded, no clustering mechanisms need to be observed.

ICD-11 Reference Guide 57

 E.g. Condition: Acute ST elevation myocardial infarction BA41.0 Acute ST elevation myocardial
infarction
2. When postcoordinating to form a cluster, stem codes are always coded before extension
codes. (Note, however, the complex clustering scenario depicted in Example 5 below, where
a combination of multiple stem codes and linked extension codes are combined in a single
complex cluster).

3. If one stem code is postcoordinated with one or more extension codes, the combining
syntax used is the ampersand (&).

Example 1: Acute ST elevation myocardial infarction, anterior wall, LAD

Condition (code) - Acute ST elevation myocardial infarction BA41.0 Acute ST elevation myocardial
infarction Specific anatomy - XA7RE3 Anterior wall of heart
Specific anatomy - XA7NQ7 Left anterior descending coronary artery Cluster: BA41.0&XA7RE3&XA7NQ7

Example 2: Acute pyelonephritis, left side, E. coli Condition (code) - GB51 Acute
pyelonephritis
Laterality - XK8G Left Infectious agent - XN6P4 Escherichia coli Cluster: GB51&XK8G&XN6P4
4. If two stem codes are postcoordinated to provide additional detail, it is important to
follow the order (within a cluster) according to the use case (e.g. mortality or
morbidity). The first stem code will be separated from the second stem code by a
slash (/).
If only one code can be retained during data analysis for mortality (underlying cause of
death) and public health prevention, priority of order should be given to the code that best
describes the aetiology of a condition. If only one code can be retained for morbidity data
analysis, priority should be given to the main condition (reason for admission after study
established at the end of the episode of health care).
Example 3: Mortality (underlying cause of death) code ordering within a cluster
Patient died because of their diabetic coma. The patient had Type 2 diabetes mellitus. Condition (terminal
cause of death): 5A23 Diabetic coma Condition (underlying cause of death): 5A11 Type 2 diabetes mellitus
Mortality cluster order: 5A11/5A23

Example 4: Morbidity (main condition) code ordering within a cluster (if only one code can
be retained during data analysis)
Patient admitted to hospital in a diabetic coma. The patient had Type 2 diabetes mellitus.
Main condition: 5A23 Diabetic coma Other condition: 5A11 Type 2 diabetes mellitus Morbidity cluster
order: 5A23/5A11
5. If a stem code is postcoordinated with extension codes and another stem code with
some more extension codes is also coded within a cluster, the specific syntax should
be designed to make a clear distinction between which extension codes in the
cluster belong to which stem codes. The following syntax must be followed: The first
stem code is reported, followed by an ‘&’ followed by one or more extension codes,
each of them separated by ‘&’. Then a slash ‘/’ separates this first section of the
cluster from the next stem code which is followed by ‘&’ and the extension codes for
this specific stem code, each again separated by ‘&’.
Example 5: stem code & extension code / stem code & extension code & extension code

58 ICD-11 MMS
Left inguinal hernia with acute obstruction Condition (code) - DD51 Inguinal hernia
Laterality - XK8G Left
Has manifestation (use additional code, if desired) - ME24.2 Digestive system obstruction
Temporal pattern and onset - XT5R Acute Cluster: DD51&XK8G/ME24.2&XT5R

Postcoordination is only to be used to combine codes to describe and fully characterise a

documented clinical concept. If the documentation describes two distinct clinical concepts
that are represented by separate stem codes, they should not be reported together in a
postcoordinated cluster.
Example 6: Pedestrian fall injury
Concussion and open fracture shaft of left ulna due to fall on uneven sidewalk:
Condition (code) 1 - NA07.0Z Concussion, unspecified
Associated with (use additional code, if desired) - PA60 Unintentional fall on the same level or from less
than 1 metre
Object or substance producing injury - XE1DA Uneven surface, not elsewhere classified
Place of occurrence - XE53A Sidewalk Cluster - NA07.0/ PA60& XE1DA&XE53A
Condition (code) 2 - NC32.2 Fracture of shaft of ulna
Laterality - XK8G Left
Fracture open or closed - XJ7YM Open fracture
Associated with: PA60 Unintentional fall on the same level or from less than 1 metre
Objects of living things involved in causing - XE1DA Uneven surface, not elsewhere classified
Place of occurrence - XE53A Sidewalk Cluster: NC32.2 & XK8G& XJ7YM /PA60 & XE1DA & XE53A

Programmatically embedded instructions in the Foundation component of ICD-11 facilitate

use of frequently used code combinations. Code combinations are not limited to the ones
facilitated by these instructions. Additional instructions are added, based on user demands.
2.10.3 Diagnosis Timing - ‘Present on admission’ vs. ‘Developed after admission’

Among the new Type 2 Extension codes -Diagnosis Code Descriptors, diagnosis timing is the
particularly important set of extension codes that allow for distinction of diagnoses present
on admission from diagnoses arising after admission, i.e. during the period of
hospitalisation.
The latter distinction is particularly important, because it allows for the targeted
identification of a number of in-hospital diagnoses that may represent adverse events
associated with health care. The majority of coded concepts in a hospital record are
conditions present on admission. Recognising this, it will be of significant interest to flag a
diagnosis that developed after admission.
Example 1:
A patient with long-standing type 1 diabetes, admitted to hospital because of a myocardial infarction.
Main condition: Myocardial infarction
Other condition: Diabetes mellitus, type 1
In this instance, both conditions are present at admission, but one of them (myocardial infarction) does
not need to be coded as being ‘present on admission’ because it is the main condition, designated in this
example as being ‘the condition that is determined to be the reason for admission, established at the end
of the episode of health care’. The appropriate coding of this scenario therefore includes two clusters,
each of which involves a stem code linked to an accompanying extension code i.e.:

ICD-11 Reference Guide 59

 • ‘Stem code for acute myocardial infarction’&‘Discharge Diagnosis Type Extension
code for main condition’; BA41.Z&XY0Y
• ‘Stem code for diabetes mellitus type 1’&‘Diagnosis timing Extension code for
present on admission’; 5A10&XY6M
Note that for both coded entities in the above example, an ampersand (&) is used. In the
first cluster, the stem code for myocardial infarction is linked to a diagnosis type extension
code for main condition diagnosis type. In the second cluster, the stem code for diabetes
mellitus type 1 is linked to a diagnosis timing extension code for present on admission.
Example 2:
A patient with long-standing type 1 diabetes, admitted to hospital because of chest pain. After assessment
diagnosed with myocardial infarction. The patient develops deep vein thrombosis in right lower limb as
an in-hospital complication of care.
Main condition: Myocardial infarction
Other conditions: Diabetes mellitus, type 1; Deep vein thrombosis (arising after hospital stay began)

In this example, a diagnosis timing extension code for ‘developed after admission’ is linked
by cluster coding to a stem code for ‘deep vein thrombosis’. The first two diagnostic
concepts, meanwhile, are coded exactly as per the preceding example. i.e.
• ‘Stem code for acute myocardial infarction’&‘Discharge Diagnosis Type Extension
code for main condition’; BA41&XY0Y
• ‘Stem code for diabetes mellitus type 1’&‘Diagnosis Timing Extension code for
present on admission’; 5A10&XY6M
• ‘Stem code for lower limb deep vein thrombosis’&‘Right’&‘Diagnosis Timing
Extension code for developed after admission’; BD71.4&XK9K&XY69
Again, each of the three cluster entities uses an ampersand ‘&’ because the second code
(and third code) in the cluster is an extension code.

2.11 Functioning section

The Functioning section of ICD-11 allows coding and assessment of functioning in line with
ICF but at an operational level. For detailed recording and assessment, the full ICF should be
used. This section’s concepts are aligned with ICF and allow an easy transition to ICF. The
design of the functioning section in ICD-11 addresses documentation and assessment of the
level of functioning of persons, for
• general medical practice, as work incapacity assessment
• social benefits as for disability, or accident pension
• payment or reimbursement purposes
• needs assessment as in rehabilitation, occupational assistance, or long term care
• outcome evaluation of treatment
The functioning section in ICD-11 provides clinician-friendly tools for standardized
assessment and documentation of functioning. The functioning section of ICD-11 allows for
adding future additional assessment instruments.

60 ICD-11 MMS
2.11.1 Functioning assessment

[Link] WHO DAS 2.0: features and use cases

The WHO Disability Assessment Schedule (WHO-DAS 2.0) is the internationally, culturally
and socioeconomically validated generic functioning assessment instrument for an adult
population. WHO DAS 2.0 is focused on ICF Activity and Participation domains and allows to
compute an overall and domain specific functioning score covering the following domains:
• Cognition – understanding & communicating
• Mobility– moving & getting around
• Self-care– hygiene, dressing, eating & staying alone
• Getting along– interacting with other people
• Life activities– domestic responsibilities, leisure, work & school
• Participation – joining in community activities, participating in society
WHO DAS scoring takes into account multiple levels of difficulty for each WHODAS 2.0 item
(i.e. IRT based scoring). This type of scoring for WHODAS 2.0 allows for more fine-grained
analyses that make use of the full information of the response categories for comparative
analysis across populations or subpopulations. It takes the coding for each item response as
“none”, “mild”, “moderate”, “severe” and “extreme” separately, and then uses a
computation to determine the summary score by differentially weighting the items and the
levels of severity.
The scoring has three steps:
• Step 1 – Summing of recoded item scores within each domain.
• Step 2 – Summing of all six domain scores.
• Step 3 – Converting the summary score into a metric ranging from 0 to 100 (where 0
= no disability; 100 = full disability).
The WHO DAS 2.0 scoring syntax is listed online via the link shared below.
Key features of WHO-DAS 2.0 include:
• ICF derived clinical scale with well-established psychometric properties of validity, reliability
and sensitivity to change over time.

• Cardinal measure which is applicable across all health conditions and allows to generate an
overall and domain specific functioning scores.

• Established population norms.

The combination of this features sets WHO DAS 2.0 apart from other clinical instruments.

WHO DAS 2.0 can be used for assessment of functioning in multiple use cases:

• Clinicians can quantify the effectiveness of their intervention within their clinical population
and with reference to the general population.

• Disability evaluators can determine disability status in fair, transparent, impartial and
comparable way.

ICD-11 Reference Guide 61

 • Reimbursement experts can measure quality (functioning outcome) of Case-mix/DRG
groups.

WHO DAS 2.0 has been developed for use in adult population and currently does not assess
body impairments or environmental factors. Users who wish to asses impairments in body
functions and can make use of the WHO Model Disability Survey (MDS)[1] items which are
also included in the function assessment part of the V Chapter.
WHO DAS 2.0 versions in three different formats (i.e. clinician administered, self-
administered and proxy-administered) can be found via the link below.
WHO DAS 2.0 manual provides practical guidance for administering and scoring WHO DAS
2.0. including information on the simple and complex (Item-Response-Theory, IRT) scoring
algorithm and population norms for the WHO DAS 12 and 36 item version. The WHO DAS
2.0 manual can be downloaded from the WHO website link - WHO Disability Assessment
Schedule (WHODAS 2.0) - [Link]
classification-of-functioning-disability-and-health/who-disability-assessment-schedule
together with other languages version of the WHO DAS 2.0.
[1] The MDS is a ICF based general population survey developed by WHO and the World
Bank that provides detailed and nuanced information on the lives of people with disability.
It allows direct comparison between groups with differing levels and profiles of disability.

[Link] WHO DAS 2.0: representation and coding structure

To enable easy information retrieval each WHO DAS 2.0 item has an assigned alphanumeric
code to represent the captured concepts of the respective item. The code starts with the
letters “VD” followed by a randomly assign number. Additional item specific information
and values (i.e. item question, five-point response scale) are included in the ICD-11 APIs to
allow for easy integration of the instrument and the automated scoring computation in any
software application (e.g. integration of WHO DAS 2.0 as health outcome measure in EMR
software). The six WHO DAS 2.0 domains under which the 36 items of the instrument are
grouped are represented as block heading. Like other ICD-11 block headings they are
assigned an URI but not a code. Table 1 below shows an example of how a WHO DAS 2.0
item are represented.

62 ICD-11 MMS
 WHO DAS 2.0 item ICD-11 Code URI
Attention functions VD00 [Link]
Item description Item response scale Mapped ICF category
question value set
Because of your health 1=no difficulty, d160 Focusing attention
condition, in the past 30 2=mild difficulty,
days, how much difficulty 3=moderate
did you have in difficulty, 4=severe
concentrating on doing difficulty,
something for ten 5=complete
minutes? difficulty
2.11.2 Generic functioning entity

[Link] Functioning entities: features and use cases

The main tool for documenting functioning is a list of generic functioning domains derived
from the ICF Annex 9 and the ICF generic core set.
The generic list allows clinicians to generate a coded functioning profile of an individual
which can be used for multiple purposes like - goal setting - monitoring change -
communicating across the continuum of care.
Because the list is directly linked to the ICF, it may - Facilitate joint use of ICD & ICF (code
once – use multiple times) - Serve as an entry point the use of the full ICF.

[Link] Functioning entity: representation and coding structure

In accordance with the WHO FIC content model a functioning entity has two components
i.e. category and a qualifier. Both have an assigned alphanumeric code and an URI to
represent the captured concepts. The code starts with the letters “VV” followed by a
randomly assign number. The functioning category and the qualifier are linked through
postcoordination.

2.12 Electronic recording and reporting

Electronic documentation will follow the principle of lossless collection of information at the
source. Best practice includes reporting of:
1. A text field that captures the clinical term or cause of death with the exact wording
reported by the health provider, and
2. A data field that retains the identifier (URI) of the chosen entity of ICD-11 (index,
code title or other element) that represents the most exact match for that text.
3. A data field for the relevant ICD-11 code.
In this way, the quality of the coding can be verified at any point in time. Also, specific
conditions can be identified and analysed, independently of them being linked to an
individual ICD code or lumped together in a code with other conditions.
Coding shall be done using tools based on the ICD-11 API, like the ICD-11 coding tool.
Software must not include lists or other prompts to guide the recording or coding, as these

ICD-11 Reference Guide 63

necessarily limit the range of diagnoses and therefore have negative impact on the accuracy
and usefulness of the record and report.

2.13 Foundation Component and Tabular lists

The Foundation Component is a multi-dimensional collection of all ICD entities. Entities can
be diseases, disorders, injuries, external causes, signs and symptoms. Some entities may be
very broad, for example ‘Injuries to the elbow or forearm’, while others are more detailed,
for example ‘Fracture of upper end of ulna, extending into joint’. The Foundation
Component also has the necessary information to use the entities to build a tabular list. The
Foundation Component includes information on where and how a certain entity is
represented in a tabular list, whether it becomes a grouping, a category with a stem code,
or whether it is mentioned as an inclusion term in a particular category.
Several different tabular lists can be built from the Foundation Component. Drawing on the
same Foundation Component, a set of tabular lists that builds on the same hierarchical tree
structure can be created – producing congruent tabular lists. The Foundation Component
includes instructions on how to combine certain codes in a tabular list to achieve more
detail in coding. These rules help coders and computer systems to visualise the permitted
code combinations when they are using a tabular list.
Core tabular lists for international use:
• Mortality and Morbidity Statistics (MMS)
• Primary care low resources settings (PCL)
• Verbal Autopsy (VA)
• Startup Mortality List (SMoL)
The full name of such a tabular list will always include ‘ICD–11’, e.g. ICD–11 MMS.
In a Tabular list, entities of the Foundation Component become categories. The categories
are mutually exclusive and jointly exhaustive and linked to a mono hierarchical tree (they
have only one parent). The information related to an entity that has become a category and
has multiple parents is still available from the Foundation. This information can be used to
visualise that category in more than one place in the Tabular list, e.g. showing them in black
in its place for reference tabulation and in grey in any other place for browsing or
alternative tabulations. ICD–11 has multiple congruent tabular lists with varying levels of
detail.
The Foundation Component is also the data source for production and maintenance of
Tabular lists, index and the Reference Guide. It also includes additional content (see
‘content model’) that goes beyond the traditional paper-based use of a classification.
Depending on the setting within a country, it may be decided to use the full Foundation
Component or to focus on the parts that are essential to production and maintenance of the
Index and the Tabular list.
The Foundation Component serves to align the content of the different tabular lists and to
define their categories. As such it allows standardised use of the ICD-11, independent of the
setting in which it is used. The Foundation Component includes, for example, links to other
classifications or terminologies that can be expanded in the future. Please note that the

64 ICD-11 MMS
mention of a term or entity in the Foundation exclusively serves ontological purposes.
Mention of a term or entity in the Foundation does not mean approval or endorsement of a
particular condition.

2.14 Main uses of the ICD: Mortality

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. Guidelines are also provided for the application of the rules and for coding of
the condition selected for tabulation. Implementation of the ICD for mortality requires
setting up an infrastructure for reporting and storing information, designing information
flows, quality assurance and feedback, and training for classification users working with the
input or output of data.
Following the introductory information in this Section and 2.15, Section 2.16 explains the
basic concepts used in mortality coding. Sections 2.17 - 2.20, supplemented by Annexes in
Section 3.14, guides how to code and identify the underlying cause of death, and Section
2.25 explains descriptions used in statistical tabulation and international reporting for
mortality.

2.15 Mortality statistics

Mortality statistics are widely used for medical research, monitoring of public health,
evaluating health interventions, allocation of health resources and planning and for, and
follow-up of health care. Analysis of mortality data typically involves comparisons of data
sets, for example those representing different geographical regions or different points in
time. Unless the data have been produced by the same methods and according to the same
standards, such comparisons will yield misleading results.
To standardise production of mortality data, WHO issues international instructions on data
collection, coding and classification, and statistical presentation of causes of death. It is of
utmost importance that production of mortality data follows the procedures detailed next,
since any deviation from the international instructions will impair international
comparability. The description of a single underlying cause of death, and selected
approaches to capture further information on causes of death also reported on a certificate,
enables the identification of trends in health for a given population. The following sections
contain information on coding causes of death for mortality statistics. They explain the basic
concepts, how to code conditions reported on death certificates, and how to select and
tabulate the underlying cause of death.
The aim of these instructions is to optimise the mortality statistics from a public health point
of view. Some of the instructions may appear wrong or questionable from a purely medical
perspective. They should still not be set aside, since they may be motivated by well-founded
epidemiological and public health principles. If an apparent error is found, it should be
reported to WHO through the online proposal mechanism. WHO will either explain the
rationale or take steps to correct the error at the international level. Individual countries
should not correct what is assumed to be an error, since changes at the national level will
lead to data that are less comparable to data from other countries, and thus less useful for
analysis.

ICD-11 Reference Guide 65

2.15.1 What is tabulated: Underlying cause of death

Effective public health interventions prevent harm or death by breaking the chain of events
that lead to harm. For this purpose, the underlying cause of death 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’, and is
selected for routine single-cause tabulation of mortality statistics. See Sections 2.17.2
Selecting the underlying cause of death and 2.17 Coding instructions for mortality for
specific coding instructions to identify the underlying cause of death.
2.15.2 Data source: The international form of Medical Certificate of Cause of Death
(MCCD)

The international mortality coding instructions presuppose that data have been collected
with a death certificate conforming to the international form of Medical Certificate of Cause
of Death as recommended by the WHO. Frame A, the medical data part of the international
form is split into two parts: Part 1 is for diseases related to the chain of events directly
leading to death, and Part 2 is for other significant conditions contributing to death. Other
information in the form is also used in identifying the underlying cause of death for
tabulation.
In order to align the way this information is collected internationally, the form should be
followed as closely as possible. Otherwise, the causes of death cannot be coded and
selected according to the international standard and the data will not be internationally
comparable. For example, some coding instructions apply to conditions reported as caused
by certain other conditions, and in such cases, it is important to have a clear distinction
between causes reported in Part 1 and in Part 2 of the death certificate. Further,
information reported elsewhere on the certificate, such as manner of death or whether
pregnancy contributed to the death, is essential when assigning multiple cause codes to the
conditions stated on the certificate and selecting an underlying cause for tabulation.
It is the responsibility of the medical practitioner or other qualified certifier signing the
death certificate to indicate which morbid conditions led directly to death and to state any
pre-existing conditions giving rise to this cause. The 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.

66 ICD-11 MMS
The 2016 International form of the Medical Certificate of Cause of Death
See 3.14 Annex C: Annexes for Mortality Coding for further details and guidance.

ICD-11 Reference Guide 67

2.15.3 Routine use and special cases

[Link] Routine cause of death reporting systems

In routine cause of death reporting systems, every individual death is certified by a qualified
medical doctor who carries out an accurate postmortem examination, collects history from
relatives, and has access to all pre-existing medical information about the defunct. The
medical certification of the cause of death is usually the responsibility of the attending
physician and should be in line with international recommendations. Administrative
procedures should ensure confidentiality of data from death certificates or other medical
records.
In the case of deaths certified by coroners or other legal authorities, the medical evidence
supplied to the certifier should be stated on the certificate in addition to any legal findings.
Routine cause of death reporting is usually embedded in the certification of death process.
Death certificates are a legal requirement for burial and for inheritance.

[Link] Verbal autopsy

Verbal autopsy (VA) is a method used to ascertain the cause of a death based on an
interview with next of kin or other caregivers where no medical certification is available.
This is done using a standardised instrument that elicits information on signs, symptoms,
medical history, and circumstances preceding death. The cause of death, or the sequence of
causes that led to death, are assigned based on the data collected by the instrument and
other available information. Rules and guidelines, algorithms or computer programs, may
assist in evaluating the information to determine the cause of death.
The main objective of the VA is to describe the causes of death at the community or
population level in areas, where civil registration and death certification systems are weak
and where most people die at home without having had contact with the health system. A
standard VA instrument comprises a VA questionnaire, cause of death or mortality
classification system, and diagnostic criteria (either expert or data derived algorithms) for
deriving causes of death.
The VA process consists of interviews, data recording, and identification of the cause of
death from the reports. At any step, factors can influence the cause-specific mortality
fractions estimated throughout the process. Besides research, VA is a viable method for
causes of death identification in settings where no physician can evaluate the deceased.
More information can be found on the WHO Verbal autopsy webpage.
See 3.14.14 Target list of causes of death for verbal autopsy with corresponding ICD-11
codes.

2.16 Basic concepts

Mortality coders must be familiar with the basic concepts introduced in this section.

68 ICD-11 MMS
Basic Concepts
Basic concepts for mortality coding in the international form of the Medical Certificate of
Cause of Death
2.16.1 Terminal cause of death

The disease or condition entered first on the first used line of Part 1 of the death certificate
is the cause directly leading to death. This is known as the terminal or immediate cause of
death.

Example 1
1 (a) Myocardial infarction
due to
(b) Coronary atherosclerosis
due to
(c)
due to
(d)
2
The myocardial infarction is the terminal cause of death, since it is entered first on the first used line of
the certificate.

ICD-11 Reference Guide 69

 Example 2
1 (a) Myocardial infarction and pulmonary oedema
due to
(b) Coronary atherosclerosis
due to
(c)
due to
(d)
2
The myocardial infarction is the terminal cause of death, since it is entered first on the first used line of
the certificate.
2.16.2 Causal relationship and sequence

A causal relationship exists if a condition mentioned on the death certificate can be caused
by another condition also mentioned on the certificate. The term ‘sequence’ refers to a
chain or series of medical events in which each step is a complication of, or is caused by, the
previous step. A causal relationship can exist between any two conditions, including
conditions assigned to the same ICD-11 code, regardless of where each condition was
reported. In a correctly completed death certificate, a sequence is a set of conditions
reported line by line with a causal relationship between each element. Four lines are
provided in Part 1 of the certificate for recording the sequence of events leading to the
death. A certifier may only use as many lines as are required to describe the sequence.
A causal relationship is considered acceptable for mortality coding if it is founded not only
on a medical assessment but also on epidemiological and public health considerations.
Therefore, a medically acceptable relationship might be listed as unacceptable in the coding
instructions because a later step in the sequence is more important from a public health
point of view.
In addition, a reported sequence that appears improbable should be accepted if one or
more intervening steps would explain the causal relationship, even if these have not been
reported. However, such assumed intervening causes are not to be coded, as they are
assumptions and not reported conditions.
To decide whether a stated causal relationship is acceptable, always apply the instructions
in Section 2.19.1 Special instructions on accepted and rejected sequences (Steps SP3 and
SP4). Stated relationships that are not listed in Section 2.19.1 should be accepted as far as
possible, because the certifier’s opinion about the causes leading to death should not be
disregarded.

70 ICD-11 MMS
 Example 1
1 (a) Myocardial infarction
due to
(b) Coronary thrombosis
due to
(c) Coronary atherosclerosis
due to
(d)
2
The terminal cause of death is myocardial infarction. It is caused by the coronary thrombosis, which, in
turn, is caused by coronary atherosclerosis. Consequently, the sequence is: myocardial infarction due to
coronary thrombosis due to coronary atherosclerosis.

Example 2
1 (a) Extensive haemorrhage
due to
(b) Traumatic amputation of right leg
due to
(c) Run over by a bus
due to
(d)
2
The terminal cause of death is haemorrhage. It is a complication of the traumatic amputation of the right
leg, which, in turn, is caused by the bus accident. Consequently, the sequence is: extensive haemorrhage
due to traumatic amputation of the right leg due to being run over by a bus.
2.16.3 Starting point

The starting point is the condition or event that started the sequence of acceptable causal
relationships ending with the terminal cause of death. In a correctly completed death
certificate, the condition reported first on the lowest used line in Part 1 is the starting point
of the sequence. The instructions on how to identify the starting point is provided in Section
2.17.3 Find the starting point (Steps SP1 to SP8).
If the death certificate is not correctly filled out, the starting point may be reported
elsewhere, and instructions are given to identify the starting point also for such cases in a
standardised manner. Therefore, it is important to apply the instructions in Section 2.17.3 in
a sequential manner.
The condition provisionally considered as the starting point when applying the instructions
step by step is referred to as the ‘tentative starting point (TSP)’ and may change several
times as the instructions are applied to the death certificate.

ICD-11 Reference Guide 71

 Example 1
1 (a) Myocardial infarction and pulmonary oedema
due to
(b) Coronary atherosclerosis
due to
(c)
due to
(d)
2
Coronary atherosclerosis is the starting point, since it led to the myocardial infarction.

Example 2
1 (a) Pneumonia
due to
(b) Hip fracture
due to
(c) Tripped on carpet
due to
(d)
2
Tripped on carpet is the starting point, since it started the sequence of events leading to death.
2.16.4 Duration

On death certificates, each reported condition should also include information about
duration. The duration refers to the interval from the onset of the disease or condition to
the time of death. Note that it is not always the same as the time of diagnosis of the
condition, which may be at the same time as, or after, the onset of symptoms.
2.16.5 First-mentioned sequence

A death certificate may contain several sequences of acceptable causal relationships ending
with the terminal cause of death. The coding instructions are given to identify the starting
point of the first-mentioned sequence in Part 1 (See also Step SP4).
The figures below illustrate examples of certificates where each condition reported is shown
by a circle. The starting point of the first-mentioned sequence is in grey, and the causal
relationship of the first-mentioned sequence is indicated by an arrow.
To identify the first-mentioned sequence, begin with the terminal cause of death (the
condition entered first on the first used line of Part 1). Check if the conditions on the next
line in Part 1 can result in the terminal cause of death. If several conditions are reported on
the same line, check from left to right in turn until you find a condition that could cause the
terminal cause.

72 ICD-11 MMS
If no condition on the next line can cause the terminal cause of death, there is no sequence
ending with the terminal cause of death. The terminal cause of death is the tentative
starting point. Specific instruction is given also when you find no sequence (see Step SP5).

NoSequence
No Sequence ending with the terminal cause of death
If there is a condition that can cause the terminal cause of death, the first condition found
to be able to cause the terminal cause of death is the tentative starting point. If there are no
conditions reported on lower lines, the sequence between this tentative starting point and
the terminal cause is the first-mentioned sequence.

First Mentioned Sequence A

First Mentioned Sequence B

If there are conditions reported on lower lines in Part 1, repeat the procedure for the next
lower line. Start with the tentative starting point identified in the previous step. Check the
conditions on the next lower line in Part 1, from left to right, to determine if they can cause
the tentative starting point. Continue until you have found a condition that can cause the
tentative starting point. This is the new tentative starting point.

ICD-11 Reference Guide 73

First Mentioned Sequence C

First Mentioned Sequence D

74 ICD-11 MMS
First Mentioned Sequence E

If there are still conditions reported on lower lines in Part 1, repeat the procedure for as
long as a new tentative starting point can be identified. When no condition can be found
that could cause the tentative starting point, the last identified tentative starting point is
also the starting point of the first-mentioned sequence.

Example 1
1 (a) Pneumonia
due to
(b) Hip fracture and heart failure
due to
(c) Tripped on carpet, coronary atherosclerosis
due to
(d)
2
Pneumonia can be due to hip fracture, and therefore hip fracture is the tentative starting point. Hip
fracture can be due to tripping, which is the new tentative starting point. Since there are no causes
reported below line 1(c), tripping on carpet is the starting point of the first-mentioned sequence.

ICD-11 Reference Guide 75

 Example 2
1 (a) Pneumonia
due to
(b) Heart failure and hip fracture
due to
(c) Coronary atherosclerosis and tripped on carpet
due to
(d)
2
Pneumonia can be due to heart failure, and therefore heart failure is the tentative starting point. Heart
failure can be due to coronary atherosclerosis, which is the new tentative starting point. Since there are
no causes reported below line 1(c), coronary atherosclerosis is the starting point of the first-mentioned
sequence.

Example 3
1 (a) Pneumonia
due to
(b) Hip fracture and heart failure
due to
(c) Coronary atherosclerosis and tripped on carpet
due to
(d)
2
Pneumonia can be due to hip fracture, and therefore hip fracture is the tentative starting point. However,
hip fracture cannot be due to coronary atherosclerosis, but hip fracture can be due to tripping, which is
the new tentative starting point. Since there are no causes reported below line 1(c), tripped on carpet is
the starting point of the first-mentioned sequence.
2.16.6 Underlying cause of death (UCOD)

The underlying cause of death (UCOD), as defined in Section 2.15.1, is the condition selected
for single-cause tabulation of mortality statistics.
A condition that is provisionally considered as the underlying cause of death when applying
the instructions step by step is referred to as a ‘tentative underlying cause of death (TUC)’
and may change several times as the instructions are applied to the death certificate.

76 ICD-11 MMS
 Example 1
1 (a) Myocardial infarction
due to
(b) Coronary atherosclerosis
due to
(c) Generalised atherosclerosis
due to
(d)
2
Generalised atherosclerosis started the sequence of events leading to death, so it is the starting point.
There are special modification instructions relating to atherosclerosis and coronary heart disease in the
ICD, and, in the next step, coronary atherosclerosis is selected as the tentative underlying cause of death.
But there are further instructions on coronary atherosclerosis and myocardial infarction, and in the final
step, myocardial infarction is selected as the tentative underlying cause, and is the underlying cause of
death in this case.
2.16.7 Priority underlying condition

Some mortality coding instructions (e.g. Steps SP6, M1) refer to the ‘priority underlying
condition’. It is a concept to set a priority order giving precedence to the underlying
condition, when specific requirements in each instruction apply to several conditions in the
death certificate.
To identify the priority underlying condition, start from the first condition reported on the
lowest used line of Part 1. If there are several conditions reported, search from the lowest
used line, and the next line above in turn, and from left to right for each line. If you cannot
find the priority underlying condition in Part 1, then search Part 2, again from left to right.

Priority Underlying Condition

ICD-11 Reference Guide 77

2.16.8 Modification

Special coding instructions on specific sequences and ICD categories may have the effect
that a condition other than the starting point is selected as the underlying cause of death for
use in the statistics. In such cases, the code for underlying cause often expresses a
combination of the starting point with another reported condition, or a complication or
consequence of the starting point that is of particular importance to public health. The
procedure by which the ICD code for the starting point is replaced by another code is called
modification. Instructions on how to apply these special instructions to identify the
underlying cause of death is given in Section 2.18 Check for modifications of the starting
point (Steps M1 to M4).

Example 1
1 (a) Heart disease
due to
(b) Generalised atherosclerosis
due to
(c)
due to
(d)
2
Generalised atherosclerosis started the sequence of events leading to death, so it is the starting point.
However, according to a special instruction on generalised atherosclerosis, generalised atherosclerosis
leading to heart disease is assigned to atherosclerotic heart disease in mortality statistics. Because of this
modification, atherosclerotic heart disease is the underlying cause of death.
2.17 Coding instructions for mortality
When coding causes of death, first assign ICD codes to all the conditions mentioned on the
death certificate. Many coding instructions are based on specific ICD codes, and to
determine whether or not any of the instructions apply, all conditions on the certificate
must be coded. Other conditions reported on the certificate may affect the coding any
condition. Assigning codes for all reported conditions and applying any effect one code has
on another is called multiple cause coding.
2.17.1 Basic coding and multiple cause coding guidelines

To start coding, refer to basic coding guidelines given in sections in the beginning of Part 2
(for example Sections2.1, 2.6, and 2.10.1. When multiple causes are reported also refer to
Section 2.20 Coding instructions for mortality: multiple cause coding and other specific
instructions. Multiple cause coding permits in-depth analysis of causes of death, for example
of serious but avoidable complications of certain underlying causes, and the impact of
coexisting conditions on the outcome of a disease process. Therefore, in mortality coding,
both underlying cause and multiple causes should be recorded. Complete multiple cause
coding is essential for a correct application of the ICD instructions for selection and
modification of the underlying cause of death.

78 ICD-11 MMS
To ensure consistent reporting of emerging conditions of international public health
importance, WHO may sometimes publish special instructions for coding of named
conditions, or selection of the underlying cause of death where named conditions are
mentioned on the Medical Certificate Cause of Death (MCCD). This will usually involve codes
in Chapter 25: Codes for special purposes - International provisional assignment of new
diseases of uncertain aetiology and emergency use. Such special instructions should be
applied in preference to any instructions in the Reference Guide that would otherwise
apply.
Once ICD codes are assigned to each disease or condition on the certificate, apply the
instructions to select the underlying cause of death.
2.17.2 Selecting the underlying cause of death

For most death certificates, selecting the underlying cause of death is a straightforward
procedure. There are, however, many cases where the underlying cause is not immediately
obvious. To ensure that both straightforward and complex cases are coded according to the
ICD mortality rules, it is important to follow the coding instructions carefully, step by step.
Otherwise, the resulting mortality statistics will not be internationally comparable, which
seriously reduces the value of the data for public health purposes.
Selecting the underlying cause of death involves two separate steps. The first step is to
identify the starting point (Steps SP1 through SP8 below). The next step is to modify the
starting point, if any of the modification instructions apply, to reflect further information
provided on the death certificate (Steps M1 through M4 below). See Sections 2.18 - 2.19 for
specific instructions. In addition, Mortality Annex 3.14.4 includes a workflow diagram to
illustrate the coding instructions for the selection of the underlying cause of death. This is
intended as a supplement to help coders follow the coding instructions.
Note that the purpose of the selection procedure is to produce the most useful mortality
statistics possible. Thus, the following instructions may reflect the importance of some
conditions for public health rather than what is correct from a purely medical point of view.
The following instructions always apply, whether they might be considered medically
correct or not.
In the coding examples that follow, the ‘due to’ statement between the lines in Part 1 is not
included. But it is important to bear in mind that anything reported on an upper line in Part
1 is meant to be due to what is reported on the line below.

ICD-11 Reference Guide 79

80 ICD-11 MMS
Workflow
Workflow diagram of steps SP1 to SP8, and to Steps M1 to M4 for mortality coding.
2.17.3 Find the starting point (Steps SP1 to SP8)

To identify the starting point, follow the eight steps specified in this section. The steps are
named SP1 to SP8 (Starting point rule 1 to Starting point rule 8). Each step contains one
selection rule. At each step, there is a description of the selection rule itself and an
instruction on what to do next.
2.17.4 Step SP1 – Single cause on certificate

If there is only one condition reported on the certificate, in either Part 1 or Part 2, this is the
starting point. Next verify whether either step M1 or M4 apply, go to Section 2.18 Check for
modifications of the starting point (Steps M1 to M4).
If there are two or more conditions on the certificate, go to Step SP2.
2.17.5 Step SP2 – First condition on the only line used

If the certifier has used only one line in Part 1 and:

• has reported only one condition on this line, but has reported one or more
conditions in Part 2, then the single condition in Part 1 is the tentative starting point.
Next, go to Step SP6.
• has reported two or more conditions on this line, then the first condition is the
tentative starting point. This applies whether or not one or more conditions are
reported in Part 2. Next, go to Step SP6.
If the certifier has used more than one line in Part 1, go to Step SP3.
If the certifier has used only Part 2, but has reported two or more conditions there, then the
first condition is the tentative starting point.

Example 1
1 (a) Myocardial infarction and diabetes mellitus
(b)
(c)
(d)
2
Myocardial infarction is mentioned first on the certificate and is the tentative starting point. Next, go to
Step SP6, to check whether further selection and modification rules apply.

ICD-11 Reference Guide 81

 Example 2
1 (a) Myocardial infarction
(b)
(c)
(d)
2 Diabetes mellitus
Myocardial infarction is mentioned first on the certificate and is the tentative starting point. Next, go to
Step SP6, to check whether further selection and modification rules apply.
2.17.6 Step SP3 – First condition on the lowest used line causing all entries above

If there are conditions reported on more than one line in Part 1, check if each of the
conditions reported on the line(s) above the lowest used line in Part 1 can be caused by the
first condition on the lowest used line.
• If yes, then this condition is the tentative starting point. Next, go to Step SP6.
• If not, go to Step SP4.
To assess causal relationship, refer to Section 2.16.2 Causal relationship and sequence, and
to Section 2.19.1 Special instructions on accepted and rejected sequences (Steps SP3 and
SP4).

Example 1
1 (a) Bronchopneumonia
(b) Hemiplegia
(c) Cerebral infarction
(d)
2
Both bronchopneumonia and hemiplegia can be caused by cerebral infarction. This means that cerebral
infarction is the tentative starting point.

Example 2
1 (a) Liver metastases 2 months
(b) Bronchopneumonia 4 days
(c) Stomach cancer 6 months
(d)
2
Both liver metastases and bronchopneumonia can be caused by stomach cancer. This means that stomach
cancer is the tentative starting point, even though bronchopneumonia cannot cause liver metastases and
the bronchopneumonia has a shorter duration than the liver metastases.

82 ICD-11 MMS
 Example 3
1 (a) Liver metastases
(b) Bronchopneumonia
(c) Stomach cancer and cerebral infarction
(d)
2
Both liver metastases and bronchopneumonia can be caused by stomach cancer, which is the first
condition mentioned on the lowest used line in Part 1. This means that stomach cancer is the tentative
starting point.

Example 4
1 (a) Liver metastases
(b) Bronchopneumonia and stomach cancer
(c)
(d)
2
Liver metastases cannot be due to bronchopneumonia. This means that no tentative starting point can be
identified at Step SP3. Therefore, go to Step SP4.
2.17.7 Step SP4 – Starting point of the first-mentioned sequence

The first-mentioned sequence is always found in Part 1 (see Section 2.16.5).

• If one or more sequences ending with the terminal cause of death are reported in
Part 1, identify the first-mentioned sequence (see Section 2.16.5). The starting point
of this sequence is the tentative starting point. Next go to Step SP6.
If no sequence ending with the terminal cause of death is reported in Part 1, go to Step SP5.
To assess causal relationship, refer to Section 2.16.2 Causal relationship and sequence, and
to Section 2.19.1 Special instructions on accepted and rejected sequences (Steps SP3 and
SP4).

Example 1
1 (a) Liver metastases
(b) Bronchopneumonia and stomach cancer
(c)
(d)
2
Bronchopneumonia cannot cause liver metastases (Step SP3 does not apply), but liver metastases can be
due to stomach cancer. This is the first-mentioned sequence ending with the terminal cause of death, so
stomach cancer is the tentative starting point.

ICD-11 Reference Guide 83

 Example 2
1 (a) Bronchopneumonia
(b) Cerebral infarction and liver metastases
(c) Atherosclerosis and stomach cancer
(d)
2
Atherosclerosis cannot cause liver metastases (Step SP3 does not apply). There are three acceptable
sequences on the certificate: (1) bronchopneumonia caused by cerebral infarction, in its turn caused by
atherosclerosis; (2) bronchopneumonia caused by cerebral infarction, in its turn caused by stomach
cancer; and (3) bronchopneumonia caused by liver metastases, in its turn caused by stomach cancer. The
first-mentioned sequence is bronchopneumonia caused by cerebral infarction, in its turn caused by
atherosclerosis. Consequently, atherosclerosis is the tentative starting point.
2.17.8 Step SP5 – Terminal cause of death when no sequence

If no sequence ending with the terminal cause of death is reported in Part 1, the terminal
cause of death is also the tentative starting point. Next, go to Step SP6.

Example 1
1 (a) Liver metastases
(b) Cerebral infarction
(c) Atherosclerosis
(d)
2 Stomach cancer
Atherosclerosis cannot cause liver metastases (Step SP3 does not apply). Cerebral infarction cannot cause
liver metastases (Step SP4 does not apply). No sequence ending with the terminal cause of death is
reported in Part 1, so the terminal cause of death – liver metastases – is the tentative starting point.
2.17.9 Step SP6 – Obvious cause

If the tentative starting point selected in Steps SP1 to SP5 was obviously caused by another
condition on the certificate, select the obvious cause as the new tentative starting point.
Conditions that are considered to have an ‘obvious’ causal relationship are specified in
Section 2.19.2 Special instructions on obvious cause (Step SP6). To identify which Part of the
certificate you should search for, apply following rules:
• If the tentative starting point is in Part 1, the obvious cause must be either on the
same or lower line, in Part 1, or in Part 2. Do not look for obvious causes on lines
above the tentative starting point.
• If the tentative starting point is in Part 2, the obvious cause must also be in Part 2.
Do not look for obvious causes in Part 1.
Next, reapply Step SP6 to the new tentative starting point. Continue looking for a new
tentative starting point until you find a tentative starting point that is not obviously caused
by a condition reported on the same line or further down on the certificate. Then go to Step
SP7.
If there is no condition reported on the certificate that obviously caused the tentative
starting point selected in Steps SP2 to SP5, go to Step SP7.

84 ICD-11 MMS
An obvious causal relationship is a type of causal relationship (see Section 2.19.1) and a
rejected sequence in Section [2.19.2] should also be rejected in considering an ‘obvious’
relationship between conditions. However, in considering accepting sequences, the word
‘obviously’ is important, and there must be no doubt about the relationship between the
conditions. It is not sufficient that the sequence would have been accepted if the tentative
starting point had been reported as due to the other condition. In applying Step SP6, always
refer to Section 2.19.2.
Do not apply Step SP6 if the tentative starting point has a longer duration than the obvious
cause.
If more than one obvious cause of the tentative starting point is reported, select the priority
underlying condition (see Section 2.16.7).

Example 1
1 (a) Sepsis
(b) Peritonitis
(c)
(d)
2 Appendicitis with rupture
Sepsis can be caused by peritonitis, and peritonitis is the tentative starting point (Step SP3). Appendicitis
with rupture is an obvious cause of peritonitis, and appendicitis with rupture is the new tentative starting
point.

Example 2
1 (a) Liver metastases
(b) Cerebral infarction
(c)
(d)
2 Stomach cancer
Cerebral infarction cannot cause liver metastases, and liver metastases is the tentative starting point
(Step SP5). Stomach cancer is an obvious cause of liver metastases, and stomach cancer is the new
tentative starting point.

Example 3
1 (a) Sepsis
(b) Peritonitis, mesenteric embolism
(c)
(d)
2
Sepsis can be caused by peritonitis, and peritonitis is the tentative starting point (Step SP3). Mesenteric
embolism is an obvious cause of peritonitis, and mesenteric embolism is the new tentative starting point.

ICD-11 Reference Guide 85

 Example 4
1 (a) Sepsis
(b) Peritonitis
(c)
(d)
2 Mesenteric embolism, rupture appendicitis
Sepsis can be caused by peritonitis, and peritonitis is the tentative starting point (Step SP3). Next, both
mesenteric embolism and ruptured appendicitis are obvious causes of peritonitis. Because mesenteric
embolism is mentioned first and is the priority underlying condition, it is the new tentative starting point.

Example 5
1 (a) Sepsis
(b) Peritonitis
(c)
(d)
2 Necrosis of intestine, mesenteric infarction
Sepsis can be caused by peritonitis, and peritonitis is the tentative starting point (Step SP3). Necrosis of
intestine is an obvious cause of peritonitis, so necrosis of intestine is the new tentative starting point.
Next, mesenteric infarction is an obvious cause of necrosis of intestine, and mesenteric infarction is the
final starting point.
2.17.10 Step SP7 – Ill-defined conditions

If the tentative starting point selected in Steps SP1 to SP6 is in the List of ill-defined
conditions, and:
• If there is at least one condition that is not ill-defined, then disregard the ill-defined
condition. Go to Step SP1 and select another starting point, as if the ill-defined
condition had not been mentioned on the certificate.
• If all other conditions reported on the certificate, are ill- defined, go to Step M1.
If the tentative starting point is not ill-defined, go to Step SP8.
Note that the following are not considered ill-defined:
3.14.6 List of ill-defined conditions.

Example 1
1 (a) Respiratory failure
(b)
(c)
(d)
2 Mesenteric embolism
Respiratory failure is the only condition mentioned in Part 1 and it is the tentative starting point
according to Steps SP2. Respiratory failure is in the table of ill-defined conditions, and there is a condition
not ill-defined, Mesenteric embolism, so disregard respiratory failure and restart the selection procedure.
Mesenteric embolism is the new starting point according to Step SP1.

86 ICD-11 MMS
2.17.11 Step SP8 – Conditions unlikely to cause death

If the tentative starting point selected in Steps SP1 to SP7 is in the List of conditions unlikely
to cause death (see Mortality Annex 3.14.10, and:
• If all other conditions reported on the certificate are also unlikely to cause death or
ill-defined, then keep this condition ‘unlikely to cause death’ as the starting point.
Next, go to Step M1.
• If this condition was the cause of another condition that is not ‘unlikely to cause
death’ and that is not ill-defined, then keep this condition unlikely to cause death as
the starting point. Next, go to Step M1.
• If the death was caused by a reaction to treatment of the condition unlikely to cause
death, select the reaction to treatment as the starting point. Next, go to Step M1
• If none of these three apply, and there is at least one condition that is not ‘unlikely
to cause death’ and not ‘ill-defined’, then disregard the condition unlikely to cause
death. Go to Step SP1 and select another starting point, as if the condition unlikely to
cause death had not been mentioned on the certificate.
If the tentative starting point is not in the ‘List of conditions unlikely to cause death’, keep
that condition as the starting point and go to Step M1.
If the certificate mentions more than one treatment for the condition unlikely to cause
death, select the first-mentioned treatment.

Example 1
1 (a) Hearing loss
(b)
(c)
(d)
2 Ischaemic heart disease
Hearing loss is the tentative starting point (Step SP2), but it in the ‘List of conditions considered unlikely
to cause death’. There is another condition on the certificate, ischaemic heart disease, which is not in the
‘List of conditions considered unlikely to cause death’. Disregard hearing loss and restart the selection
procedure from Step SP1. Ischaemic heart disease is the new starting point (Step SP1).

Example 2
1 (a) Liver failure
(b) Excessive use of paracetamol
(c) Migraine-type headache
(d)
2
Migraine type headache is the tentative starting point (Step SP3), but it is in the ‘List of conditions
considered unlikely to cause death’. Migraine type headache was treated with paracetamol and there was
a reaction to the treatment, liver failure. Select the reaction to the treatment, liver failure, as the starting
point.

ICD-11 Reference Guide 87

 Example 3
1 (a) Sepsis
(b) Submandibular abscess
(c) Caries
(d)
2
Caries is the tentative starting point (Step SP3), but it is in the ‘List of conditions considered unlikely to
cause death’. In this case caries caused submandibular abscess, a condition that is not unlikely to cause
death and that is not ill-defined. Because of that, keep caries as the starting point.

Example 4
1 (a) Headache
(b) Caries
(c)
(d)
2 Ischaemic heart disease
Caries is the tentative starting point (Step SP3), but it is in the ‘List of conditions considered unlikely to
cause death’. In this case caries caused headache, a condition that is in the list of ill-defined conditions.
Disregard both caries (Step SP8) and headache (Step SP7) and restart the selection procedure from Step
SP1. Ischaemic heart disease is the new starting point (Step SP1).
2.18 Check for modifications of the starting point (Steps M1 to M4)
The starting point identified using Steps SP1 to SP8 is now considered the tentative
underlying cause. There may be special coding instructions on this tentative underlying
cause, or other reasons to modify the tentative underlying cause. Check whether the
tentative underlying cause should be modified by applying the modification rules described
in steps M1 to M3 (Modification rule 1 to Modification rule 3). Each step contains one
modification rule. At each step, there is a description of the modification rule itself and what
to do next. There are also bullet points with more detailed instructions and explanations.
2.18.1 Step M1 – Special instructions

If the tentative underlying cause (TUC) selected in Steps SP1 to SP8 applies to a special
instruction listed in Section 2.19.3 Special instructions on linkages and other provisions (Step
M1), assign a new tentative underlying cause according to the instruction.
Next, reapply Step M1 to the new tentative underlying cause. Repeat until you have found a
tentative underlying cause that is not affected by any further special coding instruction.
Next, go to Step M2.
If the tentative underlying cause does not apply to instructions in Section 2.19.3, go to Step
M2.
If more than one instruction in Section 2.19.3 applies to the tentative underlying cause,
select the instruction relating to the priority underlying condition (see Section 2.16.7).
Note that there are two types of combinations of codes, ‘with mention of’ and ‘when
reported as a cause of’. Refer to Section 2.19.3 for details.

88 ICD-11 MMS
Sometimes the classification itself indicates a code for a combination of the tentative
underlying cause with another cause mentioned on the certificate. Use the combination
code unless an instruction on mortality coding in Section 2.19.3 indicates otherwise.
Examples of ‘with mention of’:

Example 1
1 (a) Myocardial infarction
(b) Ischaemic heart disease
(c)
(d)
2
Ischaemic heart disease is the tentative starting point (Step SP3). There is a special instruction on
ischaemic heart disease reported with mention of myocardial infarction, and, according to this
instruction, myocardial infarction is the new tentative underlying cause.

Example 2
1 (a) Ischaemic heart disease
(b) Atherosclerosis
(c)
(d)
2 Cerebral infarction
Atherosclerosis is the tentative starting point (Step SP3). There is a special instruction on ‘atherosclerosis
reported with ischaemic heart disease’, and another one on ‘atherosclerosis reported with cerebral
infarction’. Ischaemic heart disease is the priority underlying condition, so apply the instruction on
‘atherosclerosis reported with ischaemic heart disease’ and select ischaemic heart disease as the new
tentative underlying cause.

Example 3
1 (a) Cerebrovascular infarction
(b) Atherosclerosis
(c) Hypertension
(d)
2 Myocardial infarction
Hypertension is the tentative starting point (Step SP3). There are special instructions on ‘hypertension
reported with mention of cerebrovascular infarction’ and with myocardial infarction. Cerebrovascular
infarction is the priority underlying condition, so apply the instruction on ‘hypertension reported with
mention of cerebrovascular infarction’ and select cerebrovascular infarction as the new tentative
underlying cause.

ICD-11 Reference Guide 89

 Example 4
1 (a) Ischaemic heart disease
(b) Atherosclerosis
(c)
(d)
2 Myocardial infarction
Atherosclerosis is the tentative starting point (Step SP3). There is a special instruction on ‘atherosclerosis
reported with mention of ischaemic heart disease’, and another one on ‘atherosclerosis reported with
mention of myocardial infarction’. Ischaemic heart disease is the priority underlying condition, so apply
the instruction on ‘atherosclerosis reported with mention of ischaemic heart disease’ and select ischaemic
heart disease as the new starting point. Next, there is a special instruction on ‘ischaemic heart disease
reported with mention of myocardial infarction’. Apply this instruction and select myocardial infarction
as the new tentative underlying cause.

Examples of ‘when reported as the cause of’:

Example 5
1 (a) Chronic kidney disease
(b) Atherosclerosis
(c)
(d)
2
Atherosclerosis is the tentative starting point (Step SP3). There is a special instruction on ‘atherosclerosis
reported as the cause of chronic kidney disease’. Apply this instruction and select hypertensive renal
disese (BA02) as the new tentative underlying cause.

Example 6
1 (a) Atherosclerosis
(b)
(c)
(d)
2 Chronic kidney disease
Atherosclerosis is the tentative starting point (Step SP2). Although there is a special instruction on
‘atherosclerosis reported as the cause of chronic kidney disease’, this instruction does not apply here
because chronic kidney disease is reported in Part 2 and not as caused by atherosclerosis. In this case,
atherosclerosis remains the tentative starting point.
2.18.2 Step M2 – Specificity

If the tentative underlying cause describes a condition in general terms and another term
that provides more precise information about the site or nature of the same condition is
reported on the certificate, use the more informative term. This rule will often apply when
the general term becomes an adjective, qualifying the more precise term.
If the tentative underlying cause is an infectious disease reported as the cause of a specific
manifestation, there may be a provision in the classification to combine the two codes into

90 ICD-11 MMS
one code providing more precise information about the site or nature of the tentative
starting point. This code is the new tentative underlying cause of death.
Next, reapply Step M2 to the new tentative underlying cause. Repeat until you have found a
tentative underlying cause that cannot be specified further.
• If there is no term that further specifies the tentative underlying cause (TUC), go to Step
M3.
• If there are several other expressions that provide more precise information on the
tentative underlying cause, select the priority underlying condition (see Section 2.16.7).
• If the TUC is an unspecified condition and this condition appears with more specificity
somewhere on the death certificate, this last more specific condition should be considered
as the new TUC.

Example 1
1 (a) Meningitis 1D01.Z
(b) Tuberculosis 1B1Z
(c)
(d)
2
Tuberculosis is the tentative starting point (Step SP3). A term providing more precise information about
the site or nature of this condition is reported on the certificate: menigitis. There is a provision in the
classification to combine the two codes, and according to instruction of step M2, tuberculous meningitis
(1B11.0) is a new tentative underlying cause.

Example 2
1 (a) Syphilis, unspecified 1A6Z
(b)
(c)
(d)
2 Primary genital syphilis 1A61.0
Syphilis, is the tentative starting point (Step SP2). A more specific condition for syphilis appears
elsewhere on the death certificate: primary genital syphilis, and according to instruction of step M2,
primary genital syphilis is a new tentative underlying cause.

Example 3
1 (a) Acute gastrointestinal bleeding ME24.90
(b) Malignant neoplasms of colon, unspecified 2B90.Z
(c)
(d)
2 Malignant neoplasm of transverse colon 2B90.2
Malignant neoplasms of colon, is the tentative starting point (Step SP3). A more specific condition appears
elsewhere on the death certificate: malignant neoplasm of transverse colon, and according to instruction
of step M2, malignant neoplasm of transverse colon 2B90.2 is a new tentative underlying cause.

ICD-11 Reference Guide 91

Regarding coding, this specificity can occur even between parents:

Example 4
1 (a) Sepsis without septic shock 1G40
(b) Diabetes mellitus 5A14
(c)
(d)
2 Type 1 diabetes mellitus 5A10
Diabetes mellitus, type unspecified, is the tentative starting point (Step SP3). A more specific condition
appears elsewhere on the death certificate: Type 1 diabetes mellitus, and according to instruction of step
M2, Type 1 diabetes mellitus 5A10 is a new tentative underlying cause.

Example 5
1 (a) Stroke 8B20
(b)
(c)
(d)
2 Intracerebral Haemorrhage 8B00
Stroke, not known if ischaemic or haemorrhagic, is the tentative starting point (Step SP2). A term
providing more precise information about the nature of this condition is reported on the certificate:
intracerebral haemorrhage. According to instruction of step M2, intracerebral haemorrhage 8B00 is a
new tentative underlying cause.

Example 6
1 (a) Acute pancreatitis DC31.Z
(b) Cytomegaloviral disease 1D82.Z
(c)
(d)
2
Cytomegaloviral disease, unspecified, is the tentative starting point (Step SP3). The manifestation is
described as acute pancreatitis, unspecified, and the two terms combine into cytomegaloviral pancreatitis
(1D82.1), which is the new tentative underlying cause.
2.18.3 Step M3 – Recheck Steps SP6, M1 and M2

If, at this point, the tentative underlying cause is not the same as the starting point you
selected in Steps SP1 to SP8, then go back to Step SP6. Repeat the procedures described in
Steps SP6, M1 and M2.
If the tentative underlying cause is the same with the starting point selected in Step SP1 to
SP8, go to Step M4.

92 ICD-11 MMS
 • Do not go back to Step SP6 if the cause selected in Step M1 or M2 is correctly
reported as due to another condition, except when this condition is ill-defined.
• Also, do not go back to Step SP6 if the tentative underlying cause is a reaction to
treatment of a condition unlikely to cause death, as selected in Step SP8.
Example 1
1 (a) Sepsis
(b) Arterial disease, arterial embolism of left leg
(c)
(d)
2 Colon cancer

Arterial disease is the tentative starting point according to Step SP3. Arterial embolism of
left leg, reported as the second condition on line 1(b), is a specific type of arterial disease.
Therefore, select arterial embolism of left leg as the tentative underlying cause in Step M2.
Reapply Step SP6, because the tentative starting point is not the same as the one selected in
Steps SP1 to SP8. But colon cancer is an obvious cause of arterial embolism, and colon
cancer is the new starting point. No further modifications apply. Code colon cancer (2B90.Z),
Malignant neoplasms of colon, unspecified) as the underlying cause of death.

Example 1
1 (a) Sepsis
(b) Arterial disease, arterial embolism of left leg
(c) Atherosclerosis
(d)
2 Colon cancer
Atherosclerosis is the tentative starting point (Step SP3). There is a special instruction on ‘atherosclerosis
reported as the cause of arterial disease’, and, according to this instruction, arterial disease is the new
starting point according to Step M1. Arterial embolism of left leg, reported as the second condition on line
1(b), is a more specific description of the type of arterial disease and is selected as the tentative starting
point in Step M2. Do not reapply Step SP6, because arterial embolism of left leg is reported as due to
atherosclerosis, and this is a correct causal relationship. No further modifications apply. Code ‘arterial
embolism of left leg’ as the underlying cause of death.
2.18.4 Step M4 - Instructions on medical procedures, main injury, poisoning, and
maternal deaths

Finally, apply the following instructions to the tentative underlying cause selected by
applying Steps SP1 to SP8 and Steps M1 to M3.
If the tentative underlying cause is:
• Surgery, another type of medical procedure, a complication or postprocedural
condition, apply the instructions in Section 2.19.4 Special instructions on surgery and
other medical procedures (Step M4).
• In Chapter 22 ‘Injury, poisoning or certain other consequences of external causes’,
first code the external cause of the injury or poisoning as the underlying cause of

ICD-11 Reference Guide 93

 death. Also add the main injury to the cluster by following instructions in Section
2.19.5 Special instructions on main injury in deaths from external causes (Step M4).
• In Chapter 23 ‘External causes of morbidity and mortality’ also add the main injury to
the cluster by following instructions in Section 2.19.5 Special instructions on main
injury in deaths from external causes (Step M4).
• Poisoning, use additional extension code from Section X (Extension Codes), if
applicable, to identify the specific name of drug or toxic substance reported. If more
than one drug or toxic substance is reported on the certificate, apply instructions in
Section 2.19.6 Special instructions on poisoning by drugs, medications and biological
substances (Step M4), to identify the drug, medicament or substance most likely to
have caused the death.
If the decedent is a woman, and pregnancy, childbirth or puerperium is reported on the
certificate, determine whether to code the tentative underlying cause to Chapter 18
‘Pregnancy, childbirth and the puerperium’ according to the instructions in Section 2.19.7
Special instructions on maternal mortality (Step M4).
When creating a cluster in Step M4, always put the code for the underlying cause of death
at the beginning of the cluster.
After applying Step M4, the tentative underlying cause, modified or not, becomes the
underlying cause of death.
If Step M4 does not apply, the tentative underlying cause becomes the underlying cause of
death.
Note that other restrictions may apply, for example that the cause is limited to one of the
sexes (see also Sections 2.21.7 and 3.14 (3.14.11 and 3.14.12)) or to a specific age range, or
that the cause of death is improbable, considering the geographical setting. Therefore,
always check whether any such restrictions apply to the underlying cause you selected.

2.19 Special instructions on selecting the underlying cause of death

The following sections are to be referred to in applying each instruction of Section 2.17.3
(Steps SP1 to SP8) and Section 2.18 (Steps M1 to M4).
2.19.1 Special instructions on accepted and rejected sequences (Steps SP3 and SP4)

This section lists sequences of causes of death that should be accepted or rejected when
selecting the underlying cause of death. As described in Section 2.16.2 Causal relationship
and sequence, these instructions are set with the aim of producing the most useful
mortality statistics. Individual countries should not correct what is assumed to be an error,
since changes at the national level will lead to data that are less comparable to data from
other countries, and thus less useful for analysis.
A reported causal relationship not listed as rejected in this section should be accepted, as
far as possible, because the certifier’s opinion about the causes leading to death should not
be disregarded lightly.
When applying Steps SP3 and SP4, reject the relationships listed in this section. Exceptions
are listed as ‘accept’ in the table following each instruction.

94 ICD-11 MMS
Note that all information on causal relationship provided on the certificate should be
considered. This applies also if the information appears in the ‘wrong’ place of the
certificate. For example, if the sequence in Part 1 starts with a disease ‘A’, and information
elsewhere on the certificate states that disease ‘A’ was due to a disease ‘B’, then consider
‘B’ as the tentative starting point. This also applies if disease ‘A’ and disease ‘B’ are coded to
the same ICD-11 code and reported on separate lines of Part 1.

[Link] Conflicting durations

Do not accept a condition with a stated duration as due to a condition with a shorter
duration.

Consequence Caused by
A condition with a stated duration Do not accept a condition with a shorter duration

When a duration of a condition is unknown or not stated assume the duration do not
conflict, and do not reject a causal relationship by duration in such case.

[Link] Infectious diseases due to other conditions

Cholera and certain infectious diseases due to other conditions

Do not accept the following infectious and parasitic diseases as due to any other causes, not
even human immunodeficiency virus (HIV) disease, malignant neoplasms or conditions
impairing the immune system:

ICD-11 Reference Guide 95

Condition Code
1A00 Cholera
1A11 Botulism
1B20 Leprosy
1B50 Scarlet fever
1B91 Leptospirosis
1B93 Plague
1B94 Tularaemia
1B95 Brucellosis
1B97 Anthrax
1C11.1 Trench fever
1C12 Whooping cough
1C13 Tetanus
1C14 Obstetrical tetanus
1C15 Tetanus neonatorum
1C17 Diphtheria
1C1C Meningococcal disease
1C22 Infections due to Chlamydia psittaci
1C23.Z Trachoma
1C3Z Rickettsioses
1C80-1C8Z Viral infections of the central nervous system
1D20-1D2Z Dengue
1D47 Yellow fever
1D40 Chikungunya virus disease
1D42 O’nyong-nyong fever
1D44 Rift Valley fever
1D46 West Nile virus infection
1D48 Zika virus disease
1D49 Crimean-Congo haemorrhagic fever
1D4A Omsk haemorrhagic fever
1D4B Kyasanur Forest disease
1D4C Alkhurma haemorrhagic fever
1D40-1D4Z Certain arthropod-borne viral fevers
1D60.0 Ebola disease
1D60.1 Marburg disease
1D61.0 Argentinian haemorrhagic fever
1D61.1 Bolivian haemorrhagic fever
1D61.2 Lassa fever

96 ICD-11 MMS
 Condition Code
1D62.0 Haemorrhagic fever with renal syndrome
1D65 Severe acute respiratory syndrome
1D80 Mumps
1D86 Viral haemorrhagic fever, not elsewhere classified
1E30-1E32 Influenza
1E50.1 Acute hepatitis B
1E50.2 Acute hepatitis C
1E51.0 Chronic hepatitis B
1E51.1 Chronic hepatitis C
1E51.2 Chronic hepatitis D
1E70 Smallpox
1E71 Mpox (Monkeypox)
1F02 Rubella
1F03 Measles
1F40-1F4Z Malaria
1F51 African trypanosomiasis
1F53 Chagas disease
1F54 Leishmaniasis
8A45.01 Subacute sclerosing panencephalitis
8E02.0 Genetic Creutzfeldt-Jakob disease
R- Other emerging diseases reportable to WHO (e.g. RA01.- COVID-19)

Consequence condition Causal condition

Cholera etc., listed above Do not accept other causes

Typhoid and certain infectious disease due to other conditions

Do not accept the following infectious diseases as due to other causes, except HIV disease,
malignant neoplasms and conditions impairing the immune system:
• 1A02 Intestinal infections due to Shigella
• 1A07 Typhoid fever
• 1A08 Paratyphoid fever
• 1A09 Infections due to other Salmonella
• 1B10-1B1Z Tuberculosis

ICD-11 Reference Guide 97

 Consequence condition Causal condition
Intestinal infections due to Accept HIV disease, malignant neoplasms, and conditions
Shigella impairing the immune system
Typhoid fever Do not accept other causes
Paratyphoid fever
Infections due to other
Salmonella
Tuberculosis

HIV due to other conditions

Do not accept HIV disease (1C60 - 1C62) as due to other conditions, except:
• conditions necessitating blood transfusion, such as haemophilia, anaemia and major
injuries
• invasive procedures, such as surgery
• drug abuse
Examples of such conditions are given in the Mortality Annex 3.14. Note that the list in
Mortality Annex 3.14 is not complete and should be considered indicative.

Consequence Causal condition

condition
HIV Accept
- conditions necessitating blood transfusion, such as haemophilia,
anaemia and major injuries
- invasive procedures, such as surgery
- drug abuse
(for examples, refer to Mortality Annex 3.14.)
Do not accept other causes

Infectious diseases not listed above due to other conditions

Infectious diseases not listed above are accepted to be caused by other conditions.

Consequence condition Causal condition

Infectious diseases not listed above Accept other causes

98 ICD-11 MMS
[Link] Malignant neoplasms due to other conditions
Do not accept a malignant neoplasm as due to any other cause, except the following
malignant neoplasms as due to HIV disease (1C60 - 1C62) :
• 2A60.5 Blastic plasmacytoid dendritic cell neoplasm, specified as primary in brain
• 2A80 Follicular lymphoma, specified as primary in brain
• 2A81 Diffuse large B-cell lymphomas, specified as immunoblastic
• 2A85.5 Mantle cell lymphoma, specified as primary in brain
• 2A85.6 Burkitt lymphoma including Burkitt leukaemia
• 2A86 B-cell lymphoma, mixed features, specified as primary in brain
• 2A8Z Mature B-cell neoplasms, unspecified, specified as primary in brain
• 2A90-2B2Z Mature T-cell or NK-cell neoplasms, specified as primary in brain
• 2B30 Hodgkin lymphoma, specified as primary in brain
• 2B57 Kaposi sarcoma, primary site
• 2B6A Malignant neoplasms of oropharynx
• 2C00 Malignant neoplasms of anus or anal canal
• 2C70 Malignant neoplasms of vulva
• 2C71 Malignant neoplasms of vagina
• 2C77 Malignant neoplasms of cervix uteri, specified as invasive
• 2C81 Malignant neoplasms of penis

Consequence condition Causal condition

Malignant neoplasm of oropharynx etc., listed above Accept HIV diseases
Do not accept other causes
Malignant neoplasms not listed above Do not accept other causes

[Link] Congenital or constitutional haemorrhagic condition due to other

conditions
Do not accept congenital or constitutional haemorrhagic condition 3B10-3B1Z as due to any
other cause.

Consequence condition Causal condition

Congenital or constitutional haemorrhagic condition Do not accept other causes

[Link] Anaphylaxis due to external causes

Do not accept Anaphylaxis (4A84) as due to any other causes except Intentional self-harm
(PB80-PD3Z) or Assault (PD50-PF2Z).

ICD-11 Reference Guide 99

 Consequence Caused by
Anaphylaxis Accept Intentional self-harm or Assault
Do not accept other causes

[Link] Diabetes due to other conditions

Do not accept Type 1 diabetes mellitus as due to any other cause except conditions causing
autoimmune destruction of beta-cells.
Do not accept Type 2 diabetes mellitus as due to any other cause except conditions causing
insulin resistance.
Do not accept ‘Other and Unspecified diabetes mellitus’ as due to any other cause except
conditions causing damage to the pancreas.
See Mortality Annex 3.14.8 for a list of the conditions that can cause diabetes.

Consequence condition Causal condition

Type 1 diabetes mellitus Accept conditions causing autoimmune destruction
of beta cells
Do not accept other causes
Type 2 diabetes mellitus Accept conditions causing insulin resistance
Do not accept other causes
Other and Unspecified diabetes Accept conditions causing damage to the pancreas
mellitus
Do not accept other causes

[Link] Rheumatic fever due to other conditions

Do not accept Acute rheumatic fever (1B40-1B42), Heart valve diseases (BB60-BC0Z) with
fifth character .0 rheumatic (if the fifth character is available), and BC20 Chronic rheumatic
heart diseases, not elsewhere classified due to other cause, except:
• 1B50 Scarlet fever
• 1B51 Streptococcal pharyngitis
• CA03.0 Streptococcal tonsillitis

100 ICD-11 MMS

 Consequence condition Causal condition
Acute rheumatic fever Accept
Rheumatic heart valve diseases - Scarlet fever
Chronic rheumatic heart diseases NEC - Streptococcal pharyngitis
- Acute tonsillitis
Do not accept other causes

[Link] Hypertension due to other conditions

Do not accept hypertensive conditions as due to a neoplasm, except:
• Endocrine neoplasms

• Renal neoplasms

• Carcinoid tumours

Consequence condition Causal condition

Hypertensive conditions Accept
- endocrine neoplasms
- renal neoplasms
- carcinoid tumours
Do not accept other neoplasms

[Link] Certain ischaemic heart disease due to other conditions

Do not accept Angina pectoris (BA40) and Chronic ischaemic heart disease (BA50-BA5Z) or
Coronary atherosclerosis (BA52) as due to a neoplasm.

Consequence condition Causal condition

Angina pectoris Accept other causes
Chronic ischaemic heart disease
Coronary atherosclerosis Do not accept neoplasms

[Link] Atherosclerosis due to other conditions

Do not accept an atherosclerotic condition as due to a neoplasm.

Consequence condition Causal condition

An atherosclerotic condition Accept other causes
Do not accept neoplasms

ICD-11 Reference Guide 101

[Link] Developmental anomalies due to other conditions
Do not accept [Developmental anomalies] as due to any other cause, including immaturity,
except:
• developmental anomalies due to a chromosome abnormality or a congenital
malformation syndrome
• Congenital hypoplasia of lung (LA75.2) due to a congenital anomaly
Consequence condition Causal condition
A developmental anomaly Accept chromosome abnormality, congenital malformation
syndrome
Do not accept other causes, including immaturity
Congenital hypoplasia of Accept a developmental anomaly
lung
Do not accept other causes, including immaturity

[Link] Unintentional cause of morbidity or mortality due to other conditions

Do not accept unintentional cause of morbidity or mortality as due to causes coded in other
chapters, except:
• Fall or a fracture as due to a ‘Certain specified disorders of bone density or structure’
or ‘Low bone mass disorders’
• Fall as due to a (pathological) fracture caused by ‘Certain specified disorders of bone
density or structure’ or ‘Low bone mass disorders’
• Inhalation or aspiration as due to other causes

102 ICD-11 MMS

 Consequence condition Causal condition
Unintentional cause of morbidity or mortality PA00- Do not accept causes in other
PB6Z not listed below chapters
Fall PA60-PA6Z Accept FB80 or FB83
Accept a (pathological) fracture
caused by FB80 or FB83
Do not accept other causes in
other chapters
PB6Z , specified as fracture Accept FB80 or FB83
Do not accept other causes in
other chapters
PB04 Unintentional threat to breathing by inhalation Accept other causes
or ingestion of gastric contents
PB05 Unintentional threat to breathing by inhalation Accept other causes
or ingestion of liquids
PB06 Unintentional threat to breathing by inhalation Accept other causes
or ingestion of food
PB07 Unintentional threat to breathing by inhalation Accept other causes
or ingestion of other objects or materials

[Link] Suicide due to other conditions

Do not accept suicide (PB80-PD3Z) as due to any other cause.

Consequence condition Causal condition

Suicide Do not accept other causes

[Link] Obstetric conditions due to other conditions

Do not accept Ectopic pregnancy (JA01) and Molar pregnancy (JA02) as due to other
causes.

Consequence condition Causal condition

JA01 Ectopic pregnancy Do not accept other causes
JA02 Molar pregnancy —

Do not accept Hypertensive disorders in pregnancy, childbirth, or the puerperium (JA20-21,

JA23-JA25) as due to other causes.

ICD-11 Reference Guide 103

 Consequence condition Causal condition
JA20-JA21, JA23-JA25 Hypertensive disorders in pregnancy, Do not accept other
childbirth, or the puerperium causes

Do not accept Maternal care related to placenta praevia or low lying placenta (JA8B) as due
to other causes.

Consequence condition Causal condition

JA8B Maternal care related to placenta praevia or low lying Do not accept other
placenta causes

2.19.2 Special instructions on obvious cause (Step SP6)

This section lists conditions that should be considered an obvious cause of conditions
selected as tentative starting point in Steps SP1 to SP5.

[Link] Complications of HIV

Infectious diseases and HIV

Consider HIV disease (1C60-1C62) and (MA14.0 Laboratory evidence of human
immunodeficiency virus as an obvious cause of infectious diseases:
• 1A32 Cryptosporidiosis
• 1A33 Cystoisosporiasis
• 1B21 Infections due to non-tuberculous mycobacteria
• EA5Y Cutaneous involvement by other specified bacterial infection
• 8A45.02 Progressive multifocal leukoencephalopathy
• Herpes simplex infection, of skin or mucous membrane (1F00.0), disseminated
(1F00.3), other (1F00.Y)or unspecified (1F00.Z), specified as chronic ulcers,
bronchitis, pneumonia, or oesophagitis
• 1D82 Cytomegaloviral disease, except Cytomegaloviral hepatitis (1D82.0), and
except for liver, spleen, lymph nodes
• 1F23.2 Candidosis of gastrointestinal tract, specified as oesophagus
• 1F23.31 Pulmonary candidosis
• 1F25 Coccidioidomycosis
• 1F2A Histoplasmosis
• 1F27Cryptococcosis
• CA40.20 Pneumonia due to pneumocystis
Consider HIV disease HIV disease (1C60 - 1C62 ), but not [Laboratory evidence of human
immunodeficiency virus] (MA14.0), as an obvious cause of infectious diseases (Chapter 01)
not listed above, except those listed in Section ([Link] Infectious diseases due to other
conditions.

104 ICD-11 MMS

Malignant neoplasms and HIV
Consider both HIV disease (1C60-1C62) and Laboratory evidence of HIV (MA14.0) as obvious
causes of the following malignant neoplasms:
• 2A80 Follicular lymphoma, specified as primary in brain
• 2A81 Diffuse large B-cell lymphomas, specified as immunoblastic
• 2A85.5 Mantle cell lymphoma, specified as primary in brain
• 2A85.6 Burkitt lymphoma including Burkitt leukaemia
• 2A86 B-cell lymphoma, mixed features, specified as primary in brain
• 2A8Z Mature B-cell neoplasms, unspecified, specified as primary in brain
• 2B30 Hodgkin lymphoma, specified as primary in brain
• 2B57 Kaposi sarcoma, primary site
• 2C77 Malignant neoplasms of cervix uteri, specified as invasive

Immune deficiency and HIV

Consider HIV disease (1C60-1C62) as an obvious cause of immune deficiency.

Pneumonia and HIV

Consider HIV disease (1C60-1C62) as an obvious cause of pneumonia (CA40.

Cachexia and HIV

Consider HIV disease (1C60-1C62) as an obvious cause of Cachexia, unspecified (MG20.Z).

[Link] Enterocolitis due to Clostridium difficile

Consider enterocolitis due to Clostridium difficile (1A04) as an obvious consequence of
([Drugs, medicaments or biological substances associated with injury or harm in therapeutic
use] (PL00), specified as antibiotic therapy.

[Link] Sepsis
Consider the following as obvious causes of sepsis (1G40-1G41):
• Conditions that impair the immune system

• Wasting Diseases

• Diseases causing paralysis - sepsis

• Serious respiratory conditions

• Serious injuries (grade 1–4 according to the injury priority list in the Mortality Annex
(3.14.5).

• Diseases of infectious origin (this includes all the infections across the classification such as
meningitis, peritonitis, osteomyelitis, pancreatitis, etc.)

[Link] Complications of diabetes

Consider Diabetes mellitus (5A10-5A14) as an obvious cause of the following conditions:

ICD-11 Reference Guide 105

 • 5C73 Acidosis
• 8C0Z Polyneuropathy, unspecified
• 8C12 Certain specified mononeuropathies
• 8C7Y Other specified primary disorders of muscles, specified as amyotrophy but
without specification of aetiology
• 8D8Z Disorders of autonomic nervous system, unspecified
• 9A96.Z Anterior uveitis, unspecified
• 9B10.Z Cataract, unspecified
• 9B65.2] Chorioretinal inflammation
• 9B74 Retinal vascular occlusions
• 9B78.1 Background retinopathy and retinal vascular changes
• 9B78.2 Other proliferative retinopathy
• 9B78.5 Retinal haemorrhage
• 9B7Z Disorders of the retina, unspecified
• BD40.0 Lower limb atherosclerosis
• BD4Z Chronic arterial occlusive disease, unspecified
• EE80.1 Necrobiosis lipoidica
• ME60.2 Ulcer of skin of uncertain nature, specified as lower limb
• FA2Z Inflammatory arthropathies, unspecified
• MG30.5Z Chronic neuropathic pain, unspecified
• GB40 Nephritic syndrome
• GB41 Nephrotic syndrome
• GB42 Persistent proteinuria or albuminuria
• GB61 Chronic kidney disease
• GB6Z Kidney failure, unspecified
• MF54.0 Smooth contracted kidney
• GC2Z Diseases of the urinary system, unspecified, specified as kidney conditions
• MC85 Gangrene
• MB20.1 Coma
• MA18.Y Other specified abnormal findings of blood chemistry, specified as
acetonaemia, azotaemia, or related conditions

[Link] Dehydration
Consider any intestinal infectious disease as an obvious cause of Volume depletion (5C70).

[Link] Dementia
Consider conditions that typically involve [irreversible brain damage] as obvious causes of
dementia if no other cause of the dementia is stated. - 8B00-8B2Z Cerebrovascular diseases
(Exclusions : 8B10 Transient ischaemic attack and 8B21 Cerebrovascular disease with no
acute cerebral symptom) - 8E44 Post anoxic brain damage - 8E40-8E4A.Z Other specified
disorders of the nervous system (inclusion terms) - 8B24.0 Anoxic-ischaemic
encephalopathy - KA40.0 Intracranial laceration or haemorrhage due to birth injury - KA40.1

106 ICD-11 MMS

Cerebral oedema due to birth injury - KA40.Y Other specified birth injury to central nervous
system
Consider trisomy 21 (Down syndrome) (LD40.0) as an obvious cause of Dementia due to
Alzheimer disease (6D80), Dementia, unknown or unspecified cause (6D8Z) or Alzheimer
disease (8A20).

[Link] Disorders of intellectual development

Consider the following conditions as obvious causes of disorders of intellectual development
(6A00):
• 8D64.2 Post haemorrhagic hydrocephalus, specified as neonatal
• KA00-KA0Z Fetus or newborn affected by maternal factors or by complications of
pregnancy, labour or delivery
• KA20 Disorders of newborn related to slow foetal growth or foetal malnutrition
• KA21 Disorders of newborn related to short gestation or low birth weight, not
elsewhere classified
• KA40.0 Intracranial laceration or haemorrhage due to birth injury
• KA40.1 Cerebral oedema due to birth injury
• KA40.Z Birth injury to central nervous system, unspecified
• KA4Z Birth injury, unspecified
• KA61 Other bacterial infections of the newborn
• KA62 Viral infection in the fetus or newborn
• KA63 Fungal infection of fetus or newborn
• KA64 Parasitic diseases in the fetus or newborn
• KA6Y Other specified infections of the fetus or newborn
• KA6Z Infections of the fetus or newborn, unspecified
• KB20 Intrauterine hypoxia
• KB21 Birth asphyxia
• KA82 Intracranial nontraumatic haemorrhage of fetus or newborn
• KA86 Neonatal kernicterus
• KB00 Neonatal cerebral ischaemia
• KB01 Periventricular cysts of newborn
• KB02 Neonatal cerebral leukomalacia
• KB03 Neonatal encephalopathy
• KB04 Hypoxic ischaemic encephalopathy of newborn
• KB05 Neonatal hydrocephalus
• KB06 Neonatal seizures

[Link] Heart failure and unspecified heart disease

Consider other heart conditions as obvious causes of Diseases of the myocardium or cardiac
chambers, unspecified (BC4Z) and Heart failure (BD10-BD1Z).

ICD-11 Reference Guide 107

[Link] Embolism
Consider Venous thrombosis, Phlebitis or thrombophlebitis, Valvular heart disease,
Childbirth or any Operation as obvious causes of diseases described as ‘Embolic’. However,
there must be a clear route from the place where the thrombus formed and the place of the
embolism.

[Link] Oesophageal varices

Consider the following liver diseases as obvious causes of Oesophageal varices (DA26.0):
• 1E51 Chronic viral hepatitis

• DB92 Non-alcoholic fatty liver disease

• DB93 Hepatic fibrosis or cirrhosis

• DB94 Alcoholic liver disease
• DB96.1 Primary biliary cholangitis
• DB97.2 Chronic hepatitis, not elsewhere classified
• DB98.0 Infarction of liver
• DB98.1 Peliosis hepatis
• DB98.6 Hepatic veno-occlusive disease
• DB98.7 Portal hypertension

• DB98.8 Passive congestion of liver

• DB99.2 Hepatorenal syndrome
• DB99.Y Other diseases of liver
• DB9Z Diseases of liver, unspecified

[Link] Pneumonia
Consider the following as obvious causes of Pneumonia (CA40) or Pneumonitis due to solids
and liquids (CA71) except those due to oils or essences (CA71.1):
• Conditions that impair the immune system

• Wasting Diseases

• Diseases causing paralysis

• Serious respiratory conditions

• Conditions that affect the process of swallowing

Other diseases that limit the ability to care for oneself, including dementia and degenerative
diseases of the nervous system, poisoning, and Other diseases that limit the ability to care
for oneself, including dementia and degenerative diseases of the nervous system, poisoning,
and Serious injuries (grade 1–4 according to the injury priority list in the Mortality Annex
(3.14.5).

108 ICD-11 MMS

[Link] Pulmonary oedema
Consider the following conditions as obvious causes of Pulmonary oedema (CB01):
• heart disease (including pulmonary heart disease)
• conditions affecting the lung parenchyma, such as:
– lung infections
– aspiration and inhalation
– respiratory distress syndrome
– high altitude
– circulating toxins
• conditions causing fluid overload, such as:
– kidney failure
– hypoalbuminaemia
• congenital anomalies affecting the pulmonary circulation, such as:
– congenital stenosis of pulmonary veins

[Link] Nephritic syndrome

Consider any streptococcal infection (scarlet fever, streptococcal sore throat, etc.) as the
obvious cause of Nephritic syndrome (GB40) or Nephrotic syndrome (GB41).

[Link] Pyelonephritis
Consider any urinary obstruction from conditions such as hyperplasia of prostate or ureteral
stenosis as the obvious cause of the following Renal tubulo-interstitial diseases:
• GB50 Acute tubulo-interstitial nephritis
• GB51 Acute pyelonephritis
• GB54 Tubulo-interstitial nephritis, not specified as acute or chronic
• GB55.Y Other specified chronic tubulo-interstitial nephritis
• GB55.Z Chronic tubulo-interstitial nephritis, unspecified

[Link] Acute renal failure

Consider a urinary tract infection as an obvious cause of Acute kidney failure (GB60),
provided there is no indication that the renal failure was present before the urinary tract
infection developed.

[Link] Primary atelectasis of newborn

Consider the following congenital kidney conditions, fetus or newborn affected by
premature rupture of membranes (KA01.1) or by oligohydramnios (KA01.2) as obvious
causes of Primary atelectasis of newborn (KB2B):

ICD-11 Reference Guide 109

 • GB82 Autosomal dominant tubulointerstitial disease
• GB8Y Other specified cystic or dysplastic kidney disease
• GB8Z Cystic or dysplastic kidney disease, unspecified
• LB31.8 Atresia or stenosis of ureter
• LB31.9 Agenesis of ureter
• LB31.Y Other specified structural developmental anomalies of urinary tract
• LD2F.13 Meckel-Gruber syndrome

[Link] Premature rupture of membranes and oligohydramnios

Consider the following congenital kidney conditions as obvious causes of fetus or newborn
affected by premature rupture of membranes (KA01.1) or by oligohydramnios (KA01.2):
• GB82 Autosomal dominant tubulointerstitial disease
• GB8Y Other specified cystic or dysplastic kidney disease

• GB8Z Cystic or dysplastic kidney disease, unspecified

• LB31.8 Atresia or stenosis of ureter
• LB31.9 Agenesis of ureter
• LB31.Y Other specified structural developmental anomalies of urinary tract
• LD2F.13 Meckel-Gruber syndrome

[Link] Haemorrhage
Consider anticoagulant poisoning or overdose as obvious causes of haemorrhage. However,
do not consider anticoagulant therapy, without mention of poisoning or overdose, as an
obvious cause of haemorrhage. Further, consider treatment with steroid, aspirin, and
nonsteroidal anti-inflammatory drugs (NSAIDs) as obvious causes of gastric haemorrhage
(ME24.Y). Consider gastrointestinal haemorrhage (ME24.9) as an obvious cause of
secondary ([3A00.0] ) or unspecified anaemia ([3A9Z] ).

[Link] Aspiration and inhalation

Consider conditions listed under Section [Link] Pneumonia, as obvious causes of
aspiration and inhalation PB04.-PB07.

[Link] Surgery and other invasive medical procedures

Consider surgery or other invasive medical procedures, carried out within four weeks before
death, as obvious causes of conditions that are considered common postprocedural
complications. This applies also if the surgery or procedure is reported in a separate space
on the certificate and not in Part 1 or Part 2.
A list of such conditions, with specific instructions, is given in Mortality Annex (3.14.9 List of
conditions to be considered obvious consequences of surgery and other invasive medical
procedures). If a condition that can be treated by surgery or other invasive medical
procedures is reported on the certificate and surgery or a procedure of the same site is also
reported on the certificate, then assume that this condition was the cause of the surgery or
procedure.

110 ICD-11 MMS

[Link] Common secondary conditions
Consider the following as the obvious cause of the common secondary conditions listed in
the table below:
• Wasting Diseases (such as malignant neoplasms and malnutrition)
• Diseases causing paralysis (such as cerebral haemorrhage or thrombosis)
• other disease that limits the ability to care for oneself, including dementia and
degenerative diseases of the nervous system
• Serious injuries (grade 1-4 according to the injury priority list in the Mortality Annex
(3.14.5)
However, do not consider respiratory conditions as the obvious cause of such secondary
conditions.
Conditions in categories flagged with an ‘M’ (Maybe) should be considered obvious
consequences of wasting and paralysing conditions only if they meet the prerequisite for
code assignment noted in the final column of the table.
Common secondary conditions

ICD-11 Reference Guide 111

 Consequence Maybe Qualifier
3A00.0 Acquired iron deficiency
anaemia due to blood loss
3A9Z Anaemias or other erythrocyte
disorders, unspecified
5B51 Wasting in infants, children or
adolescents
5B52 Acute malnutrition in infants,
children or adolescents
5B71 Protein deficiency
5B7Z Unspecified undernutrition
5C70 Volume depletion
8B40 Cauda equina syndrome
8E45 Locked-in syndrome
BB00 Pulmonary thromboembolism
BD30.0 Acute upper limb arterial
occlusion
BD30.2 Acute lower limb arterial
occlusion
BD71.4 Lower limb deep vein
thrombosis
BD71.Y Other specified deep vein
thrombosis
BD72 Venous thromboembolism
DA91.31 Enterolith of small intestine
DB30.3 Impaction of large intestine
DB30.2 Acute mesenteric venous
occlusion
EH90 Pressure ulceration
GB50 Acute tubulo-interstitial M Diseases causing paralysis or
nephritis inability to control bladder
GB51 Acute pyelonephritis M Diseases causing paralysis or
inability to control bladder
GB55.Y Other specified chronic tubulo- M Diseases causing paralysis or
interstitial nephritis inability to control bladder
GB55.Z Chronic tubulo-interstitial M Diseases causing paralysis or
nephritis, unspecified inability to control bladder
GB54 Tubulo-interstitial nephritis, M Diseases causing paralysis or
not specified as acute or inability to control bladder
chronic

112 ICD-11 MMS

 Consequence Maybe Qualifier
GB60- Kidney failure M Diseases causing paralysis or
GB6Z inability to control bladder
GB90.3 Ischaemia or infarction of M The condition in GB90.3 must be
kidney specified as an embolism of the
renal artery
GC00.1 Infectious cystitis M Diseases causing paralysis or
inability to control bladder
GC00.3 Interstitial cystitis M Diseases causing paralysis or
inability to control bladder
GC00.Z Cystitis, unspecified M Diseases causing paralysis or
inability to control bladder
GC01.4 Neuromuscular dysfunction of
bladder, not elsewhere
classified
GC02.0 Urethral abscess M Diseases causing paralysis or
inability to control bladder
GC02.1 Nonspecific urethritis M Diseases causing paralysis or
inability to control bladder
GC02.Y Other specified urethritis and M Diseases causing paralysis or
urethral syndrome inability to control bladder
GC03 Urethral stricture M Diseases causing paralysis or
inability to control bladder;
Exclude post traumatic urethral
strictures
GC08 Urinary tract infection, site not M Diseases causing paralysis or
specified inability to control bladder
MB50- Paralytic symptoms
MB5Z
ME05.0 Constipation
MG20.Z Cachexia, unspecified

[Link] Secondary peritonitis

Consider the following conditions as obvious causes of Secondary peritonitis (DC50.1) and
Peritonitis, unspecified (DC50.Z): Secondary peritonitis and unspecified peritonitis
2.19.3 Special instructions on linkages and other provisions (Step M1)

Use the list in this section in Step M1.

The tentative underlying cause is listed in the left-hand column. If the conditions specified in
the right-hand column apply, then use the code in bold as the new tentative underlying
cause. There are two types of combination:

ICD-11 Reference Guide 113

‘with mention of’ means that the other condition may appear anywhere
on the certificate;
‘when reported as the cause of’ means that the other condition must
appear in a correct causal relationship or be otherwise indicated as
being due to the tentative underlying cause.

For some conditions, there are further requirements, for example that a specific term has
been used either for the tentative underlying cause or for the condition that may change
the underlying cause code.

114 ICD-11 MMS

[Link] Special instructions on Chapter 01 Certain infectious or parasitic
diseases

ICD-11 Reference Guide 115

TUC is: when reported as code to:
the cause of:
[{01}([Link] 2A00-2A0Z 2A00-2A0Z
release/mms/en#1435254666)] Chapter 1 Neoplasms of brain Neoplasms of brain or
‘Certain infectious or parasitic diseases’ or central nervous central nervous
system system
2A20-2B3Z 2A20-2B3Z
Neoplasms of Neoplasms of
haematopoietic or haematopoietic or
lymphoid tissues lymphoid tissues
2B50-2E2Z 2B50-2E2Z Malignant
Malignant neoplasms, except
neoplasms, except primary neoplasms of
of lymphoid, lymphoid,
haematopoietic, haematopoietic,
central nervous central nervous
system or related system or related
tissues tissues

Exception: when reported as code to:

the cause of:
1C60.0 to 1C60.Z Human 1C60.3Z HIV disease
immunodeficiency virus disease associated clinical stage 4
with tuberculosis associated with
tuberculosis,
unspecified
1C61.0 to 1C61.Z Human Malignant 1C61.3Z HIV disease
immunodeficiency virus disease associated neoplasms listed at clinical stage 4
with malaria Section [Link].2 associated with
‘Malignant malaria, unspecified
neoplasms and HIV’
1C62.0 to 1C62.Z Human 1C62.3Z HIV disease
immunodeficiency virus disease without clinical stage 4
mention of tuberculosis or malaria without mention of
tuberculosis or
malaria
TUC is: with mention of: code to:
1A61 Early syphilis 1A62 Late syphilis 1A62 Late syphilis

TUC is: with mention of: code to:

1B10 Tuberculosis of the respiratory CA60 CA60.3
system Pneumoconiosis Pneumoconiosis
associated with
tuberculosis

116 ICD-11 MMS

 TUC is: when reported as code to:
the cause of:

TUC is: with mention of: code to:

1B11 Tuberculosis of the nervous system 1B10 Tuberculosis 1B10, unless 1B12 is
of the respiratory reported as the cause
system of 1B10 and with a
specified duration
exceeding that of the
condition in 1B10
Tuberculosis of the
respiratory system
1B12 Tuberculosis of other systems and
organs

TUC is: with mention of: code to:

1C1C.2 Meningococcaemia 1C1C.0 1C1C.0
Meningococcal Meningococcal
meningitis meningitis
1C1C.1 1C1C.1 Waterhouse-
Waterhouse- Friderichsen
Friderichsen syndrome
syndrome

TUC is: with mention of: code to:

1C41 Bacterial infection of unspecified site 1G40 Sepsis 1G40 Sepsis without
without septic septic shock
shock
1D9Z Unspecified viral infection of 1G41 Sepsis with 1G41 Sepsis with
unspecified site septic shock septic shock

TUC is: when reported as code to:

the cause of:
1E50.1 Acute hepatitis B DB93 Hepatic 1E51.0Z Chronic
fibrosis or cirrhosis hepatitis B,
unspecified
1E50.2 Acute hepatitis C DB99.8 Chronic 1E51.1 Chronic
hepatic failure hepatitis C
1E50.3 Acute hepatitis D 1E51.2 Chronic
hepatitis D
1E50.4 Acute hepatitis E 1E51.3 Chronic
hepatitis E

ICD-11 Reference Guide 117

TUC is: when reported as code to:
the cause of:
1E50.Y Other specified acute viral hepatitis 1E51.Y Other
specified chronic viral
hepatitis
1E50.Z Acute viral hepatitis, unspecified 1E51.Z Chronic viral
hepatitis, unspecified

TUC is: with mention of: code to:

1F2Z Mycoses, unspecified 1G40 Sepsis 1G40 Sepsis without
without septic septic shock
shock
1F5Z Unspecified protozoal disease 1G41 Sepsis with 1G41 Sepsis with
septic shock septic shock
1H0Z Infection, unspecified

Human immunodeficiency virus disease

118 ICD-11 MMS

 TUC is: with mention of: code to:
1A33 Cystoisosporiasis 1C60-1C62.Z Human 1C60.- Human immunodeficiency
immunodeficiency virus disease associated with
virus disease tuberculosis to 1C60.3Y Other
specified HIV disease clinical stage 4
associated with tuberculosis
1C62.- Human immunodeficiency
virus disease without mention of
tuberculosis or malaria to 1C62.3 HIV
disease clinical stage 4 without
mention of tuberculosis or malaria
Regardless of the subcode (5th to
6th character) that the TUC has, code
to 1C60 Human immunodeficiency
virus disease associated with
tuberculosis - 1C62 Human
immunodeficiency virus disease
without mention of tuberculosis or
malaria (changing the 5th character
to number 3)
1D82 Cytomegaloviral MA14.0 Laboratory
disease evidence of HIV
1B21 Infections due to Use additional code if desired, to
non-tuberculous specify the individual associated
mycobacteria condition reported.
1B2Y Other specified
mycobacterial diseases
1B2Z Mycobacterial
diseases, unspecified
1F00 Herpes simplex
infections, except 1F00.Z
Herpes simplex infections,
unspecified
1F23.2 Candidosis of
gastrointestinal tract
1F23.31 Pulmonary
candidosis
1F25 Coccidioidomycosis
1F27 Cryptococcosis
1F2A Histoplasmosis
1F2G Pneumocystosis
1F57 Toxoplasmosis

ICD-11 Reference Guide 119

TUC is: with mention of: code to:
2A60.5 Blastic
plasmacytoid dendritic cell
neoplasm, specified as
primary cerebral
2A80 Follicular lymphoma,
specified as primary
cerebral
2A81 Diffuse large B-cell
lymphomas, specified as
immunoblastic
2A85 Other specified
mature B-cell neoplasms or
lymphoma, specified as
primary cerebral
2A85.6 Burkitt lymphoma
including Burkitt leukaemia
2A86 B-cell lymphoma,
mixed features, specified
as primary cerebral
2A90-2B2Z Mature T-cell
or NK-cell neoplasms,
specified as primary
cerebral (except 2B03)
2B30 Hodgkin lymphoma,
specified as primary
cerebral
2B33 Malignant
haematopoietic neoplasms
without further
specification, specified as
primary cerebral
2C77 Malignant neoplasms
of cervix uteri
8A45.02 Progressive
multifocal
leukoencephalopathy
8E47 Encephalopathy, not
elsewhere classified
CA40.20 Pneumonia due to
pneumocystis
MG20.Z Cachexia,
unspecified

120 ICD-11 MMS

 TUC is:
1C60-1C62.Z Human immunodeficiency virus disease
Note: Modes of dying, ill-defined conditions and conditions unlikely to cause death
should not be linked to categories in 1C60-1C62.Z Human immunodeficiency virus
disease unless the coding tool guides you
Note: Use additional code if desired, to specify the individual associated condition
reported.

TUC is: with mention of: code to:

1C60-1C62.Z Human 1C60-1C62.Z Human 1C60-1C62.Z Human
immunodeficiency immunodeficiency virus immunodeficiency virus
virus disease disease, of a more severe stage disease, of a more severe
with a fifth digit greater (except stage use the highest fifth
Z) digit

TUC is: with mention of: code to:

1B10-1B1Z 1C62 Human 1C62.0 to 1C60.0; 1C62.1 to 1C60.1;
Tuberculosis immunodeficiency 1C62.2 to 1C60.2; 1C62.3 to 1C60.3Z;
virus disease without 1C62.Z to 1C60.Z: MA14.0 to 1C60.Z
mention of Regardless of the subcode (5th to 6th
tuberculosis or malaria character) that the TUC has, code to
1C60 Human immunodeficiency virus
disease associated with tuberculosis
(respecting the 5th or 6th character if
present). If the code in the second
column is MA14.0 code as 1C60.Z
Human immunodeficiency virus
disease associated with tuberculosis,
clinical stage unspecified
1G80 Sequelae of MA14.0 Laboratory
tuberculosis evidence of human
immunodeficiency
virus
1C62 Human 1B10-1B1Z 1C60 Human immunodeficiency virus
immunodeficiency Tuberculosis disease associated with tuberculosis
virus disease without
mention of
tuberculosis or malaria
MA14.0 Laboratory
evidence of human
immunodeficiency
virus

ICD-11 Reference Guide 121

TUC is: with mention of: code to:
1F40-1F4Z Malaria 1C62 Human 1C61 Human
immunodeficiency virus immunodeficiency virus
disease without mention of disease associated with
tuberculosis or malaria malaria
MA14.0 Laboratory evidence
of human immunodeficiency
virus
1C62 Human 1F40-1F4Z Malaria 1C61 Human
immunodeficiency virus immunodeficiency virus
disease without mention of disease associated with
tuberculosis or malaria malaria
MA14.0 Laboratory evidence
of human immunodeficiency
virus

TUC is: with mention of: code to:

2B57 Kaposi 1C60.30 Kaposi sarcoma associated with
sarcoma, human immunodeficiency virus disease
primary site associated with tuberculosis
1C61.30 Kaposi sarcoma associated with
human immunodeficiency virus disease
associated with malaria
1C60-1C62.Z Human 1C62.30 Kaposi sarcoma associated with
immunodeficiency virus human immunodeficiency virus disease
disease without mention of tuberculosis or malaria
MA14.0 Laboratory
eidence of HIV

122 ICD-11 MMS

 TUC is: when reported as the code to:
cause of:
[{03}([Link] 1C60-1C62.Z Human 1C60-1C62.Z
release/mms/en#1766440644)] Chapter 3 immunodeficiency Human
‘Diseases of the blood or blood-forming virus disease, and immunodeficiency
organs’ where the certificate virus disease
indicates that the HIV
disease is a result of a
blood transfusion given
treatment for the
originating condition
4A00-4A0Z Primary immunodeficiencies
4A20 Acquired immunodeficiencies
4B00-4B0Z Immune system disorders
involving white cell lineages
4B20-4B2Y Certain disorders involving the
immune system
4B4Y Other specified diseases of the
immune system
4B4Z Diseases of the immune system,
unspecified

[Link] Special instructions on Chapter 02 Neoplasms

TUC is: when reported as the code to:
cause of:
2E60-2E6Z In situ metastatic spread, or if it is the corresponding primary
neoplasms, except of clear from other malignant neoplasm
lymphoid, haematopoietic, information on the
central nervous system or certificate that the in situ
related tissues neoplasm caused
metastatic spread
If there is no indication Consider the in situ neoplasm
that the in situ neoplasm unlikely to cause death, and
caused metastatic spread, follow the instructions in
Step SP8 Conditions unlikely
to cause death.

[Link] Special instructions on Chapter 03 Diseases of the blood or blood-

forming organs

[Link] Special instructions on Chapter 04 Diseases of the immune system

ICD-11 Reference Guide 123

TUC is: with mention of: code to:
4A84.Z Exposure to or NE60 Harmful effects 4A84.1 Drug induced
Anaphylaxis, harmful effects of PB20-PB29 anaphylaxis Use
unspecified drugs, Unintentional PH40- additional extension
medicaments or PH49 Undetermined code if desired, to
biological intent, or PL00-PL0Z identify the source
substances: Substances associated agent.
with injury or harm in
therapeutic use]
Exposure to or NE61 Harmful effects 4A84.0 Anaphylaxis due
harmful effects of PB36 Unintentional to allergic reaction to
other or PH56 Undetermined food, 4A84.4
unspecified intent Anaphylaxis due to
substances chiefly inhaled allergens,
nonmedicinal as to 4A84.5 Anaphylaxis due
source: to contact with
allergens, or 4A84.Y
Other specified
anaphylaxis
Stung or PA78 Unintentional 4A84.2 Anaphylaxis due
envenomated by PG68 Undetermined to insect venom
animal: intent

[Link] Special instructions on Chapter 05 Endocrine, nutritional or metabolic

diseases
TUC is: with mention of: code to:
5C70 Volume 1A00-1A40.Z Gastroenteritis or 1A00-1A40.Z Gastroenteritis or
depletion colitis of infectious origin colitis of infectious origin

[Link] Special instructions on Chapter 06 Mental, behavioural or

neurodevelopmental disorders

124 ICD-11 MMS

 TUC is: with mention of: code to:
6C40-6C4Z Disorders due PB20-PB36 Unintentional PB20-PB36 Unintentional
to substance use exposure to or harmful exposure to or harmful
effects of substances effects of substances
6D72.1 Amnestic disorder PC90-PD05 Intentional self- PC90-PD05 Intentional self-
due to psychoactive harm by exposure to or harm by exposure to or
substances including harmful effects of harmful effects of
medications substances substances
PE80-PE95 Assault by PE80-PE95 Assault by
exposure to or harmful exposure to or harmful
effects of substances effects of substances
PH40-PH56 Exposure to or PH40-PH56 xposure to or
harmful effects of harmful effects of
substances, undetermined substances, undetermined
intent intent

TUC is: with mention of: code to:

6C40-6C4Z Disorders due to 6C40-6C4Z, with fifth 6C40-6C4Z, with fifth
substance use, with fifth character .2 (dependence) (if character .2 (if the fifth
character .1 (if the fifth the fifth character is character is available)
character is available) (harmful available)
pattern of use)
6C40-6C4Z , with fifth 6C40-6C4Z, with fifth
character .5 (substance- character .5 (if the fifth
induced delirium) (if the fifth character is available)
character is available)
6D72.1 Amnestic disorder 6D72.1 Amnestic
due to psychoactive disorder due to
substances including psychoactive substances
medications including medications

TUC is: with mention of: code to:

6C40-6C4Z Disorders due to 6C40-6C4Z, with fifth 6C40-6C4Z, with fifth
substance use, with fifth character .5 (substance- character .5 (if the fifth
character .2 (dependence) (if induced delirium) (if the character is available)
the fifth character is available) fifth character is available)
6D72.1 Amnestic disorder 6D72.1 Amnestic
due to psychoactive disorder due to
substances including psychoactive substances
medications including medications

ICD-11 Reference Guide 125

TUC is: with mention of: code to:
6C40-6C4Z Disorders due to 6C40-6C4Z, with fifth 6C40-6C4Z, with fifth
substance use, fifth character .6 character .2 (dependence) character .2 (if the fifth
(substance-induced psychotic (if the fifth character is character is available)
disorder) (if the fifth character is available)
available)
6C40-6C4Z, with fifth 6C40-6C4Z, with fifth
character .5 (substance- character .5 (if the fifth
induced delirium) (if the character is available)
fifth character is available)
6D72.1 Amnestic disorder 6D72.1 Amnestic
due to psychoactive disorder due to
substances including psychoactive substances
medications including medications

126 ICD-11 MMS

 TUC is: with mention of: code to:
6C40 Disorders 5A70.2 Pseudo-Cushing syndrome 5A70.2 Pseudo-Cushing
due to use of syndrome
alcohol
8D44 Alcohol-related neurological 8D44 Alcohol-related
disorders neurological disorders
BC43.01 Nonfamilial dilated BC43.01 Nonfamilial dilated
cardiomyopathy, specified as alcohol cardiomyopathy, specified as
alcohol
DA42.80 Alcoholic gastritis DA42.80 Alcoholic gastritis
6C40 Disorders DB91.Z Acute or subacute hepatic DB94.Z Alcoholic liver disease,
due to use of failure, unspecified unspecified
alcohol
DB94.Z Alcoholic liver disease,
unspecified
DB99.7 Hepatic failure without
mention whether acute or chronic
DB99.8 Chronic hepatic failure
DB9Z Diseases of liver, unspecified
6C40 Disorders DB92.Y Other specified non-alcoholic DB94.0 Alcoholic fatty liver
due to use of fatty liver disease, not specified as
alcohol non-alcoholic
DB92.Z Non-alcoholic fatty liver
disease, unspecified, not specified as
non-alcoholic
6C40 Disorders DB93.0 Hepatic fibrosis DB94.2 Alcoholic liver fibrosis
due to use of
alcohol
6C40 Disorders DB93.1 Hepatic cirrhosis DB94.3 Alcoholic cirrhosis of
due to use of liver without hepatitis
alcohol
6C40 Disorders DB97.2 Chronic hepatitis, not DB94.1 Alcoholic hepatitis
due to use of elsewhere classified
alcohol
DB97.Z Inflammatory liver disease,
unspecified
6C40 Disorders DC31.1 Acute alcohol-induced DC31.1 Acute alcohol-induced
due to use of pancreatitis pancreatitis
alcohol
DC31.Z Acute pancreatitis, DC31.1 Acute alcohol-induced
unspecified pancreatitis

ICD-11 Reference Guide 127

TUC is: with mention of: code to:
DC32.Z Chronic pancreatitis, DC32.3 Chronic alcohol-induced
unspecified, except when specified pancreatitis
as due to other causes than alcohol
DC32.3 Chronic alcohol-induced DC32.3 Chronic alcohol-induced
pancreatitis pancreatitis
JA85.Y Maternal care for known or JA85.Y Maternal care for known
suspected other specified fetal or suspected other specified
abnormality or damage, specified as fetal abnormality or damage
alcohol

128 ICD-11 MMS

 TUC is: when reported as the cause of: code to:
6C40 Disorders due BC43.4 Cardiomyopathy due to BC43.01 Nonfamilial dilated
to use of alcohol drugs or other external agents cardiomyopathy

[Link] Special instructions on Chapter 07 Sleep-wake disorders

[Link] Special instructions on Chapter 08 Diseases of the nervous system

[Link] Special instructions on Chapter 09 Diseases of the visual system

[Link] Special instructions on Chapter 10 Diseases of the ear or mastoid

process

[Link] Special instructions on Chapter 11 Diseases of the circulatory system

TUC is: with mention of: code to:
BA00 Essential 8B00-8B2Z Cerebrovascular diseases 8B00-8B2Z
hypertension Cerebrovascular
diseases
BA01 Hypertensive heart disease BA01 Hypertensive
heart disease
BA02 Hypertensive renal disease BA02 Hypertensive
renal disease
BA40-BA6Z Ischaemic heart diseases BA40-BA6Z
Ischaemic heart
diseases
BA81-BA8Z Diseases of coronary artery BA81-BA8Z
Diseases of
coronary artery
BD10-BD1Z Heart failure, BC42.Z Myocarditis, BA01 Hypertensive
unspecified, BC45 Cardiomegaly, or BC4Z Diseases heart disease
of the myocardium or cardiac chambers,
unspecified, except when specified as
terminal/end stage or acute, sudden, or similar
expressions of short duration (less than 24 hours)

ICD-11 Reference Guide 129

TUC is: when reported as the cause of: code to:
BA00 Essential 9B78.1 Background retinopathy and 9B78.1 Background
hypertension retinal vascular changes retinopathy and retinal
vascular changes
BB60-BC0Z Heart valve diseases, BB60-BC0Z Heart valve
except fifth character .0 (rheumatic) (if diseases, except fifth
the fifth character is available) or character .0 (rheumatic) (if
specified as rheumatic the fifth character is available)
or specified as rheumatic
GB40 Nephritic syndrome; GB41 BA02 Hypertensive renal
Nephrotic syndrome; GB4Z Glomerular disease
diseases, unspecified; GB61 Chronic
kidney disease; GB6Z Kidney failure,
unspecified; or MF54.0 Smooth
contracted kidney

TUC is: with mention of: code to:

BA01 Hypertensive heart BA40-BA6Z Ischaemic heart BA40-BA6Z Ischaemic heart
disease diseases diseases
BA81-BA8Z Diseases of BA81-BA8Z Diseases of
coronary artery coronary artery
BA02 Hypertensive renal
disease

TUC is: with mention of: code to:

BA40 Angina pectoris BA41 Acute myocardial BA41 Acute myocardial
infarction infarction
BA4Z Acute ischaemic heart BA42 Subsequent
disease, unspecified myocardial infarction
BA50-BA5Z Chronic ischaemic
heart disease
BA6Z Ischaemic heart diseases,
unspecified

[BA81-BA8Z] Diseases of
coronary artery

130 ICD-11 MMS

 TUC is: with mention of: code to:
BC20.0 Rheumatic BB60-BC0Z Heart valve diseases, BB60-BC0Z Heart valve
diseases of with fifth character .0 diseases, with fifth
endocardium, valve (rheumatic) (if the fifth character .0 (if the fifth
unspecified character is available) character is available)
BC20.1] Rheumatic heart
disease, unspecified

TUC is: with mention of: code to:

BC60-BC9Z Cardiac arrhythmia 1F53 Chagas disease 1F53 Chagas disease
BC42.Z Myocarditis, unspecified BA40-BA6Z Ischaemic BA40-BA6Z Ischaemic
heart diseases heart diseases
BC45 Cardiomegaly BA81-BA8Z Diseases of BA81-BA8Z Diseases of
coronary artery coronary artery
BC4Z Diseases of the myocardium or
cardiac chambers, unspecified
BC45 Heart failure

TUC is: with mention of: code to:

BC45 Heart failure, except when specified as BA00 Essential BA01
terminal/end stage or acute, sudden, or similar hypertension Hypertensive
expressions of short duration (less than 24 hours) heart disease
BC4Z Diseases of the myocardium or cardiac BA01 BA01
chambers, unspecified, except when specified as Hypertensive Hypertensive
terminal/end stage or acute, sudden, or similar heart disease heart disease
expressions of short duration (less than 24 hours)

TUC is: with mention of: code to:

BD1Z Heart failure, unspecified CB01 Pulmonary BD11.Z Left ventricular
oedema failure, unspecified
BC4Z Diseases of the myocardium or
cardiac chambers, unspecified

ICD-11 Reference Guide 131

TUC is: with mention of: code to:
BD40 Atherosclerotic chronic BA00 Essential BA00 Essential
arterial occlusive disease hypertension hypertension
BA01 Hypertensive heart BA01 Hypertensive heart
disease disease
BA02 Hypertensive renal BA02 Hypertensive renal
disease disease
BA03 Hypertensive crisis BA03 Hypertensive crisis
BA40-BA6Z Ischaemic BA40-BA6Z Ischaemic
heart diseases heart diseases
[BA81-BA8Z] Diseases of [BA81-BA8Z] Diseases of
coronary artery coronary artery
BC45 Heart failure BC45 Heart failure
BC42.Z Myocarditis, BC42.Y Other specific
unspecified myocarditis
8B00-8B2Z 8B00-8B2Z
Cerebrovascular diseases Cerebrovascular diseases

TUC is: when reported as the cause of: code to:

BD40 BB60-BC0Z Heart valve diseases, BB60-BC0Z Heart valve diseases,
Atherosclerotic except fifth character .0 except fifth character .0 (if the
chronic arterial (rheumatic) (if the fifth fifth character is available)
occlusive disease character is available)
BC4Z Diseases of the BA52.Z Coronary atherosclerosis,
myocardium or cardiac unspecified site
chambers, unspecified
BD30-BD5Z Diseases of arteries BD30-BD5Z Diseases of arteries
or arterioles, except BD41 Non- or arterioles, except BD41 Non-
atherosclerotic chronic arterial atherosclerotic chronic arterial
occlusive disease or BD53 occlusive disease or BD53
Secondary disorders of arteries Secondary disorders of arteries
and arterioles and arterioles
DD30-DD3Z Ischaemic vascular DD30-DD3Z Ischaemic vascular
disorders of intestine disorders of intestine
MF54.0 Smooth contracted BA02 Hypertensive renal disease
kidney

132 ICD-11 MMS

 TUC is: when reported as the cause of: code to:
BD40.2 GB40 Nephritic syndrome; GB41 Nephrotic BA02
Atherosclerosis of syndrome; GB4Z Glomerular diseases, Hypertensive
renal artery unspecified; GB61 Chronic kidney disease; GB6Z renal disease
Kidney failure, unspecified; or MF54.0 Smooth
contracted kidney

TUC is: with mention code to:

of:
BD40.Z Atherosclerotic chronic arterial MC85 BD40.0 Lower limb
occlusive disease, unspecified Gangrene atherosclerosis

TUC is: when reported as the cause of: code to:

BD40.Z Atherosclerotic 8A00.0 Parkinson disease 8A00.23
chronic arterial Vascular
occlusive disease, parkinsonism
unspecified
8A00.2Z Secondary parkinsonism, 8A00.23
unspecified Vascular
parkinsonism
8A00.Z Parkinsonism, unspecified 8A00.23
Vascular
parkinsonism
GB40 Nephritic syndrome; GB41 Nephrotic BA02
syndrome; GB4Z Glomerular diseases, Hypertensive
unspecified; GB61 Chronic kidney disease; renal disease
GB6Z Kidney failure, unspecified; or MF54.0
Smooth contracted kidney

TUC is: with mention code to:

of:
BD50.3 Thoracic BD50.4 BD50.5 Thoracoabdominal aortic aneurysm with
aortic aneurysm Abdominal the corresponding 6th character (perforation,
aortic aneurysm rupture or without mention of perforation and
rupture)
BD50.4 BD50.3 Thoracic BD50.5 Thoracoabdominal aortic aneurysm with
Abdominal aortic aneurysm the corresponding 6th character (perforation,
aortic aneurysm rupture or without mention of perforation and
rupture)

ICD-11 Reference Guide 133

TUC is: with mention of: code to:
BD55 Asymptomatic stenosis of 8B00-8B2Z 8B00-8B2Z
intracranial or extracranial artery Cerebrovascular Cerebrovascular
diseases diseases

TUC is: when reported as the code to:

cause of:
BD55 Asymptomatic stenosis of 8A00.0 Parkinson disease 8A00.23 Vascular
intracranial or extracranial artery parkinsonism
8A00.2Z Secondary 8A00.23 Vascular
parkinsonism, unspecified parkinsonism

[Link] Special instructions on Chapter 12 Diseases of the respiratory system

TUC is: with mention code to:
of:
CA00 Acute nasopharyngitis MB44.3 CA40.Z Pneumonia,
Immobility organism unspecified
CA07 Acute upper respiratory infections of
multiple and unspecified sites

134 ICD-11 MMS

 TUC is: when reported as the cause code to:
of:
CA00 Acute nasopharyngitis 1D01.Y Other specified 1D01.Y Other specified
infectious meningitis not infectious meningitis not
elsewhere classified elsewhere classified
CA07 Acute upper 1D03.3 Intracranial abscess 1D03.3 Intracranial abscess
respiratory infections of
multiple and unspecified
sites
1D04.1 Intracranial 1D04.1 Intracranial
granuloma granuloma
1E30-1E32 Influenza 1E30-1E32 Influenza
AA80-AB0Z Otitis media AA80-AB0Z Otitis media
AB11 Mastoiditis or related AB11 Mastoiditis or related
conditions conditions
CA20 Bronchitis CA20 Bronchitis
CA22 Chronic obstructive CA22 Chronic obstructive
pulmonary disease (COPD) pulmonary disease (COPD)
CA27 Tracheobronchitis CA27 Tracheobronchitis
CA40 Pneumonia CA40 Pneumonia
CA41 Acute bronchiolitis CA41 Acute bronchiolitis
CA42 Acute bronchitis CA42 Acute bronchitis
GB40 Nephritic syndrome GB40 Nephritic syndrome

TUC is: with mention of: code to:

CA42 Acute CA20.1 Chronic bronchitis CA20.1 Chronic bronchitis
bronchitis
CA22 Chronic obstructive CA22 Chronic obstructive
pulmonary disease (COPD) pulmonary disease (COPD)

TUC is: with mention of: code to:

CA20 CA21 Emphysema CA22 Chronic obstructive
Bronchitis pulmonary disease
CA22 Chronic obstructive CA22 Chronic obstructive
pulmonary disease (COPD) pulmonary disease (COPD)

ICD-11 Reference Guide 135

 TUC is: when reported as the code to:
cause of:
CA20 Bronchitis CA23 Asthma CA22 Chronic obstructive
pulmonary disease
Note: see also note below
at CA23

TUC is: with mention of: code to:

CA22.Z Chronic obstructive CA40 Pneumonia CA22.1 Certain specified chronic
pulmonary disease, unspecified obstructive pulmonary disease
CA41 Acute
bronchiolitis
CA42 Acute
bronchitis

TUC is: with mention of: code to:

CA60 1B10 Tuberculosis of the CA60.3 Pneumoconiosis associated
Pneumoconiosis respiratory system with tuberculosis

TUC is: with mention of: code to:

CB01 Pulmonary BD1Z Heart failure, unspecified BD11.Z Left ventricular
oedema failure, unspecified
BC4Z Diseases of the myocardium or
cardiac chambers, unspecified

[Link] Special instructions on Chapter 13 Diseases of the digestive system

TUC is: with mention of: code to:
DB91.Z Acute or 6C40 Disorders due to use of alcohol DB94
subacute hepatic failure, Alcoholic liver
unspecified disease
DB95 Drug-induced or DB94 Alcoholic liver disease
toxic liver disease
DB99.7 Hepatic failure NE61 Harmful effects of or exposure to
without mention noxious substances, chiefly nonmedicinal as
whether acute or chronic to source, not elsewhere classified, specified
as alcohol
DB99.8 Chronic hepatic
failure
DB9Z Diseases of liver,
unspecified

136 ICD-11 MMS

 TUC is: with mention of: code to:
DB92 Non-alcoholic fatty liver 6C40 Disorders due to use of alcohol DB94.0
disease, except DB92.1 Non- Alcoholic
alcoholic steatohepatitis fatty liver
DB94 Alcoholic liver disease
NE61 Harmful effects of or exposure to
noxious substances, chiefly nonmedicinal
as to source, not elsewhere classified,
specified as alcohol

TUC is: with mention of: code to:

DB92.1 Non-alcoholic 6C40 Disorders due to use of alcohol DB94.1
steatohepatitis Alcoholic
hepatitis
DB97.2 Chronic DB94 Alcoholic liver disease
hepatitis, not elsewhere
classified
DB97.Z Inflammatory NE61 Harmful effects of or exposure to noxious
liver disease, substances, chiefly nonmedicinal as to source,
unspecified not elsewhere classified, specified as alcohol

TUC is: with mention of: code to:

DB93 Hepatic fibrosis 6C40 Disorders due to use of alcohol DB94.3 Alcoholic
or cirrhosis, except cirrhosis of liver
DB93.0 Hepatic without hepatitis
fibrosis
DB94 Alcoholic liver disease
NE61 Harmful effects of or exposure to
noxious substances, chiefly nonmedicinal as
to source, not elsewhere classified,
specified as alcohol

ICD-11 Reference Guide 137

TUC is: with mention of: code to:
DB93.0 6C40 Disorders due to use of alcohol DB94.2
Hepatic Alcoholic liver
fibrosis fibrosis
DB94 Alcoholic liver disease
NE61 Harmful effects of or exposure to noxious
substances, chiefly nonmedicinal as to source, not
elsewhere classified, specified as alcohol

TUC is: with mention of: code to:

DC31.Z Acute pancreatitis, unspecified 6C40 Disorders DC31.1 Acute alcohol-
due to use of induced pancreatitis
alcohol
DC32.Z Chronic pancreatitis, unspecified, 6C40 Disorders DC32.3 Chronic
except when specified as due to other due to use of alcohol-induced
causes than alcohol alcohol pancreatitis

[Link] Special instructions on Chapter 14 Diseases of the skin

TUC is: when reported as the cause of: code to:
EH90 Pressure EH90 Pressure ulceration, of a EH90 Pressure ulceration, of a
ulceration more advanced stage more advanced stage

[Link] Special instructions on Chapter 15 Diseases of the musculoskeletal

system or connective tissue

[Link] Special instructions on Chapter 16 Diseases of the genitourinary system

TUC is: when reported as the cause of: code to:
GB61 Chronic GB61 Chronic kidney disease, of GB61 Chronic kidney disease, of
kidney disease a more advanced stage a more advanced stage

138 ICD-11 MMS

 TUC is: with mention of: code to:
GB61 Chronic kidney BA00.Z Essential hypertension, BA02 Hypertensive renal
disease unspecified disease
GB6Z Kidney failure, BA02 Hypertensive renal disease BA02 Hypertensive renal
unspecified disease
MF54.0 Smooth
contracted kidney

[Link] Special instructions on Chapter 17 Conditions related to sexual health

[Link] Special instructions on Chapter 18 Pregnancy, childbirth or the

puerperium
TUC is: with mention of: code to:
JA24 Pre-eclampsia JA25 Eclampsia JA25 Eclampsia

TUC is: with mention of: code to:

JA82 Maternal care for known JA83 Maternal care for JA83 Maternal care for
or suspected malpresentation known or suspected known or suspected
of fetus disproportion disproportion

TUC is: with mention of: code to:

JA83.Z Maternal care for JA83.0 Maternal care for JA83.0 Maternal care for
known or suspected disproportion due to disproportion due to
disproportion, unspecified deformity of maternal pelvic deformity of maternal pelvic
bones bones
JA83.1 Maternal care for JA83.1 Maternal care for
disproportion due to disproportion due to
generally contracted pelvis generally contracted pelvis
JA83.2 Maternal care for JA83.2 Maternal care for
disproportion due to inlet disproportion due to inlet
contraction of pelvis contraction of pelvis
JA83.3 Maternal care for JA83.3 Maternal care for
disproportion due to outlet disproportion due to outlet
contraction of pelvis contraction of pelvis

TUC is: with mention of: code to:

JB04 Obstructed labour due to JB05 Obstructed labour JB05 Obstructed labour
malposition or malpresentation due to maternal pelvic due to maternal pelvic
of fetus abnormality abnormality

ICD-11 Reference Guide 139

TUC is: when reported as the code to:
cause of:
JA61.0 Varicose veins of lower JB42.2 Obstetric blood- JB42.2 Obstetric blood-
extremity in pregnancy clot embolism clot embolism
JA61.1 Genital varices in pregnancy
JA61.2 Superficial thrombophlebitis
in pregnancy
JA61.4 Haemorrhoids in pregnancy

TUC is: when reported as the cause of: code to:

JA65.2 Excessive JA20-JA2Z Oedema, proteinuria, JA20-JA2Z Oedema, proteinuria,
weight gain in or hypertensive disorders in or hypertensive disorders in
pregnancy pregnancy, childbirth, or the pregnancy, childbirth, or the
puerperium puerperium

TUC is: with mention of: code to:

JA65.3 Low JB64.2 Endocrine, nutritional or JB64.2 Endocrine, nutritional or
weight gain in metabolic diseases complicating metabolic diseases complicating
pregnancy pregnancy, childbirth or the pregnancy, childbirth or the
puerperium puerperium

TUC is: when reported as the code to:

cause of:
JA65.4 Pregnancy care of JA00-JA0Z Abortive JA00-JA0Z Abortive
habitual aborter outcome of pregnancy outcome of pregnancy
JA65.5 Retained intrauterine JA00-JA0Z Abortive JA00-JA0Z Abortive
contraceptive device in outcome of pregnancy outcome of pregnancy
pregnancy
JA88.1 Infection of JA88.1 Infection of
amniotic sac and amniotic sac and
membranes membranes
JB00 Preterm labour or JB00 Preterm labour or
delivery delivery

140 ICD-11 MMS

 TUC is: with mention of: code to:
JA65.7 Subluxation of JB04 - JB06 Obstructed labour JB04 - JB06 Obstructed labour
symphysis pubis in due to malposition or due to malposition or
pregnancy, childbirth malpresentation of fetus, malpresentation of foetus,
or the puerperium maternal pelvic abnormality or maternal pelvic abnormality, or
due to other causes other causes
JA65.7 Subluxation of JB04 - JB06 Obstructed labour JB04 - JB06 Obstructed labour
symphysis pubis in due to malposition or due to malposition or
pregnancy, childbirth malpresentation of fetus, malpresentation of foetus,
or the puerperium maternal pelvic abnormality or maternal pelvic abnormality, or
due to other causes other causes

TUC is: when reported as the cause code to:

of:
JA67.4 Spinal and epidural JA67.2 Central nervous JA67.2 Central nervous
anaesthesia-induced system complications of system complications of
headache during anaesthesia during anaesthesia during
pregnancy pregnancy pregnancy

TUC is: when reported as the cause of: code to:

JA80 Maternal care JB04 - JB06 Obstructed labour JB04 - JB06 Obstructed labour
related to multiple due to malposition or due to malposition or
gestation malpresentation of foetus, malpresentation of foetus,
maternal pelvic abnormality, or maternal pelvic abnormality, or
other causes other causes
JB0D.3 Other complications of JB0D.3 Other complications of
obstetric surgery or procedures obstetric surgery or procedures
JA81 Maternal care JB42.1 Amniotic fluid embolism JB42.1 Amniotic fluid embolism
related to
complications specific
to multiple gestation

ICD-11 Reference Guide 141

TUC is: when reported as the cause code to:
of:
JA82 Maternal care for JA43 Postpartum JA43 Postpartum
known or suspected haemorrhage haemorrhage
malpresentation of
fetus
JA83 Maternal care for JB04 - JB06 Obstructed labour JB04 - JB06 Obstructed labour
known or suspected due to malposition or due to malposition or
disproportion malpresentation of foetus, malpresentation of foetus,
maternal pelvic abnormality, maternal pelvic abnormality,
or other causes or other causes
JA84 Maternal care for JB09 - JB0A Perineal laceration JB09 - JB0A Perineal laceration
known or suspected during delivery and other during delivery and other
abnormality of pelvic obstetric trauma obstetric trauma
organs
JA85 Maternal care for JB0D Certain specified JB0D Certain specified
known or suspected complications of labour or complications of labour or
fetal abnormality or delivery, not elsewhere delivery, not elsewhere
damage classified classified
JA86 Maternal care for JB40 Infections in the JB40 Infections in the
other known or puerperium puerperium
suspected fetal
problems

TUC is: when reported as the cause of: code to:

JA87 Maternal care JA8C Maternal care related to JA8C Maternal care related to
related to premature separation of premature separation of
polyhydramnios placenta placenta
JB03 Long labour JB03 Long labour
JB04 - JB06 Obstructed labour JB04 - JB06 Obstructed labour
due to malposition or due to malposition or
malpresentation of foetus, malpresentation of foetus,
maternal pelvic abnormality, or maternal pelvic abnormality, or
other causes other causes
JA43 Postpartum haemorrhage JA43 Postpartum haemorrhage
JB0D Certain specified JB0D Certain specified
complications of labour or complications of labour or
delivery, not elsewhere delivery, not elsewhere
classified classified
JB40 Infections in the JB40 Infections in the
puerperium puerperium
JB42.1 Amniotic fluid embolism JB42.1 Amniotic fluid embolism

142 ICD-11 MMS

 TUC is: when reported as the code to:
cause of:
JA88.0 Oligohydramnios JA43 Postpartum JA43 Postpartum
haemorrhage haemorrhage
JA88.Y, JA88.Z Other specified JA88.1 Infection of JA88.1 Infection of
disorders of amniotic fluid and amniotic sac or amniotic sac or
membranes and Disorders of membranes membranes
amniotic fluid and membranes,
unspecified
JB03 Long labour JB03 Long labour
JB40 Infections in the JB40 Infections in the
puerperium puerperium
JB0D Certain specified JB0D Certain specified
complications of labour complications of labour
or delivery, not or delivery, not
elsewhere classified elsewhere classified

TUC is: when reported as the cause of: code to:

JA89.3 Premature JA88.1 Infection of amniotic sac JA88.1 Infection of amniotic sac
rupture of or membranes or membranes
membranes
JB03 Long labour JB03 Long labour
JA43 Postpartum haemorrhage JA43 Postpartum haemorrhage
JB0D Certain specified JB0D Certain specified
complications of labour or complications of labour or
delivery, not elsewhere delivery, not elsewhere
classified classified
JB40 Infections in the JB40 Infections in the
puerperium puerperium
JB42.1 Amniotic fluid embolism JB42.1 Amniotic fluid embolism

ICD-11 Reference Guide 143

TUC is: when reported as the cause code to:
of:
JA8A.0 Placental JA8C Maternal care related to JA8C Maternal care related to
transfusion syndromes premature separation of premature separation of
placenta placenta
JA8A.1 Malformation of JA42 Intrapartum JA42 Intrapartum
placenta haemorrhage haemorrhage
JA8A.Y Other specified JA43 Postpartum JA43 Postpartum
maternal care related to haemorrhage haemorrhage
placental disorders
JA8A.Z Maternal care JB0D Certain specified JB0D Certain specified
related to placental complications of labour or complications of labour or
disorders, unspecified delivery, not elsewhere delivery, not elsewhere
classified classified
JB40 Infections in the JB40 Infections in the
puerperium puerperium

TUC is: when reported as the cause of: code to:

JA8A.2 Morbidly JA8B.1 Placenta praevia with JA8B.1 Placenta praevia with
adherent haemorrhage haemorrhage
placenta
JA8B.0 Placenta praevia specified JA8B.0 Placenta praevia specified
as without haemorrhage as without haemorrhage
JA8B.Z Maternal care related to JA8B.Z Maternal care related to
placenta praevia or low lying placenta praevia or low lying
placenta, unspecified placenta, unspecified

TUC is: when reported as the cause of: code to:

JA8E Maternal care JB0D Certain specified JB0D Certain specified
related to prolonged complications of labour or complications of labour or
pregnancy delivery, not elsewhere delivery, not elsewhere
classified classified

144 ICD-11 MMS

 TUC is: when reported as the cause of: code to:
JB00 Preterm labour JA8C Maternal care related to JA8C Maternal care related to
or delivery premature separation of premature separation of
placenta placenta
JB01 Failed induction JA42 Intrapartum haemorrhage JA42 Intrapartum haemorrhage
of labour
JB02 Abnormalities of JA43 Postpartum haemorrhage JA43 Postpartum haemorrhage
forces of labour
JB03 Long labour JB04 - JB06 Obstructed labour JB04 - JB06 Obstructed labour
due to malposition or due to malposition or
malpresentation of foetus, malpresentation of foetus,
maternal pelvic abnormality, or maternal pelvic abnormality, or
other causes other causes
JB07 Labour or JB0D Certain specified JB0D Certain specified
delivery complicated complications of labour or complications of labour or
by foetal distress delivery, not elsewhere delivery, not elsewhere
classified classified
JB08 Labour or JB40 Infections in the JB40 Infections in the
delivery complicated puerperium puerperium
by umbilical cord
complications

TUC is: when reported as code to:

the cause of:
JB09.2, JB09.3, JB09.Z Third, fourth or JA43 Postpartum JA43 Postpartum
unspecified degree perineal laceration haemorrhage haemorrhage
during delivery
JB40 Infections in the JB40 Infections in the
puerperium puerperium

TUC is: when reported as the cause code to:

of:
JB0C.5 Spinal and epidural JB0C.3 Central nervous JB0C.3 Central nervous
anaesthesia-induced system complications of system complications of
headache during labour anaesthesia during labour or anaesthesia during labour or
and delivery delivery delivery

ICD-11 Reference Guide 145

TUC is: when reported as the code to:
cause of:
JB0D.0 Maternal distress during JA43 Postpartum JA43 Postpartum
labour and delivery haemorrhage haemorrhage
JB0D.1 Shock during or following JB40 Infections in the JB40 Infections in the
labour and delivery puerperium puerperium

TUC is: when reported as the code to:

cause of:
JB0D.2 Pyrexia during labour, not JB40 Infections in the JB40 Infections in the
elsewhere classified puerperium puerperium

TUC is: when reported as the cause code to:

of:
JB0D.4 Delayed delivery JA43 Postpartum JA43 Postpartum
after artificial rupture of haemorrhage haemorrhage
membranes
JB0D.5 Delayed delivery JB0D Certain specified JB0D Certain specified
after spontaneous or complications of labour or complications of labour or
unspecified rupture of delivery, not elsewhere delivery, not elsewhere
membranes classified classified
JB40 Infections in the JB40 Infections in the
puerperium puerperium

146 ICD-11 MMS

 TUC is: when reported as the cause code to:
of:
JB0D.6 Vaginal JA8A.2 Morbidly adherent JA8A.2 Morbidly adherent
delivery following placenta placenta
previous caesarean
section
JB0A.1 Rupture of uterus JB0A.1 Rupture of uterus
during labour during labour
JB0A.2 Postpartum inversion of JB0A.2 Postpartum inversion of
uterus uterus
JA43 Postpartum haemorrhage JA43 Postpartum haemorrhage
JB0D Certain specified JB0D Certain specified
complications of labour or complications of labour or
delivery, not elsewhere delivery, not elsewhere
classified classified
JB40 Infections in the JB40 Infections in the
puerperium puerperium

TUC is: when reported as the code to:

cause of:
JB41.0 Superficial thrombophlebitis in JB42.2 Obstetric blood- JB42.2 Obstetric blood-
the puerperium clot embolism clot embolism
JB41.2 Haemorrhoids in the
puerperium
JB41.Y Other venous complications in
the puerperium
JB41.Z Venous complication in the
puerperium, unspecified

ICD-11 Reference Guide 147

 TUC is: when reported as the cause code to:
of:
JB43.3 Spinal and epidural JB43.2 Central nervous JB43.2 Central nervous
anaesthesia-induced system complications of system complications of
headache during the anaesthesia during the anaesthesia during the
puerperium puerperium puerperium

[Link] Special instructions on Chapter 19 Certain conditions originating in the

perinatal period

[Link] Special instructions on Chapter 20 Developmental anomalies

TUC is: with mention of: code to:
LB20.00 Fibropolycystic GB81 Autosomal dominant GB81 Autosomal dominant
liver disease polycystic kidney disease polycystic kidney disease
GB8Y Other specified cystic or GB8Y Other specified cystic or
dysplastic kidney disease dysplastic kidney disease

[Link] Special instructions on Chapter 21 Symptoms, signs or clinical findings,

not elsewhere classified
TUC is: when reported as the cause of: code to:
MA14.0 Laboratory [{01}([Link] 1C60-1C62.Z
evidence of human release/mms/en#1435254666)] Chapter 01 Human
immunodeficiency Certain infectious or parasitic diseases immunodeficiency
virus virus disease

[Link] Special instructions on Chapter 22 Injury, poisoning or certain other

consequences of external causes

[Link] Special instructions on Chapter 23 External causes of morbidity or

mortality
TUC is: with mention of: code to:
PA00-PB6Z Unintentional causes 1C13 Tetanus 1C13 Tetanus

[Link] Codes not to be used for underlying cause of death

Categories specified in the left-hand column of this section should not be used as the
underlying cause of death. Select the category in the right-hand column as appropriate.

TUC is: code to:

1D9Y & XN275 Respiratory syncytial CA40.11 Pneumonia due to Respiratory
virus infection syncytial virus (RSV)

148 ICD-11 MMS

 TUC is: code to:
2D50-2E2Z Malignant 2D40-2D4Z Malignant neoplasms of ill- or unspecified primary
neoplasm metastases sites, if the primary site of malignant neoplasm is not known or
not indicated

TUC is: code to:

5A20.0 - 5A2Y Acute complications 5A10-5A13 if type of diabetes is stated or code to
of diabetes mellitus 5A14 Diabetes mellitus, type unspecified, if the type
of diabetes is not stated
8B92.2 Diabetic lumbosacral
plexopathy
8B94 Diabetic
radiculoplexoneuropathy
8C03.0 Diabetic polyneuropathy
8D88.1 Autonomic neuropathy due
to diabetes mellitus
9B10.21 Diabetic cataract
9B71.00 - 9B71.0Z Diabetic
retinopathy
BC43.7 Diabetic cardiomyopathy
BD54 Diabetic foot ulcer
EB90.0 Diabetic skin lesions
FA38.0 Diabetic arthropathy
FA38.10 Diabetic Charcot
arthropathy
MF83 Diabetic glomerular changes

ICD-11 Reference Guide 149

TUC is:
5D40-5D46 Postprocedural See Section 2.18.4 Step M4 - Instructions on medical
endocrine or metabolic disorders procedures, main injury, poisoning, and maternal
deaths
8E60-8E66 Postprocedural
disorders of the nervous system
9D20-9D25 Postprocedural
disorders of eye or ocular adnexa
AB90-AB93 Postprocedural
disorders of ear or mastoid process
BE10-BE1F.1 Postprocedural
disorders of circulatory system
CB60-CB64 Postprocedural
disorders of the respiratory system
DE10-DE13 Postprocedural
disorders of digestive system
FC01 Postprocedural disorders of
the musculoskeletal system
GC70-GC7C Postprocedural
disorders of genitourinary system

TUC is: code to:

6C40.3 Alcohol PB30 Unintentional exposure to or harmful effects of alcohols if
intoxication Manner of death stated on MCCD is disease
PB30 Unintentional exposure to or harmful effects of alcohols if
Manner of death stated on MCCD is accident
PD00 Intentional self-harm by exposure to or harmful effects of
alcohols if Manner of death stated on MCCD is intentional self-harm
PE90 Assault by exposure to or harmful effects of alcohols if Manner
of death stated on MCCD is assault
PH50 Exposure to or harmful effects of undetermined intent of
alcohols if Manner of death stated on MCCD could not be
determined
PB30 Unintentional exposure to or harmful effects of alcohols if
Manner of death stated on MCCD is pending investigation
PB30 Unintentional exposure to or harmful effects of alcohols if
Manner of death stated on MCCD is unknown

150 ICD-11 MMS

 TUC is: code to:
6C43.3 Opioid PB20 Unintentional exposure to or harmful effects of opioids or
intoxication related analgesics if Manner of death stated on MCCD is disease
PB20 Unintentional exposure to or harmful effects of opioids or
related analgesics if Manner of death stated on MCCD is accident
PC90 Intentional self-harm by exposure to or harmful effects of
opioids or related analgesics if Manner of death stated on MCCD is
intentional self-harm
PE80 Assault by exposure to or harmful effects of opioids or related
analgesics if Manner of death stated on MCCD is assault
PH40 Exposure to or harmful effects of undetermined intent of
opioids or related analgesics if Manner of death stated on MCCD
could not be determined
PB20 Unintentional exposure to or harmful effects of opioids or
related analgesics if Manner of death stated on MCCD is pending
investigation
PB20 Unintentional exposure to or harmful effects of opioids or
related analgesics if Manner of death stated on MCCD is unknown

ICD-11 Reference Guide 151

TUC is: code to:
6C41.3 Cannabis intoxication 6C42.3 PB23 Unintentional exposure to or harmful effects
Synthetic cannabinoid intoxication of cannabinoids or hallucinogens if Manner of
6C49.3 Hallucinogen intoxication death stated on MCCD is disease
PB23 Unintentional exposure to or harmful effects
of cannabinoids or hallucinogens if Manner of
death stated on MCCD is accident
PC93 Intentional self-harm by exposure to or
harmful effects of cannabinoids or hallucinogens if
Manner of death stated on MCCD is intentional
self-harm
PE83 Assault by exposure to or harmful effects of
cannabinoids or hallucinogens if Manner of death
stated on MCCD is assault
PH43 Exposure to or harmful effects of
undetermined intent of cannabinoids or
hallucinogens if Manner of death stated on MCCD
could not be determined
PB23 Unintentional exposure to or harmful effects
of cannabinoids or hallucinogens if Manner of
death stated on MCCD is pending investigation
PB23 Unintentional exposure to or harmful effects
of cannabinoids or hallucinogens if Manner of
death stated on MCCD is unknown

152 ICD-11 MMS

 TUC is: code to:
6C45.3 Cocaine intoxication 6C46.3 Stimulant PB22 Unintentional exposure to or
intoxication including amphetamines, harmful effects of
methamphetamine or methcathinone 6C47.3 psychostimulants if Manner of
Synthetic cathinone intoxication 6C48.2 Caffeine death stated on MCCD is disease
intoxication 6C4C.3 MDMA or related drug
intoxication, including MDA
PB22 Unintentional exposure to or
harmful effects of
psychostimulants if Manner of
death stated on MCCD is accident
PC92 Intentional self-harm by
exposure to or harmful effects of
psychostimulants if Manner of
death stated on MCCD is
intentional self-harm
PE82 Assault by exposure to or
harmful effects of
psychostimulants if Manner of
death stated on MCCD is assault
PH42 Exposure to or harmful
effects of undetermined intent of
psychostimulants if Manner of
death stated on MCCD could not
be determined
PB22 Unintentional exposure to or
harmful effects of
psychostimulants if Manner of
death stated on MCCD is pending
investigation
PB22 Unintentional exposure to or
harmful effects of
psychostimulants if Manner of
death stated on MCCD is unknown

ICD-11 Reference Guide 153

TUC is: code to:
6C44.3 Sedative, hypnotic or anxiolytic PB21 Unintentional exposure to or harmful
intoxication 6C4B.3 Volatile inhalant effects of sedative hypnotic drugs or other CNS
intoxication 6C4D.3 Dissociative drug depressants if Manner of death stated on
intoxication including Ketamine or PCP MCCD is disease
PB21 Unintentional exposure to or harmful
effects of sedative hypnotic drugs or other CNS
depressants if Manner of death stated on
MCCD is accident
PC91 Intentional self-harm by exposure to or
harmful effects of sedative hypnotic drugs or
other CNS depressants if Manner of death
stated on MCCD is intentional self-harm
PE81 Assault by exposure to or harmful effects
of sedative, hypnotic drugs or other CNS
depressants if Manner of death stated on
MCCD is assault
PH41 Exposure to or harmful effects of
undetermined intent of sedative hypnotic
drugs or other CNS depressants if Manner of
death stated on MCCD could not be
determined
PB21 Unintentional exposure to or harmful
effects of sedative hypnotic drugs or other CNS
depressants if Manner of death stated on
MCCD is pending investigation
PB21 Unintentional exposure to or harmful
effects of sedative hypnotic drugs or other CNS
depressants if Manner of death stated on
MCCD is unknown

154 ICD-11 MMS

 TUC is: code to:
6C4E.3 Other specified psychoactive PB28 Unintentional exposure to or harmful
substance intoxication 6C4G.3 effects of other or unspecified drug, medicament
Intoxication due to unknown or or biological substance if Manner of death stated
unspecified psychoactive substance on MCCD is disease
PB28 Unintentional exposure to or harmful
effects of other or unspecified drug, medicament
or biological substance if Manner of death stated
on MCCD is accident
PC98 Intentional self-harm by exposure to other
and unspecified drug, medicament and biological
substance if Manner of death stated on MCCD is
intentional self-harm
PE88 Assault by exposure to or harmful effects of
other or unspecified drug, medicament or
biological substance if Manner of death stated on
MCCD is assault
PH48 Exposure to or harmful effects of
undetermined intent of other or unspecified
drugs, medicaments or biological substances if
Manner of death stated on MCCD could not be
determined
PB28 Unintentional exposure to or harmful
effects of other or unspecified drug, medicament
or biological substance if Manner of death stated
on MCCD is pending investigation
PB28 Unintentional exposure to or harmful
effects of other or unspecified drug, medicament
or biological substance if Manner of death stated
on MCCD is unknown

ICD-11 Reference Guide 155

TUC is: code to:
6D80 Dementia due to 8A20, Alzheimer disease
Alzheimer disease
6D81 Dementia due to The originating cerebrovascular disease in Chapter 08 ‘8B00
cerebrovascular disease to 8B2Z Cerebrovascular diseases, unspecified’ and if not
reported code to 8B2Z Cerebrovascular diseases, unspecified
6D82 Dementia due to 8A22, Lewy body disease
Lewy body disease
6D83 Frontotemporal 8A23, Frontotemporal lobar degeneration
dementia
6D84.0 Dementia due to The originating disorder due to use of alcohol, if not reported
use of alcohol code to 6C40.Y, other specified disorders due to use of
alcohol
6D84.1 Dementia due to The originating disorder due to use of sedative, hypnotic or
use of sedatives, anxiolytic, if not reported code to 6C44.Y, other specified
hypnotics or anxiolytics disorders due to use of sedative, hypnotic or anxiolytic
6D84.2 Dementia due to The originating disorder due to use of volatile inhalants, if not
use of volatile inhalants reported code to 6C4B.Y, other specified disorders due to use
of volatile inhalant
6D84.Y Dementia due to The originating disorder due to other specified psychoactive
other specified substance, if not reported code to 6C4G.Y Other specified
psychoactive substance disorders due to use of unknown or unspecified psychoactive
substances
6D85.0 Dementia due to 8A00.0Z, Parkinson disease, unspecifed
Parkinson disease
6D85.1 Dementia due to 8A01.10 Huntington disease, unspecifed
Huntington disease
6D85.2 Dementia due to PB36 Unintentional exposure to or harmful effects of other or
exposure to heavy metals unspecified substances chiefly nonmedicinal as to source
and other toxins PB80-PD3Z Intentional self-harm, unspecified PE95 Assualt
exposure to or harmful effects of other or unspecified
substances chiefly nonmedicinal as to source PH56 Exposure
to or harmful effects of other or unspecified substances
chiefly nonmedicinal as to source, undetermined intent
6D85.3 Dementia due to 1C62.3, HIV disease clinical stage 4 without mention of
human immunodeficiency tuberculosis or malaria
virus
6D85.4 Dementia due to 8A40.Z, multiple sclerosis, unspecifed
multiple sclerosis
6D85.5 Dementia due to Prion disease mentioned, 8E0Z Human prion diseases,
prion disease unspecified

156 ICD-11 MMS

 TUC is: code to:
6D85.6 Dementia due to 8D64.04 Normal-pressure hydrocephalus
normal pressure
hydrocephalus
6D85.7 Dementia due to External cause that caused head injury, if unspecifed Code to:
injury to the head PB6Z Unspecified unintentional cause of morbidity or
mortality PD05 Intentional self-harm , unspecified PF2Z
Assault, unspecified PH8Y Other specified injury event of
undetermined intent
6D85.8 Dementia due to 5B5C.0, Pellagra
pellagra
6D85.9 Dementia due to LD40.0, Down syndrome
Down syndrome
6D85.Y Dementia due to specified disease
other specified diseases
classified elsewhere
6D8Y Dementia, other specified cause
specified cause

TUC is:
BA42 Subsequent myocardial infarction Code to: BA41 Acute myocardial
infarction
BA60 Certain current complications following acute
myocardial infarction

TUC is:
BA43 Coronary thrombosis not Code to: BA41 Acute myocardial infarction For
resulting in myocardial infarction mortality, the occurrence of myocardial infarction is
assumed.

TUC is:
BA50 Old myocardial Code to: BA5Z Chronic ischaemic heart disease, unspecified, if
infarction the cause is not stated

ICD-11 Reference Guide 157

TUC is:
BD55 Asymptomatic stenosis of Code to: 8B11 Cerebral ischaemic stroke For
intracranial or extracranial artery mortality, the occurrence of cerebral infarction is
assumed.
BD56 Asymptomatic occlusion of
intracranial or extracranial artery

TUC is:
JA05 Complications following Code to: JA00-JA0Z Abortive outcome of pregnancy
abortion, ectopic or molar except JA05 Complications following abortion, ectopic
pregnancy or molar pregnancy

TUC is:
JB65 Sequelae of complication of pregnancy, Code to: JB62 Death from sequelae
childbirth or the puerperium of obstetric causes

TUC is:
KB60-KB6Z Transitory endocrine or metabolic disorders Code to: other perinatal
specific to Fetus or newborn, except KB60.0 Syndrome of cause. If no other perinatal
infant of mother with gestational diabetes; KB60.1 cause is reported, code to:
Syndrome of infant of a diabetic mother, type 1 or 2, KD5Z Conditions originating in
nongestational, insulin dependent; KB60.2 Neonatal the perinatal or neonatal
diabetes mellitus; or KB62.0 Transitory neonatal period, unspecified
hyperthyroidism

TUC is:
MA13.1 Finding of alcohol in Code to: MH14 Other ill-defined and unspecified causes
blood of mortality

TUC is:
MA15.Y Other specified Code to: The originating infectious disease in
microbiological findings in blood, Chapter 01 ‘Certain infectious or parasitic
blood-forming organs, or the diseases’, or to 1G40 Sepsis without septic shock -
immune system 1G41 Sepsis with septic shock.

158 ICD-11 MMS

 TUC is:
MG20.0 Malignant Code to: 2D4Z Unspecified malignant neoplasms of ill-defined or
cachexia unspecified sites

TUC is:
MG48 Unknown and unspecified Code to: MH10 - MH14 Ill-defined and unknown
causes of morbidity causes of mortality

TUC is:
Chapter 22 Injury, poisoning Not to be used for the underlying cause of death,
or certain other consequences except as an additional code to the relevant category in
of external causes Chapter 23 (see also Step M4).
Consider a fracture as pathological when a disease of
bone density is reported next to or as the cause of the
fracture, and code to: FB80.B Pathological fracture, not
elsewhere classified

TUC is:
24 Factors influencing health Not to be used during the selection of the
status or contact with health underlying cause of death
services
Code to: MH14 Other ill-defined and unspecified
causes of mortality if nothing else is reported on the
certificate

TUC is:
Chapter X Extension codes, except Code to: MH14 Other ill-defined and unspecified
infectious agents causes of mortality

TUC is:
Infectious agents in Chapter X Code to: the infection of the infectious agent of
Extension codes unspecified site. See also [Link].

2.23.19

[Link] Codes not to be used if the underlying cause is known or other specific
conditions apply
For the conditions specified in the left-hand column of this section, if the condition specified
in the right-hand column does not apply, then keep the condition as the tentative
underlying cause.

ICD-11 Reference Guide 159

TUC is:
2D43 Malignant Not to be used for the underlying cause of death, if the multiple
neoplasms of neoplasms are reported separately.
independent, multiple
primary sites
Code to: 2A00-2A0Z Neoplasms of brain or central nervous
system; 2A20-2B3Z Neoplasms of haematopoietic or lymphoid
tissues; or 2B50-2D3Z Malignant neoplasms, stated or presumed
to be primary, of specified sites, except of lymphoid,
haematopoietic, central nervous system or related tissues

TUC is:
6A00 Disorders of intellectual development 6A01 Not to be used for the
Developmental speech or language disorders 6A03 underlying cause of death,
Developmental learning disorder 6E60-6E6Z Secondary if the underlying physical
mental or behavioural syndromes associated with disorders condition is known.
or diseases classified elsewhere
Code to: the underlying
physical condition.

TUC is:
6C4A Disorders due to use Not to be used for the underlying cause of death, if the
of nicotine resultant physical condition is known.
Code to: the resultant physical condition.

TUC is:
BC00 Multiple Not to be used for underlying cause of death, if the multiple valve
valve disease diseases are reported separately and nonrheumatic origin.
Code to: each valve disease specified by the coding tool, and select the
underlying cause by applying the selection and modification rules in the
normal way.

TUC is:
JA80 Maternal care related to Not to be used for the underlying cause of death, if a
multiple gestation more specific complication is reported.
Code to: the more specific complication.
If there is no specific complication, code to JB0Z
Complications of labor or delivery, unspecified

160 ICD-11 MMS

 TUC is:
JB20 - JB2Z Not to be used for the underlying cause of death, if a more specific
Delivery complication is reported.
Code to: code to the more specific complication of JB0C.- to JB0D.- or
JB0Y. If no complication is reported code to JB0Z.

TUC is:
KA21 Disorders of Not to be used for the underlying cause of death, if any other
newborn related to cause of perinatal mortality or any developmental anomaly is
short gestation or low reported. This does not apply for KB2D Respiratory failure of
birth weight, not newborn or KB2E Respiratory Arrest of newborn, which are ill-
elsewhere classified defined conditions and should not be used for underlying cause
KA22 Disorders of of death.
newborn related to
long gestation or high
birth weight
Code to: the other specified cause of perinatal mortality, or
developmental anomaly
([{19}([Link]
release/mms/en#1306203631)] Chapter 19 Certain conditions
originating in the perinatal period except for KB2D Respiratory
failure of newborn or KB2E Respiratory arrest of newborn

TUC is:
KD3B Fetal Not to be used for the underlying cause of death of live births.
death, cause not
specified
Code to: KD5Z Conditions originating in the perinatal or neonatal
period, unspecified, if the child was born alive but the cause death is
unknown. See also: [[Link]] (#special-instructions-on-fetal-death)

TUC is:
KD3B Fetal death, cause Not to be used for the underlying cause of fetal death, if any
not specified other cause of fetal mortality is known.
Code to: the other cause of fetal mortality.

TUC is:
MB50-MB5Z Paralytic Not to be used for the underlying cause of death, if the cause
symptoms of the paralysis is known.
Code to: the cause of the paralysis.

ICD-11 Reference Guide 161

 TUC is:
NF0A Certain early complications of Not to be used for the underlying cause of
trauma, not elsewhere classified death, if the initial injury is known.
Code to: the initial injury
2.19.4 Special instructions on surgery and other medical procedures (Step M4)

[Link] Reason for the surgery or procedure stated

If the tentative underlying cause selected by applying Steps SP1 to SP8 and M1 to M3 is
surgery or other medical procedure and the certificate states the reason for which the
operation or procedure was performed, then select the reason for the operation or
procedure as the new tentative underlying cause of death. Next, reapply the instructions in
Steps SP7 and M1 to M4.

[Link] Reason for the surgery or procedure not stated, complication reported
If the reason for the surgery or procedure is not stated and a complication is reported,
proceed as described next.
a) Surgery indicates specific organ: First, if the type of surgery or procedure indicates a specific
organ or site, then use the code for the residual category for the organ or site operated on
as the new tentative underlying cause of death. Next, reapply the instructions in Steps SP7
and M1 to M4.

b) If above does not apply, then use the appropriate code from:

• JB0C Complications of anaesthesia during labour or delivery

• JB0D.3 Other complications of obstetric surgery or procedures or
• PK80-PK8Z Surgical or other medical procedures associated with injury or harm in
diagnostic or therapeutic use
• PL11 Mode of injury or harm associated with a surgical or other medical procedure
When both PK80-PK8Z and PL11 applies, then code the mode of injury or harm (PL11) first
and add the type of surgery or procedure PK80-PK8Z to the cluster.

[Link] Reason for the surgery or procedure not stated, no complication reported
If the reason for the surgery or procedure is not stated and no complication is reported,
proceed as described next:
a) Surgery indicates specific organ: If the type of surgery or procedure indicates a specific organ
or site, then use the code for the residual category for the organ or site operated on as the
new starting point. Next, reapply the instructions in Steps SP7 and M1 to M4.

b) Lastly, if above does not apply, code to MH14 Other ill-defined or unspecified causes of
mortality.

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 Example 1
1 (a) Postoperative haemorrhage
(b) Caesarean section
(c)
(d)
2
Reason for surgery Prolonged labour
The certificate states the reason why the surgery was performed. Code the reason for the surgery,
prolonged labour, as the underlying cause of death JB03.Z Long labour, unspecified.

Example 2
1 (a) Pulmonary embolism
(b) Appendectomy
(c)
(d)
2
The certificate does not specify the reason for the surgery, but a complication of the surgery pulmonary
embolism is reported. The term appendectomy indicates appendix as the organ operated on. Code DB1Z
Diseases of appendix, unspecified as the underlying cause of death.

Example 3
1 (a) Unintentional puncture of aorta
(b) Laparotomy
(c)
(d)
2
The certificate does not specify the reason for the surgery and the term laparotomy does not indicate a
specific organ. However, there is a mention of a mode of injury at the time of the surgery. Code the mode
of injury, unintentional puncture during laparotomy as the underlying cause of death PL11.0 Cut, puncture
or tear, as mode of injury or harm.

Example 4
1 (a) Laparotomy
(b)
(c)
(d)
2
The certificate does not specify why the surgery was performed and the term laparotomy does not
indicate a specific organ. There is no mention of a complication. Code MH14 Other ill-defined or unspecified
causes of mortality, as the underlying cause of death.

ICD-11 Reference Guide 163

[Link] Medical devices associated with adverse incidents due to external causes
If a death is caused by an incident involving a medical device, but the incident is due to an
external cause and not to any breakdown or malfunctioning of the device itself, code the
external cause as the underlying cause of death.
If the external cause of the incident is not specifically classified, code to PB6Z Unspecified
unintentional cause of morbidity or mortality (See example 3).

Example 1
1 (a) Inhalation pneumonia
(b) Haemorrhage of trachea
(c) Fell from bed while attached to respirator
(d)
2 Respiratory treatment following liver transplant
There is no mention of breakdown or malfunctioning of the respirator or the tracheal tube. Code PL14.E
Fall in health care, the accident that caused the haemorrhage, as the underlying cause of death, and
additional code, if desired, for XE8PK Bed, bedding or bedding accessories.

Example 2
1 (a) Pulmonary oedema
(b) Intra-aortic balloon pump stopped
(c) Power cut due to hurricane
(d) Recent myocardial infarction with mitral insufficiency
2
The balloon pump stopped working, not because of any malfunctioning or breakdown, but because of a
power cut. Code the reason of the power cut, cataclysmic storm, as the underlying cause of death, (PJ06).

Example 3
1 (a) Cardiac and respiratory failure
(b) Stopped administration of inotropic drugs
(c) Accidental removal of subclavian line
(d)
2 Surgery for acute rupture of gallbladder
There is no mention of malfunctioning or breakdown of equipment. Since the accident that caused the
removal of the subclavian line is not described, code to PB6Z Unspecified unintentional cause of morbidity
or mortality.
2.19.5 Special instructions on main injury in deaths from external causes (Step M4)

If the underlying cause selected by applying the selection and modification rules in Steps
SP1 to SP8 and M1 to M3 is an injury, code the external cause of the injury as the underlying
cause of death.
In addition to the underlying cause from Chapter 23 ‘External causes of morbidity and
mortality’, also code a main injury. This applies to both body injuries and poisoning. For
special instructions on how to identify the underlying cause and main injury in poisoning

164 ICD-11 MMS

deaths, see Section 2.19.6 Special instructions on poisoning by drugs, medications and
biological substances (Step M4).
If more than one injury is reported on the death certificate, apply the following instructions:
(a) When the injuries reported include trivial injuries (those listed in Annex 3.14.10 List
of conditions unlikely to cause death), whether in Part 1 or Part 2, select the main
injury as if the injuries in the list of Annex 3.14.10 had not been reported.
Example 1
1 (a) Contusion of arm and fracture of skull
(b) Fall from scaffolding
(c)
(d)
2
Fall from scaffolding is the underlying cause of death. Code underlying cause to PA61 Unintentional fall
from a height of 1 metre or more and use additional code, if desired, for the XE7RK Scaffolding. As main
injury, code NA02.Z Fracture of skull or facial bones, part unspecified. Disregard contusion of arm
(Superficial injury of upper limb, level unspecified), as it is in the Annex 3.14.10 List of conditions unlikely
to cause death.
(b) When non-trivial injuries are reported in both Part 1 and Part 2, select the main
injury from Part 1. This applies even when the injuries mentioned in Part 2 have a
higher rank in Annex 3.14.5 Priority ranking of Nature-of-Injury codes, than the
injuries mentioned in Part 1.
Example 2
1 (a) Multiple intrathoracic injuries
(b) Car driver, collision with bus
(c)
(d)
2 Brain injuries
Code to PA04 Unintentional land transport traffic event injuring a car occupant, and use additional code, if
desired, for XE5LJ Bus or coach as counterpart in land transport crash. As main injury, code NB32.7
Multiple injuries of intrathoracic organs. Unspecified brain injury has a higher rank in Annex 3.14.5
Priority ranking of Nature-of-Injury codes than multiple injuries of thorax, but multiple injuries of thorax
are mentioned in Part 1 and take precedence over the injuries mentioned in Part 2.
(c) When non-trivial injuries are reported only in Part 2, select a main injury from Part 2.

(d) When more than one serious injury is reported in the relevant part of the certificate, select
the main injury according to Annex 3.14.5 Priority ranking of Nature-of-Injury codes. Note
that 1 is the highest priority rank and that 6 the lowest.

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 Example 3
1 (a) Multiple intrathoracic injuries and brain injuries
(b) Car driver, collision with bus
(c)
(d)
2
Code to PA04 Unintentional land transport traffic event injuring a car occupant as underlying cause of
death. As main injury, code brain injury NA07.Z Intracranial injury, unspecified, which has a higher rank on
the priority list than NB32.7 Multiple injuries of intrathoracic organs.
(e) When more than one of the serious injuries reported in the relevant part of the
certificate have the same and highest rank, select the first mentioned of these
injuries. However, select a specific injury over an injury from the group ND30-ND37
Injuries involving multiple body regions with the same priority rank.
Example 4
1 (a) Multiple injuries with traumatic subdural haemorrhage
(b) Car driver, collision with bus
(c)
(d)
2
Code to PA04 Unintentional land transport traffic event injuring a car occupant as underlying cause of
death. As main injury, code NA07.6Z Traumatic subdural haemorrhage, unspecified whether acute or
chronic. Multiple injuries and traumatic subdural haemorrhage have the same rank on the priority list,
but a specific injury takes precedence over injury from the group Injuries involving multiple body regions.
2.19.6 Special instructions on poisoning by drugs, medications and biological
substances (Step M4)

If poisoning is the tentative underlying cause in Step M4 and multiple substances are
reported, follow the instructions in this section.

[Link] The drug most likely to have caused death is specified

If one of the substances is specified as the substance most likely to have caused the death,
code the external cause code for that substance as the underlying cause of death. Use
additional code from Chapter X, if applicable, to identify the specific substance reported,
and add the main injury from Chapter 22 to the cluster.

Example 1
1 (a) Unintentional heroin overdose
(b)
(c)
(d)
2 Diazepam and amitriptyline present
By placing heroin overdose alone in Part 1 and reporting the other substances as contributing causes of
death in Part 2, the certifier has identified heroin as the substance most likely to have caused the death.

166 ICD-11 MMS

Select PB20 Unintentional exposure to or harmful effects of opioids or related analgesics as underlying
cause. Use additional code XM05B3 Diamorphine to identify the specific substance reported. Add main
injury from Chapter 22 NE60 Harmful effects of drugs, medicaments or biological substances, not elsewhere
classified, NEC to the cluster. The cluster is PB20&XM05B3/NE60.

Example 2
1 (a) Poisoning by amphetamine
(b)
(c)
(d)
2 Toxic levels of heroin and flunitrazepam
By placing amphetamine poisoning alone in Part 1 and reporting the other substances as contributing
causes of death in Part 2, the certifier has identified amphetamine as the substance most likely to have
caused the death. Select PB22 Unintentional exposure to or harmful effects of psychostimulants as
underlying cause. Use additional code XM48Z9 Amfetamine to identify the specific substance reported.
And add NE60 Harmful effects of drugs, medicaments or biological substances, not elsewhere classified to
the cluster. The cluster is PB22&XM48Z9/NE60.

Example 3
1 (a) Poisoning by alcohol
(b)
(c)
(d)
2 Toxic levels of heroin and flunitrazepam
By placing alcohol poisoning alone in Part 1 and reporting the other substances as contributing causes of
death in Part 2, the certifier has identified alcohol as the substance most likely to have caused the death.
Select PB30 Unintentional exposure to or harmful effects of alcohols as underlying cause. And add NE61
Harmful effects of or exposure to noxious substances, chiefly nonmedicinal as to source, not elsewhere
classified to the cluster. The cluster is PB30/NE61.

Example 4
1 (a) Alcohol poisoning
(b)
(c)
(d)
2 Diazepam and amitriptyline present

By placing alcohol poisoning alone in Part 1 and reporting the other substances as
contributing causes of death in Part 2, the certifier has identified alcohol as the most
important substance in bringing about the death. Select PB30 Unintentional exposure to or
harmful effects of alcohols as underlying cause. And add NE61 Harmful effects of or
exposure to noxious substances, chiefly nonmedicinal as to source, not elsewhere classified
to the cluster. The cluster is PB30/NE61

[Link] The drug most likely to have caused death is not specified
If multiple substances are reported as contributing to the death but none of the substance is
specified as the substance most likely to have caused the death, follow these instructions:

ICD-11 Reference Guide 167

 (a) Code combinations of alcohol with a drug to the drug
Example 5
1 (a) Toxic levels of alcohol and flunitrazepam
(b)
(c)
(d)
2 Diazepam and amitriptyline present
By placing toxic levels of alcohol and flunitrazepam in Part 1 and reporting the other substances as
contributing causes of death in Part 2, the certifier has identified alcohol and flunitrazepam as the most
important substances in bringing about the death. Of these two, select poisoning by flunitrazepam
because combinations of alcohol with a drug are coded to the drug. Select PB21 Unintentional exposure to
or harmful effects of sedative hypnotic drugs or other CNS depressants as underlying cause. Use additional
code XM9W71 Flunitrazepam to identify the specific substance reported. And add NE60 Harmful effects of
drugs, medicaments or biological substances, not elsewhere classified, NEC. The cluster is
PB21&XM9W71/NE60.
(b) Code combinations of multiple drugs, as follows:
• If the external cause of the multiple drugs reported is the same select that as the
underlying cause of death.
• If the external cause of the multiple drugs reported is not the same, code PB29
Unintentional exposure to or harmful effects of multiple drugs, medicaments or
biological substances as the underlying cause of death.
Use additional code from Chapter X, if applicable, to identify the substance most likely to
have caused the death by referring to Section [Link] Identification of the drug most likely
to have caused death.
Note that when adding more than one drugs in optional use cases, the substance most likely
to have caused the death identified as above must be coded first.

Example 6
1 (a) Toxic levels of heroin and amphetamine
(b)
(c)
(d)
2
Neither heroin nor amphetamine are identified as the substance most likely to have caused the death and
the external cause of these drugs are not the same. Code to PB29 Unintentional exposure to or harmful
effects of multiple drugs, medicaments or biological substances as the underlying cause of death. Go to
Section [Link] to identify the drug most likely to have caused the death.

168 ICD-11 MMS

 Example 7
1 (a) Unintentional poisoning by alcohol, heroin, and diazepam
(b)
(c)
(d)
2
None of the substances is identified as the substance most likely to have caused the death. Poisoning by
combinations of alcohol and drugs are coded to the drugs. Because none of the drugs is identified as most
important, and the external cause code is different, code to PB29 Unintentional exposure to or harmful
effects of multiple drugs, medicaments or biological substances as the underlying cause of death. And go to
Section [Link] to identify the substance most likely to have caused the death.

[Link] Identification of the drug most likely to have caused death

Use the priority order below to identify the substance most likely to have caused the death
(1 = highest priority):
1. Opioid agonists and partial agonists and other and unspecified narcotics. Deaths that include
multiple opioids classifiable should be prioritised as:

– 1a. Heroin
– 1b. Methadone
– 1c. Opium
– 1d. Other opioids
– 1e. Other synthetic narcotics
– 1f. Other and unspecified narcotics
2. Inhaled and intravenous anaesthetic agents, Includes: Propofol

3. Tricyclic and tetracyclic antidepressants

4. Barbiturates

5. 4-Aminophenolderivatives Includes: APAP, acetaminophen, paracetamol

6. Antipsychotics and neuroleptics Includes: Phenothiazine antipsychotics and neuroleptics,

Butyrophenone and thioxanthene neuroleptics, Other and unspecified antipsychotics and
neuroleptics

7. Antiepileptic drugs, antiparkinsonism drugs and unspecified sedatives

8. Cocaine

9. Psychostimulants with abuse potential Includes: Amphetamines and derivatives

10. Monoamine oxidase inhibitor (MAO) antidepressants and other and unspecified
antidepressants. Includes: Selective serotonin reuptake inhibitors (SSRIs), venlafaxine

11. Benzodiazepines

12. Drugs and substances not listed above

If there is more than one drug in the same priority group, code to the first mentioned.

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 Example 8
1 (a) Toxic levels of cocaine, heroin, diazepam, and amitriptyline
(b)
(c)
(d)
2
None of the drugs is identified as the substance most likely to have caused the death, and the external
cause code is not the same for these substances. Code to PB29 Unintentional exposure to or harmful effects
of multiple drugs, medicaments or biological substances as the underlying cause of death. On the priority
list above, cocaine is in group 8, heroin is in group 1a, diazepam is in group 11 and amitriptyline is in
group 3. Use additional code XM05B3 Diamorphine for the drug identified (PB29 Unintentional exposure to
or harmful effects of multiple drugs, medicaments or biological substances&XM05B3). Add codes, if desired,
from Chapter X to list other drugs reported. Finally, add NE60 Harmful effects of drugs, medicaments or
biological substances, not elsewhere classified, to the cluster (PB29&XM05B3/NE60).

Example 9
1 (a) Heroin, cocaine, diazepam and amitriptyline overdose
(b)
(c)
(d)
2
None of the drugs is identified as the substance most likely to have caused the death, and the external
cause code is not the same for these substances. Code to PB29 Unintentional exposure to or harmful effects
of multiple drugs, medicaments or biological substances as the underlying cause of death. On the priority
list above, heroin is in group 1a, cocaine is in group 8, diazepam is in group 11 and amitriptyline is in
group 3. Use additional code XM05B3 Diamorphine for the drug identified. Add codes, if desired, from
Chapter X to list other drugs reported. Finally, add NE60 Harmful effects of drugs, medicaments or
biological substances, not elsewhere classified to the cluster. (PB29&XM05B3/NE60)

Example 10
1 (a) Unintentional poisoning by alcohol, heroin and diazepam
(b)
(c)
(d)
2
Poisoning by combinations of alcohol and drug(s) is coded to the drug(s), see instruction in Section
[Link], above. None of the drugs reported in Part 1 is identified as the substance most likely to have
caused the death, and the external cause code is not the same for these substances. Code to PB29
Unintentional exposure to or harmful effects of multiple drugs, medicaments or biological substances as the
underlying cause of death. On the priority list above, heroin is in group 1a and diazepam is in group 11.
Use additional code XM05B3 Diamorphine identified as most likely to have caused death. Add code
XM8P99 Diazepam, if desired. Finally, add NE60 Harmful effects of drugs, medicaments or biological
substances, not elsewhere classified to the cluster. (PB29&XM05B3&XM8P99/NE60).
2.19.7 Special instructions on maternal mortality (Step M4)

For coding of maternal mortality, follow general coding instructions.

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After assigning a code for each condition reported (See Coding instructions for maternal
mortality in Section [Link] apply the selection and modification instructions in the normal
way starting from SP1 as same as other causes of death.
Then, apply Steps SP1 to SP8 and M1 to M3 and M4 for Surgery, Injury, External causes, and
Poisoning, then Step M4 for maternal mortality.
Apply the following instructions against the tentative underlying cause of death (TUC).
Terms used Terms used here in the instruction is is as follows:
• Certain maternal diseases: JA00.- to JB4Z, JB60, JB6Y, 1C14
• Maternal diseases classified elsewhere: JB63.- (infections), JB64.- (other)
• Injury or external causes: Chapter 22, Chapter 23
• Other conditions: other than above
Maternal diseases
• If the tentative underlying cause (TUC) is ‘certain maternal diseases’ and the
deceased was pregnant at the time of death, within 42 days, or the duration is
unknown or unstated, keep the TUC.
• If the TUC is ‘maternal diseases classified elsewhere’ keep the TUC and
postcoordinate the code for the specific disease classified elsewhere from Chapter
01-19.
• If the TUC is JB61.0, JB61.Z, JB62.0 or JB62.Z keep it and its post-coordinated code, if
any, as the TUC.
• If the TUC is ‘certain maternal diseases’ or maternal diseases classified elsewhere’
but the death occurred after 42 days but less than one year after the obstetric event,
then code to JB61.- as the TUC and add the code for the specific maternal disease to
the cluster.
Other conditions or indirect obstetric causes
• If the TUC is JB61.1 or JB62.1, keep it and its post-coordinated code if any as the TUC.
• If the TUC is ‘other conditions’, and the pregnancy contributed to death, and the
deceased was pregnant at the time of death, within 42 days, or the duration is
unknown or unstated, code to JB63.- or JB64.- as appropriate and add the specific
‘other condition’ to the cluster.
• If the TUC is ‘other conditions’, and the pregnancy did not contribute to death, but
the deceased was pregnant at the time of death, within 42 days, keep the TUC and
add XT0S Pregnancy to the cluster.
• If the TUC is ‘other conditions’, and the pregnancy did not contribute to death, and
the death occurred after 42 days or more, or the duration is unknown or unstated,
keep the TUC.
See ‘Determining whether pregnancy contributed to death’ in section [Link] to decide
whether pregnancy contributed to death from the information on the death certificate.
Injury or external causes

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 • If the TUC is ‘injury or external cause’, and the deceased was pregnant at the time of
death, within 42 days, keep the TUC and add XT0S Pregnancy to the cluster.
• If the TUC is ‘injury or external cause’, and the death occurred after 42 days or more,
or the duration is unknown or unstated, keep the TUC.
2.20 Coding instructions for mortality: multiple cause coding and other specific
instructions
Multiple cause coding (see also Sections 2.21.1 - 2.21.8) permits in-depth analysis of causes
of death, for example of serious but avoidable complications of certain underlying causes,
and the impact of coexisting conditions on the outcome of a disease process. Therefore, in
mortality coding, both underlying cause and multiple causes should be recorded. Also,
complete multiple cause coding is essential for a correct application of the ICD instructions
for selection and modification of the underlying cause of death (see Sections 2.17 - 2.19).
All possible detail should be retained in the multiple cause coding, since records containing
all multiple cause conditions permit more thorough analysis than records with only a
selection of the conditions reported on the death certificate. In particular:
• the position of the individual codes in the data record should reflect where on the
certificate the corresponding diagnostic expressions were entered by the certifier,
because some analyses may focus on the terminal cause of death, or on conditions
reported in Part 2
• codes for common conditions, or for conditions regarded as symptomatic or less
informative, should not be deleted or left out, since they may be of special interest
in analysis of avoidable complications and may serve as markers of the seriousness
of other conditions reported on the death certificate;
• multiple cause data should be stored in two formats:
1. one format that shows as clearly as possible which term the certifier used on
the certificate and where on the certificate each term was reported
2. one format that takes the stated or implied relationships between the
reported conditions into consideration, and where the codes have been
harmonised according to the instructions in the ICD volumes.
Note that the syntax of a code string to retain ICD codes provided in a death certificate
should be distinguishable from the syntax used for cluster coding in ICD (i.e. forward slash
(/), ampersand (&)), while the specific syntax may differ according to different settings. Such
code string could be for example, BD10|BA5Z*5A11/9B71.0Z, where a vertical bar (|)
expresses the separator between lines in Part 1, and an asterisk expresses the separator
between Part 1 and Part 2, and the forward-slash (/) shows the cluster as a separator
between stems following the convention of ICD.

2.21 Mortality Rules – Knowledgebase

The Mortality Knowledge Database will be a collection of rules that are used for determining
the Underlying Cause of Death from death certificates. These rules will be based upon the
Mortality coding guidelines of the ICD. The rules will cover permitted sequences, such as
disease ‘a’ due to disease ‘b’, and cases where the selected cause may be modified to
provide more relevant information for public health. Short summaries will describe the

172 ICD-11 MMS

scope of a rule, and decision tables will specify explicitly and independent of language the
use of the rule with the codes of the mortality tabular list. ‘Code sets’ of the decision tables
will group ICD codes that often occur together in the knowledge base or are handled
similarly by the selection and modification rules; for example, as causes or consequences of
diseases with some common characteristic. The information on the rules will be maintained
in a database, so that the data in the rules code table can be easily validated against
changes in the classification, and vice versa.
The decision tables can be used for manual coding and selection of the underlying cause of
death, or for programming of software that assists in this task. In the past such Rule bases
have been developed by users of ICD-10 mortality coding in an international approach,
relying on decision for changes to the tables by an international group accredited by WHO.
2.21.1 Uncertain diagnosis

Ignore expressions indicating doubt as to the certainty of the diagnosis, for example
‘apparently’, ‘presumably’, ‘probably’ or ‘possibly’. A tentative diagnosis, although
uncertain, is of better use to mortality statistics than no diagnosis at all.

[Link] Either … or
The certifier might report alternative diagnoses, ‘either diagnosis A or diagnosis B’. In such
cases, proceed as follows.

[Link] One condition, either one site or another

(a) If the sites are in the same anatomical system, code to the residual category for the
group or anatomical system in which the reported sites are classified.
Example 1
1 (a) Cancer of kidney or bladder
(b)
(c)
(d)
2
Code as 2C9Z Malignant neoplasms of urinary tract, unspecified.
(b) If the reported sites are in different anatomical systems, or if there is no residual
category for the group or anatomical system, code to the residual category for the
disease or condition specified.
Example 2
1 (a) Cancer of adrenal gland or kidney
(b)
(c)
(d)
2
Code as 2D42 Malignant neoplasms of ill-defined sites, since adrenal gland and kidney are in different
anatomical systems.

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[Link] One site or system, either one condition or another condition
(a) If the reported conditions are classifiable to different subcategories, and ICD
provides a group or category for the disease in general, code to the residual category
of this group/category.
Example
1
1 (a) Sigmoid volvulus DB30.1 or adhesions of large intestine with DB30
obstruction DB30.2
(b)
(c)
(d)
2
Since both sigmoid volvulus (DB30.1) and adhesion of large intestine with obstruction (DB30.2) are in the
same group, code to the residual category DB30.Z Obstruction of large intestine, unspecified

Example
2
1 (a) Dissection of cerebral arteries 8B22.0 or cerebral 8B00-
infarction 8B11.5Z 8B2Z
(b)
(c)
(d)
2
Since dissection of the cerebral arteries (8B22.0) and cerebral infarction (8B11.5Z) are in the same group,
code to the residual category 8B2Z Cerebrovascular diseases, unspecified.
(b) If there is no group or category for the disease in general, code to the residual
category of the disease of the anatomical site/system common to the reported
conditions.
Example 3
1 (a) Tuberculosis or cancer of lung
(b)
(c)
(d)
2
Code as CB40.Y Other specified diseases of the respiratory system. Both conditions involve the lung.

174 ICD-11 MMS

 Example 4
1 (a) Stroke or heart attack
(b)
(c)
(d)
2
Code as BE2Z Diseases of the circulatory system, unspecified. Although stroke is classified to the nervous
system chapter, both conditions are diseases of the circulatory system.

[Link] Either one condition or another, different anatomical systems

When different diseases of different anatomical systems are reported as ‘either … or’, code
to MG6Y Other specified clinical findings in specimens from other specified organs, systems
and tissues.

Example 1
1 (a) Gallbladder colic or coronary thrombosis
(b)
(c)
(d)
2
Code as MG6Y Other specified clinical findings in specimens from other specified organs, systems and tissues.

[Link] Either disease or injury

When death is reported as due to either a disease or an injury, code to MH14 Other ill-
defined or unspecified causes of mortality.

Example 1
1 (a) Coronary occlusion or war injuries
(b)
(c)
(d)
2
Code as MH14 Other ill-defined or unspecified causes of mortality.
2.21.2 Effect of connecting terms

When the certifier uses a connecting term, the codes assigned must be arranged to reflect
the certifier intention. There are two types of connecting terms: those implying a causal
relationship, and those not implying a causal relationship between reported causes of
death.

ICD-11 Reference Guide 175

[Link] Connecting terms implying a causal relationship
A causal relationship can be expressed in two ways: ‘due to’ written or implied by a similar
term; or ‘resulting in’ written or implied by a similar term. This applies to other connecting
terms or signs that indicate a ‘due to’ relationship, such as ‘caused by’, ‘because of’, or
similar.

‘Due to’ written or implied by a similar term

When one cause is certified with a connecting term implying it is due to another cause,
enter the code for the first cause on the line where reported and the code for the other
cause on the next lower line. Code any causes reported on the remaining lines in Part 1 on
the next lower lines.

Example 1
1 (a) Heart failure due to ischaemic heart disease
(b) Diabetes
(c)
(d)
2
Heart failure is the first cause on line (a), so code it to line (a). It is reported as due to ischaemic heart
disease, so code ischaemic heart disease to line (b). Move diabetes, which is written on line (b), to line (c).

Example 2
1 (a) Heart failure due to hepatocellular carcinoma
(b) Ischaemic heart disease
(c) Diabetes
(d)
2
Heart failure is the first cause on line 1(a), so code it to line (a). It is reported as due to hepatocellular
carcinoma, so code hepatocellular carcinoma to line 1(b). Move ischaemic heart disease, which is
reported on line 1(b), to line 1(c). Also move diabetes, which is reported on line 1(c), to line 1(d).

‘Resulting in’ written or implied by a similar term

When one cause is certified with a connecting term implying it resulted in another cause,
enter the code for the cause following the connecting term on the line where reported, and
the code for the cause preceding the connecting term on the next lower line. Code any
causes reported on the remaining lines in Part 1 on the next lower lines.

176 ICD-11 MMS

 Example 1
1 (a) Ischaemic heart disease resulting in heart failure
(b) Diabetes
(c)
(d)
2
Code heart failure, which follows the connecting term ‘resulting in’, on line (a). Code ischaemic heart
disease, which is reported before the connecting term, is moved to line (b). Move diabetes, reported on
line (b), one line down and code it on line (c).

Example 2
1 (a) Hepatocellular carcinoma causing heart failure
(b) Ischaemic heart disease
(c) Diabetes
(d)
2
Code heart failure reported after the connecting term ‘causing’, on line 1(a). Code hepatocellular
carcinoma, which is reported before the connecting term, on line 1(b). Move ischaemic heart disease,
reported on line 1(b), to line 1(c), and move diabetes, which is reported on line 1(c), to line 1(d). This
applies to other connecting terms or signs that indicate a ‘resulting in’ relationship, such as ‘causing’,
‘leading to’, ‘developing into’, and similar.

[Link] Connecting terms not implying a causal relationship

‘And’ written or implied by a similar term first or last on a line

The connecting term ‘and’ does not imply a causal relationship, but it indicates that the
terms before and after it should be counted. Therefore, when a line ends with ‘and’, code
the cause(s) mentioned on the line immediately below for this line, so that the coding
reflects the enumeration implied by the connecting term. Similarly, when a line starts with
‘and’, consider this as a continuation of an enumeration starting on the line above, and code
the cause or causes on that line last on the line above. Code any causes reported on the
remaining lines in Part 1 where reported. This applies to other connecting terms or signs
that indicate an enumeration but do not imply a causal relationship, such as ‘also’, ‘plus’,
‘besides’, ‘in addition’, ‘+’ or comma.

Example 1
1 (a) Heart failure and
(b) Ischaemic heart disease
(c) Diabetes
(d)
2
Line 1(a) ends with ‘and’, so consider ‘ischaemic heart disease’, reported on line (b) as a part of the
enumeration ‘heart failure and ischaemic heart disease’. Code accordingly and place the codes for both
heart failure and ischaemic heart disease on line 1(a). Code diabetes on line (c).

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 Example 2
1 (a) Heart failure
(b) Ischaemic heart disease
(c) and diabetes
(d)
2
Line 1(c) starts with ‘and’. Consider diabetes, reported on line (c), as a part of the enumeration ‘ischaemic
heart disease and diabetes’. Code accordingly, and place the codes for both ischaemic heart disease and
diabetes on line 1(b).

‘And’ written or implied by a similar term but not first or last on a line
If a connecting term that does not imply a causal relationship is written on a line but not
first or last, then treat it as a comma. Do not reformat the text and do not move any part of
the causes reported to another line.

Diagnostic terms that do not stop at the end of the line

If a diagnostic term starts on one line in Part 1 and continues on the next line, code as if the
entire diagnostic term had been written on the line where the diagnostic term starts. Code
any causes reported on the remaining lines in Part 1 where reported.

Example 1
1 (a) Ischaemic
(b) Heart disease
(c) Diabetes type 2
(d)
2
‘Ischaemic heart disease’ is a diagnostic term reported on two lines. Code as if the complete term had
been written on line (a). Code diabetes where it is reported, on line (c).

Example 2
1 (a) Pneumonia
(b) Chronic kidney
(c) disease, diabetes type 2
(d)
2
‘Chronic kidney disease’ is a diagnostic term reported on two lines. Reformat the certificate and code the
complete term ‘chronic kidney disease’ on line (b). Also code diabetes on line (b), since it continues the
line where ‘chronic kidney’ has been written.
2.21.3 Duration of conditions

[Link] Single duration stated for multiple conditions

When more than one condition is reported in the same line with only one stated duration,
consider that each condition reported had the same duration.

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[Link] Modifying temporality of conditions by stated duration
Duration should not usually be used to qualify a condition as acute or chronic unless the
Indexed Term provides specific duration criterium or it is otherwise instructed in the
reference guide (e.g. Section [Link] Acute or chronic rheumatic heart diseases). Note that
the Description in the classification is not to be used for coding (Section 3.4).
2.21.4 ‘Code also’ instructions in mortality use case

Generally, the ‘code also’ instruction (see also Section [Link] ‘Code also’ and ‘Use
additional code, if desired’ instructions) is not used in in multiple cause coding since the
information on aetiology is provided as a stand-alone expression separately on the death
certificate and will be coded on its own, or is not provided at all.
Apply the ‘Code also’ instruction when both information on the manifestation and the
aetiology appear in a single diagnostic term reported by the certifier, and information on
the aetiology is not reported separately. Whenever applying the ‘code also’ instruction, put
the code for the aetiology at the beginning of the cluster and add the code for the
manifestation.
Example 1: Heart failure
BD10-BD1Z Heart failure has an instruction to ‘Code also’ the causing condition. However, in
the diagnostic term reported by the certifier no information is given on such causing
condition. Do not apply the ‘Code also’ instruction.
Example 2: Type 1 diabetic acidosis
5A22 Diabetic acidosis has an instruction to ‘Code also’ the causing condition. The causing
condition is reported, which in this case is 5A10 Type 1 diabetes mellitus. The aetiological
condition Type 1 diabetes mellitus is considered the causing condition for primary
tabulation and is coded first (5A10 Type 1 diabetes mellitus/5A22 Diabetic acidosis).
Example 3: Salmonella Sepsis
Salmonella sepsis is an index term of 1G40 Sepsis without septic shock which has an
instruction to ‘Code also’ the causing condition supplemented by a coding note to code the
type of infection first. The type of infection in this case is 1A09 Infections due to other
Salmonella and is coded first (1A09/1G40).
2.21.5 Malignant neoplasms

To assign the correct multiple cause code for a neoplasm, there are two concepts to
consider: whether the reported neoplasms is primary or secondary, and its behaviour.
The primary site is the anatomical location where the neoplasm originated. A malignant
neoplasm may spread to other parts of the body, and these sites are referred to as a
secondary or metastasis.
The behaviour (malignant, in situ, benign, uncertain or unknown) of a neoplasm is the way it
spreads within the body:

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 • Malignant - the neoplasm invades surrounding tissue or disseminates from its point
of origin and begins to grow at another site
• In situ - the neoplasm is malignant but still fully confined to the tissue in which it
originated
• Benign - the neoplasm grows in the place of origin without the potential for spread
• Uncertain behaviour - A neoplasm displaying morphologic, phenotypic, or genotypic
characteristics that are clearly not benign but do not permit the establishment of a
definitive diagnosis of malignancy
• Unknown behaviour - it is unknown whether the neoplasm is benign or malignant.
The broad structure of Chapter 02 ‘Neoplasms’ given below can be understood from these
concepts as follows:
• Neoplasms of brain or central nervous system (2A00-2A0Z)
• Neoplasms of haematopoietic or lymphoid tissues (2A20-2B3Z)
• Neoplasms, except of lymphoid, haematopoietic, central nervous system or related
tissues (2B50-2F9Z)
Neoplasms originating in the brain or central nervous systems, classified to 2A00-2A0Z, are
further classified by site, histopathology or behaviour.
Neoplasms originating in the haematopoietic or lymphoid tissues, classified to 2A20-2B3Z,
are further classified by histopathology.
In other words, 2A00-2A0Z or 2A20-2B3Z includes primary neoplasms, which could be either
malignant or benign.
Neoplasms originating in other sites are classified to ([2B50]-2F9Z) and this group is further
classified by behaviour (i.e. malignant, in situ, benign, uncertain, or unknown), site or
histopathology. Note that neoplasms originating in other sites and disseminating into the
brain, central nervous system, lymphoid, haematopoietic tissues, are included here under
the block of malignant neoplasm metastases.
In mortality coding, it is most important to determine the primary site of the neoplasm.
When the death certificate is ambiguous as to the primary site, every effort should be made
to obtain clarification from the certifier. The instructions that follow should be applied only
when clarification cannot be obtained.
In the examples in this section, ICD codes are provided to the right of the death certificate.
These codes represent the multiple cause codes assigned to each entry. These multiple
cause codes could be different from a code assigned when the given diagnostic entry was
reported alone on the certificate (direct coding). In such cases, the code for direct coding is
given in curly brackets ‘{ }’ next to the diagnostic expression. The explanation for each
example describes that the codes in brackets will be modified by other information on the
certificate (application of multiple cause coding) and to code to the multiple cause code
indicated to the right.

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Using the coding tool for neoplasms
Using the ICD coding tool, search for the term reported on the certificate to describe the
neoplasm. If both histopathology and site are stated, enter both into the coding tool. If the
histopathology is incompatible with the stated site of the neoplasm (i.e. the neoplasm
cannot be primary of the stated site according to textbooks and other reference literature),
then assign a code for a neoplasm of unspecified site for the histopathology indicated. If the
histopathology is not stated, code by site and behaviour, if reported.
Do not assign 2D43 Malignant neoplasms of independent, multiple primary sites when
multiple neoplasms are mentioned. Code each malignant neoplasms by the coding tool, and
select the underlying cause by applying the selection and modification rules in the normal
way.

[Link] Behaviour: malignant, in situ, benign, uncertain or unknown behaviour

To assign the correct multiple cause code for a neoplasm, first determine behaviour
(malignant, in situ, benign, uncertain or unknown) for each of the neoplasms reported on
the death certificate. For malignant neoplasms, also determine whether to code them as
primary or secondary. To that end, apply the instructions that follow.

The term itself indicates behaviour

First, use the coding tool to assign a code for terms used to describe the neoplasms. A
specific histopathology or term may be assigned to a certain group of behaviour.
For neoplasms coded to the following categories, presume it behaviour is malignant, unless
otherwise specified, and go to Section [Link] Malignant neoplasms: primary or
secondary?:
• 2A00-2A0Z Neoplasms of central nervous system or related structures
• 2A20-2B3Z Neoplasms of haematopoietic or lymphoid tissues
• 2A02.3 Benign neoplasm of cranial nerves
Note that the behaviour given by the coding tool for a specific term may change by other
information on the certificate. Follow the instructions in this Section to decide the correct
behaviour in multiple cause coding.

Other information on the certificate indicates behaviour

If the term used to describe the neoplasm does not indicate a specific behaviour, then look
for other information on the certificate indicating behaviour. Code a neoplasm of
unspecified behaviour, a neoplasm described as ‘in situ’, or a growth that is not coded to
Chapter 02 (for example, certain polyps), as malignant if any of the conditions below apply:

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 • it is reported as the cause of secondary spread (terms such as infiltration,
metastases, secondaries or similar) or of (malignant) cachexia, or;
• it is reported immediately beside a mention of secondary spread, or;
• all other neoplasms reported are specified as secondary spread, or;
• there is no mention of another neoplasm on the same part of the certificate, but
there are other indications of malignancy reported anywhere on the certificate (for
example, carcinosis, malignant cachexia, malignant transformation), or;
• it is reported as due to a malignant neoplasm.
If a neoplasm is coded to the Chapter 02 category for benign neoplasm but is reported as
the cause of metastases or infiltration, check for a code for a malignant variety in the coding
tool and in the tabular list. If found, code it as malignant. If there is no code for a malignant
variety, first try to obtain clarification from the certifier. If no further information is
available, then accept the statement on the certificate and code the neoplasm as benign.
If other information on the certificate indicates that a neoplasms is malignant, go to Section
[Link] Malignant neoplasms: primary or secondary? to assign the correct code.
If there is no other information on the certificate that indicates behaviour, code as unknown
behaviour.

Example 1
1 (a) Liver metastases 2D80.0
(b) Colon tumour {2F90.0} 2B90.Z
(c)
2
The colon tumour is reported as the cause of liver metastases so code as Malignant neoplasms of colon,
unspecified (2B90.Z).

Example 2
1 (a) Cancer cachexia MG20.0
(b) Colon tumour {2F90.0} 2B90.Z
(c)
2
The colon tumour is reported as the cause of malignant cachexia so code as Malignant neoplasms of colon,
unspecified (2B90.Z).

Example 3
1 (a) Liver and lung metastases 2D80.0, 2D70
(b) Respiratory failure CB41.2Z
(c) Colon tumour {2F90.0} 2B90.Z
2
Both metastases and respiratory failure can be due to a colon tumour. According to the instructions on
how to interpret causal relationships in Part 1 (Step SP3) this means that two valid causal relationships
are reported on this certificate, 1) liver and lung metastases due to colon tumour, and 2) respiratory
failure due to colon tumour. These relationships are valid even if liver and lung metastases cannot be due

182 ICD-11 MMS

to respiratory failure. The colon tumour is reported as the cause of secondary spread so code as
Malignant neoplasms of colon, unspecified (2B90.Z).

Example 4
1 (a) Colon tumour {2F90.0} with liver metastases 2B90.Z, 2D80.0
(b)
(c)
2
The colon tumour is reported on the same line as and next to liver metastases so code as Malignant
neoplasms of colon, unspecified (2B90.Z).

Example
5
1 (a) Breast tumour, generalized atherosclerosis, 2F95, BD40.Z,
colon cancer with liver metastases 2B90.Z, 2D80.0
(b)
(c)
2
The breast tumour is reported on the same line as but not next to secondary spread. Do not consider it
malignant. Code as Neoplasms of unknown behaviour of breast (2F95).

Example 6
1 (a) Respiratory failure CB41.2Z
(b) Colon tumour {2F90.0} 2B90.Z
(c)
2 Liver and lung metastases 2D80.0, 2D70
All other neoplasms are specified as secondary spread so code colon tumour as Malignant neoplasms of
colon, unspecified (2B90.Z).

Example 7
1 (a) Colon tumour {2F90.0} 2B90.Z
(b)
(c)
2 Cancer cachexia MG20.0
There is no mention of another neoplasm but cancer cachexia, another indication of malignancy, is
reported in Part 2 so code colon tumour as Malignant neoplasms of colon, unspecified (2B90.Z).

Example 8
1 (a) Bladder tumour 2F98
(b) Lung tumour 2F91.1
(c)
2
There is no information on the certificate that indicates behaviour, code bladder tumour as Neoplasms of
unknown behaviour of urinary organs (2F98) and lung tumour as Neoplasms of unknown behaviour of
trachea, bronchus or lung (2F91.1).

ICD-11 Reference Guide 183

[Link] Malignant neoplasms: primary or secondary?
If a neoplasm is coded as malignant or its behaviour is presumed to be malignant by Section
[Link] Behaviour: malignant, in situ, benign, uncertain or unknown behaviour above, next
decide whether it is primary or secondary.
Sometimes malignant neoplasms are described as ‘metastatic’, which might refer either to a
primary malignant neoplasm that has metastasized to another site, or to secondary
malignant neoplasms originating somewhere else. For instructions on how to code
neoplasms described as ‘metastatic’, see Section [Link] ‘Metastatic’ cancer.

Common sites of metastases

When choosing between codes for primary and secondary malignant neoplasms, refer to
the following list of common sites of metastases:
• bone (2B5Z)
• brain (2A00.5)
• diaphragm (2B5K & XA2JL0)
• ill-defined site (2D42)
• liver (2C12.0Z)
• lung (2C25.Z & XA57M6)
• lymph nodes (2D60-2D6Z)
• mediastinum (2C28.Z & XA7WA2)
• meninges (2A01.2)
• peritoneum (2C51.Z)
• pleura (2C28.Z & XA5TT2)
• retroperitoneum (2C50.Z)
• spinal cord (2A02.2)
• omentum (2C52.Z)
Note: these sites should be considered common sites of metastases, unless a specific
histopathology is described.
See below for further instructions on how to code these neoplasms.

Malignant neoplasm reported as primary

Code a malignant neoplasm specified as primary if it is specified as ‘primary’, ‘primary in’,
‘originating in’, or other similar terms.

Other indication of primary malignant neoplasm

Code a malignant neoplasm as primary, although not described as primary by the certifier,
if:

184 ICD-11 MMS

 • all other malignant neoplasms on the certificate are specified as secondary or as
metastases. This applies whether the site not specified as secondary or as metastasis
is on the list of common sites of metastases.
• it is in the code range 2A20-2B3Z Neoplasms of haematopoietic or lymphoid tissues:
Code all malignant neoplasms of haematopoietic or lymphoid tissues as primary,
unless the certifier specifies them as secondary;
– note: A primary neoplasm of haematopoietic and lymphoid tissues may occur
simultaneously with another primary neoplasm in the same code range.
• the site is not on the list of common sites of metastases.
If the site is on the list of common sites of metastases, code the malignant neoplasm as
primary if:
• the histopathology indicates that it is primary of the reported site;
• it is described as caused by a known risk factor for malignant neoplasms of the
stated site (To determine if the condition reported as causing the neoplasm is a
known risk factor, check if it is mentioned as a risk factor of the site involved in
textbooks or other reliable sources);
• it is the only malignant neoplasm mentioned on the death certificate, and it is not
specified as ‘metastatic’:
– exception: code malignant neoplasm of lymph nodes as secondary, even if it
is the only reported neoplasm on the certificate, unless it is specified as
primary;
– note: if the only malignant neoplasm reported on the certificate is malignant
neoplasm of liver, and it is not specified as either primary or secondary, then
code it as primary;
• it is malignant neoplasm of lung, and all other malignant neoplasms mentioned on
the certificate are on the list of common sites of metastases;
– exception: code lung as secondary if another malignant neoplasm is reported
in the same part of the certificate (Part 1 or Part 2) and this other malignant
neoplasm is coded as a primary malignant neoplasm;
• it is malignant neoplasm of lung specified as bronchogenic or of bronchus.
Code a neoplasm of behaviour other than malignant as primary malignant if it is reported as
causing secondary or metastatic spread. See ‘Other information on the certificate indicates
behaviour’ above.
• exception: If durations are stated, the secondary neoplasms must not have a longer
duration than the presumed primary malignant neoplasm;
• exception: If morphologies are stated, the secondary and presumed primary
malignant neoplasms must have the same histopathology.
Do not code a neoplasm of behaviour other than malignant as primary malignant if it is
reported as the cause of another neoplasm that would not be coded as malignant. Do not
assume malignancy or metastatic spread. Code both neoplasms according to the coding
tool.

ICD-11 Reference Guide 185

 Example 1
1 (a) Brain metastasis 2D50
(b) Lung tumour 2C25.Z
(c)
(d)
2
The lung tumour caused brain metastasis so is coded as malignant. The other malignant neoplasms on the
certificate is described as metastasis (2D50) so code the lung tumour as primary at 2C25.Z)].

Example 2
1 (a) Cancer of pancreas 2C10.Z
(b) Cancer of stomach 2B72.Z
(c)
(d)
2
Pancreas and stomach are not on the list of common sites of metastases so code both as primary at
Malignant neoplasm of pancreas, unspecified (2C10.Z)] and Malignant neoplasms of stomach, unspecified
(2B72.Z).

Example 3
1 (a) Cancer of liver and lung {2C25.Z} 2C12.02 2D70
(b) Chronic hepatitis DB97.2
(c)
(d)
2
Chronic hepatitis increases the risk of primary liver cancer so code the liver cancer as primary at
Hepatocellular carcinoma of liver (2C12.02). Code the lung cancer as secondary at Malignant neoplasm
metastasis in lung (2D70), because the other malignant neoplasm reported in the same part of the
certificate is coded as primary.

Example 4
1 (a) Kidney cancer and lung cancer {2C25.Z } [2C90], 2D70
(b)
(c)
(d)
2
Code the kidney cancer as primary (2C90.Z) since it is not on the list of common sites of metastases. Code
lung cancer as secondary at Malignant neoplasm metastasis in lung (2D70) since it is reported in the
same part of the certificate as the kidney cancer and the kidney cancer is considered primary.

186 ICD-11 MMS

 Example 5
1 (a) Liver tumour {2F90.Y} 2C12.02
(b)
(c)
(d)
2 Lung tumour, probably secondary 2D70
Code both tumours as malignant, since the certifier described one of the two as secondary, which is
evidence of malignant behaviour. Code the liver tumour as primary, since the other malignant neoplasm
on the certificate is described as secondary. The qualification ‘probably’ is ignored; see Section 2.21.1
Uncertain diagnosis.

Example 6
1 (a) Metastatic involvement of chest wall 2E0Y
(b) Carcinoma in situ of breast {2E65.Z} 2C6Z
(c)
(d)
2
Code the carcinoma in situ of breast as malignant because it is reported as the cause of secondary spread,
and code as primary at Malignant neoplasms of breast, unspecified (2C6Z) as the other malignant
neoplasm is described as secondary.

Example 7
1 (a) Secondary malignant neoplasm of lung and brain 2D70, 2D50
(b) Polyp of stomach {DA44.Z} 2B72.Z
(c)
(d)
2
Code the polyp of stomach as malignant as it is reported as the cause of secondary spread, and code as
primary at Malignant neoplasms of stomach, unspecified (2B72.Z) as all other malignant neoplasms are
described as secondary.

Example 8
1 (a) Brain cancer (glioma) 2A00.0Z
(b)
(c)
(d)
2 Kidney cancer 2C90.Z
Brain is on the list of common sites of metastases, but the histopathology glioma indicates that it is
primary in brain. Code the brain cancer as primary at Gliomas of brain, unspecified (2A00.0Z). Kidney is
not on the list of common sites so code as primary at Malignant neoplasms of kidney, except renal pelvis,
unspecified (2C90.Z).

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 Example 9
1 (a) Bone cancer (osteosarcoma) 2B51.Z
(b) Colon cancer
(c)
(d) 2B90.Z
2
Bone is on the list of common sites of metastases, but the histopathology osteosarcoma indicates that it is
primary in bone. Code the bone cancer as primary at Osteosarcoma of bone and articular cartilage of
unspecified sites (2B51.Z). Colon is not on the list of common sites so code as primary at Malignant
neoplasms of colon, unspecified (2B90.Z).

Example 10
1 (a) Brain cancer 2A00.5
(b)
(c)
(d)
2
Brain is on the list of common sites of metastases, but it is the only malignant neoplasm mentioned on the
certificate and is not described as metastatic. Code the brain cancer as primary at Primary neoplasm of
brain of unknown or unspecified type (2A00.5).

Example 11
1 (a) Cancer of cervical lymph nodes 2D60.0
(b)
(c)
(d)
2
Lymph nodes are on the list of common sites of metastases, and it is the only malignant neoplasm
mentioned on the certificate, but it is not described as primary. Code the cancer of cervical lymph nodes
as secondary at Malignant neoplasm metastasis in lymph nodes of head, face or neck (2D60.0).

Example 12
1 (a) Cancer primary in prostate 2C82.Z
(b)
(c)
(d)
2
The cancer is described as primary in prostate. Code at Malignant neoplasms of prostate, unspecified
(2C82.Z).

Malignant neoplasm reported as secondary

If the certifier describes a neoplasm as secondary, code as a secondary malignant neoplasm
at Malignant neoplasm metastases (2D50-2E2Z). Use the coding tool to find the appropriate
code.

188 ICD-11 MMS

Other indication of secondary malignant neoplasm
Code a malignant neoplasm not specified as primary or secondary as secondary if:
• the site is on the list of common sites of metastases:
– exception: if there is only one malignant neoplasm mentioned and it is not
specified as ‘metastatic’, then code the neoplasm as primary. note: this does
not apply to lymph nodes, which are always coded as secondary, even if it is
the only reported neoplasm on the certificate, unless it is specified as
primary.
– exception: code lung as primary if all other sites in the same part of the
certificate (Part 1 or Part 2) are on the list of common sites of metastases.
However, code lung as secondary if one of the common sites of metastases
reported on the same part of the certificate is considered primary, from its
histopathology or by being described as caused by a known risk factor for
malignant neoplasms of this site.
– exception: code a malignant neoplasm on the list of common sites of
metastases as primary, if all other malignant neoplasms on the certificate are
specified as secondary or as metastases. This applies whether or not these
other malignant neoplasms are on the list of common sites of metastases.
– exception: code a malignant neoplasm on the list of common sites of
metastases as primary, if the histopathology is stated and is compatible with
the site. (To determine if a stated histopathology is compatible with the site,
refer to textbooks or other reliable sources).
• unspecified whether primary or secondary, and the certifier states that the cancer is
primary in another site. This applies whether or not the site is on the list of common
sites of metastases:
– regardless of site, do not code a neoplasm as secondary if it is of a different
histopathology from another neoplasm stated to be primary. See also Section
‘[Link] More than one primary malignant neoplasm’.
• unspecified whether malignant, in situ or benign, and it is reported as due to a
malignant neoplasm:
– exception: if durations are stated, do not code the unspecified neoplasm as
secondary if it has a duration that is longer than the durations of the
malignant neoplasm reported as the cause of the unspecified neoplasm.
• the histopathology indicates that the neoplasm cannot be primary of the stated site.
In that case, use both the default code for a primary neoplasm of the histopathology
involved and a code for a secondary malignant neoplasm of the stated site.
If all sites are on the list of common sites of metastases, then code all sites as secondary. It
is recommended adding a code for unknown primary. Code to [2D4Z Unspecified malignant
neoplasms of ill-defined or unspecified sites], if no histopathology is stated. If the
histopathology is stated, then code to the ‘unspecified site’ code for the histopathology
involved. - exception: If all sites are on the list of common sites of metastases but one of
them is lung, then code lung as primary.

ICD-11 Reference Guide 189

If the certificate states that the primary site was unknown, then code all neoplasm sites
mentioned on the certificate as secondary. (See also Section [Link] Primary site
unknown).
Do not use order of entry alone to determine whether a neoplasm specified as malignant is
primary or secondary. Code a malignant neoplasm reported as due to another malignant
neoplasm as secondary only if it is described as secondary, metastatic spread or similar, or if
it is on the list of common sites of metastases.
Do not confuse ‘primary’ with ‘primary in’. While ‘primary in’ identifies one of several
malignant tumours of the same or unspecified histopathology as the primary tumour,
‘primary’ simply means that the malignant neoplasm was not secondary. It does not
necessarily mean that all other malignant neoplasms mentioned on the certificate were
secondary.

Example 1
1 (a) Carcinoma of adrenal glands {2D11.Z} 2E07
(b)
(c)
(d)
2 Primary in kidney 2C90.Z
The malignant neoplasm of adrenal glands is considered secondary since the certificate states that the
cancer was primary in kidney. Code the adrenal carcinoma as secondary at Malignant neoplasm
metastasis in adrenal gland (2E07) and the primary in kidney as primary at Malignant neoplasms of
kidney, except renal pelvis, unspecified (2C90.Z).

Example 2
1 (a) Prostate cancer {2C82.Z} 2E06
(b) Primary site unknown
(c)
(d)
2
The primary site is described as unknown. Code to Unspecified malignant neoplasms of ill-defined or
unspecified sites (2D4Z). Code prostate cancer as secondary at Malignant neoplasm metastasis in male
genital organs (2E06) since the primary malignant neoplasm clearly was in another site.

Example 3
1 (a) Brain tumour {2A00.5} 2D50
(b) Breast cancer 2C6Z
(c)
(d)
2
Code the brain tumour as malignant, since it is reported as due to a malignant neoplasm breast cancer.
Also, code as secondary at 2D50, since it is on the list of common sites of metastases. Code the breast
cancer as Malignant neoplasms of breast, unspecified (2C6Z).

190 ICD-11 MMS

 Example 4
1 (a) Brain tumour {2A00.5} 2D50
(b) Lung cancer 2C25.Z
(c)
(d)
2
Code the brain tumour as malignant, since it is reported as due to a malignant neoplasm lung cancer. Also
code as secondary at Malignant neoplasm metastasis in brain (2D50)), since it is on the list of common
sites of metastases and reported together with lung cancer. Code the lung cancer as primary at Malignant
neoplasms of bronchus or lung, unspecified (2C25.Z), since the only other reported neoplasm is on the list
of common sites of metastases.

Example 5
1 (a) Cancer growth in liver {2C12.02} and lymph nodes 2D80.0, 2D6Z
(b)
(c)
(d)
2 Malignant neoplasm of stomach 2B72.Z
Code the cancer growth in liver and lymph nodes as secondary, at Malignant neoplasm metastasis in liver
(2D80.0) and at Metastatic malignant neoplasm to unspecified lymph node (2D6Z), respectively, since
they are both on the list of common sites of metastases. Also code the stomach as primary at Malignant
neoplasms of stomach, unspecified (2B72.Z).

Example
6
1 (a) Cancer of lung, pleura {2C26.Z} and chest wall 2C25.Z, 2D72,
{2D4Z} 2E0Y
(b)
(c)
(d)
2
Code the cancer of lung as primary at Malignant neoplasms of bronchus or lung, unspecified (2C25.Z),
since the other sites mentioned on the certificate, pleura and chest wall, are on the list of common sites of
metastases. Code cancer of pleura and chest wall as secondary at 2D72 and malignant neoplasm
Malignant neoplasm metastasis in other specified sites (2E0Y), respectively.

Example 7
1 (a) Mesothelioma of pleura and lymph nodes 2C26.0, 2D60.Z
(b)
(c)
(d)
2
Pleura is on the list of common sites of metastases but the histopathology mesothelioma indicates that it
is primary in pleura. Code as primary at Mesothelioma of pleura (2C26.0). Code the malignant neoplasm
of lymph nodes as secondary at 2D60.Z, since lymph nodes is on the list of common sites of metastases.

ICD-11 Reference Guide 191

 Example 8
1 (a) Cancer of bladder 2C94.Z
(b) Cancer of kidney 2C90.Z
(c)
(d)
2
Bladder and kidney are not on the list of common sites of metastases, and neither is described as primary,
so code both as primary at Malignant neoplasms of bladder, unspecified (2C94.Z) and 2C90.Z Malignant
neoplasms of kidney, except renal pelvis, unspecified.

Example 9
1 (a) Osteosarcoma of sacrum 2B51.2
(b) Clear cell cancer of kidney 2C90.Y
(c)
(d)
2
Code both malignant neoplasms as primary. Bone is on the list of common sites of metastases but the
histopathology osteosarcoma indicates that it is primary in sacrum. Code as a primary at Osteosarcoma of
bone or articular cartilage of pelvis (2B51.2). Also, it is of different histopathology than clear cell cancer of
kidney.

Example 10
1 (a) Osteosarcoma of lung 2B51.Z, 2D70
(b)
(c)
(d)
2
The histopathology (osteosarcoma) indicates a primary neoplasm of bone, and the reported site (lung) is
incompatible with the histopathology. Code as primary at Osteosarcoma of bone and articular cartilage of
unspecified sites (2B51.Z), and add a code for Malignant neoplasm metastasis in lung (2D70).

[Link] More than one primary malignant neoplasm

If more than one primary malignant neoplasm is reported on the same certificate, code each
primary malignant neoplasm as primary. Indications of more than one primary malignant
neoplasms are:
• different histopathologies;
• a site-specific histopathology reported with a malignant neoplasm of another site
that is not on the list of common sites of metastases;
• the sites are not on the list of common sites of metastases:
If one histopathology term is more specific and is an example of a more general
histopathological term also reported on the certificate, then consider the two as referring to
same neoplasm.

192 ICD-11 MMS

Do not consider ‘cancer’ a histopathologic term, but as synonym of ‘malignant neoplasm’.
On the contrary, ‘carcinoma’ is a histopathological term, describing a malignant tumour of
epithelial origin.

Example 1
1 (a) Transitional cell carcinoma of bladder 2C94.2
(b)
(c)
(d)
2 Osteosarcoma, primary in knee 2B51.1
Bladder on line (a) is not on the list of common sites of metastases. The malignant neoplasm reported in
Part 2 is specified as primary in knee but since the two neoplasms are of different histopathology, code
both as primary at Urothelial carcinoma of bladder (2C94.2) and at Osteosarcoma of bone or articular
cartilage of limbs (2B51.1), respectively.

Example 2
1 (a) Hepatoma 2C12.02
(b) Cancer of breast 2C6Z
(c)
(d)
2
Code hepatoma as primary at Hepatocellular carcinoma of liver (2C12.02), since the histopathology
‘hepatoma’ indicates a primary malignant neoplasm of liver. Code breast cancer as primary at Malignant
neoplasms of breast, unspecified (2C6Z), since breast is not on the list of common sites of metastases.

Example 3
1 (a) Glioblastoma of brain 2A00.00
(b) Cancer of breast 2C6Z
(c)
(d)
2
Brain is on the list of common sites of metastases, but the histopathology glioblastoma indicates that it is
primary in the central nervous system, usually in brain. Code glioblastoma of brain as primary at
Glioblastoma of brain (2A00.00). Also code the breast cancer as primary at Malignant neoplasms of
breast, unspecified (2C6Z), since breast is not on the list of common sites of metastases.

[Link] Site not clearly indicated

If a malignant neoplasm is described as in the ‘area’ or ‘region’ of a site, or if the site is
prefixed by ‘peri’, ‘para’, ‘pre’, ‘supra’, ‘infra’ or similar expressions, then first check whether
this compound term is included in the coding tool.
If the compound term is not in the coding tool, then code to the appropriate histopathology
of the ill-defined site unspecified. Other specified malignant neoplasms of ill-defined or
unspecified primary sites (2D4Y) is used for histopathologies specified but not classifiable
elsewhere.

ICD-11 Reference Guide 193

If neither of these apply, or the histopathology is not stated, then code to 2D42 Malignant
neoplasms of ill-defined sites.
When the site of a primary malignant neoplasm is not specified, do not make any
assumption of the primary site from the location of other reported conditions such as
perforation, obstruction or haemorrhage. These conditions may arise in sites unrelated to
the neoplasm. For example, intestinal obstruction may be caused by the spread of a
malignant neoplasm of ovary.

Example 1
1 (a) Leiomyosarcoma in the region of the pancreas 2B58.Z
(b)
(c)
(d)
2
Code as Leiomyosarcoma, unspecified primary site (2B58.Z).

Example 2
1 (a) Cancer in the lung area 2C29.Z
(b)
(c)
(d)
2
Code as Malignant neoplasms of other or ill-defined sites in the respiratory system or intrathoracic
organs, unspecified (2C29.Z)

Example 3
1 (a) Obstruction of intestines DB30.Z
(b) Carcinoma 2D41
(c)
(d)
2
Code the carcinoma as 2D41 Unspecified carcinoma of unspecified site (2D41)

[Link] Primary site unknown

If the certificate states that the primary site is unknown and does not mention a possible
primary site or a specific histopathology, code to (2D44). If the primary site is unknown but
a specific histopathology is stated code to the category for unspecified site for the
histopathological type involved. For example, code adenocarcinoma to (2D40), and
osteosarcoma to ([2B51.Z Osteosarcoma of bone and articular cartilage of unspecified sites]
).
If the certificate mentions a probable or possible primary site, disregard the expression
indicating doubt and code to that site. See also Section 2.21.1 Uncertain diagnosis.

194 ICD-11 MMS

If the certificate mentions several possible primary sites, select a code according to the
instructions in Section [Link] One condition, either one site or another above.

Example 1
1 (a) Secondary carcinoma of liver 2D80.0
(b) Primary site unknown 2D44
(c)
(d)
2
The certificate states that the primary site is unknown. For line 1(b), code as 2D44.

Example 2
1 (a) Generalised metastases 2E2Z
(b) Melanoma 2C30.Z
(c) Primary site unknown 2D44
(d)
2
The certificate states that the primary site is unknown, code to 2D44, Malignant neoplasm, primary site
unknown, so stated. Code as 2C30.Z.

Example
3
1 (a) Secondary carcinoma of liver 2D80.0
(b) Primary site unknown, 2B72.Z Malignant neoplasms of
possibly stomach stomach, unspecified
(c)
(d)
2
The certificate states that the primary site is unknown, but it also mentions stomach as a possible primary
site. Ignore primary site unknown, ‘possibly’ and code line 1(b) as Malignant neoplasms of stomach,
unspecified 2B72.Z Malignant neoplasms of stomach, unspecified.

Example
4
1 (a) Secondary carcinoma of liver 2D80.0
(b) Primary site unknown, probably stomach {2B72.Z} or colon 2C11.Z
{2B90.Z }
(c)
(d)
2
The certificate states that the primary site is unknown, but it also mentions stomach or colon as a possible
primary site. Code line 1(b) as Malignant neoplasms of other or ill-defined digestive organs, unspecified
(2C11.Z).

ICD-11 Reference Guide 195

[Link] ‘Metastatic’ cancer
Note: The expression ‘metastatic’ often poses a problem in the English language. Countries
using languages other than English should translate only as much as needed of this section.
Neoplasms qualified as metastatic are always malignant. The adjective ‘metastatic’ can be
used in two ways; mostly describing a primary tumour that has spread = metastasised to
another site or organ (e.g. metastatic breast cancer), and sometimes describing the
secondary site or location where the primary tumour has spread = metastasised
(e.g. metastatic cancer in liver).
In the ICD-11 Foundation the adjective ‘metastatic’ followed by a site/organ (without a
preposition) is always used in the meaning of a primary neoplasm of that particular
site/organ that has spread into another site.
For multiple cause mortality coding, always follow the instructions in this section. This
applies even if the coding tool indicates an ICD code for a ‘metastatic’ neoplasm or
‘metastatic’ disease other than the code you would arrive at by following these instructions.
For example, the search might lead to a code in the section for ‘malignant neoplasm
metastases’, but the multiple cause coding instructions might tell you to code the neoplasm
as primary. If so, follow the instructions and code the neoplasm as primary.

Malignant neoplasm ‘metastatic from’ a specified site

If a malignant neoplasm is described as ‘metastatic from’ a specified site, or if a ‘due to’
relationship implies a spread from a specified site, code to primary of this site. This also
applies to sites on the list of common sites of metastases. See Section [Link] for the blocks
used for primary malignant neoplasms.

Malignant neoplasm ‘metastatic to’ a specified site

If a malignant neoplasm is described as ‘metastatic to’ a specified site, or if a ‘due to’
relationship implies a spread to a specified site, code to secondary of this site, whether the
site is on the list of common sites of metastases or not. Use a code in 2D50-2E2Z ‘Malignant
neoplasm metastases’ for this secondary site. However, if a histopathology is reported, code
to the ‘unspecified site’ subcategory of that histopathological type.

Malignant neoplasm metastatic of site A to site B

A malignant neoplasm described as metastatic of site A to site B should be interpreted as
primary of site A and secondary of site B.

‘Metastatic’ neoplasm of a specific histopathology

If the certificate reports a malignant neoplasm specified as ‘metastatic’ of a
histopathological type classifiable to a cancer category that mentions a specific
histopathology only, and the site reported is consistent with the histopathological type,
then code to a primary malignant neoplasm of the specified histopathological type. Use the
appropriate site subcategory for the specified histopathological type or site.
If the ‘metastatic’ cancer reported on the certificate and the site are not consistent with the
histopathological type, then code to a secondary malignant neoplasm of the specified site.

196 ICD-11 MMS

Also add a code for a primary malignant neoplasm of unspecified site for the stated
histopathological type.
When applying the remaining instructions on ‘metastatic’, do not change codes in 2A00-
2A0Z Neoplasms of central nervous system or related structures, 2B50-2B5Z Malignant
mesenchymal neoplasms, 2C30-2C3Z Malignant neoplasms of skin, 2C40-2C4Z Malignant
neoplasms of peripheral nerves or autonomic nervous system, or assigned according to the
instructions in this subsection ‘Metastatic’ neoplasm of a specific histopathology, to codes
for secondary malignant neoplasms (2D50-2E2Z).

Example 1
1 (a) Osteosarcoma of sacrum, metastatic 2B51.2
(b)
(c)
(d)
2
The site sacrum is consistent with a primary cancer of bone. Code as Osteosarcoma of bone or articular
cartilage of pelvis (2B51.2).

‘Metastatic’ malignant neoplasm on the list of common sites of metastases

If the certificate mentions a single malignant neoplasm, and it is on the list of common sites
of metastases and is specified as ‘metastatic’, then code the neoplasm as secondary, even if
no other neoplasm is mentioned on the certificate. Also add a code for unspecified primary
malignant neoplasm (2D4Z).
• exception: Code a neoplasm, even if described as ‘metastatic’, of a site on the list of
common sites of metastases as primary when it is reported as due to a condition
that increases the risk of a malignant neoplasm of that site or tissue.
• exception: If the only malignant neoplasm mentioned on the certificate is
‘metastatic’ neoplasm of lung, code to Malignant neoplasms of bronchus or lung,
unspecified (2C25.Z). If another malignant neoplasm is mentioned that is not on the
list of common sites of metastases, then code a ‘metastatic’ malignant neoplasm of
lung as Malignant neoplasm metastasis in lung (2D70). This applies whether or not
lung is mentioned in the same part of the certificate as the other malignant
neoplasm.
• exception: For ‘metastatic’ neoplasms of a specified histopathology and on the list of
common sites of metastases, see ‘Metastatic neoplasm of a specific histopathology’
above.
Note that a malignant neoplasm of a site on the list of common sites of metastases is coded
as primary if it is the only site mentioned and it is not described as ‘metastatic’. See also
‘Other indication of primary malignant neoplasm’ above.

ICD-11 Reference Guide 197

 Example 1
1 (a) Metastatic cancer of lung (adenocarcinoma) 2C25.0
(b)
(c)
(d)
2
Adenocarcinoma can be primary in lung. Lung is the only site mentioned or implied on the certificate.
Code as primary malignant neoplasm of lung at Adenocarcinoma of bronchus or lung (2C25.0).

If the certificate mentions several malignant neoplasms that are on the list of common sites
of metastases and one or more of them are specified as ‘metastatic’, then code all of them
as secondary malignant neoplasms. Also add a code for unspecified primary malignant
neoplasm 2D4Z.
• exception: Code a ‘metastatic neoplasm of lung’ as primary malignant neoplasm of
the lung Malignant neoplasms of bronchus or lung, unspecified (2C25.Z) if all other
neoplasm sites reported on the death certificate are on the list of common sites of
metastases, whether they are described as ‘metastatic’ or not.
• exception: For ‘metastatic’ neoplasms of a specified histopathology’ which are on the
list of common sites of metastases, see subsection ‘Metastatic malignant neoplasm
of a specific histopathology’ above.

‘Metastatic’ malignant neoplasm not on the list of common sites of metastases

If the certificate mentions a single malignant neoplasm, and this neoplasm is not on the list
of common sites of metastases but it is specified as ‘metastatic’, then code as primary
malignant neoplasm of that particular site.
If the certificate mentions several malignant neoplasms that are not on the list of common
sites of metastases and all of them are specified as ‘metastatic’, then code all neoplasms as
primary.
If the certificate mentions several malignant neoplasms, and none of them is on the list of
common sites of metastases and some but not all are specified as ‘metastatic’, then code a
neoplasm not specified as ‘metastatic’ as primary and a neoplasm specified as ‘metastatic’
as secondary.
See Section [Link] Malignant neoplasms: primary or secondary? for blocks used for
primary or secondary.

‘Metastatic’ malignant neoplasm, some on the list of common sites of metastases

and some not
If the certificate mentions several malignant neoplasms and some but not all are on the list
of common sites of metastases and some but not all are specified as ‘metastatic’, then code
a neoplasm on the list of common sites of metastases as secondary (2D50-2E2Z). Also, code
a neoplasm not on the list of common sites of metastases and specified as ‘metastatic’ as
secondary, and a neoplasm not on the list of common sites of metastases and not specified

198 ICD-11 MMS

as ‘metastatic’ as primary (See Section [Link] for the blocks used for primary malignant
neoplasms).
• exception: Code neoplasms, even if described as ‘metastatic’, as primary when
reported as due to a condition that increases the risk of a malignant neoplasm of
that site or tissue, whether the site is on the list of common sites of metastases or
not.

Example 1
1 (a) Liver cancer 2D80.0
(b) Metastatic colon cancer [2B90.Z]
(c)
(d)
2
Code as Malignant neoplasm metastasis in liver (2D80.0) and Malignant neoplasms of colon, unspecified
(2B90.Z) . Liver is on the list of common sites of metastases but colon is not.

Example 2
1 (a) Metastatic gallbladder cancer 2C13.Z
(b) Metastatic colon cancer 2B90.Z
(c)
(d)
2
Code both Malignant neoplasms of gallbladder, unspecified (2C13.Z) and Malignant neoplasms of colon,
unspecified (2B90.Z) as primary. The order of entry does not affect the coding.
2.21.6 Sequelae

A sequela is a chronic condition resulting from an acute condition and which begins during
that acute condition. The acute condition is itself no longer present.
The classification provides certain categories to be used when conditions are reported as
sequelae, late effects, or other conditions specified in this section (e.g. 1G80-1G8Z Sequelae
of infectious diseases). Where no specific category is provided for the condition described as
a sequela (e.g. late effects of injuries are coded to the residual category of the chapter that
may also include acute conditions), use additional code XT9C Cause of late effect, if desired,
to identify that the first condition was reported as a cause of a sequela condition (e.g. Head
injury sequelae: NA0Z&XT9C Injuries to the head, unspecified & Cause of late effect).
Note: When deciding whether a condition is a sequelae or late effect, the stated duration of
all subsequent conditions should be taken into account.

ICD-11 Reference Guide 199

 Example 1 Duration
1 (a) Aspiration pneumonia
(b) Dysphagia
(c) Stroke 1 year
(d)
2

Code stroke to the late effect of stroke, as it has caused something with a duration longer
than the required time for stroke to be considered late effect.

[Link] Conditions considered to be sequelae

Consider the following categories present one year or more after onset of the previous
condition as a late effect:
• 1G84 Sequelae of viral encephalitis
• 1G85 Sequelae of diphtheria
• 1G8Y Sequelae of other specified infectious diseases
• 5B63 Sequelae of rickets
• 8B25 Late effects of cerebrovascular disease
• Late effects of injuries, of poisoning or of certain other consequences of external
causes
• Late effects of external causes of morbidity or mortality

[Link] Sequelae of tuberculosis

Code tuberculosis (1B10.0 -1B10-1B1Z) to sequelae of tuberculosis (1G80) if the condition is
specified as such or as arrested, cured, healed, inactive, old or quiescent, or similar
descriptions unless there is evidence of active tuberculosis. This does not include chronic
tuberculosis, which should be coded as active infectious disease.

[Link] Sequelae of trachoma

Code trachoma (1C23) to sequelae of trachoma (1G81) if trachoma is specified as healed or
inactive and certain specified sequelae, such as blindness, cicatricial entropion and
conjunctival scars, unless there is evidence of active infection. It does not include chronic
trachoma, which should be coded as active infectious disease.

200 ICD-11 MMS

[Link] Sequelae of viral encephalitis, diphtheria or other specified infectious
diseases
Condition Active Codes Sequelae
Code
Viral encephalitis 1C80, 1C83 – 1C8D 1G84
Diphtheria 1C17 1G85
Other specified infectious disease, 1A00 - 1A9Z,1B21 - 1B2Z, 1B50 - 1C16, 1G8Y
except for acute rheumatic fever, 1C18 - 1C22, 1C2Y - 1C2Z, 1C82, 1C8E,
and HIV 1C8F, 1C8Y, 1G80

Code the above infectious disease to the appropriate sequelae code of the infectious
condition if the condition is specified as such or as arrested, cured, healed, inactive, old or
quiescent. Sequelae also include conditions present one year or more after onset of
conditions classifiable to infectious disease categories, unless there is evidence of active
disease. This does not include chronic infectious diseases, which should be coded as active
infectious disease.

[Link] Sequelae of malnutrition or certain specified nutritional deficiencies

Condition Active Codes Sequelae Code
Protein energy malnutrition 5B50 - 5B54, 5B71 5B60
Vitamin A deficiency 5B55 5B61
Vitamin C deficiency 5B56 5B62
Rickets 5B57.0 5B63
Other specified nutritional deficiencies 5B57.1 – 5B5K, 5B70, 5B7Y 5B6Y
Unspecified nutritional deficiencies 5B7Z 5B6Z

Code the above malnutrition or certain specified nutritional deficiencies to the appropriate
sequelae code of malnutrition or certain specified nutritional deficiencies if the condition is
stated to be a sequela or late effect of or as the cause of conditions present one year or
more after onset of the condition. This does not include chronic malnutrition or nutritional
deficiency, which should be coded to current malnutrition or nutritional deficiency.

[Link] Late effects of Chapter 22 and Chapter 23

Code any injury, poisoning or certain other consequences of external causes (Chapter 22) or
external causes of morbidity or mortality (Chapter 23) to late effects of injury, poisoning or
certain other consequences of external causes or late effects of external causes of morbidity
or mortality include those specified as such, or as sequelae, and those present one year or
more after the acute injury or originating event. Code to the originating active condition or
external cause and use additional code XT9C if desired to the cluster to retain the
information that it was reported as a late effect.

[Link] Sequelae of leprosy

Code leprosy (1B20) to sequelae of leprosy if leprosy is stated to be a sequela or late effect
of leprosy, or if a chronic condition or a condition with a duration of longer than a year that
is reported due to leprosy is reported.

ICD-11 Reference Guide 201

[Link] Sequelae of poliomyelitis
Code poliomyelitis (1C81) to sequelae of poliomyelitis (1G83):
• if poliomyelitis is specified as such or as history (of) or old, or duration of onset is
more than a year
or
• if a chronic condition or a condition with a duration of longer than a year that is
reported due to poliomyelitis is reported.
2.21.7 Consistency between sex of patient and diagnosis

Most categories of ICD–11 apply to all persons without reference to sex. However, some
diseases are more likely to occur in one biological sex. A list of those conditions is given in:
• 3.14 Annex C: Annexes for Mortality Coding
• 3.14.11 List of categories limited to, or more likely to occur in, female persons
• 3.14.12 List of categories limited to, or more likely to occur in, male persons
When addressing cases of inconsistency between sex of patient and diagnosis reported, it is
important to be aware of issues around gender identity. National legislation may regulate
the recognition of gender identity or gender reassignment (sex-change) including protection
of privacy. If there are special obligations to respect confidentiality around gender
reassignment cases, these must be taken into account in the coding decisions and the
onward dissemination of the coded data.
The general recommendation for handling the situation where there is an apparent
inconsistency between sex and diagnosis reported follows. However, this is a general
guideline which may not always be applicable because legal requirements vary among
countries. It is recommended to manually check all cases of inconsistencies between sex of
patient and diagnosis reported. When data processed automatically in line with guidelines
below, these cases should be flagged for additional manual check.
If there might be an inconsistency between the sex of the deceased and the cause of death
reported:
• check the information and make sure that no reporting error occurred. Further
information may be available from the certifier or registration officials. If checking
shows that either sex or diagnosis is an error, correct the one which is believed to be
wrong.
If no further information is available and:
• it cannot be decided whether there is an error, or which of the two data items (sex
and diagnosis) is the one that is wrong, retain the recorded sex and code to MH14
Other ill- defined and unspecified causes of mortality*.
• it appears that a gender reassignment case or similar situation is involved, retain the
recorded sex and code if possible, to a substitute code which is similar to the
reported diagnosis but not specific to either sex. For example, a neoplasm of sex-
specific genital organs could be coded to 2D4Y Other specified malignant neoplasms

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 of unspecified primary sites. If no suitable substitute code exists, code to MH14
Other ill- defined and unspecified causes of mortality*.
*Consider adding a note to the statistics, specifying the number of cases recoded because of
apparent inconsistencies between sex and cause, while taking into consideration
confidentiality required in each country.
2.21.8 Specific instructions on other ICD categories

[Link] Acute or chronic rheumatic heart diseases

Rheumatic heart diseases are classified to Acute rheumatic fever with heart involvement
(1B41) or to chronic conditions at fifth character 0 of BB60-BC0Z Heart valve diseases, or
BC20 Chronic rheumatic heart diseases, not elsewhere classified, depending on whether the
rheumatic process being described is active or inactive. If there is no statement that the
rheumatic process was active or inactive at the time of death, code the following cardiac
conditions as active (1B41 Acute rheumatic fever with heart involvement):
• a cardiac condition reported as due to rheumatic fever, except cardiac arrest, acute
heart failure, bacterial endocarditis;
• a cardiac condition specified as rheumatic and described as acute or subacute;
• carditis, endocarditis, heart disease, myocarditis or pancarditis, described as
rheumatic or reported as due to a rheumatic disease, and the duration is less than
one year;
• carditis, endocarditis, heart disease, myocarditis or pancarditis, described as
rheumatic or reported as due to a rheumatic disease, and the deceased is less than
15 years old.

[Link] Obstetric death of unspecified cause, Obstetric deaths 42 days–1 year

after delivery, sequelae of obstetric causes
The International form of medical certificate of cause of death (See Mortality Annex 3.14 is
structured to allow reporting on obstetric causes, the time elapsed between the obstetric
event and the person’s death, and whether the pregnancy contributed to death. Use all
information available on the death certificate. When information provided is ambiguous it is
recommended to verify where possible, while means of verification may vary among
countries according to different legal systems or profiles in maternal mortality. Additional
information may be obtained through clinical summaries of medical institutions, verbal
autopsy reports, or by certain verification processes which may require not only queries to
the certifier but also establishing an inquiry system to analyse specific cases.
Following concepts related to statistical tabulation of maternal mortality is provided in
Section 2.25.5 Standards and reporting requirements related for maternal mortality.

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 • [Link] Maternal death
• [Link] Late Maternal death
• [Link] Comprehensive maternal death
• [Link] Direct and indirect obstetric deaths
• [Link] Death occurring during pregnancy, childbirth and puerperium
• [Link] Recording requirements of maternal mortality
• [Link] International reporting of maternal mortality
• [Link] Numerator, denominator, and ratios of published maternal mortality
Briefly the underlying cause of death categories for Maternal Mortality is summarized in the
table below:

JB00 -JB60, JB63.-, JB61.- Late Maternal JB62.- Sequealae of

JB64.-, JB6Y, 1C14 death obstetric
Maternal death conditions
Decesed was at the time of death, more than 42 days but one year or more
pregnant: and within 42 days less than one year before the death
before the death before the death

On a death certificate usually the timespan is recorded in day unit where 42 days are
included in maternal death and 43 days are included in late maternal death. In a
mathmatical explanation, this means exactly 42 days are included in maternal death, while
for example 42 days and one hour is included in late maternal death. Also note that JB61.-
and JB62.- includes deaths due to any obstetric cause. The obstetric cause reported
including cause unknown (JB60) is postcoordinated to JB61.- or JB62.- to retain information
on the cause. Coding instructions are provided to select the UCOD and capture further
details in a cluster.
Coding instructions for maternal mortality
For coding of maternal mortality, follow the general coding instructions.
To assign the correct multiple cause code for a certificate with mention of pregnancy, first
use the coding tool to assign a specific code for each condition reported. Categories out of
Chapter 18 may also be assigned. When a condition suggests it is an obstetric condition, by
using certain modifiers such as ‘obstetric’ or ‘maternal’, search if there is a direct match of
the diagnosis reported. The coding tool also supports coding by providing the icon ‘J’ ( ) for
certain condition that have a compatible category for maternal conditions.

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 Example 1
1 (a) Pulmonary oedema CB01
(b) Mitral valve insufficiency, pregnancy JB64.4/BB61.Z
(c)
(d)
2

Mitral valve insufficiency nos is coded to BB61.Z, however assign JB64.4/BB61.Z because it is
described as ‘pregnancy’.

Example 2
1 (a) Pulmonary oedema CB01
(b) Mitral valve insufficiency BB61.Z
(c)
(d)
2 XX completed weeks of gestation

Code mitral valve insufficiency to BB61.Z. Pregnancy is mentioned in Part 2 and it is

considered that pregnancy contributed to death. Apply Step M4 and code the underlying
cause of death to JB64.4 Diseases of the circulatory system complicating pregnancy,
childbirth or the puerperium. For greater specificity, also add the code for BB61.Z Mitral
valve insufficiency, unspecified to the cluster (JB64.4/BB61.Z).
Structure of Chapter 18 and other related categories
The following categories are used for deaths due to an obstetric event occurring within 42
days after termination of pregnancy:
• JA00 - JB4Z, 1C14: Direct obstetric causes
• JB63.-, JB64.-: Maternal diseases classifiable elsewhere but complicating pregnancy
• JB60 is used when a woman dies during pregnancy, labor, delivery or the puerperium
and the only information provided is ‘maternal’ or ‘obstetric’ death. If obstetric
cause of death is specified, do not use JB60 but code to the appropriate category.
• JB6Y is used for other specified obstetric conditions not elsewhere classified
Category JB61.- is used for death of a woman due to an obstetric cause but more than 42
days but less than one year after termination of pregnancy.
Category JB62.- is used for death of a woman due to an obstetric cause of one year or more
after termination of pregnancy.
JB6Z is used when both obstetric condition is unspecified, and the time elapsed between the
obstetric event and death is unknown. Note that this code is not to be used for underlying
cause of death (See section 2.19.4 Special instructions on surgery and other medical
procedures (Step M4)) .
Determining whether pregnancy contributed to death

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Consider pregnancy contribute to death when pregnancy, puerperium or childbirth is
reported in Part 1 or Part 2;or is reported elsewhere and the answer to the question “Did
the pregnancy contribute to death?” is yes, unknown, or is unstated.
Determining the time elapsed
The time elapsed between the obstetric event and the death is determined by the duration
reported for the obstetric cause. If duration is unknown or unspecified, use the information
in Frame B of the death certificate. When duration is unknown or unstated, but pregnancy
contributed to death, it is assumed that the death occurred within 42 days after the
obstetric event.

[Link] Deaths due to Certain conditions originating in the perinatal period

Chapter 19 ‘Certain conditions originating in the perinatal period’ includes conditions that
have their origin in the perinatal period even though death or morbidity occurs later.
For decedents less than 28 days old, assume that a reported condition developed in the
perinatal period, unless the duration is stated, and the onset was after the first completed
week of life.
Use a code from Chapter 19, if:
• the condition is included in Chapter 19.
• the condition is specified as congenital/perinatal/newborn.
• the duration of the condition indicates that the condition developed in the neonatal
or perinatal period. This applies even if the condition is not specified as neonatal or
perinatal on the certificate.
Some conditions originating in the perinatal period are excluded from Chapter 19, such as:

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 • Intestinal infectious diseases (1A00-1A40.Z)
• Congenital syphilis (1A60)
• Congenital gonococcal infection (1A70-1A70-1A7Z)
• Tetanus neonatorum (1C15)
• HIV disease (1C60-1C62.Z)
• Infectious diseases(1A00-[1H0Z]), acquired after birth
• Neoplasms (2A00-2F9Z)
• Hereditary haemolytic anaemia (3A10)
• Transient hypogammaglobulinaemia of infancy (4A01.03)
• Endocrine, nutritional and metabolic diseases (5A00-5D46)
• Certain congenital diseases of the nervous system (8A00-8E7Z)
• Endocardial fibroelastosis (BC43.3)
• Intestinal obstruction or paralytic ileus (DA93.0)
• Pemphigus neonatorum and Staphylococcal scalded skin syndrome (EA50)
• Cradle cap (EH40.00)
• Diaper (napkin) dermatitis (EH40.10)
• Developmental anomalies (LA00-LD9Z)
• Injury, poisoning and certain other consequences of external causes (NA00-NF2Z)
For some conditions diagnosed under a specific age, it is assumed that the condition was
congenital. See the following section, ‘Developmental anomalies’.

Fetus or newborn affected by maternal factors or by complications of pregnancy, labour or

delivery
Conditions of the mother affecting the fetus or newborn are to be reported in Part 1 or Part
2 of the death certificate and should, where possible, be coded to KA00-KA0Z Fetus or
newborn affected by maternal factors or by complications of pregnancy, labour or delivery.
When a specified maternal condition affecting the fetus or newborn is initially coded
outside Chapter 19 by the coding tool, code to KA00-KA0Z. Also use additional code if
desired to identify the specific maternal condition reported.
Consider a condition as maternal if it is specified as such, or if the term itself indicates it is a
maternal condition (e.g. obstetric haemorrhage), or additional information reported in
Frame B: Other medical data, suggests the condition is maternal.

Example 1
1 (a) Prematurity KA21.4Z
(b) Cervical incompetence KA01.0
(c)
(d)
2
The maternal condition, cervical incompetence, affected the newborn by causing prematurity. The code
provided by the coding tool is GA15.6 which is outside Chapter 19. However, there is an exclusion note for

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fetus or newborn affected by incompetence of cervix uteri. So, code to KA01.0 Fetus or newborn affected
by incompetence of cervix uteri.

The following table provides codes for certain maternal conditions and the corresponding
codes for these conditions when affecting the fetus or newborn. Note that there are
conditions not listed but are still coded to KA00-KA0Z. For example, maternal chemotherapy
or surgical procedure on mother may not be assigned a code but still can be classified to
KA00.9 and KA00.A respectively.

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 Maternal conditions Code to:
JA20-JA2Z Oedema, proteinuria, or hypertensive KA00.0 Fetus or newborn affected by
disorders in pregnancy, childbirth, or the maternal hypertensive disorders
puerperium, except JA22
JA22 Gestational oedema or proteinuria without KA00.1 Fetus or newborn affected by
hypertension gestational oedema or proteinuria
without hypertension
GB40-GC2Z Diseases of the urinary system KA00.2 Fetus or newborn affected by
maternal renal or urinary tract
diseases
Chapter 01 Certain infectious or parasitic KA00.3 Fetus or newborn affected by
diseases maternal infectious diseases
DA0C Periodontal disease KA00.4 Fetus or newborn affected by
periodontal disease in mother
Chapter 12 Diseases of the respiratory system, or KA00.5 Fetus or newborn affected by
LA70-LA7Z Structural developmental anomalies maternal respiratory diseases
of the respiratory system
5B50-5C3Z Nutritional disorders KA00.6 Fetus or newborn affected by
maternal nutritional disorders
Chapter 22 Injury, poisoning or certain other KA00.8 Fetus or newborn affected by
consequences of external causes maternal injury
JB64.0 Anaemia complicating pregnancy, KA00.B Fetus or newborn affected by
childbirth or the puerperium maternal anaemia
GA15.6 Incompetence of cervix uteri KA01 Fetus or newborn affected by
maternal complications of pregnancy
JA01 Ectopic pregnancy KA01 Fetus or newborn affected by
maternal complications of pregnancy
JA40-JA4Z Obstetric haemorrhage KA01 Fetus or newborn affected by
maternal complications of pregnancy
JA80 Maternal care related to multiple gestation KA01 Fetus or newborn affected by
maternal complications of pregnancy
JA87 Maternal care related to polyhydramnios KA01 Fetus or newborn affected by
maternal complications of pregnancy
JA88.0 Oligohydramnios KA01 Fetus or newborn affected by
maternal complications of pregnancy
JA89 Maternal care related to premature rupture KA01 Fetus or newborn affected by
of membranes maternal complications of pregnancy
JA8A Maternal care related to placental disorders KA02 Fetus or newborn affected by
- JA8C Maternal care related to premature complications of placenta
separation of placenta
JB08 Labour or delivery complicated by umbilical KA03 Fetus or newborn affected by
cord complications complications of umbilical cord

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 Maternal conditions Code to:
JA88 Maternal care related to certain specified KA04 Fetus or newborn affected by
disorders of amniotic fluid or membranes, except other abnormalities of membranes
JA88.0
JB00-JB0Z Complications of labour or delivery KA05 Fetus or newborn affected by
certain complications of labour or
delivery

[Link] Special instructions on fetal deaths

Some international agencies require data on both live births and fetal deaths, but others do
not include fetal deaths in their mortality statistics. Therefore, if fetal deaths are included in
the national mortality register, they must be easy to identify, so that data include or do not
include fetal deaths as requested by the agency to which the data will be delivered.
If it is not clear whether the death certificate relates to a fetal death or a child born alive,
refer back to the certifier if possible. If the certifier confirms that it was a case of fetal death,
or if other evidence points to a fetal death, then flag the death as a fetal death in the
mortality statistics. If no cause of death is stated, code to KD3B.Z Unspecified time of fetal
death, cause not specified.
If the certifier states that the child was born alive but does not report the cause of death,
then code to KD5Z Conditions originating in the perinatal or neonatal period, unspecified.
Refer to [Link] for the definitions of live birth and fetal death.

[Link] Developmental anomalies

Conditions classified as Developmental anomalies should be coded as congenital if the
duration of the condition indicates that it existed from birth, even if the condition is not
specified as congenital on the death certificate. This applies to all conditions for which a
specific congenital code is available, whether or not the code is in Chapter 20. Refer to the
coding tool for the appropriate code for the condition with the modifier ‘congenital’.
Further, the following conditions should be coded as congenital at the ages stated, provided
there is no indication that they were acquired after birth:

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 • Under l year of age
– aneurysm
– aortic stenosis
– atresia
– atrophy of brain
– cyst of brain
– deformity
– displacement of organ
– ectopia
– hypoplasia of organ
– malformation
– pulmonary stenosis
– valvular heart disease
• Under 4 weeks of age
– heart disease NOS
– hydrocephalus NOS

[Link] Multiple injuries in the same body region and Injuries involving multiple
body regions
In multiple cause coding, do not use codes for multiple injuries of the same body region
Multiple injuries of specific sites’ (NA00-ND1Z) or codes for ND30-ND37 Injuries involving
multiple body regions, if specific information on the injuries involved is available. Code each
injury separately and use as specific injury codes as possible. The information on multiple
injuries is obtained in the multiple cause code string as a set of specific injury codes.

[Link] Complications of surgical and medical care

There is a short list of specific complications not elsewhere classified in Chapter 22, (NE8Z).
Early complications and conditions arising from devices, implants or grafts are coded here.
Code late complications and longstanding complications of organ function to the
postprocedural section in the appropriate system chapter.

[Link] Intent of external causes

Undetermined intent
The block for undetermined intent (PF40-PH8Z) covers events where available information is
insufficient to enable a medical or legal authority to make a distinction between
unintentional causes, intentional self-harm or assault ([PA00-PF2Z]). The following cases are
included:
• When external causes are reported as the intent could not be determined
• When self-inflicted injuries are reported without specification of intent
Note that self-inflicted poisonings reported without specification of intent are assumed to
be unintentional and are coded to PB20-PB36 Unintentional exposure to or harmful effects
of substances.

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Note that reporting of the intent may be affected by legal provisions in each country or
region - assignment of codes should follow such provisions where appropriate.

[Link] Coding of transport injury events

See Section 2.23.19 for descriptions on transport injury events.
1. Land transport injury events can be “road traffic” or “off-road nontraffic”. Consider it
as a road traffic injury event unless one of the following is true, in which case
consider it as an off-road nontraffic injury event:
–
a) Place of occurrence was stated explicitly as off-road or non-traffic
–
b) Place other than a public street or highway is specified
–
c) Only pedestrians or animals were involved
Special vehicles (see [Link] categories u, v, w and x) are an exception to this rule. If the
place of occurrence (on-road or off-road) is not available, and it is unknown whether the
special vehicle type primarily operates on-road or off-road in your country or setting, code
to categories in “Unintentional land transport injury event unknown whether road traffic or
off-road nontraffic.
2. When unintentional injury involving more than one kind of transport is reported, use
the following order of precedence:
– aircraft and spacecraft
– watercraft
– other modes of transport
3. When a land transport injury event description does not specify the role of person
injured:
• Consider the person injured as a pedestrian, if the person injured is described as
crushed, dragged, hit, injured, killed, knocked down, or run over by any vehicle.
• If not, consider the person injured as an occupant or rider of the vehicle mentioned.
4. When more than one vehicle is mentioned, do not make any assumption as to which
vehicle was occupied by the person injured unless the vehicles are of the same type.
Instead, code to the appropriate categories, taking into account the order of
precedence given in note 2 above.

[Link] Factors influencing health status or contact with health services

This chapter should not be used for international comparison or for primary mortality
coding (that is, as the underlying cause of death). Codes in the chapter may be added as
multiple cause codes.

[Link] Infectious agents reported alone on a death certificate

When an infectious agent is reported alone on a death certificate and if no Index Term is
found for the infection of the infectious agent, refer to Chapter X and code to the infection
of unspecified site of the most detailed parent of the infectious agent.

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 Example 1
1 (a) Adenovirus 1D90
(b)
(c)
(d)
2
Adenovirus is an infectious agent classified to XN000. Code to 1D90 Adenovirus infection of
unspecified site.

Example 2
1 (a) Staphylococcus aureus 1C41&XN6BM
(b)
(c)
(d)
2
Staphylococcus aureus is an infectious agent classified to XN6BM. There is no Index Term for infection by
staphylococcus aureus. Code to the infection of its most detailed parent Staphylococcus, 1C41 Bacterial
infection of unspecified site and add XN6BM to identify the specific infectious agent reported.

Example 3
1 (a) Escherichia Coli 1C41&XN6P4
(b)
(c)
(d)
2
Escherichia Coli is an infectious agent classified to XN6P4. There is no Index Term for infection by
‘Escherichia Coli’, and nor for its parents XN4WC Escherichia and XN5PZ Gram Negative Bacteria. Code to
the infection of its most detailed parent Bacteria at 1C41 Bacterial infection of unspecified site, and add
XN6P4 to identify the specific infectious agent reported.
2.22 Mortality digital end to end solution (forms, tools and training modules)
electronic Medical Certificate of Cause of Death (eMCCD)
The medical certificate of cause of death is the basis for collecting information on causes of
death. The form is designed to collect all relevant aspects to assigning the cause of death
and is independent of the revision of ICD. In addition to the paper form template in section
3.14, the technical specifications for a digital form are made available. The specifications
serve to standardize input in line with the standard form and include a data dictionary for
field names and content-encoding that allows processing the content with the API for
coding, as well as with software for selection of the single underlying cause of death.
Digital tools for the Cause of Death
Coding software for mortality consists of programs that assist in coding, selecting the single
underlying cause of death and assessing the quality of the coding or the quality of the data
at the population level.

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The WHO Digital Open Rule Integrated Cause of Death Selection (DORIS) software assists in
the selection of the underlying cause of death selection. It can be used online and offline.
The ICD mortality rules detailed in section 2.21 were converted into a digital format for
processing by this software. WHO is aiming at convergence in the different efforts in
programming such software.
Analysing Mortality and Causes of Death 3 (ANACOD-3)
This software performs a comprehensive and systematic analysis of mortality and cause-of-
death data. ANACoD3 analyzes sub-national level data to inform of potential health equity
issues or outbreak patterns; it also analyzes data over multiple time periods for trend
analyses and allows for the analysis of cause-of-death data coded in ICD-10 as well as ICD-11
formats. It is available in multiple languages. For assistance in using the tool, please send an
email to mortality@[Link].
CodEdit
Software that helps producers of cause-of-death statistics in strengthening their capacity to
perform routine plausibility checks on their coding of data. Allows for the analysis of cause-
of-death data coded in ICD-10 as well as ICD-11 formats
WHO Interactive self-learning tool
The WHO electronic training tool is designed for self-learning and classroom use. The
modular structure of this training permits user groups specific tailoring of courses on
individual paths if desired. There are two mortality related modules of the training tool.
Certification self-learning module
A training module using the cause of death certificate version for persons that fill in causes
of death on a death certificate.
Recommendations for conducting an external inspection of a body module and how to fill
in a death certificate
A document providing recommendations for conducting an external inspection of a body
and filling in the medical certificate of cause of death (MCCD) using the WHO 2016
international medical certificate of cause of death.
Other software or tools can be accessed through
[Link] or [Link]

2.23 Main uses of the ICD: Morbidity

Morbidity data are used for statistical reporting mostly at national or local levels. While
some of this statistical reporting is conducted within an academic research context, it is
commonly conducted in applied settings to inform health system and public health agency
decision- making. ICD coded data also forms the basis of different casemix systems such as
different varieties of Diagnosis Related Groups (DRGs). Coded morbidity data can also be
used to inform a variety of clinical guidelines through provision of foundational information
on burden of disease. The rules given here are primarily for international reporting and
analysing purposes but are also recommended as a standard for national use.

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2.23.1 ICD use in clinical care

Clinical care comprises different levels of treatment, all of which mean a level of diagnostic
capacity that is higher than in primary care. The ICD addresses this level of detail primarily
through multidimensional coding. Secondary care refers to the health care services provided
by medical specialists and other health professionals who generally do not have first contact
with patients, for example, cardiologists, urologists, or dermatologists. It includes acute
care, necessary treatment for a short period of time for a brief but serious illness, injury or
other health condition, such as in a hospital emergency department. It also includes skilled
attendants during childbirth, intensive care, and medical imaging services. ‘Secondary care’
is sometimes used synonymously with ‘hospital care’. However, many secondary care
providers do not necessarily work in hospitals, such as psychiatrists, clinical psychologists, or
physiotherapists, and some primary care services are delivered within hospitals. Depending
on the organisation and policies of the national health system, patients may be required to
see a primary care provider for a referral before they can access secondary care. Tertiary
care refers to specialised consultative health care, usually for inpatients and following a
referral from a primary or secondary health professional, in a facility that has personnel and
facilities for advanced medical investigation and treatment, such as a tertiary referral
hospital.
2.23.2 ICD use for epidemiological purposes

Epidemiology is the study of the distribution and determinants of health-related states or

events (including disease) and the application of this study to the control of diseases and
other health problems. Various methods can be used to carry out epidemiological
investigations- surveillance and descriptive studies are used to study distribution and
analytical studies are used to study determinants. ICD coded data, either from morbidity or
mortality sources, contribute to the understanding of the health of a population.
2.23.3 ICD use in quality and patient safety

Coded health information is used to measure and report on various aspects of quality of
care and patient safety (e.g. reporting on in-hospital mortality or adverse event rates for
various conditions or reporting on patient safety indicators). Users of this kind of health
information are health system payers (e.g. ministries of health, or in privately-funded health
care systems, health insurance companies) and other stakeholders, such as health quality
councils, hospital administrators, clinical leaders/groups, or public advocacy organisations.

[Link] The quality and safety use case for ICD–11

The quality and safety use case of the ICD is based on the availability of large numbers of
methodological tools that are originally based on ICD–10. Specific examples include the
Charlson and Elixhauser co-morbidity indices, AHRQ (Agency for Healthcare Research and
Quality) Patient Safety Indicators, the Hospital Standardised Mortality Ratio, and various
other administrative data quality indicators. WHO recommendations on coding rules for
hospital separation episodes improve comparability of records across hospitals and
jurisdictions. Specific examples of coding rules include: a) rules for specifying the main
condition, b) numbers of codes per record, c) code clustering mechanisms, and d) use of a
status display system that distinguishes diagnoses arising during a hospital stay from those
present at admission. Quality and patient safety reporting is often focused not only on

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diagnostic information available in the International Classification of Diseases, but also on
procedure information, that is currently coded in various country-specific procedure coding
systems. The harmonisation of ontological concepts in international procedure coding
systems will be important going forward. The available medical and surgical complication
codes of ICD–11 are in line with current knowledge in the domain of safety and adverse
events.

[Link] Reporting on indicators of quality of care and patient safety

This use case relates to the use of coded health information to measure and report on
various aspects of quality of care and patient safety (e.g. reporting on in-hospital mortality
or adverse event rates for various conditions, or reporting on patient safety indicators). The
initiating actor may be a health quality council, hospital administrators, clinical
leaders/groups, a health system payer (e.g. ministries of health, or in privately-funded
health care systems, health insurance companies) or a public advocacy ‘watch-dog’
organisations. The participating actors are hospital administrators, clinicians, health system
decision makers, public representatives, patients and their families, and sometimes even
the media. Requirements for reporting of quality and safety data are: - Availability of
person-level data on episodes of health care delivery (e.g. hospitalisations, physician visits) -
Identifiers that permit attribution of the health care delivery episode to a provider, provider
group, or a given health facility/hospital. - Clinical information on diagnoses present and
procedures performed during a health care delivery episode. - Clinical information on
relevant outcomes such as mortality, length of stay, and specific adverse events. - Analytical
expertise among initiating actors so that attention is paid to data validity considerations,
knowledge of ‘best’ indicators (e.g. the most valid patient safety indicators), risk adjustment
methodology, etc.
The outputs are reports containing information on dimensions of system quality. These can
either provide global information on system performance, or comparative information
stratified by provider unit (e.g. physician-level, hospital-level, or regional reporting).

[Link] Functionality:
An ideal course of events for such use would include: - The initiating actor communicates
desire to conduct quality/safety measurement and reporting to relevant stakeholders. -
Appropriate applications are made to secure access to the data needed to conduct the
planned reporting. - Appropriate methodological and clinical expertise is enlisted to ensure
that best methodological practices are incorporated into the planned reporting, and that
clinical face validity and acceptability are considered. - Data analysis and reporting are
undertaken. - Broad dissemination and knowledge translation to stakeholders is
undertaken. A continuous quality improvement process is undertaken in response to reports
(with consideration given to quality improvement interventions, and repeat measurement
after intervention). - Exceptions: Quality/safety reporting that does not follow the sequence
of steps described above can be compromised. Indeed, there are many historical instances
of failed or suboptimal quality/safety reporting from administrative data because of skipped
steps. (e.g. 1. quality reporting without valid indicators, or appropriate methodologies for
risk adjustment, 2. quality reporting without good clinical face validity, 3. quality reporting
without a Continuous Quality Improvement (CQI) mind set, etc.). - Examples of sub-use
cases (addressing the quality dimensions of effectiveness, efficiency, safety, access) -

216 ICD-11 MMS

reporting on global mortality by facility (e.g. the hospital standardised mortality ratio -
HSMR) - reporting on condition-specific mortality - reporting on patient safety indicators -
reporting on global or condition-specific length of stay - reporting on readmission rates after
hospitalisation - reporting on global or condition-specific costs of care (e.g. cost per
hospitalisation) - reporting on waiting times - reporting on small area variability in utilisation

[Link] Additional information:

Requirements:
See ‘Requirements’ section above. There needs to be ongoing development and refinement
of quality reporting methodologies (in essence, ongoing research around the development
of new administrative data quality indicators and new methodologies for risk adjustment in
outcome/quality reporting).
Assumptions:
An underlying assumption in quality or patient safety reporting from administrative data is
uniformity of data format and data validity across comparator units (i.e. across provides,
hospitals, or jurisdictions). Uniformity in data format and validity is not always present and
has been a common reason for criticism of quality or patient safety reports derived from
administrative data. In this regard, WHO is promoting ongoing efforts towards standardised
coding rules help to facilitate comparative reporting by reducing data variability across
comparator units (e.g. rules on factors such as the definition of the ‘main condition’,
numbers of possible codes per record, and the implementation of diagnosis-timing codes).
See also the separate use case description for international comparative reporting.
In countries with well developed health information systems, it is quite typical for episodes
of hospital-based care to be recorded with varying numbers of ICD codes describing all
medical conditions/diagnoses that impacted an episode of care. Furthermore, some systems
allow for distinction between diagnoses that were present at time of admission versus
diagnoses that arose de novo during the hospital stay. In such systems, the resulting
“discharge abstract” can be used for comprehensive and routine morbidity reporting, within
which quality and safety concepts are a core component. These include: - adverse events
causally linked to medical care - problems in the care process (e.g. error in administration of
drug), but without actual adverse event - new diagnoses arising during a hospital stay where
causal link to medical care is uncertain
To record and analyse the occurrence of such events, it is crucial for health information
systems to have routine morbidity reporting, within which quality and safety concepts are
an important component of morbidity coding.

[Link] Recommendations for use and interpretation of coded data

These recommendations apply to the use of records in which data were captured and
organised as recommended in the previous section: - Select records involving a quality or
patient safety event: these are all records with any quality or patient safety harm code. -
Summarise types of quality or patient safety harm represented in a set of records: select
records with any quality or patient safety harm code. - Summarise the distribution of quality
or patient safety Harm codes present in the selected set. - Summarise quality or patient

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safety causes of harm in a set of records. - Summarise quality or patient safety mechanisms
in a set of records. - Summarise quality or patient safety harm in a set of records.

[Link] ICD use for research purposes

The morbidity use case for ICD–11 includes a number of situations where the primary goal is
to work in an academic research paradigm to extract information from ICD–11 coded data
to study burden of disease, clusters of disease, geographic distribution of diseases, and
health impacts associated with various diseases. The research paradigm is of course most
relevant when it has translational relevance to either health system policy or public health
policy, in which case the research paradigm, labelled as such, becomes indistinguishable
from applied morbidity analyses conducted for the purposed of health planning. Explicit
mention is made here of the widespread use of ICD–11 coded data in a research paradigm,
recognising that this is a significant driver for developing a clinically rich and detailed
classification system, with novel features and coding rules that enhance the classification’s
potential as a research tool.

[Link] ICD use in primary care

Primary care has been defined as essential front line health care based on practical,
scientifically sound, and socially acceptable methods and technology made universally
accessible to individuals and families in the community through their full participation and
at a cost that the community and the country can afford to maintain. Of relevance to
primary care, ICD–11 includes many diagnostic and disease entities that are common
reasons for care at the first level of health services. This could be family practitioners, local
health nurses, or in other settings also specialists, like Ophthalmologists.
ICD–11 has a simplified version for low diagnostic resource primary care settings. For high
diagnostic resource settings, the tabular list for mortality and morbidity statistics contains
all elements relevant to primary care and is thus able to be used in high resource
environments for primary care, as well as for secondary and tertiary care.
The new version of WONCA’s (World Organization of National Colleges, Academies, and
Academic Associations of General Practice/Family Practitioners) International Classification
of Primary Care and the ICD–11 will share a common subset of categories.

[Link] ICD use in Casemix groupings

In casemix grouping systems such as the Diagnosis Related Group (DRG) system, ICD based
data are used for reimbursement and/or resource allocation. Such systems are used
nationally in systematic fashion.
The assignment of patient cases to groups is based on an algorithm using, in addition to
coded diagnosis information, coded procedures, and a number of other variables. The
scientific basis of the casemix systems is grounded in health care economics and in the
theory of medicine. Since casemix systems are an essential part of administration in
countries that use them, smooth transfer to the new revision of the ICD in these systems is
essential for the approval and implementation of the new revision.
ICD–11 has been developed to accommodate the different levels of detail that are required
in diagnosis-related casemix groupings, in close collaboration with the custodians of the

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diverse casemix systems. Joint use in a specific casemix system is driven by the relevant
grouper algorithms, and partly also by national legislation.
For matters of international comparability of hospital activity, it is recommended that
countries adopt the new WHO definition of main diagnosis and country implementations of
ICD–11 apply the new extension codes for the types of diagnoses that are provided with
ICD–11.
For international tabulations, in view of the differences in definitions of hospital, episode
and in-patient, the resulting diagnoses are listed with the aid of the International Shortlist
for Hospital Morbidity Tabulation (refer to section 2.25).
2.23.4 What is coded: Patient conditions

[Link] Main condition

The definition of main condition relates to the description of an episode of hospital-based
care.
The health care practitioner should record and identify as the main condition the one
condition that is determined to be the reason for admission, established at the end of the
episode of health care. This determination is supported through evaluations and
investigations that aim to establish the diagnosis responsible for the admission.

[Link] Multiple conditions contributing to need for admission

Where an episode of health care includes more than one condition contributing to the need
for admission (e.g. congestive heart failure and pneumonia; acute cerebral haemorrhage
and hip fracture; multiple injuries - concussion, rib fracture, right femur fracture after MVA;
or influenza A and Type 1 diabetic ketoacidosis), the health care practitioner should record
and identify the main condition to be the one condition that is deemed to be the most
clinically significant reason for admission.

[Link] Other conditions

In addition to the main condition, the health care practitioner should, whenever possible,
also list separately all other conditions or problems dealt with during the episode of health
care. Other conditions (also known as additional diagnoses) are defined as those conditions
that coexist at the time of admission or develop during the episode of health care and affect
the management of the patient. Conditions related to an earlier episode that have no
bearing on the current episode should not be recorded as other conditions. It is
recommended, where practicable, to carry out multiple-condition coding and analysis to
supplement the routine data.
2.23.5 Health care practitioner documentation guidelines for morbidity coding

The health care practitioner responsible for the patient’s treatment is also responsible for
documenting the patient’s health conditions. This information should be organised
systematically by using standard recording methods. A properly completed medical record is
essential for good patient management. It is also an essential prerequisite to the creation of
a valid coded record of patient diagnoses, derived through a coding process from written

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information describing a patient’s medical condition. When a good written record of patient
conditions is available, successful coding of this information in ICD and associated
classifications produces a valuable source of epidemiological and other statistical data on
morbidity and other health care problems.
The person transforming the information on the stated condition to codes (the ‘coder’) may
be the health care practitioner or a clinical coder who is not responsible for the patient’s
treatment but is specially trained in use of the classification to assign the code(s). In the
latter situation, which is quite common among member countries, the coder depends on
the adequacy of clinical documentation relating to the patient’s condition(s) provided by
health care practitioners in the medical record. The primary importance of clinical
documentation by health care practitioners as the starting point for coded health data
cannot be overstated and needs to be underlined as being a matter of key importance
within countries and internationally – with implications for health information and clinical
documentation teaching within health care practitioner training programs.
For clinical and resource allocation purposes, in many instances, the manifestation of a
disease (kind and severity, e.g. ulcer grade 3) may be more relevant during a specific
treatment episode than the underlying disease (e.g. Diabetes mellitus). For prevention
programs at national levels, knowledge about the underlying aetiology may be more
important. Quality and safety assessments will require reporting additional detail related to
the stay. For comprehensive analysis and use of morbidity data, it is crucial to have a
dataset with multiple fields allowing capture of codes relating to all the aspects above.
Morbidity data are increasingly being used in the formulation of health policies and
programmes, and in their management, monitoring and evaluation, in epidemiology, in
identification of at risk populations, and in clinical research (including studies of disease
occurrence in different socioeconomic groups).
In the context of these morbidity coding rules, the term practitioner is used throughout the
morbidity rules to mean physician or any qualified health care practitioner who is legally
accountable for establishing the patient’s diagnosis. This information should be organised
systematically by using standard recording methods. A properly completed record is
essential for good patient management and is a valuable source of epidemiological and
other statistical data on morbidity and other healthcare problems.
The term episode is used for all settings, including hospital admissions. It is acknowledged
that the definition may be different in each country, though it is most often considered to
be a continuous hospital care period, which begins on the first day of a patient’s admission
to a health care facility and ends on the day upon which they are separated from that
facility through discharge, transfer or death. Some countries consider sequential care
periods on different wards within the same hospital to be distinct episodes of care.
The health care practitioner responsible for the patient’s treatment is also responsible for
documenting the patient’s health conditions during an episode of health care. Good clinical
documentation is critical to continuity and quality of patient care, communication between
members of the treatment team, patient safety and is the legal record of a patient’s episode
of care. When a sound written record of patient condition(s) is available, successful coding

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of this information using the International Classification of Diseases (ICD) and associated
classifications produces a valuable source of morbidity data to support:
• Health care planning, management, monitoring and evaluation
• Epidemiology
• Identification of risk populations
• Clinical research
• Reimbursement and health care funding.
The health care practitioner responsible for the patient’s treatment should select and
document the main condition, as well as any other conditions, for each episode of health
care. It is recommended, where practicable, that all conditions are documented to support
multiple condition coding and analysis to supplement routine data collection and reporting.

[Link] Documentation guidelines involving the term ‘Multiple’-For Single

condition reporting
In cases involving, for example, ‘multiple fractures’, ‘multiple head injuries’ or ‘multiple
valvular disease’, it is acceptable documentation practice to record the diagnoses using the
term ‘multiple’ and then list separately the specific conditions or injuries. For example,
Multiple fractures of pelvis: fracture of os pubis, sacrum, ilium.

[Link] Specificity and detail

Each diagnostic statement should be as informative as possible in order for the clinical coder
to classify the condition to condition to a code that best captures the specific detail
provided in the diagnostic statement. Examples of such diagnostic statements include:
• transitional cell carcinoma of trigone of bladder
• acute appendicitis with localised peritonitis
• meningococcal pericarditis
• pregnancy-induced hypertension
• diplopia due to reaction to antihistamine taken as prescribed
• osteoarthritis of hip due to an old hip fracture
• fracture of neck of femur following a fall at home
• full thickness burn of palm of left hand due to grilling accident
• unintentional puncture of the sigmoid colon during colonoscopy

[Link] Unconfirmed diagnoses

If no definite diagnosis has been established at the end of an episode of health care, then
the health care practitioner should document the information that permits the greatest
degree of specificity and knowledge about the reason for admission that has been
established at the end of the episode of care. This could be a symptom, abnormal finding or
problem. Rather than qualifying a diagnosis as “possible”, or “suspected”, when a diagnosis
has been considered but not established, when applicable, record the symptom, abnormal
finding or problem.

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[Link] Documentation of a ruled out condition
The health care practitioner should document as main condition a “ruled out” condition
when the episode of care involves a person who presents some symptoms or evidence of an
abnormal condition which requires study, but who, after examination and observation,
show no need for further treatment, follow-up or other medical care.
The health care practitioner should not document a ruled out condition as a main condition
if some treatment was provided for a symptom or follow-up is required to determine the
cause of the sign or symptom. In that instance, the health care practitioner should
document the presenting sign or symptom that was treated as the main condition.
Example 1
Admitted for suspected deep vein thrombosis of leg, which after investigation is ruled out
and no follow-up necessary.
Main Condition: Ruled out deep vein thrombosis.
Example 2
A child is found playing with an empty acetaminophen bottle. The mother is uncertain if
there were any tablets in the bottle. The child is brought to the hospital and following
investigation, it is determined that the child did not ingest any pills
Main condition: Ruled out unintentional ingestion acetaminophen (paracetamol)
Example 3
A patient had an elevated PSA and presented for biopsy of the prostate. Biopsy revealed no
evidence of malignancy. No further follow-up planned for the patient.
Main condition: Ruled out prostate malignancy
See Section 2.23.17 Coding a “ruled out” condition for more detail.

[Link] Contact with health services for reasons other than illness
Episodes of health care or contact with health services are not restricted to identification,
treatment or investigation of current illness or injury. Episodes may also occur when
someone who may not currently be sick requires or receives limited care or services. In this
case the health care practitioner should document the details of the relevant circumstances
as the ‘main condition’.
Examples include:

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 • monitoring of previously treated conditions
• immunisation
• contraceptive management, antenatal and postpartum care
• surveillance of persons at risk because of personal or family history
• examinations of healthy persons, e.g. for insurance or occupational reasons
• seeking of health-related advice
• requests for advice by persons with social problems
• consultation on behalf of a third party
• organ or tissue donors
• circumstances related to drugs, procedures, or devices without documented injury
or harm to patient
Chapter 24 ‘Factors influencing health status and contact with health services’ provides a
broad range of categories for classifying these circumstances. Reference to this chapter will
give an indication of the detail required to permit coding to the most relevant category.

[Link] Conditions due to external causes

When a condition such as an injury, poisoning or other effect of an external causes is
recorded, it is important to document fully both the nature of the condition and the
circumstances that gave rise to it. For example:
• ‘fracture of neck of femur caused by fall due to slipping on pavement’
• ‘cerebral contusion caused when patient lost control of car, which hit a tree’
• ‘unintentional poisoning, patient drank disinfectant in mistake for soft drink’
• ‘severe hypothermia, patient fell in her garden in cold weather’
See also Section [Link] Causation in the context of quality and safety.

[Link] Documentation of sequelae

Where an episode of care is for the treatment or investigation of a residual condition
(sequela) of a disease that is itself no longer present, the health care practitioner should
document the residual condition (sequela) and its origin, together with a clear indication
that the original disease is no longer present. For example:
• ‘deflected nasal septum– fracture of nose in childhood’
• ‘contracture of Achilles tendon – late effect of injury to tendon’
• ‘infertility due to tubal occlusion from old tuberculosis’.
Where multiple sequelae are present and treatment or investigation is not directed
predominantly at one of them, a documented statement such as ‘sequelae of
cerebrovascular accident’ or ‘sequelae of multiple fractures’ is acceptable.
2.23.6 Coder guidelines for selecting ‘main condition’ and ‘other conditions’ for coding
purposes

The main condition and other condition(s) relevant to an episode of health care should have
been identified and recorded by the responsible health care practitioner, and coding will

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therefore usually be straightforward. The main condition recorded should be accepted for
coding and reporting unless it is obvious that the health care practitioner did not follow the
guidelines for recording diagnostic information for morbidity data analysis. Whenever
possible, a record with an obviously inconsistent or incorrectly recorded main condition
should be returned to the health care practitioner for clarification.
If clarification of potentially erroneous documentation is not possible, one of the following
rules can be applied by the clinical coder and the main condition reselected for reporting
purposes. The rules are for use when it is unclear which recorded condition should be
selected as the main condition for reporting purposes.
• MB1 Several conditions recorded as ‘main condition’; or
• MB2 Condition recorded as ‘main condition’ is presenting symptom of diagnosed,
treated condition; or
• MB3 Signs and symptoms recorded as ‘main condition’ with alternative conditions
recorded as the cause
Coder rules for reselection of main condition

[Link] MB1 - Several conditions recorded as ‘main condition’

If several different conditions (that cannot be classified to a single stem code) are recorded
as the ‘main condition’, and other details on the record point to one of them being the
‘main condition’ (one condition determined to be the reason for admission established at
the end of the episode of care), select that condition; otherwise, select the condition first
recorded.
If there is the desire to also report other discharge diagnosis types i.e. main resource
condition or initial reason for encounter or admission, then the applicable extension code(s)
from Chapter X ‘Extension codes’, should be assigned to indicate the different types of
discharge diagnosis types that are reported.
Example 1:
A patient was admitted with complaints of fever, chills, severe headache and stiff neck.
Following investigation, a diagnosis of staphylococcal meningitis was confirmed. While in
hospital the patient developed pneumonia.
Main condition: Staphylococcal meningitis. Pneumonia
Two conditions have been recorded as the main condition and querying the health care
practitioner is not possible. The details in the example point to staphylococcal meningitis as
the one condition being the reason for admission established at the end of the episode of
care, therefore the coder should code staphylococcal meningitis as the ‘main condition’.
Pneumonia is coded as an ‘other condition’. It meets the definition of an ‘other condition’ as
it is a diagnosis that arose during the episode of care.
Example 2:

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A patient who has a history of COPD was admitted for a biopsy of the prostate. Patient was
evaluated for COPD. Biopsy was performed and the final diagnosis from pathology results
was benign prostatic hypertrophy.
Main condition: Chronic obstructive pulmonary disease (COPD). Hypertrophy of prostate.
Two conditions have been recorded as the main condition and querying the health care
practitioner is not possible. The details in the example point to benign prostatic hypertrophy
as the condition being the reason for admission established at the end of the episode of
care; therefore, the coder should code hypertrophy of prostate as the ‘main condition’.
COPD is coded as an ‘other condition’ as the physician documented it as co-existing at the
time of admission and affecting the management of the patient.
Example 3:
A patient presents to hospital at 35 weeks gestation with spontaneous premature rupture of
membranes. She is not having any contractions. Examination reveals the baby is in breech
presentation; therefore, delivery by caesarean section is recommended. Mother delivers
healthy preterm infant by caesarean section.
Main condition: Premature rupture of membranes. Breech presentation.
Procedure: Delivery by caesarean section
Two conditions have been recorded as the main condition and querying the health care
practitioner is not possible. The details in the example point to premature rupture of
membranes as the condition being the reason for admission established at the end of the
episode of care. Therefore, the coder should code premature rupture of membranes as the
‘main condition’ and breech presentation and preterm delivery as ‘other condition’.
Example 4:
A patient is admitted to the hospital with pneumonia and congestive heart failure.
Main condition: Pneumonia and Congestive Heart Failure.
Two conditions have been recorded as the main condition and querying the health care
practitioner is not possible. There are no other details on the record to point to one of the
conditions as being the main condition, therefore, in this instance, the coder should code
the first listed condition as the main condition. Pneumonia is coded as the ‘main condition’
and congestive heart failure is coded as an ‘other condition’.

[Link] MB2 - Condition recorded as ‘main condition’ is presenting symptom of

diagnosed, treated condition
If a symptom or sign (usually classifiable to Chapter 21 Symptoms, signs or clinical findings,
not elsewhere classified), or a problem classifiable to Chapter 24 Factors influencing health
status or contact with health services, is recorded as the ‘main condition’, and this is
obviously the presenting sign, symptom or problem of a diagnosed condition recorded
elsewhere and care was given for the latter, reselect the diagnosed condition as the ‘main
condition’.
Example 1:

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The patient presents to hospital with complaint of haematuria. Investigations reveal a
papilloma in the posterior wall of the bladder as the cause of the haematuria. The papilloma
was excised by diathermy.
Main condition: Haematuria
Other conditions: Papilloma of posterior wall of bladder
Haematuria (symptom) is recorded as the main condition; however, it was determined to be
caused by the papilloma of the bladder (diagnosed and treated condition). Therefore, the
coder should reselect and code papilloma of posterior wall of bladder as the ‘main
condition’.
Example 2:
The patient presents to hospital with abdominal pain. Investigations reveal acute
appendicitis and the patient undergoes an appendectomy.
Main condition: Abdominal pain
Other conditions: Acute appendicitis
The symptom ‘abdominal pain’ was recorded as the main condition; however, it was
determined to be caused by appendicitis. Therefore, the coder should reselect and code
acute appendicitis as the ‘main condition’.
Example 3:
A patient with known COPD is admitted to hospital with acute respiratory failure which after
investigation is found to be caused by an acute exacerbation of COPD.
Main condition: Acute respiratory failure
Other condition: Acute exacerbation of COPD
The symptom “acute respiratory failure” was recorded as the main condition; however, it
was determined to be caused by exacerbation of COPD with acute exacerbation. Therefore,
the coder should reselect and code the COPD as the ‘main condition’

[Link] MB3 - Signs and symptoms recorded as ‘main condition’ with alternative
conditions recorded as the cause
Where a symptom or sign is recorded as the ‘main condition’ with documentation that it
may be due to either one condition or another, select the symptom as the ‘main condition’.
Example 1:
Main condition: Headache due to tension or acute sinusitis
The symptom ‘headache’ is recorded as the main condition with two possible causes;
therefore, the coder should code headache as the ‘main condition’.

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2.23.7 Coding using postcoordination in morbidity

A significant new feature in ICD–11 is an embedded functionality for postcoordinating detail

related to diagnostic concepts see Section 2.10.2 Combining stem codes and extension
codes, and how to order these in a complex code cluster, and Section 2.10.1 Adding detail –
postcoordination and cluster coding with multiple stem codes and extension codes.
The postcoordinated coding of diagnostic concepts described by the health care practitioner
is shown in the following examples:
Example 1
A patient is admitted to the hospital for laser treatment of their diabetic retinopathy due to Type 2
diabetes mellitus. During the admission the patient’s medication for arterial hypertension required
adjustment on a number of occasions before discharge. Code as main condition the diabetic retinopathy,
unspecified postcoordinated with the stem code type 2 diabetes mellitus (9B71.0Z/5A11). Code the other
condition, essential hypertension (BA00.Z).

For morbidity coding, the order of the codes in the first cluster in Example 1 has the diabetic
retinopathy ordered first as it is the diabetic retinopathy that meets the definition of main
condition followed by the causing condition Type 2 diabetes. (Note: The classification
instructs to code also the type of diabetes.)
Where an established causal relationship is not documented or cannot be inferred, the two
stem codes cannot be part of the same cluster.
Example 2
Patient admitted for right cataract extraction. The patient also has Type 2 diabetes mellitus and was
reviewed by the endocrinologist and dietitian for their long-term diet and insulin plan. Code the main
condition as Cataract, unspecified, right (9B10&XK9K). Code the other condition as Type 2 diabetes
mellitus (5A11).

Example 2 demonstrates postcoordination where a causal relationship between the cataract

and the Type 2 diabetes has not been documented and cannot be inferred; therefore, the
two stem codes for each condition are reported separately. Postcoordination for the
laterality for the cataract was applied here.

[Link] Coder rule for use of extension codes

Adding detail to Stem codes using Extension Codes
Type 2 extension codes (a new section of codes in ICD–11) provide distinct codes that serve
as concept modifying flags for marking how a diagnosis is to be used and/or interpreted.
Examples of these extension code modifiers include:
• Discharge diagnosis types (main condition; main resource condition; initial reason for
encounter or admission);
• Diagnosis certainty (Provisional diagnosis; Differential diagnosis)
• Diagnosis Timing (Present on admission; Developed after admission; Uncertain
timing of onset relative to admission)
For more detail about the use of all available extension codes, see Section 2.9Extension
codes.

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Example 1
A patient is admitted to hospital with chest pain and after investigation is diagnosed with a
myocardial infarction and then develops a stroke that leads to a one-month hospitalisation.
Myocardial infarction is coded as the main condition because it was the reason for
admission established at the end of the stay. The stroke is coded separately and can be
postcoordinated with a diagnosis-type extension code flag indicating that the stroke
diagnosis arose after admission.
Such a system with diagnosis flags meets the objectives of countries that want a reason-for-
admission coding rule, while also meeting the objectives of countries that want to be able to
make inferences regarding complications of care and resource consumption (which are of
relevance to casemix systems and patient safety and quality assessments).
2.23.8 Coding from health care practitioner documentation of ‘causal relationships’

Sometimes conditions that have a causal relationship are clearly documented by the health
care practitioner using terms such as ‘due to’, ‘caused by’, or ‘arising from’. These
connecting terms indicate the health care practitioner has made a causal link between, for
example, condition A due to condition B. However, sometimes conditions are documented
with connecting terms that are ambiguous for the coder such as ‘with’, ‘after’, ‘in’, and
‘following’. When ambiguous terms are documented, and it is not clear whether the health
care practitioner means a causal relationship or not, the clinical coder should code each
condition separately and not link the conditions in a cluster.
The clustering (postcoordination) is a particularly notable new feature in ICD-11 that has
permitted the introduction of powerful new clinical coding mechanisms for capturing clinical
information in dimensions such as:
• quality and safety coding for health care related injury and harms (see three-part
model described in Section [Link])
• injury and the external cause of injury
• the addition of clinical detail using extension codes
• the specification of diagnosis type and diagnosis timing using extension codes
• the comprehensive description of late effects (sequelae) arising from prior
conditions (See Section 2.21.6)
• the description of inter related stem code diagnoses where there is a clear causal
relationship between them
For more information on causal inference in the context of quality and safety, refer to
Section [Link] Causation in the context of quality and safety.
2.23.9 Coding of suspected conditions or symptoms, abnormal findings and non-illness
situations

If the episode of health care was for an inpatient, the coder should be cautious about
classifying the main condition to Chapters 21 Symptoms, signs or clinical findings, not
elsewhere classified and Chapter 24 Factors influencing health status or contact with health
services. If a more specific diagnosis has not been made by the end of the inpatient stay, or
if there was truly no codable current illness or injury, then codes from the above chapters

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are permissible. The categories can be used in the normal way for other episodes of contact
with health services.
If, after an episode of health care, the main condition is recorded as ‘suspected’,
‘questionable’, etc., and there is no further information or clarification, the suspected
diagnosis must be coded as if established.
Example 1
Main condition: Suspected acute cholecystitis If there is no further information available that indicates
that a definitive diagnosis was reached, code to acute cholecystitis, unspecified (DC12.0Z) as ‘main
condition’.

Example 2
Main condition: Severe epistaxis. Patient in hospital one day. No procedures or investigations reported.
Code to epistaxis (MD20). Although epistaxis is a sign/symptom, it is acceptable since the patient was
obviously admitted to deal with the immediate emergency only.
2.23.10 Coding using combination categories

The ICD provides certain categories where two conditions or a condition and an associated
secondary process can be represented by a single code (i.e. precoordinated concept). Such
combination categories should be used where appropriate information is recorded.
Example 1:
Main condition: Chronic Kidney Disease (CKD), Stage 4 secondary to hypertensive renal disease Other
condition: Essential hypertension Code to Chronic Kidney disease, stage 4 (GB61.4) and add the
Hypertensive renal disease (BA02) in a cluster. Main condition Cluster: GB61.4/BA02 Other condition:
BA00 Essential hypertension

Example 2:
Main condition: Glaucoma secondary to eye inflammation Code to 9C61.24 Glaucoma due to eye
inflammation. This is a precoordinated code in ICD-11.

Example 3:
Main condition: Diabetic cataract. Type 1 diabetes mellitus Other conditions: Hypertension Code Diabetic
cataract (9B10.21) and ‘code also’ the type of diabetes mellitus (5A10). Postcoordinate the stem code for
diabetic cataract and stem code for Type 1 diabetes mellitus. Main condition Cluster: 9B10.21/5A10. The
hypertension is not linked to the cataract or diabetes, so it is not part of the cluster. It is coded as an ‘other
condition’.

Example 4:
Main condition: Rheumatoid arthritis Other conditions: Hypertension, Type 2 diabetes mellitus, Cataract
Code to Rheumatoid arthritis, serology unspecified (FA20.Z) as ‘main condition’. Code the other
conditions (hypertension (BA00.Z), type 2 diabetes mellitus (5A11), cataract (9B10.Z)) separately. If any
optional extension codes are added to any one of the conditions, then a cluster(s) is created as applicable
because extension codes cannot be reported alone. Note that in this example, the linkage (through
clustering) of cataract with diabetes must not be made as the cataract has not been documented as a
diabetic cataract. In this case there is no combination indicating clustering should be used.

Main condition: FA20.Z Other condition: BA00.Z Other condition: 5A11 Other condition:
9B10.Z

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2.23.11 Coding using external causes of morbidity

For injuries and other conditions due to external causes, both the nature of the condition
and the circumstances of the external cause should be coded. The preferred ‘main
condition’ code should be that describing the nature of the condition. This will often, but
not always, be classifiable to Chapter 22 Injury, poisoning or certain other consequences of
external causes. The code from Chapter 23 External causes of morbidity or mortality
indicating the external cause is assigned as an additional code and postcoordinated with the
nature of the condition as it may be regarded as a modifier. See also Section [Link].
Example 1:
Main condition: Fracture of neck of femur caused by fall Other conditions: Contusions to elbow and upper
arm The health care practitioner has identified the fracture as the main condition and since there is no
other information to make the coder question the main condition recorded, the coder should code
fracture of neck of femur, unspecified (NC72.2Z) as the ‘main condition’. The external cause code for
unintentional fall from unspecified height (PA6Z) is used as an additional code linked to the fracture code
through postcoordination. The contusion of elbow (NC30.1) and upper arm (NC10.1) are coded as
another condition cluster and the external cause code for unintentional fall (PA6Z) is linked to the
contusion code through postcoordination.
Main condition cluster: NC72.2Z/PA6Z Other condition cluster: NC30/NC30.1/NC10.1

Example 2:
Main condition: Hip fracture from fall Other condition: Severe hypothermia resulting from exposure to
the cold weather Code to NC72.2Z Fracture of neck of femur, unspecified as ‘main condition’ and
postcoordinate the external cause code for PA6Z Unintentional fall from unspecified height. Code as “other
condition” hypothermia (NF02) and postcoordinate the external cause code PB16. Main condition cluster:
NC72.2Z /PA6Z Other condition cluster: NF02/PB16

Example 3:
Main condition: Diplopia due to reaction to antihistamine taken as prescribed Code to diplopia 9D46 and
postcoordinate the external cause code for PL00 Drugs, medicaments or biological substances associated
with injury or harm in therapeutic use and PL13.2 Drug-related injury or harm in the context of correct
administration or dosage, as mode of injury or harm. An optional extension code may be added to identify
the specific drug was an antihistamine XM4J58.
Main condition cluster: 9D46/PL00&XM4J58/PL13.2
2.23.12 Coding of acute and chronic conditions recorded as main condition

Where the main condition is recorded as being both acute (or subacute) and chronic, and
the ICD provides separate categories or subcategories for each, but not for the combination,
the code for the acute condition should be reported as the main condition (the condition
determined to be the reason for admission established at the end of the episode of care).
When an appropriate combination code is provided for both the acute and chronic
condition, assign the combination code as the main condition.
Example 1:
Main condition: Acute on chronic cholecystitis Code DC12.00 Acute on chronic cholecystitis as the ‘main
condition’. This is an example of combination code for both the acute and chronic condition in ICD-11.

Example 2:

230 ICD-11 MMS

Main condition: Acute exacerbation of chronic obstructive pulmonary disease Code to CA22.0 Chronic
obstructive pulmonary disease with acute exacerbation, unspecified as the ‘main condition’ since the ICD
provides an appropriate single precoordinated code for the combination.
2.23.13 Coding of injuries or harm arising from surgical or medical care

Refer to Section [Link] Overview of code-set in ICD–11 for quality and patient safety.
2.23.14 Coding of adverse events and circumstances in health care that do not cause
actual injury or harm

Refer to Section [Link] Overview of code-set in ICD–11 for quality and patient safety.
2.23.15 Coding of chronic postprocedural conditions

Most body-system chapters also contain categories for permanent (chronic) conditions that
occur either as a consequence of specific procedures and techniques or as a result of the
removal of an organ, e.g. postmastectomy lymphoedema syndrome, post-irradiation
hypothyroidism. Immediate or acute conditions that occur as a consequence of a procedure
may require coding with the 3-part quality and safety model. See also Section [Link]
Overview of code-set in ICD–11 for quality and patient safety. The categories of
postprocedural conditions do not have residual codes (i.e. other and unspecified). This is
intentional so as to prevent users inadvertently classifying conditions to these categories
that should, in fact, be classified elsewhere.
2.23.16 Coding ‘History of’ and ‘Family history of’

Chapter 24 ‘Factors influencing health status or contact with health services’ of the
classification includes a number of codes that describe both a personal history of various
conditions, and a family history of various conditions. The classification of this documented
concept may be coded in one of two ways.
Option 1: Assign the applicable stem code from Chapter 24 ‘history of’ (or ‘family history of’)
by itself.
Option 2: Assign the applicable stem code from Chapter 24 clustered with a code from
another chapter to add specificity as to what the previous ‘disease’ was. The order of stem
codes in the cluster is always the ‘history of’ stem code first, followed by any other codes
that may be added for detail.
Example 1:
A patient has history of sigmoid colon cancer that was curatively resected. Code: QC40.0 Personal history
of malignant neoplasm of digestive organs/2B90.3Z Malignant neoplasm of sigmoid colon, unspecified

In example 1, it is acceptable to code only QC40.0 as the code simply captures the notion
that the patient has a personal history of cancer of the digestive organs. However, the
documented clinical concept (history sigmoid colon cancer) is fully described through use of
the clustering mechanism and linking of stem codes QC40.0/2B90.3Z.
Example 2:
A patient has a family history of macular degeneration. Code: QC66 Family history of eye or ear
disorders/9B78.3Z Degeneration of macula or posterior pole, unspecified

ICD-11 Reference Guide 231

2.23.17 Coding a “ruled out” condition

Many health care encounters are undertaken to evaluate patients for suspected conditions,
to then determine after investigations that the patient does not have the condition in
question. In medical documentation, such scenarios often use the term “ruled out”. It is
essential for health information systems to have an ability to report on such encounters.
ICD-11 includes a number of codes that can be used to describe encounters where a
suspected condition has been “ruled out”. These appear in Chapter 24 as children of QA02
Medical observation or evaluation for suspected diseases or conditions, ruled out. Some of
these codes specify the suspected condition in question:
• Observation for suspected malignant neoplasm, ruled out
• Observation for suspected tuberculosis, ruled out
• Observation for suspected allergy or hypersensitivity, ruled out
In many other common scenarios, there is no code for a specified suspected condition, in
which case, QA02.Y Medical observation or evaluation for other suspected diseases or
conditions, ruled out, is used. In such cases, postcoordination can be used to specify the
suspected condition that was ruled out. The classification of the documented concept “ruled
out” may be coded in one of two ways. Option 1: Assign the applicable code from QA02
Medical observation or evaluation for suspected diseases or conditions, ruled out, by itself.
Option 2: Assign the applicable code from QA02 Medical observation or evaluation for
suspected diseases or conditions, ruled out, clustered with a code from another chapter to
add specificity as to what was the suspected disease that was ruled out. The order of stem
codes in the cluster is always the QA02 stem code first.
Example 1
Admitted for suspected deep vein thrombosis of leg, which after investigation is ruled out and no follow-
up necessary. Main Condition: Ruled out deep vein thrombosis. Code main condition cluster:
QA02.Y/BD71.4

Explanation: QA02.Y indicates that an other specified condition was ruled out and
postcoordination allows specification of what the suspected condition was (deep vein
thrombosis leg).
Example 2
A child is found playing with an empty acetaminophen bottle. The mother is uncertain if there were any
tablets in the bottle. The child is brought to the hospital and following investigation, it is determined that
the child did not ingest any pills. Main condition: Ruled out unintentional ingestion of acetaminophen.
Code: QA02.5 Observation for suspected toxic effect from ingested substance, ruled out. Explanation: In this
example, QA02.5 specifies the condition that was ruled out.
2.23.18 Coding of conditions documented as sequela (late effect)

‘Sequelae’ include residual effects of diseases or disorders, injuries or poisonings specified

as such, or as late effect of, arrested, cured, healed, inactive, old or quiescent condition
unless there is evidence of active disease. Conditions documented as a sequela (late effect)
will typically be classified using postcoordination depending on the case.
The cluster should contain:

232 ICD-11 MMS

 • first, a stem code identifying the specific manifestation (i.e. nature of the effect), and
• second, a stem code designating ‘late effect of’ (either a code from the body system
chapters or a code from Chapter 24 Factors influencing health status or contact with
health services)
• third, if required, a stem code representing the prior condition causing the sequelae
Note: Coding of sequelae of an injury with all detail will require four codes in the cluster, the
fourth code being the external cause code.
Example 1:
Joint contracture present as a late effect of a prior burn. Code cluster: FA34.3 Contracture of joint QC50
Late effect of prior health problem, not elsewhere classified NE11 Burn of unspecified body region/PB1Z
Unintentional exposure to unspecified thermal mechanism

Example 2:
Hemiplegia present as a late effect of old cerebral ischemic stroke. Code cluster: MB53.Z Hemiplegia,
unspecified/8B25.0 Late effects of cerebral ischemic stroke Note: In Example 2, the concept of late effect
and underlying cause is already precoordinated in the stem code 8B25.0.
2.23.19 Standards and coding instructions for injury events

The WHO definition of an ‘injury’ is: ‘acute exposure to physical agents such as mechanical
energy, heat, electricity, chemicals, and ionizing radiation interacting with the body in
amounts or at rates that exceed the threshold of human tolerance. In some cases, (for
example, drowning and frostbite), injuries result from the sudden lack of essential agents
such as oxygen or heat’. Injuries may be categorised in a number of ways. However, for
most analytical purposes and for identifying intervention opportunities, it is especially useful
to categorise injuries according to whether or not they were deliberately inflicted and by
whom. Commonly used categories are:
• unintentional (i.e. accidental)
• intentional (i.e. deliberate)
• interpersonal (e.g. assault and homicide)
• self-harm (e.g. abuse of drugs and alcohol, self-mutilation, suicide)
• legal intervention (e.g. action by police or other law enforcement personnel)
• war, civil insurrection and disturbances (e.g. demonstrations and riots)
• undetermined intent
Regarding the collection of events that cause injuries, a set of definitions apply. See section
‘Definition related to transport injury events’ below.

[Link] Descriptions related to transport injury events

(a) A ‘transport injury event’ is any unintentional injury involving a device designed primarily
for, or being used at the time primarily for, conveying persons or goods from one place to
another.

(b) A public highway (trafficway) or street is the entire width between property lines (or other
boundary lines). It includes the space of open public land used for purposes of moving
persons or property from one place to another. A roadway is that part of the public highway
designed, improved and customarily used for vehicular traffic.

ICD-11 Reference Guide 233

 (c) A road traffic injury event is any unintentional injury occurring on the public highway
[i.e. originating on, terminating on, or involving a vehicle partially on the highway]. An
unintentional injury involving a vehicle is assumed to have occurred on the public highway
unless another place is specified, except in the case of unintentional injury involving only off-
road motor vehicles, which are classified as unintentional injury not caused by traffic unless
the contrary is stated.

(d) An off-road, nontraffic road injury event is any unintentional injury that occurs entirely in
any place other than a public highway.

(e) A pedestrian is any unintentionally injured person involved who was not at the time of the
event riding in or on a motor vehicle, railway train, streetcar or bus or animal-drawn or other
vehicle, or on a pedal cycle or animal.

• Pedestrians include those:

– changing a tire of vehicle

– making an adjustment to the motor of a vehicle

– on or in items which assist with pedestrian conveyance, including:

• baby carriage
• ice-skates
• perambulator
• push-chair
• roller-skates
• scooter
• skateboard
• skis
• sled
• wheelchair (powered)
(f) A driver is an occupant of a transport vehicle who is operating or intending to operate it.

(g) A passenger is any occupant of a transport vehicle other than the driver.

Excludes: person traveling on outside of vehicle - see definition (h) below

(h) A person ‘traveling on’ a transport vehicle includes any person being transported by a
vehicle but not occupying the space normally reserved for the driver or passengers, or the
space intended for the transport of property.

– ‘Traveling on’ includes:

• bodywork
• bumper [fender]
• hanging on outside
• roof (rack)
• running-board
• step
(i) A pedal cycle is any land transport vehicle operated solely by pedals.

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 Includes: bicycle tricycle Excludes: motorised bicycle - see definition (k)

(j) A pedal cyclist is any person riding on a pedal cycle or in a sidecar or trailer attached to such
a vehicle.

(k) A motorcycle is a two-wheeled motor vehicle with one or two riding saddles and sometimes
with a third wheel for the support of a sidecar. The sidecar is considered part of the
motorcycle.

• Includes:

– moped motor scooter motorcycle:

• NOS
• combination
• with sidecar
• motorised bicycle
• speed-limited motor-driven cycle
• Excludes: motor-driven tricycle - see definition (m)

(l) A motorcycle rider is any person riding on a motorcycle or in a sidecar or trailer attached to
such a vehicle.

(m) A three-wheeled motor vehicle is a motorised tricycle designed primarily for on-road use.

• Includes:

– motor-driven tricycle
– motorised rickshaw
– three-wheeled motor car
• Excludes:

– motorcycle with sidecar - see definition (k)

– special all-terrain vehicle - see definition (x)
(n) A car (automobile) is a light transport vehicle with four or more wheels designed
primarily for carrying up to 10 persons. A trailer or caravan being towed by a car is
considered a part of the car.
Includes: minibus
(o) A motor vehicle or vehicle may refer to various transport vehicles. The local usage of the
terms should be established to determine the appropriate code. If the terms are used
ambiguously, use the code for ‘unspecified’. A trailer or caravan being towed by a vehicle is
considered a part of the vehicle.

(p) A light goods vehicle (pick-up truck or van) is a motor vehicle with four or more wheels
designed primarily for carrying property on roads, weighing less than the local limit for
classification as a heavy goods vehicle (usually less than 3500 kg), and not requiring a special
driver’s licence. A trailer or caravan being towed by a light goods vehicle is considered a part
of the vehicle.

ICD-11 Reference Guide 235

 (q) A heavy goods vehicle is a motor vehicle designed primarily for carrying property on roads,
meeting local criteria for classification as a heavy goods vehicle in terms of curbside weight
(usually above 3500 kg), and requiring a special driver’s licence.

(r) A bus is a motor vehicle designed or adapted primarily for carrying more than 10 persons
and requiring a special driver’s licence to operate.

(s) A railway train or railway vehicle is any device, with or without cars coupled to it, designed
for traffic on a railway.

• Includes:

– interurban:

• electric car
• street car (operated chiefly on its own right-of-way, not open to other
traffic) railway train, any power [diesel] [electric] [steam]
• funicular
• monorail or two-rail subterranean or elevated other vehicle designed
to run on a railway track
• Excludes:

– interurban electric cars (streetcars) specified to be operating on a right-of-

way that forms part of the public street or highway - see definition (t)
(t) A streetcar is a vehicle designed and used primarily for transporting persons within a
municipality, running on rails, usually subject to normal traffic control signals, and
operated principally on a right-of-way that forms part of the roadway. A trailer being
towed by a streetcar is considered a part of the streetcar.
• Includes:

– interurban electric car or streetcar, when specified to be operating on a

street or public highway
– tram (car)
– trolley (car)
(u) A special vehicle mainly used on industrial premises is a motor vehicle designed
primarily for use within the buildings and premises of industrial or commercial
establishments.
• Includes:

– battery-powered:

236 ICD-11 MMS

 • airport passenger vehicle
• truck (baggage)(mail)
• coal-car in mine
• forklift (truck)
• logging car
• self-propelled truck, industrial
• station baggage truck (powered)
• tram, truck or tub (powered) in mine or quarry
(v) A special vehicle mainly used in agriculture is a motor vehicle designed specifically
for use in farming and agriculture (horticulture), for example to work the land, tend
and harvest crops and transport materials on the farm.
• Includes:

– combine harvester
– self-propelled farm machinery
– tractor (and trailer)
(w) A special construction vehicle is a motor vehicle designed specifically for use in the
construction (and demolition) of roads, buildings and other structures.
• Includes:

– bulldozer
– digger
– dumper truck
– earth-leveller
– mechanical shovel
– road-roller
(x) A special all-terrain vehicle is a motor vehicle of special design to enable it to
negotiate rough or soft terrain or snow. Examples of special design are high
construction, special wheels and tyres, tracks, and support on a cushion of air.
• Includes: - hovercraft on land or swamp - snowmobile

• Excludes: hovercraft on open water - see definition (y)

(y) A watercraft is any device for transporting passengers or goods on water.

Includes: hovercraft NOS
(z) An aircraft is any device for transporting passengers or goods in the air.

[Link] Classification and coding instructions for unintentional injury caused by

transport
Transport injury events are counted for official statistics where they are unintentional.
1. If an event is unspecified as to whether it was a traffic or a nontraffic-injury event, the
following definitions should be used:

a) Classify as a traffic injury event occurs when the event is classifiable to the traffic
categories.

ICD-11 Reference Guide 237

 b) Classify as a nontraffic injury event occurs when the event is classifiable to nontraffic
categories.

For these categories the victim is either a pedestrian, or an occupant of a vehicle designed
primarily for off-road use.

2. When unintentional injury involving more than one kind of transport are reported, the
following order of precedence should be used:

– aircraft and spacecraft

– watercraft
– other modes of transport
3. Where transport injury event descriptions do not specify the victim as being a vehicle
occupant and the victim is described as crushed, dragged, hit, injured, killed, knocked down,
run over by any vehicle including:

– animal being ridden

– animal-drawn vehicle
– bicycle
– bulldozer
– bus
– car
– motorcycle
– motorised tricycle
– pick-up (truck)
– recreational vehicle
– streetcar
– tractor
– train
– tram
– truck
– van
Classify the victim as a pedestrian.
4. Where transport injury event descriptions do not indicate the victim’s role, classify the
victim as an occupant or rider of the vehicle if there is mention of vehicles such as:

238 ICD-11 MMS

 – airplane
– bicycle
– boat
– bulldozer
– bus
– car
– motorcycle
– motorised tricycle
– pick-up (truck)
– recreational vehicle
– spacecraft
– tractor
– train
– tram
– truck
– van
– watercraft
– accident
– collision
– crash
– wreck
– NOS
Classify the victim as an occupant or rider of the vehicle mentioned. If more than one
vehicle is mentioned, do not make any assumption as to which vehicle was occupied by the
victim unless the vehicles are the same. Instead, code to the appropriate categories, taking
into account the order of precedence given in note 2 above.
5. Where a transport injury event, such as:

– vehicle (motor) (non-motor): – going out of control (due to):

– burst tyre (blowout)
– driver falling asleep
– driver inattention
– excessive speed
– failure of mechanical part resulted in a subsequent collision
Classify the unintentional injury as a collision. If an unintentional injury other than a collision
resulted, classify it as a noncollision injury according to the vehicle type involved.

ICD-11 Reference Guide 239

 6. Where an unintentional injury involving a vehicle in motion, such as:
• unintentional poisoning from exhaust gas generated by breakage of any part or
explosion of any part of
• fall, jump or being unintentionally pushed from
• fire starting in
• hit by object thrown into or onto
• injured by being thrown against some part of, or object in
• injury from moving part of
• object falling in or on vehicle in motion
• resulted in a subsequent collision
Classify as a collision.
If an accident other than a collision resulted, classify it as a noncollision injury according to
the vehicle type involved.
Unintentional injury due to land transport described as:
• collision (due to loss of control) (on highway) between vehicle and:
– abutment (bridge)(overpass)
– fallen stone
– guard rail or boundary fence
– inter-highway divider
– landslide (not moving)
– object thrown in front of motor vehicle
– safety island
– tree
– traffic sign or marker (temporary)
– utility pole
– wall of cut made for road
– other object, fixed, movable or moving
• overturning (without collision)
• collision with animal (herded)(unattended)
• collision with animal-drawn vehicle or animal being ridden are included.
2.23.20 Conceptual model for quality and patient safety

Exposure to health care events sometimes has unintended and undesired consequences.
Health care, the people to whom it is provided, and the complications that can arise in the
course of care are highly diverse and complex. Representing them comprehensively in an
information system is challenging and is presently beyond the bounds of practicality for
routine administrative information systems of the types that are intended to make use of
the ICD. The conceptual model has three components:

240 ICD-11 MMS

 1. Harm to the patient: What was the main consequence for the patient’s health?
2. Cause or source of harm: What caused the harm?
3. Mode or mechanism: In what way? How did the source of harm actually produce
harm?

[Link] Overview of code-set in ICD–11 for quality and patient safety

A key feature of the quality and patient safety code-set in ICD–11 is that a cluster of codes is
required to represent a case. Use of the term ‘cluster’ is novel in ICD–11 and so is the extent
and formalisation of the requirement for postcoordination. The quality and safety use case
of the ICD is based on the availability of large numbers of methodological tools that are
originally based on ICD–10. Specific examples include the Charlson and Elixhauser co-
morbidity indices, AHRQ (Agency for Healthcare Research and Quality) Patient Safety
Indicators, the Hospital Standardised Mortality Ratio, and various other administrative data
quality indicators. WHO recommendations on coding rules for hospital separation episodes
are designed to improve comparability of records across hospitals and jurisdictions. Specific
examples of coding rules include:
• rules for specifying the main condition,
• numbers of codes per record,
• code clustering mechanisms, and
• use of a status display system that distinguishes diagnoses arising during a hospital
stay from those present at admission.
Quality and patient safety reporting is often focused not only on diagnostic information
available in the International Classification of Diseases, but also on procedure information,
that is currently coded in various country-specific procedure coding systems. The
harmonisation of ontological concepts in international procedure coding systems will be
important going forward. The available medical and surgical complication codes of ICD–11
are in line with current knowledge in the domain of safety and adverse events.
There are three parts to the Quality and Safety model. The first component, quality and
patient safety Harm, is usually represented by a standard ICD–11 diagnosis code, from
(almost) any chapter of the classification. Some forms of harm that can result from quality
and safety events are not adequately represented by a standard ICD–11 diagnosis code. A
special set of categories to represent these forms of harm are provided in the injury chapter
of ICD–11 (Chapter 22 ‘Injury, poisoning or certain other consequences of external causes’),
under the category titled ‘Injury or harm arising from surgical or medical care, not
elsewhere classified’. Quality and patient safety causes (sources of harm) fall into four types
of causes at the top level that capture events caused by:
1. substances (drugs and medicaments, etc.),
2. procedures,
3. devices, and
4. a mix of other types of causes.
The full quality and safety external cause codes are found in Chapter 23 ‘External causes of
morbidity or mortality’ within category titled ‘Causes of health care related harm or injury’.

ICD-11 Reference Guide 241

Quality and safety Mode or Mechanism (‘Mode’ is the term used in ICD-11 external cause
codes) is the second part of the model, and refers to the main way in which the Quality and
safety Cause leads to the Harm which is represented in the third concept, Quality and safety
Harm. Quality and safety Modes are specific to the types of Quality and safety Cause.
Examples are:
Table 1: Examples of corresponding quality and safety mode or mechanism

Cause or Source of Mode or Mechanism

Harm
Substance Overdose, underdose, incorrect substance, or harm arising despite
correct administration and dosing
Procedure Unintentional perforation of an organ during a procedure
Device Dislodgement, malfunction
Other cause Mismatched blood; Patient dropped during transfer from operating
room table

Examples for the ICD–11 Quality and safety coding model

The ICD–11 quality and safety coding model is demonstrated by the examples in the
following table.
Table 2: Demonstration of the quality and safety model using examples

242 ICD-11 MMS

 Example Criterion Detail
1 Case A woman has been admitted to hospital for stabilisation of
diabetes. She is erroneously prescribed three times the usual dose
of an antidiabetic medication. The abnormally high dose is given,
and the patient has a hypoglycaemic episode
Harm Hypoglycaemia in the context of diabetes, unspecified (5A21.Z)
Cause Drugs, medicaments or biologic substances associated with injury or
harm in therapeutic use (PL00); Medication (use additional code, if
desired) - Antidiabetic (XM8S35)
Mode Overdose of substance as mode of injury or harm (PL13.0)
Cluster 5A21.Z/PL00&XM8S35/PL13.0
2 Case Patient presented to hospital with visual hallucinations due to
malaria prophylaxis with mefloquine prescribed and taken at the
correct dose.
Harm Visual hallucinations (MB27.27)
Cause Drugs, medicaments or biological substances associated with injury
or harm in therapeutic use (PL00); Medication (use additional code,
if desired) - Mefloquine (XM50J2)
Mode Drug-related injury or harm in context of correct administration or
dosage, as mode of injury or harm (PL13.2)
Cluster MB27.27/PL00&XM50J2/PL13.2
3 Case A man visits a primary care physician for removal of a skin lump,
mainly to exclude the possibility of malignancy. The lesion is excised
and the wound is sutured. It later becomes known that the
physician had Hepatitis C and the patient has now contracted this
disease.
Harm Acute hepatitis C (1E50.2)
Cause Biopsy procedure, not elsewhere classified, associated with injury
or harm in therapeutic use (PK81.5)
Mode Failure of sterile precautions as mode of injury or harm (PL11.4)
Cluster 1E50.2/PK81.5/PL11.4
4 Case An elderly woman is admitted due to a fractured neck of femur.
Surgical fixation is undertaken. The operative site bleeds heavily the
day after surgery, requiring return to theatre.
Harm Haemorrhage or haematoma of other or unspecified site
complicating a procedure, not elsewhere classified (NE81.0Z) &
XA1673 Femoral neck
Cause Musculoskeletal procedure associated with injury or harm, open
approach (PK80.80) (Orthopaedic surgical procedures are included
here)

ICD-11 Reference Guide 243

Example Criterion Detail
Mode Unspecified mode of injury or harm associated with a surgical or
other medical procedure (PL11.Z) (Note: Select PL11.Z because case
documentation does not mention any specific mode or mechanism
by which haemorrhage occurred)
Cluster NE81.0Z & XA1673 /PK80.80/PL11.Z
5 Case A 63 year old man had a left knee-replacement less than a year ago,
because of arthritis. The implanted device has come loose, resulting
in pain and reduced function.
Harm Pain in joint (ME82); Specific Anatomy (use additional code, if
desired) Knee joint (XA8RL1); Laterality (use additional code, if
desired) – Left (XK8G)
Cause Orthopaedic devices associated with adverse incidents, prosthetic
or other implants, materials or accessory devices (PK99.2)
Mode Dislodgement, misconnection or de-attachment, as mode of injury
or harm (PL12.4)
Cluster ME82&XA8RL1&XK8G/PK99.2/PL12.4
6 Case A man has bowel cancer. Abdominal surgery was done several days
ago to resect the affected part of the colon and re-join the
preserved part of the colon. The anastomosis has leaked and
required surgical revision.
Harm Postsurgical leak (NE81.3) (anastomosis leak is an index term)
Cause Gastrointestinal, abdominal, or abdominal wall procedure
associated with injury or harm in therapeutic use PK80.3Z
Mode Unspecified mode of injury or harm associated with surgical or
other medical procedure (PL11.Z). (Note: Select PL11.Z because
case documentation does not mention any specific mode or
mechanism by which the anastomotic leak occurred).
Cluster NE81.3/PK80.3Z/[PL11.Z]
7 Case Refractory urinary tract infection due to chronic indwelling
catheter.
Harm Urinary tract infection, site and agent not specified (GC08.Z)
Cause Gastroenterology or urology devices associated with adverse
incidents, urinary catheter (PK93.10)
Mode Other specified mode of injury or harm associated with a surgical or
other medical device, implant or graft (PL12.Y) (Note: Select PL12.Y
because none of the more specific mode types appears to lead to
infection of device)
Cluster GC08.Z/PK93.10/PL12.Y
8 Case Elderly patient falls out of bed in a hospital and suffers a left hip
fracture. The documentation describes that the nurse forgot to put
the bedrails in place which lead to the patients fall.

244 ICD-11 MMS

 Example Criterion Detail
Harm Fracture of neck of femur, unspecified (NC72.2Z; Laterality (use
additional code, if desired) - Left (XK8G)
Cause Other health care related causes of injury or harm (PL10)
Mode Fall in health care (PL14.E)
Cluster NC72.2Z & XK8G/PL10/PL14.E
9 Case Patient received an infusion of red blood cells and develops severe
rigors that subside after an hour. It was discovered that there was a
blood mismatch (not ABO or Rh incompatibility).
Harm Other serum reactions (NE80.3)
Cause Other health care related causes of injury or harm (PL10)
Mode Mismatched blood used in transfusion (PL14.3)
Cluster NE80.3/PL10/PL14.3
10 Case Right sided pneumothorax caused by mechanical ventilation in an
intensive case setting
Harm Pneumothorax, unspecified (CB21.Z); Laterality (use additional
code, if desired) - Right (XK9K)
Cause Ventilation associated with injury or harm in therapeutic use
(PK81.0)
Mode Unspecified mode of injury or harm associated with a surgical or
other medical procedure (PL11.Z)
Cluster CB21.Z&XK9K/PK81.0/PL11.Z
11 Case Patient with neutropenia due to chronic therapy with clozapine.
Harm Acquired neutropenia (4B00.01)
Cause Drugs, medicaments or biological substances associated with injury
or harm in therapeutic use (PL00); Medication (use additional code,
if desired) - XM8UG6)]
Mode Drug-related injury or harm in the context of correct administration
or dosage, as mode of injury or harm (PL13.2)])
Cluster 4B00.01/PL00&XM8UG6/PL13.2

Note that in each of these examples, a mode/mechanism of harm is coded alongside the
cause of harm code for all cases. This is true, even when a mode of harm is not apparent. In
the latter situations, a code for ‘mode or mechanism of injury unspecified’ should be
selected, for any of substance-related harm, procedure-related harm, or device-related
harm. For the ‘other health care related causes’ the harm should be coded (from anywhere
in the classification) followed by code PL10 Other health care related causes of injury or
harm followed by the appropriate code from category PL14 Mode of injury or harm
associated with other health care related causes (where there are several mode options).
Considerations around distinguishing poisoning versus overdose of drugs, medicaments or
biologic substances in the clinical context

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It is important to make a distinction between an overdose in the context of clinical care and
a poisoning that is not in a clinical context. The former would be coded using codes in the
‘Causes of health care related harm or injury’ section of Chapter 23, whereas poisonings
would be coded in the ‘Unintentional causes’ or ‘Intentional self-harm’ sections of Chapter
23.
The following scenarios will help to illustrate the distinction:
1. An adult medical inpatient receives an overdose of a prescribed medication, because
an excess dose is inadvertently injected by a nurse.
2. An adult inadvertently takes an overdose of their own prescribed medication,
because the physician wrote the prescription incorrectly.
3. An adult inadvertently takes an overdose of their own prescribed medication,
because they were given incorrect instructions by the pharmacist.
4. An adult inadvertently takes an overdose of their own prescribed medication,
because they misunderstood instructions on the pill bottle and verbal instructions
given to them by both the pharmacist and their doctor.
5. An adult inadvertently takes an overdose of their own prescribed medication, and it
is unclear from documentation or case investigation as to why a mistake was made.
6. An adult takes and overdose of their own prescribed medication with undetermined
intent.
7. An adult intentionally takes an overdose of their own prescribed medication with
intent for self-harm.
8. A child ingests a number of pills from his mother’s prescribed pill bottle and
becomes somnolent.
Scenario 1 is clearly an overdose arising from an error in a health care context, while
scenario 8 is clearly a poisoning of a child who is not in a therapeutic health care context.
Scenario 7 should also be coded as an episode of poisoning, because the pills were not
taken with a therapeutic intent, but with intent for self-harm (the ‘Intentional self-harm’
concept overrides other considerations).
Scenarios 2 and 3 are overdoses arising from problems in a health care context (and are
coded using the’ Causes of health care related harm or injury’ codes). In both scenarios, the
context is one of medication treatment, and the actions of health care providers.
Scenarios 4, 5 & 6 are less straightforward, though rather common in patient care. The
context of the medication use is still clearly that of treating a medical condition and the fact
that the medication was prescribed to the patients makes it a context of therapeutic use
(provided there is no mention of intentional self-harm). Because of the therapeutic context,
these scenarios should be coded using the ‘Causes of health care related harm or injury’
codes, rather than poisoning codes.

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Overdose Flowchart
Figure 1: Flowchart for coding poisoning versus overdose.
Instructions on when the three-part quality and safety model applies, and when it does
not
The above sections and examples describe scenarios in which an aspect of care (a drug,
procedure, device, or other aspect of care) has been causally linked to a condition that a
patient has developed. In many instances, however, conditions arise in the health care
setting without explicit documentation suggesting a causal link to an aspect of care. Specific
examples include:

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 • pulmonary embolism arising two days after a surgical procedure
• atrial fibrillation after surgery
• low blood pressure one day after administration of a drug
• pneumonia developing on day four of a hospital stay
• urinary tract infection arising in hospital without any mention of catheters
In each of these examples, the three-part model for quality and safety would NOT apply if
there is no explicit documentation asserting a causal link to another aspect of care, whether
that is a drug, procedure, device, or other aspect of care. Importantly, the mere mention of
a surgical procedure or a drug administration in the above examples, does NOT mean that
those factors played a causal role, because the clinical statements merely declare timing of
the diagnosis, with descriptive words like ‘after’, ‘following’, ‘occurring on day XX’. In such
cases, the correct coding of the conditions would be to code the medical condition from any
chapter from ICD-11 along with an extension code for timing (in particular, the extension
codes for diagnoses arising during a hospital stay, plus or minus the optional extension
codes for intraoperative or postoperative timing of a diagnosis).
The above examples would be coded in the following way:
• BB00.0 Acute pulmonary thromboembolism &XY69 Developed after admission
&XY7V Postoperative
• BC81.3 Atrial fibrillation &XT5R Acute &XY69 Developed after admission &XY7V
Postoperative
• BA2Z Hypotension, unspecified &XY69 Developed after admission
• CA40.Z Pneumonia, organism unspecified &XY69 Developed after admission
• GC08.Z Urinary tract infection, site and agent not specified &XY69 Developed after
admission

[Link] Causation in the context of quality and safety

There are nuances of language in documentation that will indicate whether there is a causal
link between a cause and harm.
Connecting terms implying a causal relationship
A causal relationship is strongly suggested by the following terms:

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 Terms Additional Notes
as (a) complication of, complicated by, -
complicating, complication(s) of
as a cause of, cause of, caused, caused -
by, causing
as a result of, resulted in, resulting in, -
with resultant, with resulting
because of -
due to -
from -
induced, induced by -
leading to, led to -
related to, -
precipitated by -
producing -
secondary to -
likely related to Coding judgment call. However, the clinician is
making a causal inference with this term
possibly secondary to, probably Coding judgment call. However, the clinician is
secondary to making a causal inference with this term
may be the reason for Coding judgment call. However, the clinician is
making a causal inference with this term

Connecting terms where the causal relationship is unclear

Occasionally there may be connecting terms that hint at causation, but without explicit
assertion of a causal link. Examples are shown below. In these circumstances, coders need
to check with the documenting clinician, or look for supplementary wording or ancillary
information that implies causation.

Terms
Associated with
Accompanied by
Incidental to

Connecting terms NOT implying a causal relationship

In clinical documentation, terms are often used to describe a temporal association. The
many terms listed in the preceding table (from ‘connecting terms implying a causal
relationship’) are connecting terms that do suggest a causal association that is typically also
a temporal association. In contrast, there are a number of terms that describe only temporal
associations. Examples of such terms are listed below:

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 Terms
after
also
and
during
with
arising in or during
consistent with
followed by, following
incurred after/during/in/when
occurred after/during/in/when/while
postoperatively, postoperative, occurred post-op

If connecting terms of this sort appear in clinical documentation without any of the causal
connectors discussed earlier, avoid using the three-part quality and safety model.
Terms like ‘postoperative’, ‘post-op’, ‘postprocedural’, etc., are a special situation because
these have historically been considered, in some coding systems to be indicative of a causal
link. However, as noted in the specific examples above, conditions such as urinary tract
infection, pneumonia, and atrial fibrillation may temporally arise after surgery, without
necessarily being caused by surgery. It is for this reason that the guidelines presented here
instruct coders to look for explicit causal connections. (Importantly, postoperative
conditions such as pneumonia, urinary tract infection, and atrial fibrillation can still be
coded with informative extension codes that specify timing – i.e. ‘arising during hospital
stay’ and/or ‘postoperative’–and permit the derivation of adverse events in indicators in
data analysis).
Other specific situations where the clinical context implies a causal relationship
There are some clinical situations where there may not be connecting terms that explicitly
point to causation, but where the clinical circumstances nevertheless clearly point to
causation. Some examples appear below:

Specific situations
failed device
infected device
loose screws
postprocedural bleeding
post-op wound infection
dehiscence
wound hematoma

In each of these, it is clear that the situation would not have occurred in the absence of a
procedure or a device problem. Accordingly, the three-part quality and safety model should
be applied.

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In contrast, conditions such as postoperative pneumonia or postoperative pulmonary
embolism, or postoperative atrial fibrillation are different than the specific situations listed
in the table above. This is because problems such as pneumonia, pulmonary embolism, or
atrial fibrillation can be triggered by factors unrelated to the surgical procedure
(i.e. different from a ‘wound’ that is without question caused by surgery).

[Link] Chronic postprocedural conditions

There are many chronic clinical conditions that occur either as a consequence of specific
procedures and techniques or as a result of the removal of an organ, e.g. postmastectomy
lymphedema syndrome, postirradiation hypothyroidism. In many instances, codes for such
chronic postprocedural conditions are in ICD-11 within various body system chapters.
Examples include:
• BE10 Postcardiotomy syndrome
• 5D40.Z Postprocedural hypothyroidism, unspecified
• GC72 Postprocedural urethral stricture
• GC70 Postoperative adhesions of vagina
These are, by their very nature, precoordinated codes that capture both the a clinical
condition and the notion of it being caused by a procedure. It is possible to use such codes
on alone without any clustering. However, coders can use the three-part model with such
codes to add specificity. The model allows the addition of more specificity about the specific
type of surgical procedure that caused the condition, and also the mode through which the
procedure caused the condition.
Example 1: Urethral stricture due to previous radiation for treatment of prostate cancer.
Code to GC72 Postprocedural urethral stricture Further detail can be added to the code
GC72 with the addition of: PK81.C Radiation therapy associated with injury or harm in
therapeutic use and PL11.Y Other specified mode of injury or harm associated with a surgical
or other medical procedure Cluster: GC72/PK81.C/PL11.Y
Note, however, that there will occasionally be instances where it is entirely unnecessary to
use the three-part model because the code for the chronic postprocedural condition already
contains full clinical detail. For example:
• 9D21 Cataract lens fragments in eye following cataract surgery (for this, it would be
highly redundant to code “ophthalmic procedure” and a corresponding mode, given
all the detail that is inherently embedded in this single code).
• EL61 Chronic radiodermatitis following radiotherapy (again, redundant to code
“radiation therapy” as the procedure causing harm, and “mode unspecified” for this
case).
In relation to the two preceding examples, we reiterate that the overriding recommendation
is that the three-part model should be used whenever possible. Coders must simply make a
case by case judgement when it is obvious to them that the added procedure code and
mode code are redundant.

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[Link] Adverse events and circumstances in health care that do not cause
actual injury or harm
There are instances in the context of health care where things happen to patients, and
where problems arise, but where there is no actual adverse consequence to the patient as a
recorded medical condition. Specific examples include:
• A fall in the health care setting without fracture or other injury
• An incorrect drug administered without harm to patient
• A drug given to the wrong patient without harm to the patient
• A delay in drug administration without negative effect on clinical course
• Documented failure of sterile precautions in a surgical procedure without ensuing
infection
• Dislodged orthopaedic device without symptoms or problems
• Inadvertent needle stick without documented injury or other harm
In these circumstances, codes should be chosen from Chapter 24 Factors influencing health
status or contact with health services in the section of codes entitled ‘Health care related
circumstances influencing the episode of care, without documented injury or harm’. These
codes are organised using the four categories of health care related harm that appear in
Chapter 23 External causes of morbidity or mortality (drugs, devices, procedures and other
health care related causes), but with the important distinction that the circumstances being
described through coding did NOT cause actual harm to the patient.
The above examples would be coded in the following way:
• QA8E Fall in health care without injury or harm
• QA72 Incorrect substance without injury or harm
• QA8D Patient received diagnostic test or treatment intended for another patient
without injury or harm
• QA8B Delayed treatment without injury or harm
• QA52 Failure of sterile precautions without injury or harm
• QA62 Dislodgement, misconnection or de-attachment without injury or harm
• QA8F Needle stick without injury or harm
Figure 1: Summary algorithm for coding events and conditions that arise in the context of
health care

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Q&S Algorithm

[Link] Recommendations for data capture and organisation

Information systems must be capable of capturing the three components and marking the
three codes as belonging to the same cluster (see also instructions for postcoordination and
cluster coding).

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2.23.21 Chapter-specific notes

Coder guidance is given below for specific chapters where problems may be encountered in
selecting preferred ‘main condition’ codes. The preceding general guidelines and rules apply
to all chapters unless a specific chapter note states otherwise.

[Link] Chapter 1: Infectious and parasitic diseases

Human immunodeficiency virus [HIV] disease
A patient with a compromised immune system due to HIV disease may sometimes require
treatment during the same episode of care for more than one disease, for example
mycobacterial and cytomegalovirus infections. Only subcategories for HIV disease
associated with tuberculosis and malaria are precoordinated in this block for HIV disease.
When another specified HIV-caused disease is documented by the health care practitioner,
postcoordinate the HIV-caused disease with the appropriate subcategory for HIV disease as
recorded by the health care practitioner.
Example 1:
The patient has HIV disease and is admitted for treatment of Kaposi sarcoma of the soft palate.
Main condition: Kaposi sarcoma due to HIV disease
Kaposi sarcoma is documented as an HIV-caused disease. Therefore, the stem code for Kaposi sarcoma is
postcoordinated with the applicable stem code for HIV.
Main condition: 2B57.Y Kaposi sarcoma of other specified primary sites &XA8HL5 Soft palate/1C62.3 HIV
disease clinical stage 4 without mention of tuberculosis or malaria.

Example 2:
The patient has HIV disease and is admitted for treatment of toxoplasmosis.
Main condition: Toxoplasmosis due to HIV
Main condition: 1F57.Z Toxoplasmosis, unspecified/1C62.3 HIV disease clinical stage 4 without mention
of tuberculosis or malaria

Sepsis with or without septic shock

The concept of sepsis has undergone major changes during the last decades and the current
description established and widely accepted internationally in 2016 is that sepsis is a life-
threatening organ dysfunction caused by a dysregulated host response to infection.
Sepsis is not considered to be a disease in itself, but a reaction to an infectious disease
which may be of bacterial, viral, fungal or protozoal aetiology. Septic shock is defined as a
subset of sepsis in which circulatory, cellular and metabolic abnormalities are profound
enough to substantially increase mortality.
A cluster involving a case of documented sepsis should include:

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 • First, a stem code representing the causing infection (specified or unspecified) and as
applicable, an optional extension code for the infectious agent if it is known.
• Second, a stem code for sepsis with or without septic shock depending on the
documentation
Note: If the causing infection is documented as generalised or a specific infection is not
documented, assign a stem code for greatest level of specificity documented in relation to
the infection.
Example 1:
Patient admitted for treatment of pneumococcal pneumonia causing sepsis
Main condition: Pneumococcal pneumonia causing sepsis
Code first the causing infection, CA40.07 Pneumonia due to Streptococcus pneumoniae and postcoordinate
with the stem code for 1G40 Sepsis without septic shock
Main condition cluster: CA40.07/1G40

Example 2:
Patient admitted for treatment of severe influenza A H1N1 causing sepsis.
Code first the causing infection, Influenza 1E30 Influenza due to identified seasonal influenza virus with
optional extension code for (XN297 Influenza A H1N1 virus) and postcoordinate with the stem code for
(1G40 Sepsis without septic shock)
Main condition cluster: 1E30 &XN297/1G40

Example 3:
Patient admitted for treatment of sepsis due to [Link].
Main condition: Sepsis due to E Coli.
Code first the causing infection. In this example, a specific infection is not documented; therefore a code
for (1C41 Bacterial infection of unspecified site), is coded with optional extension code for (XN6P4
Escherichia coli) and postcoordinate with the stem code for (1G40 Sepsis without septic shock).
Main condition cluster 1C41&XN6P4/1G40

Example 4:
Patient presented with septic shock and died shortly after admission.
Main condition: Septic shock, unknown infection
Code first the causing infection. In this example, a specific infection is unknown; therefore, a code for
[1H0Z Infection, unspecified] and then postcoordinate with the code for (1G41 Sepsis with septic shock)
Main condition cluster: [1H0Z] /1G41

[Link] Chapter 2: Neoplasms

When coding neoplasms, refer to the instructions regarding code assignment at the level of
the individual categories, and the use of additional morphological or site descriptions from
the extension codes. A neoplasm, whether primary or metastatic, that is the focus of care
during a relevant episode of health care, should be recorded.
When the ‘main condition’ recorded by the health care practitioner is a primary neoplasm
and the ‘other condition’ is a secondary neoplasm (metastasis), code each neoplasm

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separately. Do not postcoordinate the stem code for primary neoplasm with the stem code
for secondary neoplasm.
When the main condition recorded by the health care practitioner is a secondary neoplasm
(metastasis) and the primary neoplasm is no longer present (having been removed during a
previous episode of care or where the documentation indicates a personal history of that
neoplasm), code the secondary neoplasm (metastasis) as the main condition and separately
code as an other condition the stem code for ‘personal history of’. Do not postcoordinate
the stem code for secondary neoplasm with the stem code for ‘personal history of’. (See
example below). Also, refer to Section 2.23.16 Coding ‘History of’ and ‘Family history of’ for
further coding direction.
When the main condition recorded by the health care practitioner is ‘Follow-up
examination’ (a circumstance codable to Chapter 24 ‘Factors influencing health status or
contact with health services’) and the ‘other condition’ recorded is a ‘personal history of’,
code the applicable ‘follow-up examination’ code as the main condition and separately code
the stem code for ‘personal history of’ as the other condition. Do not postcoordinate the
‘follow-up examination’ stem code with the stem code for ‘personal history of’. Refer to
Section 2.23.16 Coding ‘History of’ and ‘Family history of’ for coding direction.
Example 1:
A patient is admitted for investigation of a lump in the breast. Investigation concludes a malignancy in the
left breast. Mastectomy is performed and histopathology shows an invasive ductal carcinoma which has
spread to regional lymph nodes (left axilla). Chemotherapy is planned.
Main condition: Invasive ductal carcinoma
Other condition: Metastases to regional lymph nodes
Procedure: Mastectomy
Code the main condition as invasive ductal carcinoma with optional extension code ‘left’. (2C61.0&XK8G).
Cluster code secondary malignancy in axillary lymph nodes with optional extension code ‘left’ as other
condition (2D60.3&XK8G).

Example 2:
Patient who has a history of carcinoma of breast resected two years ago is admitted for a bronchoscopy
with biopsy. Investigation revealed secondary carcinoma in lung.
Main condition: Secondary carcinoma in lung
Other conditions: Carcinoma of breast resected two years ago
Procedure: Bronchoscopy with biopsy
Code the main condition as [2D70 Malignant neoplasm metastasis in lung] . Code QC40.3 Personal history
of malignant neoplasm of breast as another condition and postcoordinate the stem code 2C6Z Malignant
neoplasms of breast, unspecified to specify the personal history is related to malignant primary breast
cancer. Refer to Section 2.23.16 Coding ‘History of’ and ‘Family history of’’. Main condition: 2D70 Other
condition: Option 1: QC40.3; Option 2: QC40.3/2C6Z

Example 3:
Patient is admitted for bladder cancer recheck by cystoscopy. The patient has a history of previously
excised bladder cancer. No evidence of recurrence seen.
Main condition: Follow-up examination by cystoscopy
Other conditions: History of bladder cancer

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Procedure: Cystoscopy
Code the main condition as QA06 Follow-up examination after treatment for malignant neoplasms. Option
1: Code QC40.5 Personal history of malignant neoplasm of urinary tract. Option 2: Code QC40.5 Personal
history of malignant neoplasm of urinary tract as an other condition and postcoordinate the stem code
2C94.Z to specify the personal history is related to bladder cancer. Refer to Section 2.23.16 Coding
‘History of’ and ‘Family history of’. Main condition: QA06 Other condition: Option 1: QC40.5; Option 2:
QC40.5/2C94.Z

Malignant neoplasms of independent, multiple primary sites

The stem code for Malignant neoplasms of independent (primary) multiple sites should be
coded as the main condition when the health care practitioner records as the main
condition two or more independent primary malignant neoplasms, none of which
predominates. Then, optionally, additional codes to identify the individual neoplasms may
be coded as other conditions to identify the individual primary malignant neoplasms
recorded by the health care practitioner. Extension codes may be added to each primary
malignant neoplasm stem code to identify additional detail of the histopathology and the
site.
Example 1:
The documentation states that the patient has carcinomatosis of the peritoneum from an unknown
primary neoplasm.
Main condition: Carcinomatosis of peritoneum
Code the main condition as 2D91 Malignant neoplasm metastasis in peritoneum. Code as another condition
[2D4Z Unspecified malignant neoplasms of ill-defined or unspecified sites]. Main condition: 2D91 Other
condition: 2D4Z

Example 2:
Main condition: Multiple myeloma
Other conditions: Primary adenocarcinoma of prostate
Code the main condition as [2A83.1 Plasma cell myeloma]. Code as an other condition [2C82.0
Adenocarcinoma of prostate]. Main condition: 2A83.1 Other condition: 2C82.0

Unspecified malignant neoplasms of unspecified sites

This code should be used only when the health care practitioner has clearly recorded the
neoplasm as an unknown primary site or as an unspecified malignancy, assumed primary.
Malignant neoplasm metastases, unspecified site
This code should be used as the main condition only when the malignancy is described as
‘disseminated metastases’ or ‘metastatic carcinoma’ (or other similar terms as described in
the inclusion list of the code) but the specific sites are not documented.

[Link] Chapter 3: Diseases of the blood or blood-forming organs

Certain conditions classifiable to this chapter may result from drugs or other external
causes. Codes from Chapter 23 ‘External causes of morbidity and mortality’ may be used as
optional additional codes.
Example 1:

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Patient who is on long-term treatment with the drug trimethoprim is admitted and treated for
trimethoprim-induced folate deficiency anaemia. Main condition: Trimethoprim-induced folate deficiency
anaemia Code the main condition as [3A02.4 Drug-induced folate deficiency anaemia] and postcoordinate
with the external cause code [PL00 Drugs medicaments and biological substances associated with injury or
harm in therapeutic use] and the external cause code [PL13.2 Drug-related injury or harm in context of
correct administration or dosage, as mode of injury or harm]. The extension code [XM7NY9 Trimethoprim],
may be added optionally to identify the drug. Main condition cluster: 3A02.4 /PL00&XM7NY9 /PL13.2

[Link] Chapter 5: Endocrine, nutritional or metabolic diseases

Certain conditions classifiable to this chapter may result from drugs or other external
causes. Codes from Chapter 23 ‘External causes of morbidity and mortality’ may be used as
optional additional codes.
Diabetes mellitus
When the health care practitioner has documented a condition as due to diabetes mellitus,
postcoordinate the condition and the diabetes mellitus stem codes. If more than one
condition is documented as being due to diabetes mellitus, each distinct clinical concept
(each diabetes caused condition) is coded on its own and postcoordinated with the diabetes
mellitus stem code even though it means repeating the diabetes code in each cluster. (Refer
to Example 2 below).
Example 1:
Main condition: Chronic kidney failure due to type 2 diabetes mellitus. Chronic kidney failure is
documented as due to diabetes mellitus; therefore, code to GB61.Z Chronic kidney disease, stage
unspecified and postcoordinate with the stem code 5A11 Type 2 diabetes mellitus. Main condition cluster:
GB61.Z/5A11

Example 2:
Main condition: Type 1 diabetes with diabetic nephropathy Other condition: Diabetic cataract Code the
main condition as 5A10 Type 1 diabetes mellitus postcoordinated with the stem code GB61.Z Chronic
kidney disease, stage unspecified. Code as an other condition 9B10.21 Diabetic cataract postcoordinated
with the stem code 5A10 Type 1 diabetes mellitus.
Main condition cluster: 5A10/GB61.Z Other condition cluster: 9B10.21/5A10

Carcinoid syndrome
This code is not to be used as the preferred code for main condition if a carcinoid neoplasm
is recorded, unless the episode of care was directed predominantly at the endocrine
syndrome itself.

[Link] Chapter 6: Mental, behavioural or neurodevelopmental disorders

Dementia
Always code the underlying aetiology, if documented.

[Link] Chapter 8: Diseases of the nervous system

Certain conditions classifiable to this chapter may result from the effects of drugs or other
external causes. Codes from Chapter 23 ‘External causes of morbidity and mortality’ may be
used as optional additional codes.

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Late effect of cerebrovascular disease
These codes are not to be used as the preferred code for the ‘main condition’ if the nature
of the residual condition is recorded. Refer to Section 2.23.18 Coding of conditions
documented as sequela (late effect).
Paralytic symptoms
These codes are not to be used as the preferred code for the main condition if a current
cause is recorded, unless the episode of care was mainly for the paralysis itself.
Example 1:
Patient is admitted with left side hemiplegia and following investigation determined to be due to acute
ischaemic stroke. Main condition: Acute ischaemic stroke with hemiplegia. Code the main condition as
8B11.5Z Cerebral ischaemic stroke, unspecified and postcoordinate the stem code MB53.Z Hemiplegia,
unspecified. An optional extension code to specify XK8G Left may be added. Main condition cluster:
8B11.5Z Cerebral ischaemic stroke, unspecified/MB53.Z&XK8G

Example 2:
Patient is admitted for rehabilitation training for paralysis of left leg resulting from cerebral infarction
three years ago. Main condition: Paralysis of left leg Code the main condition as MB55.Z Monoplegia of
lower extremity, unspecified and an optional extension code to specify XK8G Left may be added.
Postcoordinate the stem code 8B25.0 Late effects of cerebral ischemic stroke Main condition cluster:
MB55.Z&XK8G/8B25.0

[Link] Chapter 9: Diseases of the visual system

Vision impairment including blindness
These codes are not to be used as the preferred code for the main condition if the cause is
recorded, unless the episode of care was mainly for the blindness itself.

[Link] Chapter 10: Diseases of the ear or mastoid process

Acquired hearing impairment
These codes are not to be used alone if the cause is recorded, unless the episode of care
was mainly for the hearing loss itself.

[Link] Chapter 11: Diseases of the circulatory system

Secondary hypertension
This code is not to be used as the preferred code for the main condition if the cause is
recorded. When coding to the cause, secondary hypertension is used as an additional code
(in a cluster) to indicate that this manifestation has been relevant in the context of
treatment.

[Link] Chapter 15: Diseases of the musculoskeletal system or connective

tissue
Many musculoskeletal conditions are treated without knowing the underlying disease. In
such cases only the musculoskeletal condition is coded.

ICD-11 Reference Guide 259

[Link] Chapter 18: Pregnancy, childbirth or the puerperium
JA05 Complications following abortion, ectopic or molar pregnancy
These codes are not to be used as the preferred code for the main condition, except where
a new episode of care is solely for treatment of a complication, e.g. a current complication
of a previous abortion. These codes may be used as an optional additional code with
‘Abortive outcome of pregnancy’ codes to identify associated complications and to give
fuller details of the complication.
Example 1:
Main condition: Ruptured tubal pregnancy causing shock
Other conditions: -
Specialty: Gynaecology
Code the main condition as JA01.1 Tubal pregnancy and since the shock is documented as a complication
of the tubal pregnancy, postcoordinate JA05.3 Shock following abortion, ectopic or molar pregnancy.
Main condition cluster: JA01.1/JA05.3

Example 2:
Patient is diagnosed with endometritis following a spontaneous abortion that was diagnosed and treated
at a previous episode of care.
Main condition: Endometritis following spontaneous abortion
Specialty: Gynaecology
This example represents a new episode of care solely for treatment of a current complication of a
previous spontaneous abortion; therefore, code the main condition as JA05.0 Genital tract or pelvic
infection following abortion, ectopic or molar pregnancy. No other code is required since the abortion took
place during a previous episode of care.
Main condition: JA05.0

Delivery
Use of these codes to describe the ‘main condition’ should be limited to cases where the
only information recorded is a statement of delivery or the method of delivery. These codes
may be used as additional codes to indicate a method or type of delivery where no separate
data item or procedural classification is being used for this purpose.
Example 3:
Patient is admitted in labour and delivers a healthy newborn without complication.
Main condition: Normal delivery
Other conditions: -
Procedure: Spontaneous vaginal delivery
Code JB20.Z Single spontaneous delivery, unspecified as ‘main condition’ and postcoordinate QA46.0 Single
live birth.
Main condition cluster: JB20.Z/QA46.0

Example 4:

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Patient who has a history of previous caesarean section is admitted for in labour. A trial of labour is
unsuccessful for vaginal delivery due to arrested active phase and unplanned repeat Caesarean section is
performed.
Main condition: Failed trial of labour, unspecified
Other conditions: Secondary uterine inertia
Procedure: Caesarean section
Code JB0D.8 Failed trial of labour, unspecified as the ‘main condition’ and postcoordinate JB02.1 Secondary
uterine inertia because the health care practitioner has documented the cause of the failed trial of labour.
Code JB22.Z as an other condition to indicate the method of delivery.
Main condition cluster: JB0D.8/JB02.1
Other condition: JB22.Z

Example 5:
Patient who is known to have a twin pregnancy is admitted in labour and delivers two healthy newborns.
Main condition: Multiple delivery, all spontaneous
Other conditions: Twins, both liveborn
Procedure: Spontaneous delivery
Code JB24.0 Multiple delivery, all spontaneous/QA46.2
Main condition cluster: JB24.0/QA46.2

Example 6:
Patient is admitted in labour at 38 weeks gestation. On examination, no fetal heart rate could be detected.
Main condition: Maternal care for fetal death
Other conditions: -
Procedure: Spontaneous delivery
Code to JA86.3 Maternal care for intrauterine death and postcoordinate [XT6G Duration of pregnancy
more than 36 completed weeks] . Code as an other condition JB20.Z Single spontaneous delivery,
unspecified to indicate the method of delivery.
Main condition: JA86.3 & XT6G
Other condition: JB20.Z

Certain maternal diseases classifiable elsewhere but complicating pregnancy, childbirth or

the puerperium
The subcategories provided should be used as ‘main condition’ codes in preference to
categories outside Chapter 18 ‘Pregnancy, childbirth or the puerperium’ when the
conditions being classified have been indicated by the health care practitioner to have
complicated the pregnant state, to have been aggravated by the pregnancy, or to have been
the reason for obstetric care. The pertinent codes from other chapters may be used as
optional additional codes to allow specification of the condition. Postcoordination applies
when the additional code to specify the condition is coded.
Example 7:
Patient is admitted at 28 weeks gestation with toxoplasmosis.
Main condition: Toxoplasmosis
Other conditions: Pregnancy undelivered

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Code JB63.6Z Protozoal diseases complicating pregnancy, childbirth or the puerperium, unspecified as the
main condition and optionally, code 1F57.Z Toxoplasmosis, unspecified to identify the specific protozoal
disease that is complicating the pregnancy. When the additional code to identify the specific complication
is coded, then postcoordination applies because 1F57.Z is adding additional detail/specificity to the stem
code JB63.6Z.
Main condition cluster: JB63.6Z/1F57.Z

[Link] Chapter 21: Symptoms, signs or clinical findings, not elsewhere

classified
Categories from this chapter should not be used as ‘main condition’ codes unless the
symptom, sign or clinical finding was clearly the main condition treated or investigated
during an episode of care. Codes from this chapter should not be assigned where an
explanatory diagnosis is determined during the episode of care.

[Link] Chapter 22: Injury, poisoning or certain other consequences of

external causes
Where multiple injuries are recorded and no one of these has been selected as the ‘main
condition’, code to one of the categories provided for statements of multiple injuries of:
• same type to the same body region;
• different types to the same body region; and
• same type to different body regions
and postcoordinate the stem codes that describe each individual injury.
Note the following exceptions:
• for internal injuries recorded with superficial injuries and/or open wounds only, code
to internal injuries as the ‘main condition’;
• for fractures of skull and facial bones with associated intracranial injury, code to the
intracranial injury as the ‘main condition’;
• for intracranial haemorrhage recorded with other injuries to the head only, code to
intracranial haemorrhage as the ‘main condition’;
• for fractures recorded with open wounds of the same location only, code to fracture
as the ‘main condition’.
When the multiple injury categories are used, codes for any individual injuries listed are
used as additional codes in the same cluster.
Example 1:
Patient suffered injuries to the bladder and urethra following an assault. Main condition: Injury to bladder
and urethra Other conditions: - Code as main condition NB92.8 Injury of multiple pelvic organs and
postcoordinate the stem codes for NB92.2Z Injury of bladder, unspecified and NB92.3Z Injury of urethra,
unspecified as these codes are adding additional detail/specificity to NB92.8. Main condition cluster:
NB92.8/NB92.2Z

Example 2:
Patient, who was the driver of a motorcycle, lost control on the highway and crashed. Investigations
revealed open intracranial wound with cerebellar haemorrhage. Main condition: Open intracranial

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wound with cerebellar haemorrhage Other conditions: - Code the main condition NA07.82 Traumatic
haemorrhage in cerebellum. Code the other condition NA07.Y Other specified intracranial injury.

[Link] Chapter 23: External causes of morbidity or mortality

These codes are not to be used as ‘main condition’ codes. They are intended for use as
additional codes to identify the external cause of conditions classified in Chapter 22 and
may also be used as optional additional codes with conditions classified in any other
chapter, but which have an external cause.

[Link] Chapter 24: Factors influencing health status or contact with health
services
There are some health care episodes that are not related to the treatment of or
investigation for current illness or injury (e.g. monitoring of previously-treated conditions,
immunisation visits, seeking of health-related advice). In such circumstances, a code for the
main condition can potentially be found in Chapter 24 ‘Factors influencing health status and
contact with health services’.
2.23.22 Traditional Medicine Conditions - Module 1 (TM1)

Traditional Medicine (TM) is an integral part of health services provided in many countries.
International standardisation by including Traditional Medicine conditions within the ICD
allows for measuring, counting, comparing, formulating questions and monitoring its use
over time. ICD-11’s supplementary chapter on Traditional Medicine disorders and patterns
(TM1) is designed to be used in conjunction with the Western Medicine concepts of ICD
Chapters 01-25.
As with other ICD chapters, the TM1 chapter is a tool for classifying, diagnosing, counting,
communicating and comparing TM conditions, it will also assist research and evaluation to
assess the safety and efficacy of TM. This chapter not judging or endorsing TM practice or
the efficacy of any TM intervention.
2.23.23 Use in Traditional Medicine

Reporting at regional, national and international levels:

• Counting episodes of care for Traditional Medicine disorders and/or patterns in the
same way as for Western Medicine diseases for morbidity data reporting purposes
• Counting episodes of care by Traditional Medicine practitioners who may use a
combination of Western Medicine and Traditional Medicine terminology
• Describing and quantifying utilisation of Traditional Medicine services and reasons
for encounter
• Monitoring use of resources for Traditional Medicine services
• Standardising descriptions of disorders and patterns among TM clinicians,
practitioners and coders
Research:

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 • Facilitating evidence-based research on safety and efficacy of Traditional Medicine
interventions
• Allowing clinical research within the Traditional Medicine framework and integrating
Western Medicine with Traditional Medicine
• Understanding interrelationships between Western Medicine diseases and
Traditional Medicine disorders and patterns
• Studying treatment patterns and outcomes for specific disorders and patterns using
ICD-11 in conjunction with country specific procedure classifications and the TM
component of the International Classification of Health Interventions (ICHI)
Casemix reimbursement and insurance:
• There are precedents in China, Japan, and Korea for use of existing Traditional
Medicine classifications (with or without Western Medicine concepts) for
reimbursements to hospitals and for insurance claims and for clinical costing
measures.
• Incorporating Traditional Medicine as a chapter of ICD-11 allows much greater scope
for describing patient conditions (diseases, disorders (TM1) and patterns (TM1)
across the Western Medicine and TM1 chapters) as well as complications and
comorbidities.
Quality and safety of care:
• Standardising use of codes reflecting quality and safety of care between Western
Medicine diseases and TM1 disorders will allow TM practitioners to interpret data
from ICD-11 on quality, safety, and efficacy of care.
Education:
• Educating TM practitioners in regard to standardisation of diagnosis
• Educating TM clinicians and coders in application and interpretation of ICD-11 data.
Standardising terminology for use in electronic health records:
• To enable more consistent and efficient recording and extraction of data
• To allow computer assisted coding of TM1 disorders and patterns
2.23.24 Coding instructions for Traditional Medicine conditions - Module 1 (TM1)

Codes from the Traditional Medicine chapter can be used across settings (hospital inpatient
or ambulatory care in hospital or community) but must not be used for reporting cause of
death. When coding in primary care, disorders and patterns may not be fully developed so
that it may be more feasible to identify reason for encounter rather than main condition
and associated conditions.
General principles:

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 • Consult all parts of the patient record including discharge summary, history, physical
examination, investigations, laboratory data, treatments and final diagnoses.
• Coding should relate to reasons for treatment during this episode and need not
describe the whole patient’s lifetime history unless a past condition affects current
care.
• Be as specific and explicit as possible, using codes to represent aetiology, pathology
and manifestations of TM condition.
• Use codes from relevant chapters of the ICD to match the clinical disorders noted on
the patient record.
• Code threatened TM conditions (i.e. those not well defined or not manifest).
The inclusion of the supplementary chapter on Traditional Medicine conditions in ICD-11
aims to foster integration of TM into the health system. Hence, it is recommended that -
wherever possible - TM1 codes should be used in conjunction with those from other ICD-11
chapters (Chapter 01-25) to enable comparison of Western medicine diagnosis and
Traditional Medicine diagnosis.
The following generic coding scheme and alternative coding options can be used:
1. Read the patient summary and medical record.
2. Select WM diagnosis/diagnoses, TM1 disorder(s) (TM1), and/or pattern(s) (TM1) to
be coded.
Options Examples ICD-11 Coding
Examples
a. WM diagnosis alone Asthma CA23.32
b. WM diagnosis with Asthma CA23.32
TM1 pattern
Turbid phlegm accumulation in the SF86
lung pattern (TM1)
c. WM diagnosis with Asthma CA23.32
TM1 disorder
Wheezing disorder (TM1) SF81

You may choose more than one disorder (TM1) and more than one pattern (TM1) from the
TM chapter.
3. Consult the electronic Coding Tool or relevant Alphabetic Indexes for WM and TM1
entries
4. Go to tabular list for the relevant code. Take note of inclusions and exclusion notes
and textual descriptions.
5. Assign the appropriate code and follow any specific guidelines for that code.
Applying the above listed generic coding scheme and alternative coding options for a given
clinical picture must take into account the regulatory context, coding practice and setting
specific requirements at country level. Additional coding conventions may be developed in
response to country specific information needs (e.g. coding of main condition, use of

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extension codes, coding of neoplasms and injury, chronic and complicated conditions, sub-
clinical or constitutional complaints, external cause of injury and adverse reaction).

2.24 General statistical recommendations

2.24.1 Data quality

To ensure high quality, processes for monitoring the quality of the coded data need to be
implemented. This is referred to as Quality Assurance. On the following pages you will find
some suggestions relating to the application of Quality Assurance for mortality and
morbidity statistics. As a basic principle, those responsible for the collection and analysis of
data should be involved in the development of the protocols for the processing and coding
of the data, and in determination of the other data items to be cross-tabulated with them.
Collecting quality data requires a clearly designed workflow (from reporting to coding to
analysis), and adequate training of all involved parties. In particular, all participants need to
understand the process and their part in it. The basic stages of the workflow include:
1. Documentation – This is where the information starts. Identifying a condition and
then documenting it on a death certificate, in a medical record or on another
medical form need to be carried out completely and accurately, using the best
possible evidence. For this reason, this part of the workflow, should generally be
carried out by a well-trained physician.
2. Reporting – Documented information should be reported in the format specified by
the responsible agencies. There may be differences in the required reporting
structure, timeframe and obligations, depending on the country and/or data
collection circumstances.
3. Verification– Where unclear information, incomplete or illogical statements are
reported, a feedback loop and return of queries to the certifiers and documenters
should be used.
4. Grouping and analysis – Both serve to aggregate data in ways that are determined by
the diverse use cases. Rules and constraints should be clearly understood and
communicated when analysis is undertaken and results are reported and used.
2.24.2 Specificity versus ill-defined codes

Reported information should be coded to the highest level of detail possible. In some
instances, the details available are sparse, incompletely documented or only trivial details
are reported. Though the ICD provides categories for these cases, such non-specific
information does not allow understanding of epidemiological patterns and/or utilisation of
health systems nor does it support prevention of disease.
2.24.3 Problems of a small population

Population size is one of the factors that need to be considered when the health status of a
population is assessed by means of mortality or morbidity data. In countries with small
populations, the annual numbers of events in many categories will be very small and may
fluctuate from year to year, especially when disaggregated by recommended age and sex.
These problems can be alleviated through one or more of the following measures:

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 • use or presentation of broad groupings of ICD rubrics, such as chapters
• aggregation of data over a longer time period, e.g. to take the preceding two years
of data together with those for the current year and produce a ‘moving average’
figure
• using the broadest possible age groupings
The recommendations that apply for small national populations also hold true, in general,
for reporting the data relating to subnational segments of larger populations. Investigations
of health issues in population subgroups have to take into consideration the effect of the
size of each of the subgroups on the type of analysis used. This need is generally recognised
when dealing with sample surveys, but often overlooked when the investigation concerns
the health problems of special groups in a national population.
2.24.4 ‘Empty cells’ and cells with low frequencies

Regardless of the list of causes being used, it may be found that no cases for one or more
listed cause(s) occur in certain cells in a statistical table. Where there are many empty lines
in a table, it is worth considering the omission of such lines from a published table. When
only the occasional case of a disease occurs in a country, the line can be regularly omitted
from the published statistical table and a footnote added to indicate either that there were
no cases in the reported timeframe or, when sporadic cases do occur, in which cell the case
would have appeared. For cells with very low frequencies, especially those relating to
diseases that would not be expected to occur, it is important to establish that the cases
existed and did not result from a coding or processing error. This should be carried out as
part of the general quality control of the data.
2.24.5 Precautions needed when tabulation lists include subtotals

It may not always be apparent to those processing the data that some of the items in the
tabulation lists are in fact subtotals or earlier reported categories. These items may include
titles of blocks and titles of four- character categories or the items for chapter titles (in the
condensed versions of the mortality tabulation lists). These entries should be ignored when
totals are calculated, otherwise cases may be counted more than once.
2.24.6 Ethical Aspects

Confidentiality refers to the obligation to not disclose information (data to third parties
where that information has originally been delivered in confidence. This duty was codified in
the Hippocratic Oath in the 4th century BCE and is still one of the core principles of medical
ethics. Any information that might allow the identification of a specific person should only
be viewed by people who are authorised to do so. Authorisation means that a person is
legally permitted to access the information. e.g. medical staff, coroners and coders are all
people who may be authorised to see sensitive information.
Generally, the only way for confidential information to become publicly accessible is
through legislation, statutes and regulations. Sometimes confidential information can
become public record after a certain period of time. For instance, in some regions of the
world the passage of time can render death certificates matters of public record and,
therefore, the requirement for them to remain confidential no longer applies.

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The authorised supplier of confidential information must verify that the requesting person is
an authorised user and determine their level of authorisation. The supplier must be aware
of the level of information that can be made available to the authorised user and take
appropriate steps to guard against unauthorised disclosure. The authorised user must not
attempt to gain access to information which they are not authorised to obtain. Additionally,
the user must also guard against unauthorised access to the information that has been
supplied to them. This means that users must secure the confidential information and any
recordings of that information in a way that prevents unauthorised access. The information
must only be used for appropriate purposes and must be returned as required. National
legal frameworks, state and local regulations, and institutional guidelines provide specific
rules and information regarding how to maintain confidentiality.
2.24.7 Avoidance of Potential Harm

Direct and serious harm can result from a breach of confidentiality. For example, the
disclosure of sensitive information can potentially lead to stigma and discrimination against
an individual. Conversely, greater harm can result from maintaining confidentiality than
from not doing so. Some circumstances may require a judgement that involves balancing
the harms to or disclosure against the interests of, the patient, deceased person and other
relevant parties. A person may suffer ‘harm’ physically, socially or psychologically as a result
of a breach of confidentiality. A confidential diagnosis that is breached makes the patient
lose faith or trust in the clinician, and the patient may then suffer abuse from another
person or suffer the stigma associated with certain conditions. In other circumstances the
nondisclosure of one person’s confidential information may result in another individual or a
community being at risk of developing a harmful condition or being exposed to a harmful
situation.
This is a difficult concept and one that must be approached in a thoughtful way. As
previously mentioned, there are times when it is justifiable to give others confidential
information, such as when reporting communicable disease incidence. In such cases the
reporting of confidential information is usually allowed. This is an example of where the
nondisclosure of a disease could result in major harm to others.
If it is necessary to disclose information, it is preferable to contact the relevant person and
let them know about the need to do so. In some cases, this may not be possible or
appropriate, and users should be guided by legal and institutional guidelines. The harms
that can be caused by disclosure of certain information must be considered. Some
information that can be particularly sensitive includes tests for genetic disorders and
diseases, incidence of communicable diseases, and HIV test results. Sometimes there are
special requests for confidentiality that may require increased levels of confidentiality
assurances. These special requests cannot supersede legal requirements for disclosure but
should be respected when possible.
2.24.8 Security of Privacy – Confidentiality

Privacy relates to protecting an individual’s control over what personal information and
decisions may or may not be shared with others. For instance, when a physician examines or
speaks with a patient it is usually done in a non-public area so that the information given to
the physician by the patient cannot be heard by anyone else. It also enables the physician to

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give a patient their diagnosis in private. Data are shared with consent by the patient or
where required by law or legislation. Security of privacy and confidentiality of health (and
other) data are usually addressed by national laws and regulations.

2.25 Recommendations in relation to statistical tables for international

comparison
The following recommendations aim to standardise the presentation of coded data to allow
national and international comparisons between different countries or regions.
2.25.1 The recommended Special tabulation lists

There are standard ways of listing causes coded according to the ICD, and there are formal
recommendations concerning lists for tabulation that allow for national and international
comparisons. The hierarchical structure of the ICD allows considerable flexibility for other
possible tabulations. For mortality, the ICD includes special tabulation lists which are
intended for circumstances in which the four-character list is too detailed, and are designed
so that international comparison of significant diseases and groups of diseases is not
compromised by different groupings used in different countries.
It should be noted that the special tabulation lists are designed for the aggregation and
reporting of coded data. They are not for coding purposes.
The special tabulation lists are:
• List 1 Mortality tabulation list
• List 2 Morbidity tabulation list
• List 3 International Shortlist for Hospital Morbidity Tabulation (ISHMT)
• List 4 Infectious diseases by agent condensed list
• List 5 Sustainable Development Goals (SDGs)
• List 6 WHO Verbal autopsy list
The mortality list is based on the codes assigned for the underlying cause of death.
Morbidity list do not include codes from traditional medicine conditions.
Use of prefixes to identify the special tabulation lists
Use of the numerical prefixes prevents confusion between the special tabulation lists, as the
ICD four-character codes have a letter in the second position. Where an adapted list is used
for national or sub-national purposes, an alternative identifying prefix should be used.
The special tabulation list for mortality
The mortality tabulation list provides items for each ICD chapter and also, within most
chapters, identify the items with residual items entitled ‘Remainder of…’ that complete the
coverage of the respective chapter. The list covers the full range of ICD four-character codes
applicable for mortality, required for reporting and publication purposes.
Locally designed lists for mortality

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For most countries, the mortality tabulation list provides enough information on the most
important diseases and external causes of death. They also facilitate comparison over time
and observation of shifts in the relative frequencies as health programmes take effect, of
e.g. infectious diseases and degenerative diseases. It permits comparison between sub-
national areas and population sub-groups. In addition, it makes meaningful international
comparisons of causes of death possible.
Lists similar to the special tabulation list can also be designed for local use. The ICD rubrics
in such lists can be selected and grouped in any way. Special lists may be needed, for
example, for monitoring progress, in terms of mortality and also morbidity, of many local
health programmes. When adapting the special tabulation lists to national requirements, or
when a tabulation list is being devised for a new or special project, a trial run is helpful by
counting the number of cases for each four-character category. In such way, it can be
determined which conditions are appropriate for broad grouping, and where subcategories
are necessary.
Where a local list is constructed, the key to the condensed categories should contain the
same four- (or five-) character codes of the core classification.
The special tabulation list for morbidity
The morbidity special tabulation list is intended as a basis for national lists and for intra- and
inter-country comparison. National lists can be constructed by either condensing or
expanding the core classification as appropriate. The list is suitable for data on inpatient
care and, with suitable adaptation (notably through aggregation of some items and
expansion of items relating to Chapter 21 ‘Symptoms, signs or clinical findings, not
elsewhere classified’ and Chapter 24 ‘Factors influencing health status and contact with
health services’) for information from other sources, such as ambulatory care and surveys.
When a local list is constructed, the key to the condensed categories should contain the four
(or five) character codes of the core classification. The list has been designed for
international comparisons of hospital morbidity statistics. This concise list allows for
comparison of hospital activity, independent of health systems. The conditions have been
selected in a way that they can always be treated in an admission of at least 24 hours. If,
after examination of the frequencies of the ICD four-character rubrics, it is necessary to
expand the list, some of the items within ICD categories can be subdivided according to the
core classification or even to the five-character level. If the recommended list is too detailed
or if a shorter list is required, selection can be made based on national or local health
concerns. Depending on a country’s ‘epidemiological profile’, categories may be combined
to shorten the list.
2.25.2 International morbidity reporting

International morbidity reporting and comparison of data among different countries

requires internationally agreed definitions of:

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 • inpatient, recoding of day-patients, outpatient
• hospital
• treatment episode
• reason for encounter used instead of diagnosis
See Section 1.4 for more detail.

[Link] Minimum data set and markup for postcoordination

A minimum data set suitable for international comparison would include age, sex, main
diagnosis, (reason for admission after assessment at the end of the stay), and health sector
(hospital, practitioner, other), is ideally accompanied by the definitions in place for the
variables mentioned above, and the main intervention. In an extended data set, ideally,
additional diagnoses and interventions are reported in separate data fields. The markup for
international reporting of postcoordinated codes in clusters will follow the specifications
below:
• a slash ‘/’ separates 2 stem codes
• an ‘&’ links stem codes with extension codes
• a cluster may consist of a single code or One condition with additional detail in one
cluster
• stem code & extension code & extension code
Two unrelated conditions will have two clusters:
• stem code - stem code
Two clusters with multiple codes:
• stem code & extension code/stem code & extension code & extension code
Example 1:
Diabetes mellitus / Diabetic retinopathy
Example 2:
Multiple fractures of forearm / fracture of shaft of ulna & compound fracture / fracture of
shaft of radius & compound fracture /external cause code
2.25.3 Presentation of statistical tables

The degree of detail in cross-classification by cause, sex, age, and geographical area will
depend both on the purpose and range of the statistical reportings and on the practical
limits to their tabulation. The following patterns, which are designed to promote
international compatibility, present standard ways of expressing various characteristics.
Where a different classification is used in published tables (e.g. in age-grouping) it should be
reducible to one of the recommended groupings.
(a) Analysis by the International Classification of Diseases should, as appropriate, be in
accordance with:

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 – the detailed list of four-character categories, with or without five or six-
character subcategories;
– the special tabulation list for mortality;
– the special tabulation list for morbidity.
(b) Age classification for general purposes:

– under 1 year, 1 to 4 years, 5-year groups from 5 to 84 years, 85 years and

over, 95 years and over;
– under 1 year, 1-4 years, 5-14 years, 15-24 years, 25-34 years, 35-44 years, 45-
54 years, 55-64 years, 65-74 years, 75 years and over.
– under 1 year, 1-14 years, 15-44 years, 45-64 years, 65 years and over.
(c) Classification by area should, as appropriate, be in accordance with:

– each major civil division;

– each town or conurbation of 1,000,000 population and over, otherwise the
largest town with a population of at least 100,000;
– a national aggregate of urban areas of 100,000 population and over;
– a national aggregate of urban areas of less than 100,000 population;
– a national aggregate of rural areas.
Note 1. Statistics relating to (c) should include the definitions used to determine urban and
rural.
Note 2. In countries where medical certification of the cause of death is incomplete or
limited to certain areas, figures for deaths not medically certified should be published
separately.

[Link] Tabulation of causes of death

Statistics of causes of death for a defined area should be in accordance with
recommendation ‘Statistical tables’ (a)(1) above, or, if this is not possible, with
recommendation ‘Statistical tables’ (a)(2).
Deaths should preferably be classified by sex and age group as in recommendation
‘Statistical tables’ (b)(3).
Statistics of causes of deaths for the areas in recommendation ‘Statistical tables’ (c) should
comply with recommendation ‘Statistical tables’ (a)(2), or if this is not possible, with
recommendation ‘Statistical tables’ (a)(3). They should preferably be tabulated by sex and
age group as in recommendation ‘Statistical tables’ (b)(2).

[Link] Injury mortality

Injury mortality traditionally distinguishes between injuries that are caused by:

272 ICD-11 MMS

 • Interpersonal violence and sexual abuse
• Collective violence including wars, civil insurrections and riots
• Traffic incidents
• Incidents at home, at work, and while participating in sports and other recreational
activities
In the context of mortality, the WHO recommends the retention of codes for both main
injury and external causes. In places where this is not feasible, the external cause code
should be retained. For injury-related deaths, in ICD-11 the external cause code is the single
underlying cause of death code, and incorporates the intent, mechanism, and object of the
deceased in a single code. Place of occurrence and activity are coded separately.
2.25.4 Standards and reporting requirements for mortality in perinatal and neonatal
periods

[Link] Terms used in perinatal and neonatal mortality

The perinatal period commences at 22 completed weeks of gestation and ends 7 completed
days after birth, i.e. includes days 0 – 6 after birth.
The neonatal period commences at birth and ends 28 completed days after birth
i.e. includes days 0 – 27 after birth.
Gestational age is the duration of gestation estimated based on the best obstetric estimate
of gestation, which is usually expressed in completed weeks with additional days, or in
completed days.
The best obstetric estimate of gestation is based on the birth attendant’s final estimate of
gestation, calculated from time elapsed since the first day of gestation. The first day of
gestation is usually determined by:
1) the first day of the last menstrual period (LMP) 1 if confirmed by results of early ultrasound
scan

2) by early ultrasound scan, where LMP and results of early ultrasound scan differ

3) by LMP and/or the clinical postnatal estimate of gestational age, where no early ultrasound
scan is available.

In cases of assisted reproduction when the date of embryo transfer is known, an offset of 14
days is to be added for calculating gestational age.
Gestational age is counted by calendar days where day zero (Day 0) is used to refer to the
first calendar day of gestation and day 1 for the second calendar day. The first day of
gestation i.e. day 0 corresponds to gestational age ‘zero completed weeks’ with zero
additional days (gestational age 0+0 completed weeks), and 6 days later would be
gestational age 0+6 completed weeks.
The number of completed weeks is calculated as the number of days since the first day of
gestation divided by 7, presented as a whole integer plus a remainder. For example, day 8
after gestation is 1+1 completed weeks, and day 252 corresponds to 36+0 completed weeks,
and 6 days later (258 days) would be 36+6.

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Birthweight is the first weight of the fetus or neonate obtained after birth. For live births,
birthweight should preferably be measured within the first hour of life before significant
postnatal weight loss has occurred.
Chronological age used in recording deaths in the neonatal period is counted as follows:
Day 0 is used to refer to the first 24 hours after birth. Day 1, is the remainder of the 2nd
calendar day (date of death=date of birth+1) but outside the 1st 24 hours. Day 2 is the 3rd
calendar day (date of death=date of birth+2).
Where it is not feasible to capture information on hours at death, Day 0 should be
considered to be the calendar day of birth (date of birth is equal to date of death), and
subsequently: Day of death = Date of death - date of birth.

[Link] Definitions in perinatal and neonatal mortality

Fetal death, spontaneous abortion, stillbirth, live birth, neonatal death

Death in perinatal or neonatal period should be counted based on the time of delivery (i.e. a
complete expulsion or extraction from a woman), though it may be diagnosed earlier in
utero. Delivery of an embryo or fetus may occur either spontaneously, assisted or by
caesarean section (i.e. it includes deliberate interruption of an ongoing pregnancy by
medical or surgical means intended to result in a live birth), while it should be distinguished
clearly from induced abortion.
• Fetal death is death of a fetus prior to its complete expulsion or extraction from a
woman, irrespective of the duration of pregnancy.

• Spontaneous abortion (also referred to as miscarriage) is a spontaneous loss of

pregnancy (i.e. embryo or fetus) before 22 completed weeks of gestation.

• Stillbirth is the complete expulsion or extraction from a woman of a fetus, following

its death prior to the complete expulsion or extraction, at 22 or more completed
weeks of gestation.
• Live birth is the complete expulsion or extraction from a woman of a fetus,
irrespective of the duration of the pregnancy, which, after such separation, shows
signs of life.
• Neonatal death is a death after live birth which occurs during the neonatal period.
Death of an embryo or fetus may be diagnosed in utero by absence of heart sounds,
confirmed by imaging techniques where available, or after the complete expulsion or
extraction from a woman by absence of signs of life. Signs of life at birth include breathing,
beating of the heart, pulsation of the umbilical cord and definite movement of voluntary
muscles whether or not the umbilical cord has been cut or the placenta is attached. Fleeting
reflex activity observed only in the first minute after birth does not warrant classification as
a sign of life.
Notes for national and international reporting (See also [Link]):
• Definitions and reporting criteria concerning the lower limit for fetal deaths or
spontaneous abortions may differ depending on different national legislation

274 ICD-11 MMS

 (generally medically recognised embryonic period of gestation lasts until the 12th
completed week, however another national legal limit could be set at fetus of for
example 11 or 13 weeks). Any lower limit should be specified in the statistics
produced.
• It is recommended to produce statistics for all fetal deaths and all deaths following
live births, while reporting criteria may differ depending on different national
legislation.

• For international reporting it is recommended to report stillbirths of 28 or more

completed weeks of gestation (late stillbirth) and all deaths following live birth.
Countries with ability for reporting stillbirths of 22 or more completed weeks of
gestation (early stillbirth) are recommended to do so.

• When information on gestational age is unavailable for spontaneous abortion or

stillbirth, use birthweight less than 500 grams as the criteria.

Artificial termination of pregnancy

• Artificial termination of pregnancy is a complete expulsion or extraction from a
woman of an embryo or a fetus (irrespective of the duration of the pregnancy),
following a deliberate interruption of an ongoing pregnancy by medical or surgical
means, which is not intended to result in a live birth.
Artificial termination of an ongoing pregnancy is regulated by law and may be referred to as
either legal abortion, induced abortion, fetal reduction or other terminologies. As long as it
meets the definition of artificial termination of pregnancy it should be considered separately
from spontaneous abortion or stillbirth and clearly distinguishable in the statistics.
Whilst transient signs of life may be evident after some cases of artificial termination of
pregnancy at later gestational weeks, these should never be coded as spontaneous abortion
or live births.

ICD-11 Reference Guide 275

[Link] Other terminologies used in recording and presentation of perinatal or
neonatal mortality

Fetal death (i.e. regardless of gestational age; lower limit, if any, should be stated)
• Antepartum fetal death is a fetal death before the onset of labour. If vital status of
the fetus at the onset of labour is unknown, consider it was antepartum if there is
presence of signs of maceration at the time of delivery.
• Intrapartum fetal death is a fetal death during labour. If vital status of the fetus at
the onset of labour is unknown, consider it was intrapartum if there is fresh skin
appearance or no signs of maceration at the time of delivery.

Stillbirth (i.e. 22 or more completed weeks)

• Early stillbirth is stillbirth of 22-27 completed weeks of gestation.
• Late stillbirth is stillbirth of 28 or more completed weeks of gestation.
• Antepartum stillbirth is stillbirth following antepartum fetal death (i.e. occurring
before onset of labour).
• Intrapartum stillbirth is stillbirth following intrapartum fetal death (i.e. occurring
during labour).
• Macerated stillbirth is stillbirth with presence of signs of maceration at the time of
delivery.
• Fresh stillbirth is stillbirth with fresh skin appearance and no signs of maceration at
the time of delivery.

Period of gestation
• Preterm is less than 37 completed weeks (less than 259 days) of gestation.
• Term is from 37 completed weeks to less than 42 completed weeks (259 to 293 days)
of gestation.
• Post-term is 42 completed weeks or more (294 days or more) of gestation.

Birthweight
• Extremely low birthweight is a birthweight less than 1000 g (up to and including 999
g).
• Very low birthweight is a birthweight less than 1500 g (up to and including 1499 g).
• Low birthweight is a birthweight less than 2500 g (up to and including 2499 g).
• Large birthweight is a birthweight of 4000 g or more and less than 4500 g (up to and
including 4499 g).
• Exceptionally large birthweight is a birthweight of 4500 g or more.

Neonatal death
• An early neonatal death is a death during the first 7 completed days after live birth
(days 0 - 6)
• A neonatal death is a death during the first 28 completed days after live birth (days
0-27)

Total birth

276 ICD-11 MMS

 • Total birth is the total of stillbirth and live birth. If the lower limit of stillbirth is set
different from 22 weeks, for example at 28 weeks for international reporting, this
should be clearly stated.

[Link] Certification of stillbirth and live births in the neonatal period

The reliability of the mortality estimates related to children depends on accuracy and
completeness of recording and reporting of births and deaths. A death certificate should be
issued for all fetal deaths regardless of its occurrence being spontaneous or deliberate, and
for all neonatal deaths following live births.
Under-reporting and misclassification are common, especially for stillbirths and early
neonatal deaths. Countries should arrange registration and reporting procedures so that the
events and the criteria for their inclusion in the statistics can be easily identified.
Data of fetal deaths meeting requirements for stillbirth registration should be included in
mortality statistics, but should be clearly distinguishable from neonatal deaths following live
births. Follow instructions in [Link] for details, when it is not clear whether the certificate
relates to a stillbirth or a neonatal death following live birth.
Artificial termination of pregnancy should also be included in mortality statistics, but should
be clearly distinguishable from spontaneous abortion or stillbirths.

The international form of medical certificate of cause of death and additional details
With the update of the International form of medical certificate of cause of death in 2016,
just one certificate is used for all cases including stillbirths (see 2.15. Care needs to be taken
to correctly fill in the specific section for perinatal deaths on the certificate. The previously
recommended perinatal death certificate should be replaced by the form in 2.15, and
perinatal deaths should be coded according to the general mortality coding instructions.
While not required for ICD-11 coding, the additional information mentioned in 2.15 might
be helpful for the monitoring of perinatal and infant deaths of a country or region.

Level of details for recording

Gestational age and birthweight should be recorded for all live births and stillbirths to the
degree of accuracy to which it is measured.
The gestational age should be recorded in number of completed weeks as a minimum, and
where possible an additional variable capturing the number of days should also be included.
While statistical tabulations include 500 g groupings for birthweight, weights should not be
recorded in those groupings. The actual weight should be recorded to the degree of
accuracy to which it is measured.
Chronological age at death during the first 24 hours of life (day 0) should be recorded in
units of completed minutes or hours of life. For the second (day 1), third (day 2) and through
27 completed days of life, age at death should be recorded in days. It is recommended that
these data are collected as part of a minimal perinatal dataset.

ICD-11 Reference Guide 277

[Link] Reporting criteria for fetal death, stillbirth and live birth
As a minimum all stillbirths and deaths following live births born with 22 or more completed
weeks of gestation (≥ 154 days) should be included in the statistics, though the legal
requirements for the registration may vary depending on different national legislations.
When information on gestational age is not available, the corresponding criteria for
birthweight (500g or more) should be used.
Where gestational age and birthweight are not known, for example when only crown-heel
length or estimated gestational age based on physical examination is available, or when no
such information is available, the event should be included in, rather than excluded from,
mortality statistics of the perinatal period.
Where fetal deaths and/or neonatal deaths at <22 completed weeks of gestation (or <500g)
are included in perinatal statistics these should be presented separately from stillbirths
and/or neonatal deaths at 22 or more completed weeks of gestation and the lower limit for
inclusion in perinatal statistics in the setting should be stated, for example ‘20 completed
weeks of gestation’ or ‘no lower gestational age limit’.
Note that the reporting criteria above do not apply to artificial termination of pregnancy,
which is defined irrespective of duration of pregnancy and should be presented separately
from fetal death, stillbirth or live birth.

Criteria for international reporting

In statistics for international comparison, inclusion of fetal deaths and live births born at
extremely low gestational ages disrupts the validity of comparisons and is not
recommended. Therefore, the criteria for international reporting of stillbirths and/or
neonatal deaths are set at 28 completed weeks or more, while countries are encouraged to
provide, where possible, data from 22 completed weeks or more as well.
Table 1

278 ICD-11 MMS

 Gestational age Birthweight Recommendations for registration of data
(completed (grams)
weeks)
<22 (very early <500 Only required for neonatal mortality national statistics.
gestation) When used for spontaneous abortion (miscarriages),
should be reported separately from perinatal statistics
and the lower gestational age limit for data collection
stated.
22-27 (early 500 or more For national statistics, and for international statistics of
gestation) countries with ability for reporting of early gestation
deaths (stillbirths and neonatal mortality)
28 or more 1000 or more For international statistics (stillbirths and neonatal
(late gestation) mortality)
Unknown Unknown Include in statistics only when there is a high likelihood
gestational age birthweight that the stillbirth or neonatal death occurred at the
given criteria e.g. 28 or more weeks for international
statistics.

[Link] Statistical presentation of perinatal, neonatal, infant or under-five

mortality
For perinatal mortality statistics, full-scale multiple- cause analysis of all conditions reported
will be of the greatest value.
Countries should provide the rates listed below for international comparisons:
• Late stillbirth rate = (stillbirths ≥ 28 weeks gestation/total births (stillbirths ≥ 28
weeks gestation and live births) x 1000
• Early neonatal mortality rate = (early neonatal deaths (day 0-6) ≥ 28 weeks
gestation /live births ≥ 28 weeks gestation) x 1000
• Perinatal mortality rate = (stillbirths ≥ 28 weeks gestation and early neonatal deaths
(day 0-6) ≥ 28 weeks gestation) /total births (stillbirths ≥ 28 weeks gestation and live
births) x 1000

Groupings of gestational age groups for fetal death under 22 weeks, stillbirth and neonatal
mortality statistics
<22 completed weeks (<154 days) N.B. where the under 22 week category is used, the lower
limit included should be specified
22 - 27 completed weeks (154 - <196 days)
28 - 31 completed weeks (196 - 223 days)
32 - 36 completed weeks (224 - 258 days)
37 - 41 completed weeks (259 - 293 days)
42 completed weeks and over (294 days and over)

ICD-11 Reference Guide 279

Groupings of birthweight for fetal death under 22 weeks, stillbirth and neonatal mortality
statistics
By weight intervals of 500 grams, i.e. 1000-1499 grams, etc.
499 grams or less 500 – 999 grams 1000 - 1499 grams 1500 - 1999 grams 2000 - 2499 grams
2500 - 2999 grams 3000 - 3499 grams 3500 - 3999 grams 4000 - 4499 grams 4500 - 4999
grams 5000 grams or more

Groupings by chronological age in neonatal mortality statistics

• Preferred groupings:
By single days for the first week of life (under 24 hours (day 0), 1, 2, 3, 4, 5, 6 days), 7-13
days, 14- 20 days, 21-27 days

• Alternatives if preferred groupings is not available:

Under 24 hours, 1-6 days, 7-27 days,
Under 7 days, 7-27 days

• Additional chronological age groupings for day 0 neonatal deaths:

Under 1 hour, 1–11 hours, 12–23 hours

[Link] Under-five mortality

Under-5 mortality (Under-5 mortality rate – probability of dying between birth and exactly 5
years of age, expressed per 1,000 live births.) is a leading indicator of the level of child
health, quality of life, health infrastructure, and overall development in countries. It is also
the SDG indicator.

[Link] Infant mortality

Infant mortality (infant mortality rate – probability of dying between birth and exactly 1 year
of age, expressed per 1,000 live births) is an indicator for quality of life and health
infrastructure.
2.25.5 Standards and reporting requirements related for maternal mortality

Maternal mortality is part of the assessment of the Sustainable Development Goals (SDG)
that serve to monitor the impact of the joint work of the international community in this
field.

[Link] Maternal death

A maternal death is defined as the death of a woman while pregnant or within 42 days of
termination of pregnancy, irrespective of the duration and site of the pregnancy, from any
cause related to or aggravated by the pregnancy or its management, but not from
accidental or incidental causes.

[Link] Late Maternal death

A late maternal death is defined as: the death of a woman from direct or indirect obstetric
causes, more than 42 days but less than one year after termination of pregnancy.

280 ICD-11 MMS

[Link] Comprehensive maternal death
A grouping that combines maternal death and late maternal death.

[Link] Direct and indirect obstetric deaths

Maternal deaths, late maternal deaths, and comprehensive maternal deaths are subdivided
into two groups:
• Direct obstetric deaths: those resulting from obstetric complications of the pregnant
state (pregnancy, labour, and puerperium), and from interventions, omissions,
incorrect treatment, or from a chain of events resulting from any of the above.
• Indirect obstetric deaths: those resulting from previously existing disease or disease
that developed during pregnancy, and that were not due to direct obstetric causes
but were aggravated by the physiologic effects of pregnancy.

[Link] Death occurring during pregnancy, childbirth and puerperium

A death occurring during pregnancy, childbirth, and puerperium is defined as: the death of a
woman while pregnant or within 42 days of termination of pregnancy, irrespective of the
cause of death (direct and indirect obstetric and non-obstetric death).

[Link] Recording requirements of maternal mortality

In order to improve the quality of maternal mortality data and provide alternative methods
of collecting data on deaths during pregnancy or related to pregnancy, as well as to
encourage the recording of deaths from obstetric causes occurring more than 42 days
following termination of pregnancy, the Forty-third World Health Assembly in 1990 adopted
the recommendation that countries consider including questions regarding current
pregnancy and pregnancy within one year preceding death on death certificates.
The classification also allows the recording of deaths that occur one year or more after
termination of the pregnancy (JB62 Death from sequelae of obstetric causes).

[Link] International reporting of maternal mortality

For the purpose of international reporting of maternal mortality, only those maternal
deaths occurring before the end of the 42-day reference period should be included in the
calculation of the various ratios and rates, although the recording of later deaths is useful
for national analytical purposes.

[Link] Numerator, denominator, and ratios of published maternal mortality

Published maternal mortality ratios should always specify the numerator, which can be
given as the number of recorded direct obstetric deaths, or the number of recorded
obstetric deaths (direct plus indirect). Note that cases not coded to Chapter 18 should also
be included in the numerator. These include those categories presented in the ‘Exclusion
Note’ at the beginning of Chapter 18, provided that they have been aggravated by
pregnancy or conversely aggravated the pregnancy.

ICD-11 Reference Guide 281

The denominator used for calculating maternal mortality should be specified as either the
number of live births or the number of total births (live births plus fetal deaths). Where both
denominators are available, a calculation should be published for each.
Results should be expressed as a ratio of the numerator over the denominator, multiplied
by k (where k may be 1000, 10,000 or 100,000, as preferred and indicated by the country).
Maternal mortality ratios and rates can thus be expressed as follows:
1. Maternal mortality ratio: (Maternal deaths/Live births or total births) x k
2. Direct obstetric mortality ratio: (Direct obstetric death only/Live births or total
births) x k
3. Ratio for death occurring during pregnancy, childbirth and puerperium: (Deaths
occurring during pregnancy, childbirth and puerperium/Live births) x k

3 Part 3 - New in ICD-11

3.1 ICD-11 new conventions and terminology
Table 1: Major changes from ICD-10 to ICD-11, including rationale

282 ICD-11 MMS

 ICD-10 ICD-11
Coding Scheme
Chapter numbering is roman numerals Chapter numbering is Arabic
Three-character categories, each of Stem code (category) is four characters and
which can be further divided into up to there are two levels of subcategories
10 four-character subcategories.
Alphanumeric code with a letter in the An alphanumeric code with a letter in the
first position and a number in the second position and number in the third
second, third and fourth positions. The character position to differentiate from the
fourth character follows a decimal point. codes of ICD-10. The inclusion of a forced
number at the third character position
prevents spelling ‘undesirable words’. A letter
in the second character position allows for
clear distinction between a code from ICD-11
and one from ICD-10. Alphanumeric codes
cover the range from 1A00.00 to [Link].
Codes starting with an ‘X’ indicate an extension
code (see Extension code chapter). The letters
‘O’ and ‘I’ are omitted to prevent confusion
with the numbers ‘0’ and ‘1’.
The first character of a code is a letter The first character of the code always relates
and does not relate to the chapter to the chapter. A first character of 1-9 is used
number. The letter may have been the for chapters 01 through 09 and for chapters 10
same for two short chapters through 26, the first character is a letter. The
(e.g. Chapter VII (H00-H5) and Chapter code range of a single chapter always has the
VIII (H60-H95), or two letters may have same character in the first position. For
been used for one long chapter example, 1A00 is a code in chapter 01, and
(e.g. Chapter XIX (S00-T98)). BA00 is a code in chapter 11.
Residual category identified by numeric The terminal letter ‘Y’ is reserved for the
character .8 and unspecified category residual category ‘other specified’ and the
identified by numeric character .9. terminal letter ‘Z’ is reserved for the residual
category ‘unspecified’.
Code cluster concept does not exist in ICD-11 supports postcoordination and the
ICD-10. linking codes within a code cluster.
Terminology
a range of expressions are used to The preferred term is ‘due to’ for categories
describe a causal relationship between where two conditions are mentioned and
conditions in a code title causal sequence exists. Other terms, such as
‘caused by’; or ‘attributed to’ may be allowed
synonyms. The phrase ‘secondary to’ is
equivalent and may also be included as a
synonym.

ICD-11 Reference Guide 283

 ICD-10 ICD-11
a range of expressions indicating the The preferred term is ‘associated with’ for
concurrence of two conditions in a code categories where two conditions are
title (e.g. ‘in’ or ‘with’). mentioned and there is no causal sequence
implied.

Dagger-Asterisk system and additional sub-classifications

ICD-10 ICD-11
Dagger asterisk system ICD-10 (and ICD-9) used the The ICD-11 equivalents of
dagger asterisk system to asterisk codes (i.e. codes for
describe the aetiological manifestations) and other codes
condition for primary that served to add detail, may
tabulation (dagger code) and be found in Chapter 21
the clinical manifestation, ‘Symptoms, signs or clinical
relevant site and or other findings, not elsewhere
aspects (asterisk code). In classified’, the Chapter X
addition, there were sets of ‘Extension codes’ chapter or in
codes to be used to add more a body system chapter as
detail (e.g. B95-B97) or lists appropriate. The extension
of sub-classifications to add codes include chapter groups
anatomical detail to anatomy, agents,
categories. histopathology and other
aspects that may be used to add
detail to a code.
Use of multiple codes More than one category Postcoordination - The use of
for one could be used to specify multiple codes (i.e. stem codes
condition/additional more detail for another and/or extension codes)
sub-classifications category. For example, together to fully describe a
infectious agents (B95-B97) documented clinical concept.
or the asterisk codes.
‘Code also’ instruction’ ‘Use additional code, if ‘Code also’ instructions inform
desired, to identify’ notes about additional information
were present to suggest that needs to be coded in
optional coding. conjunction with certain
categories, because that
additional information is
relevant for primary tabulation

The dagger and asterisk system has been removed in ICD-11, but the functionality of coding
the aetiology and manifestation remains. A number of former asterisk codes that were
previously used to identify manifestations of diseases are now listed in Chapter 21
‘Symptoms, signs, or clinical findings, not elsewhere classified’. A portion of former asterisk
codes also reside in the corresponding body system chapter. Asterisk codes that were
repetitions of the dagger code were removed. Lists for coding optional anatomical detail
have been grouped into one section in Chapter X ‘Extension codes’.

284 ICD-11 MMS

Other general differences

ICD-11
Category All ICD-11 categories have a short and a long description. The short
description description describes the meaning of the category in 100 words or less and
appears in the printed version of the classification. The long description is
without length restriction, including detailed information that appears in
the content model.
Content All ICD-11 categories include separate information on anatomy, aetiology
model and other aspects that can be accessed for search purposes, or when
browsing in the tabular list of the ICD-11 MMS.

Special tabulation lists of ICD-10 continue to exist, but there are two additional ones, the
Startup Mortality List (SMoL) and the list for verbal autopsy. Additional special tabulations
can be derived from the new multiple parenting technique, e.g. all WHO notifiable diseases,
listing all conditions that are assigned to the relevant section of the infectious diseases
chapter.
For morbidity, the definition of main diagnosis has changed to be ‘the reason for admission,
after assessment at the end of the stay’. This definition is less prone to interpretation, and
countries that had switched from the ‘most resource intensive’ definition to the ‘reason for
admission at the end of the stay’ using ICD-10, noticed only small changes in their activity
statistics.
3.1.1 Short Description

The description is a short characterisation (maximum of 100 words) of the entity that states
things that are always true about a disease or condition and necessary to understand the
scope of the rubric. Descriptions do not contain elements intended for use in level 3
(common epidemiology) or things that may be true for level 4 (clinical criteria). Descriptions
were formerly called ‘short definitions’. For further information refer to section 3.4The
Content Model
3.1.2 Additional Information

This is a text field that is not mandatory, but that may contain any additional information
about, or characteristics of, the diseases or conditions included in the entity. This text field
provides more context for the entity. For example, the most common epidemiologic
circumstances, putative or highly suspected aetiologic agents, or other information that may
not always be true but may be common, typical, or expected. Additional information was
formally called ‘long definition’.
3.1.3 Code Structure

The codes of the ICD–11 are alphanumeric and cover the range from 1A00.00 to [Link].
Codes starting with ‘X’ indicate an extension code (see Extension codes). The inclusion of a
forced number at the third character position prevents spelling ‘undesirable words’. A letter
in the second character position allows for clear distinction between a code from ICD–11
and one from ICD–10. For further information refer to section 1.2.4.1Code structure.

ICD-11 Reference Guide 285

3.2 Chapter Structure of ICD-11
The international core reference linearisation is the ICD-11 for Mortality and Morbidity
Statistics (ICD-11MMS). It is used for coding and reporting illnesses or causes of death for
international comparison. The naming of this linearisation highlights its two main use cases.
This core linearisation is divided into 28 chapters, of which 25 refer to health conditions
similar to past ICD versions, while one serves to identify external causes of morbidity and
mortality, and another includes concepts of traditional medicine. Lastly, there are two
additional sections for optional additional use, one for extension codes to add more detail
for different dimensions of a disease, such as anatomy, mark a condition to be present on
admission, or a disease having been relevant in the family history (see Section [Extension
Codes]) and the other for functioning assessment to provide a set of codes for assessment
and scoring in the ICD using ICF functioning domains of high explanatory power (see Section
3.2.27 Section V – Supplementary section for functioning assessment).
ICD–11 has five new chapters. As a result, the numbering of the chapters has changed. The
new chapters are:
• Chapter 03 ‘Diseases of the blood or blood-forming organs’ and Chapter 04 ‘Diseases
of the immune system’. Conditions affecting the immune system’ and conditions
affecting the blood are now in two separate chapters.
• Chapter 07 ‘Sleep-Wake disorders’. Sleep wake disorders have been regrouped
together in this new chapter.
• Chapter 17 ‘Conditions related to sexual health’. Sexual conditions have been
grouped together in this new chapter.
• Chapter 26 ‘Supplementary Chapter Traditional Medicine Conditions - Module I’. A
chapter for traditional medicine has been added.
The following is an overview of the organisational principles and classification structure
(hierarchy) for each of the 26 chapters. The revised structure and new sets of functionalities
in ICD-11 were the result of incorporating scientific updates and making the classifications
more relevant for computerisation.
3.2.1 Chapter 01 – Certain infectious or parasitic diseases

Structure of Chapter 01

[Link] Chapter 01 – Structure of chapter 01

The chapter first lists infectious disease groupings by clinical syndromes, then groups other
infections by mode of transmission, and then lists the remaining infections by their agent.
Some conditions of major public health concern are listed at the same level. Variants to the
conditions in the chapter that occasionally can occur as localised infections are primarily
coded to this chapter. Infections that are primarily localised, and where the agent usually is
either unknown, or not relevant, or there is a mixed aetiology, reside in the organ chapters.
Frequent infectious agents may be listed as individual child categories under the localised
infection. In some instances, infections could equally be located in the infectious disease
chapter and in an organ system chapter. In such cases, the decision that creates the least
change (ICD-10 legacy) has been chosen. Some grouping is also designed to be able to code

286 ICD-11 MMS

frequently reported imprecise information, as is the case for meningitis and encephalitis and
respiratory infections.
A special tabulation list groups the infections by agents and is intended for special
tabulation and reporting only.

[Link] Chapter 01 – Rationale for chapter 01

The purpose of the structure of chapter 01 is to minimise the impact on longitudinal
statistics of major infections, to allow reporting of main infections that have a common lead
symptom (e.g. diarrhoea) without mention of a specific agent. Influenza, though visibly
affecting the respiratory tract, affects multiple parts of the body and is also of important
public health concern. For that reason, it has been moved into the infectious chapter. Prion
diseases can be transmissible, genetic or arise spontaneously. They are rare conditions that
only affect the nervous system. Many are inherited. The presence of a specific gene is a
prerequisite to developing a prion disease. In view of these facts, it was decided to keep the
prion diseases grouped together and move the whole group to the neurology chapter.

[Link] Antimicrobial resistance

The ICD parts relating to Antimicrobial Resistance (AMR) have been designed to support the
Global Antimicrobial Resistance Surveillance System. Priority pathogens are identified in
combinations with currently relevant antimicrobial substances. The section is designed to
allow postcoordination of other substance and agent combinations in a cluster. The section
on AMR is located in Chapter 21 ‘Symptoms, signs or clinical findings, not elsewhere
classified’, so that the underlying disease or agent is always coded in conjunction with the
AMR category. ICD and the surveillance system focus on specific tracer pathogen-substance
combinations. However, ICD design allows the coding of the full antibiotic susceptibility
pattern if desired. For tabulation, the AMR codes should be reported in combination with
the infectious disease. Where only one condition can be reported, the infectious disease
should be retained. However, at the national level, the set of infectious diseases and the
number of AMR cases among the infection cases should be tabulated.
3.2.2 Chapter 02 – Neoplasms

[Link] Chapter 02 – Structure of chapter 02

The general hierarchy of Chapter 02 consists of the following:
1st level - Behaviour
2nd level - Broad sites or systems
3rd level - Specific site
4th level - Morphological (histological) type

There are three groups that are an exception to the above hierarchy. They are:
1. Neoplasms of brain and central nervous system

1st level - Broad sites

2nd level - Behaviour - morphological (histological) type

2. Neoplasms of haematopoietic and lymphoid tissues

ICD-11 Reference Guide 287

 1st level - Broad morphological (histological) type

2nd level - Specific morphological (histological) type

3. Malignant mesenchymal neoplasms

1st level - Specific morphological (histological) type

2nd level - Site

[Link] Chapter 02 - Rationale for Chapter 02

The progress in oncology has clearly demonstrated that a site-only based categorisation of
malignant and benign tumours provides limited information for prevention, treatment, and
prognosis for persons that are affected by a tumour. ICD–10 included a limited number of
categories based on histopathology (e.g. some lymphoid neoplasms, melanoma).
In ICD–11, main tumour sites have subdivisions of histopathology first. The groups chosen
were based on an analysis of international mortality and morbidity reporting, cancer
registries, and clinical reporting. The redesigned sections were reviewed for missing details
in relation to the ICD use cases.
Keeping the main anatomical axes intact allows backwards compatibility. However, the
structure was adjusted in a few places to match anatomical subdivisions of the TNM
classification ([Link]
For tumours of the central nervous system, the histological and behavioural distinction
between benign and malignant is a grey area. As such, it was decided to move all central
nervous system tumours outside the basic framework of behaviour and group them
together.
The field of genetic markers is rapidly changing. Whereas for some tumours, such markers
have been used for many years, for others, this is not the case. As such, with the exception
of haematological tumours, genetic markers were not included, and have not been used for
the classification. They are, however, included in Chapter X ‘Extension codes’, and can be
added as postcoordination to the relevant code from the neoplasms chapter to describe the
relevant tumour entity fully.
3.2.3 Chapter 03 – Diseases of the blood or blood-forming organs

[Link] Chapter 03 – Structure of chapter 03

This new chapter (previously part of Chapter III in ICD-10) has three main sections:
- Anaemias or other erythrocyte disorders
- Coagulation defects, purpura or other haemorrhagic or related cond
itions
- Diseases of spleen

Neoplasms of haematopoietic and lymphoid tissues are primarily located in Chapter 02

‘Neoplasms’ while Symptoms, signs or clinical findings of blood or blood-forming organs or
the immune system are primarily located in Chapter 21.

288 ICD-11 MMS

The first two major sections comprise of the following hierarchy:
1st level - Anaemias and coagulation disorders
2nd level - Broad category of disease/disorder type
3rd level - Congenital vs acquired
4th level - Further specificity of disease/disorder type

The third major section comprises of the following hierarchy:

1st level - Diseases of spleen
2nd level - Congenital vs acquired
3rd level - Specific disease/disorder type

[Link] Chapter 03 – Rationale for chapter 03

For Chapter 03, there has been a reorganisation of the chapter into a clinical view of
diseases of the blood, an aetiological view of diseases of the blood and diseases of the
spleen. Anaemias are now all under one group with a separate group for ‘Coagulation
defects, purpura or other haemorrhagic correlated conditions’.
3.2.4 Chapter 04 – Diseases of the immune system

[Link] Chapter 04 – Structure of chapter 04

This new chapter (previously part of Chapter III in ICD-10) has the following sections:
Immunodeficiencies
Non-organic specific systemic disorders
1st level - Being the main groupings above
2nd level - Broad category of disease/disorder type
3rd level - Specific disease/disorder type
4th level - Further specificity of disease/disorder type

1st level - Autoinflammatory disorders

2nd level - Specific syndrome

1st level - Allergic or hypersensitivity conditions

2nd level - Broad category for body systems

1st level - Certain diseases involving the immune system

2nd level - Specific disease/disorder type
3rd level - Further specificity of disease/disorder type

Diseases of thymus
2nd level - Specific disease/disorder type

[Link] Chapter 04 – Rationale for chapter 04

For Chapter 04, there are new sections for immune disorders that differ from the section
previously located in Chapter III of ICD–10. For the immune system they are classified mainly
by clinical syndrome, and in an alternate view the immune system conditions are shown by

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cell line. A section for Allergic or hypersensitivity conditions has been included in this
chapter. Overall, more detail has been added to the chapter.
3.2.5 Chapter 05 – Endocrine, nutritional or metabolic diseases

[Link] Chapter 05 – Structure of Chapter 05

Chapter 05 has four major sections:
1. Endocrine diseases

2nd level - Specific gland or hormone system

3rd level - Specific diseases/disorder

2. Nutritional disorders

2nd level - Broad categories of diseases/disorder

3rd level - Specific disease/disorder

3. Metabolic disorders

2nd level – Broad categories of diseases/disorder

3rd level - Specific disease/disorder

4. Postprocedural endocrine or metabolic disorders

2nd level - Specific disease/disorder

Neoplasms of the endocrine system are primarily located in Chapter 02 ‘Neoplasms’ and
Symptoms, signs or clinical findings of endocrine, nutritional or metabolic diseases are
primarily located in Chapter 21.

[Link] Chapter 05 – Rationale for Chapter 05

There is increased international standardisation of endocrine disease terminology being
used to describe the complex nature of endocrine conditions. The intent is to include all
dysfunctions that lead to a specific endocrine disorder.
Diabetes mellitus and Intermediate hyperglycaemia have been expanded to reflect current
international terminology. The complications often associated with diabetes have continued
to be included in the classification in the appropriate body system chapter in line with the
various clinical modifications. ‘Code also’ and ‘Use additional code’ notes have been
included to link the types of diabetes and the various complications to enable the addition
of codes for further specificity.
Sources of change for this section were based on the current WHO Classification of Diabetes
Mellitus and Intermediate Hyperglycaemia 2011 and the Department of Chronic Diseases,
Health Promotion, WHO.
The WHO Department of Nutrition for Health and Development proposed changes to the
section on Nutritional Disorders with advice from the Nutrition Guidance Expert Advisory
Group (NUGAG) for updates to this section of the classification. Metabolic disorders are now

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aetiologically based and have been classified into three distinct areas; ‘Inborn errors of
metabolism’, ‘Disorders of metabolite absorption and transport’ and ‘Disorders of fluid,
electrolyte and acid-base balance’ following clinical advice received from the relevant
international societies for metabolic diseases.
3.2.6 Chapter 06 – Mental, behavioural or neurodevelopmental disorders

[Link] Chapter 06 – Structure of Chapter 06

The hierarchy of Chapter 06 consists of:
1st level - Broad category of disease/disorder type
2nd level - Specific disease/disorder type
3rd level - Further specificity of disease/disorder type

[Link] Chapter 06 – Rationale for Chapter 06

The overall linear structure of the proposed Mental, behavioural or neurodevelopmental
disorders chapter for ICD–11 has been a topic of substantive and comprehensive discussions
by the Topic Disorders Advisory Group for Mental Health, as well as extensive interactions
with the American Psychiatric Association in relation to the just-published Fifth Edition of
the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) (1), from the time of the
Advisory Group’s initial appointment in 2007.
The appropriate architecture of a diagnostic classification of mental and behavioural
disorders is an issue that has received substantial attention over the course of the revision
(e.g. 2-4). One of the guiding principles of the ICD–11 is that it should reflect current
scientific evidence regarding the relationships among disorders (5) rather than antiquated
concepts such as ‘neurosis’, which have poor construct and predictive validity. In addition, a
major goal of the WHO Department of Mental Health and Substance Abuse for the current
revision is to improve the clinical utility of this part of the ICD–11 (6, 7). Because the ICD–11
uses a different coding structure that is not based on a decimal numbering system, such that
a larger number of blocks or groupings can be accommodated within the chapter, an
important opportunity was presented to bring the classification more in line with current
research and clinical practice in terms of how groupings of disorders are represented.
Three streams of work provide the rationale and evidence for the linear structure of Mental
and Behavioural Disorders in the ICD–11.
Evidence Reviews by Working Groups for ICD–11 Mental, behavioural or
neurodevelopmental disorders
The first stream of work relates to the outcome of evidence reviews by the 14 Working
Groups reporting to the Advisory Group, each of which had multiple face-to-face meetings
over at least a 2-year period. The Working Groups were asked to review the available
scientific evidence and other information about the clinical application of classifications in
various settings throughout the world, and to provide evidence and a rationale for its
groupings as well as the content and arrangement of categories within them. This work
resulted in manuscripts describing the rationale for most groupings of disorders that have
been published in or submitted to peer- reviewed journals (e.g. 8-15). Space does not
permit detailing the rationale and evidence base for each structural change here, but this

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information as it relates to any specific decision can be provided on request based on the
material generated by the Working Groups.
Formative Field Studies on Clinical Utility of the Linear Structure
The second stream of work relevant to the linear structure of Mental and Behavioural
Disorders focused on clinical utility and is represented by two formative field studies
undertaken by the WHO and the Field Studies Coordination Group reporting to the Advisory
Group (16, 17). The purpose of these studies was to examine the conceptualizations held by
mental health professionals around the world of the relationships among mental disorders
to inform decisions about the structure of the classification. From a clinical utility
perspective, particularly in terms of improving the interface between health information
and clinical practice, the most important and desirable features of a classification’s
organisation is that (a) it helps clinicians find the categories that most accurately describe
the patients they encounter as quickly, easily, and intuitively as possible and (b) the
diagnostic categories so obtained would provide them with clinically useful information
about treatment and management. A mental disorders classification that is difficult and
cumbersome to implement in clinical practice and does not provide information that is of
immediate value to the clinician has no hope of being implemented accurately at the
encounter level in real-word health care settings. In that event, clinical practice will not be
guided by the standardisation and operationalization of concepts and categories that are
inherent in the classification, and important opportunities for practice improvement and
outcomes assessment will be lost. In turn, a diagnostic system that is characterized by poor
clinical utility at the encounter level cannot generate data based on those encounters that
will be a valid basis for health programs and policies, or for global health statistics. The
rationale behind these two studies was that if the ways in which clinicians conceptualized
the organisation of mental disorders as encountered in their day-to-day clinical practice was
found to be (a) consistent across countries, languages, and disciplines, and (b) distinct from
the organisation of ICD–10, then this information could be used to create a classification of
mental disorders that corresponds more closely to clinicians’ cognitive organisation of
categories and would therefore be more intuitive and efficient for use in real- world health
care settings.
The first formative field study (17) was an internet-based study administered in both English
and Spanish, in which 1,371 psychiatrists and psychologists from 64 countries participated.
The second formative field study (16) involved the face-to-face administration of a
standardised sorting and hierarchy-formation task to 517 mental health professionals in
eight countries and five languages. Both studies found that clinicians’ conceptual map of
mental disorders was rational and highly stable across profession, language, and country
income level. Moreover, both studies found that the proposed structure for mental and
behavioural disorders in ICD–11 was more consistent with clinicians’ conceptual models
than the structure of either ICD–10 or DSM- IV. The second study also clearly demonstrated
that clinicians preferred a ‘flatter’ structure with a larger number of groupings as compared
with a more hierarchical structure with fewer groupings as found in ICD–10.
Harmonisation with DSM-5
The third stream of work relates to efforts to harmonise the structure of the ICD–11 chapter
on Mental and Behavioural Disorders with the structure of the DSM-5, where possible.

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Overall, the high degree of similarity between the overall structure of DSM-5 (1) and the
proposed linear structure for ICD–11 Mental and Behavioural Disorders represents a major
success of the ICD – DSM harmonisation effort. Relatively minor differences relate primarily
to:
1. proposals to combine the classifications of ‘organic’ and ‘non-organic’ aspects of
conditions such as sleep disorders and sexual dysfunctions in ICD–11 in separate
chapters in ways that are more consistent with current evidence and clinical
practice, which was not an option for DSM-5 given that it is by definition a
classification of mental disorders; and
2. differences in conventions related to residual categories and mental disorders
associated with other underlying disease under ICD–11 from decisions about the
organisation of such categories in DSM-5. Additional information about the rationale
for the few remaining substantive differences in overall structure between the two
classifications is available upon request. It must be emphasized that the resulting
similarity in organisation between the two systems is the product of several years of
complex negotiations. Given that DSM-5 has already been published, further
changes to the ICD–11 structure would almost certainly move ICD–11 in the
direction of reduced similarity and harmonisation with DSM-5.
References
1. American Psychiatric Association (2013). Diagnostic and statistical manual of mental
disorder, Fifth Edition (DSM-5). Washington, DC: American Psychiatric Publishing.
2. Andrews, G., Goldberg, D. P., Krueger, R. F., Carpenter, W. T. Jr., Hyman, S. E.,
Sachdev, P., & Pine, D. S. (2009). Exploring the feasibility of a meta-structure for

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 DSM-V and ICD-11: Could it improve utility and validity? Psychological Medicine, 39,
1993–2000.
3. Jablensky, A. (2009). A meta-commentary on the proposal for a meta-structure for
DSM-V and ICD-11. Psychological Medicine, 39, 2099–2103.
4. Wittchen, H.-U., Beesdo, K., & Gloster, A. T. (2009). A new meta-structure of mental
disorders: A helpful step into the future or a harmful step back to the past?
Psychological Medicine, 39, 2083–2089.
5. Hyman, S. E. (2010). The diagnosis of mental disorders: The problem of reification.
Annual Review of Clinical Psychology, 6, 155–179.
6. Reed, G.M. (2010). Toward ICD-11: Improving the clinical utility of WHO’s
international classification of mental disorders. Professional Psychology: Research
and Practice, 41, 457–464.
7. International Advisory Group for the Revision of ICD-10 Mental and Behavioural
Disorders. (2011). A conceptual framework for the revision of the ICD-10
classification of mental and behavioural disorders. World Psychiatry, 10, 86–92.
8. Al-Adawi, S., Baks, B., Bryant-Waugh, R., Claudino, A.M., Hay, P., Monteleone, P., et
al. (2013). Revision of ICD- status update on feeding and eating disorders. Advances
in Eating Disorders, 1, 10-20.
9. Creed, F., & Gureje, O. (2012). Emerging themes in the revision of the classification
of somatoform disorders. International Review of Psychiatry, 24, 556-567.
10. Drescher, J., Cohen-Kettenis, P., & Winter, S. (2012). Minding the body: Situating
gender identity diagnoses in the ICD-11. International Review of Psychiatry, 24, 568-
577.
11. Gaebel, W. (2012). The status of psychotic disorders in ICD-11. Schizophrenia
Bulletin, 38, 895-898.
12. Maercker, A., Brewin, C.R., Bryant, R.A., Cloitre, M., van Ommeren, M., Jones, L.M.,
et al. (2013). Diagnosis off classification of disorders specifically associated with
stress: Proposals for ICD-11. World Psychiatry, 12, 198-206.
13. Maj M., & Reed, G.M. (Eds.) (2012). The ICD-11 classification of mood and anxiety
disorders: background and options. World Psychiatry, 11(Suppl. 1).
14. Poznyak, V., Reed, G.M., & Clark, N. (2011). Applying an international public health
perspective to proposed changes for DSM-5. Addiction, 106, 868-870.
15. Rutter, M.C. (2011). Research review: Child psychiatric diagnosis and classification:
concepts, findings, challenges and potential. Journal of Child Psychology and
Psychiatry, 52, 647-660.
16. Reed, G.M., Roberts, M.C., Keeley, J., Hooppell, C., Matsumoto, C., Sharan, P., et
al. (2013). Mental health professionals’ natural taxonomies of mental disorders:
Implications for the clinical utility of the ICD-11 and the DSM-5. Journal of Clinical
Psychology, 69, 1191-1212.
17. Roberts, M.C., Reed, G.M., Medina-Mora, M.E., Keeley, J.W., Sharan, P., Johnson,
D.K., et al. (2012). A global clinicians’ map of mental disorders to improve ICD-11:

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 Analysing meta-structure to enhance clinical utility. International Review of
Psychiatry, 24, 578-590.
3.2.7 Chapter 07 – Sleep–wake disorders

[Link] Chapter 07 – Structure of Chapter 07

Chapter 07 is a new chapter in ICD–11. It contains Sleep-wake disorders that were
previously located within the respiratory, neurology, or mental health chapters. By
combining these disorders into one chapter, more detail can be included for many of the
sleep related disorders. The hierarchy consists of:
1st level - Broad category of disease/disorder type
2nd level - Specific disease/disorder type
3rd level - Further specificity of disease/disorder type

[Link] Chapter 07 – Rationale for Chapter 07

As Sleep-wake disorders pertain to an area of overlap between mental health, neurological
disorders and pulmonary conditions, the decision was made to place them together in one
chapter.
3.2.8 Chapter 08 – Diseases of the nervous system

[Link] Chapter 08 – Structure of Chapter 08

1st level - Mixture of diseases, disorders and sites and combination
s of both.
2nd level - Subcategory mixture of specific disease or disorder type
and sometimes site.

[Link] Chapter 08 – Rationale for Chapter 08

ICD–11 sees a major overhaul in the organisation of the blocks which make up the
neurology chapter. The restrictive decimal coding system of the ICD–10, with its capacity to
contain only 11 blocks of disorders per chapter, resulted in blocks containing miscellaneous
neurological entities which did not logically fit together, such as the episodic and
paroxysmal disorders block, containing headache disorders, epilepsy, transient ischaemic
attacks and sleep disorders. The ICD–11 now positions headache disorders, epilepsy and
cerebrovascular disorders at a block level, and sleep disorders at chapter level (Chapter 07).
Not only has the structure of the neurological chapter changed, but the approach to
classification also integrates current clinical practice and advancements in the
understanding of neurological diseases. In the time since the ICD–10 was published,
enormous progress in the fields of genetics, molecular biology and medical technologies
have been made. An increase in the number of codes is inevitable when one reflects on the
recent knowledge gain in neurology, so a balance between comprehensiveness, clinical
utility and maintaining a public health approach is the aim. The working groups tackled this
issue by considering the more common disorders to appear in the chapter, with less
common aetiological variations of these disorders being subject to a ‘double coding’
technique. One major change which illustrates the advancement of knowledge is the
addition of a block entitled ‘Paraneoplastic and autoimmune disorders of the nervous
system’. This block contains immune-mediated neurological diseases, a field in which

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knowledge has exploded in recent years. A second example of how the new version reflects
molecular biological advancement is through awarding Prion diseases block status despite
their rarity. Previously, they featured as part of the infections of the central nervous system
block, but research interest after the major public health issue in Europe in the 1990s has
led to new variants of prion diseases being discovered.
The world has seen a large rise in the elderly population since the 1990s. Neurocognitive
disorders have been declared as a major public health concern and research into its
aetiology and neuropharmacology has boomed. The ICD–11 block on Neurocognitive
disorders reflects the better understanding in this area.
One final particularly noteworthy change can be found in the ‘Other disorders of the
nervous system’ block. This block is employed to capture the ‘spill over’ from other
neurology blocks and those disorders which are deemed unclassifiable elsewhere. In the
ICD–10, due to the aforementioned decimal coding system, this block was an incongruent
collection of diseases. This block has now reduced significantly in size due to the new,
streamlined neurology chapter structure which includes new blocks of disorders previously
contained in the ‘other disorders of the nervous system’ section of ICD–10. These include
‘disorders of consciousness’, ‘disorders of cerebrospinal fluid pressure and flow’, ‘disorders
of the autonomic nervous system’, ‘nutritional and toxic disorders of the nervous system’
and ‘spinal cord disorders excluding trauma’. Their promotion to block status will hopefully
have a positive effect on coding practices.
One complicating issue facing the Neurology Topic Advisory has been the need to cross-link
disorders which have a neurological presentation or phenotype to their aetiological roots
within other chapters or blocks within the neurology chapter. One of the countless
examples of this kind of relationship would be mitochondrial disorders of neuromuscular
junction. They must be cross-linked both in the neurology chapter, and in the Endocrine,
nutritional or metabolic diseases chapter.
3.2.9 Chapter 09 – Diseases of the visual system

[Link] Chapter 09 – Structure of Chapter 09

The general hierarchy of Chapter 09 consists of the following:
1st level - Broad category of anatomy
2nd level - Specific anatomy category
3rd level - Broad category of disease/disorder type
4th level - Further specificity of disease/disorder type

3.2.10 Chapter 10 - Diseases of the ear or mastoid process

[Link] Chapter 10 – Structure of Chapter 10

The general hierarchy of Chapter 10 consists of the following:
1st level - Broad category of anatomy
2nd level - Specific disease/disorder type
3rd level - Further specificity of disease/disorder type

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3.2.11 Chapter 11 – Diseases of the circulatory system

[Link] Chapter 11 – Structure of Chapter 11

There are two main hierarchies in Chapter 11.
1st level - Broad category of disease/disorder type
2nd level - Specific disease/disorder type
3rd level - Further specificity of disease/disorder type

OR
1st level - Broad category of anatomy
2nd level - Specific anatomy type
3rd level - Specific disease/disorder type

[Link] Chapter 11 – Rationale for Chapter 11

There have been large scale changes in clinical practice in cardiovascular diseases and their
management since ICD-10 was published over 20 years ago. Changes introduced for ICD-11
in this chapter reflect these changes and the shift in disease profiles and increased survival
following procedures. As a consequence, there has been a major expansion in the number
of disease entities within ICD-11, with new classification hierarchies and updated
nomenclature. For instance, the incidence of heart valve disease is no longer dominated by
rheumatic fever in developed societies, although it remains important in developing nations,
and consequently there has been a shift in diagnostic paradigms to that of valve type, then
valve pathology followed by aetiology.
Many items previously classified in ICD-10 as ‘Other forms of heart disease’ (I30-I52) have
become major clinical issues in today’s cardiology, warranting the creation of new distinct
higher-level categories. Two examples are:
• Diseases of the myocardium, including extensive subsections on Myocarditis and
Cardiomyopathy.
• Cardiac arrhythmia, including a large new subsection on ‘Cardiac arrhythmia
associated with genetic disorder’ and ‘Pacemaker or implantable cardioverter or
defibrillator or lead dysfunction’, both of which are increasingly important areas of
clinical practice. The changes in this section have had major input and endorsement
from the Paediatric & Congenital Electrophysiology Society and the International
Society for Nomenclature of Paediatric and Congenital Heart Disease.
The change in the ICD revision process to be clinically driven has meant that areas primarily
managed by non-cardiologists have been relocated to more suitable chapters. Thus,
Cerebrovascular diseases have been reclassified to Chapter 08, `Diseases of the nervous
system’ and oesophageal varices have been relocated to Diseases of the digestive system
(Chapter 13).
A new subsection on Pulmonary Hypertension in the Pulmonary heart disease and diseases
of pulmonary circulation section, is based on the resulting paper Updated Clinical
Classification of Pulmonary Hypertension, following the 5th World Symposium held in Nice,
France, in 2013.

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The postprocedural disorders section has been markedly enlarged reflecting increased
survival after cardiovascular procedures over the last two decades with recognition of an
increasing number of patients with postprocedural morbidities and disease specific
complications.
The section on Congenital anomaly of heart and great vessels and related acquired
abnormalities classified to Chapter 20 ‘Developmental anomalies’ has been based on the
International Paediatric and Congenital Cardiac Code (IPCCC), which has been created over
the last decade by the International Society for Nomenclature of Paediatric and Congenital
Heart Disease (ISNPCHD, [Link] As a consequence, the 73 congenital
cardiology ICD-10 entities in Q20-Q29 have been expanded to 316 diagnoses, as an accurate
summation of the heterogeneity of cardiac malformations seen in clinical practice.
Reference was also made to the Anatomic and clinical classification of congenital heart
defects (ACC-CHD) with the corresponding IPCCC and ICD-10 codes.
3.2.12 Chapter 12 – Diseases of the respiratory system

[Link] Chapter 12 – Structure of Chapter 12

There are two main hierarchies in Chapter 12:
1st level - Broad category of disease/disorder type
2nd level - Specific disease/disorder type with some anatomy include
d
3rd level - Further specificity of disease/disorder type

OR
1st level - Broad category of anatomy
2nd level - Specific disease/disorder type
3rd level - Further specificity of disease/disorder type

[Link] Chapter 12 – Rationale for Chapter 12

The changes to Chapter 12 have been made principally to provide current clinical
terminology and classification of conditions primarily affecting the respiratory system and
have been based on input from international societies and stakeholders. Infectious lung
diseases have been moved to Chapter 01 to better reflect the infectious nature of these
conditions. Neoplasms of the respiratory system are in Chapter 02 ‘Neoplasms’, and
Developmental respiratory diseases are now located in Chapter 20 ‘Developmental
anomalies’.
The grouping ‘Upper respiratory tract disorders’ contains upper respiratory tract diseases
except for conditions that moved to the Infectious disease chapter.
The Lower respiratory tract diseases shifted from the Chronic lower respiratory diseases of
the ICD-10, but Chronic obstructive pulmonary disease (COPD) was made an independent
category based on an international concept.
Cystic fibrosis has been moved to Certain lower respiratory tract diseases and multi-
parented to metabolic disorders in the Endocrine chapter because: ‘The representative
clinical conditions of cystic fibrosis are intractable respiratory infection, end stage

298 ICD-11 MMS

respiratory failure, exocrine pancreatic insufficiency and digestive organ lesions such as the
meconium ileus. Cystic fibrosis is a disease due to an abnormality of the Cl ion channel
which is CFTR, symptoms of the respiratory symptom is recognised in nearly all cases of
patients. The cause of death is mainly respiratory abnormality, and this disease is the target
disease of lung transplantation.’ This description of cystic fibrosis is found in representative
textbooks (‘Diseases of the Airways’ in the textbook ‘Fraser and Pare’s Disease of the
Chest’).
• ‘OBSTRUCTIVE DISEASES’ in the textbook ‘Murray and Nadel’s Textbook of
Respiratory Medicine’
• ‘OBSTRUCTIVE LUNG DISEASES’ in the textbook ‘Fishman’s pulmonary diseases and
disorders’
• ‘Disease of the Airways’ in the textbook ‘Fraser and Pare’s Disease of the Chest’
‘Pulmonary Diseases’ in the textbook ‘Washington Manual of Medical Therapeutics,
The, 34ed.’
The section pertaining to Inhalation, occupational and environmental lung disease has been
based on input from the WHO Occupational Health Division.
The Certain specified respiratory diseases principally affecting the lung interstitium shifted
from the Other respiratory diseases principally affecting the interstitium. The Idiopathic
interstitial pneumonitis was made an independent category based on an international
concept and the category of the Primary interstitial lung diseases specific to infancy and
childhood was created independently based on the proposal of the Paediatric Topic
Advisory Group (TAG).
The section of the Certain diseases of the respiratory system and the section of the
Postprocedural respiratory disorders were shifted from Other diseases of the respiratory
system of ICD-10 except for the Mediastinal and diaphragm disorders that moved to the
section of Pleural, diaphragm and mediastinal disorders.
3.2.13 Chapter 13 – Diseases of the digestive system

[Link] Chapter 13 – Structure of Chapter 13

The general hierarchy of Chapter 13 consists of the following:
1st level - Detailed anatomy
2nd level - Specific disease/disorder type
3rd level - Further specificity of disease/disorder type

[Link] Chapter 13 – Rationale for Chapter 13

ICD-11 has been improved in structure and content to include diseases and disorders of the
orofacial complex. There are several other tissues which as essential components of the
orofacial complex, have an important function, and their impairment will have a direct
impact on oral health status. It is important to recognise that oral health is more than
having healthy teeth; having oral health is being free of chronic oral-facial pain conditions,
oral and pharyngeal cancers, oral soft tissue lesions, periodontal (gum) disease, tooth decay
and tooth loss and tooth surface loss, birth defects such as cleft lip and palate, and scores of
other diseases and disorders that affect the oral, dental, and craniofacial tissues (orofacial

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complex) as well as associations with systemic health and disease. This underlines the
importance of providing a coherent system for coding and classifying data on orofacial
complex diseases and disorders so that the oral health professional can record and collect
data from each patient at their clinics, regardless of whether such facility may be part of
large hospitals, or small clinics. It is anticipated that being able to record and interpret such
data will enable health professionals to contribute to the improvement of oral health as an
essential component of general health and will stimulate the use of ICD-11 by oral health
personnel.
Major changes have been made to this chapter with very detailed anatomical groups being
added to the hierarchy for the digestive tract, according to rostral-caudal order, with the
exception of categories for hernia, functional gastrointestinal disorders, and inflammatory
bowel diseases.
Functional gastrointestinal disorders are independently described because their
pathophysiology is considered from the standpoint of ‘Brain-Gut axis’, and not only from
their impact on the gastrointestinal tract. Inflammatory bowel diseases are also
independently described mainly because Crohn’s disease involves several organs. In each
anatomical group (organ group), aetiology based classifications are used to sub-classify
disorders. Particularly, GI disorders are arranged in the following categories:
A. Acquired anatomical or morphological alterations

B. Motor disorders

C. Inflammation including ulcer

D. Vascular disorders

E. Non-neoplastic polyps

In addition, there are two other categories listed, although Chapter 13 is not the primary
place for these disorders.
F. Structural developmental anomalies (located in Chapter 20 Develop
mental anomalies)

G. Neoplasms (located in Chapter 02 Neoplasms)

Important or common digestive diseases have been allocated their own category, for
example gastro-oesophageal reflux disease, columnar metaplastic epithelium, intestinal
malabsorption and protein-losing enteropathy, ulcerative colitis, non-alcoholic fatty liver
disease and diverticular disease. Polyps are now classified independently, and not in the
‘other diseases’ section of anatomical site.
Common digestive diseases extending over several organs are classified principally into the
disease category of the rostral organ. For example, ‘Gastroenteritis’ is classified in ‘Gastritis’,
and ‘Gastroduodenal ulcer’ is classified in ‘Gastric ulcer’. The item ‘Peptic ulcer, site
unspecified’ should not be used due to advances in medical technology. It should be
classified into either the ‘Oesophageal ulcer, Gastric ulcer, Duodenal ulcer or Anastomotic
ulcer’ category, depending on the disease site.

300 ICD-11 MMS

Vascular disorders of GI organs have been allocated their own category. Oesophageal
varices, gastric varices and haemorrhoids are now classified in Chapter 13. In ‘Diseases of
liver’, there are new independent categories including Metabolic and transporter liver
disease, Autoimmune liver diseases, Non-alcoholic fatty liver disease and Vascular disorders
of the liver.
For the classification of Chronic liver disease with cirrhosis, ‘Liver cirrhosis’, an item in
‘Hepatic fibrosis and cirrhosis’, is used. For example, ‘Chronic hepatitis B’ and ‘Liver
cirrhosis’, ‘Chronic hepatitis C’ and ‘Liver cirrhosis’, ‘Autoimmune hepatitis’ and ‘Liver
cirrhosis’, ‘Primary biliary cholangiopathy’ and ‘Liver cirrhosis’, etc. There are new
independent sections for ‘Diseases of gallbladder and biliary duct’ and ‘Diseases of
pancreas’. Within these new sections, there are new independent categories including
Structural developmental anomalies, Congenital anomalies, Acquired anatomical
alterations, Cholangitis, Cystic diseases of the pancreas, Chronic pancreatitis and
Autoimmune pancreatitis.
3.2.14 Chapter 14 – Diseases of the skin

[Link] Chapter 14 – Structure of Chapter 14

The general hierarchy of Chapter 14 consists of the following:
1st level - Broad category of disease/disorder type
2nd level - Specific disease/disorder type with some anatomical site
3rd level - Further specificity of disease/disorder type

[Link] Chapter 14 – Rationale for Chapter 14

Major changes have been made to this chapter adding detail coming from the fusion of the
American, British, and German dermatological terminologies.
3.2.15 Chapter 15 – Diseases of the musculoskeletal system or connective tissue

[Link] Chapter 15 – Structure of Chapter 15

The general hierarchy of Chapter 15 consists of the following:
1st level - Broad category of disease/disorder type
2nd level - Specific disease/disorder type with some anatomical site
3rd level - Further specificity of disease/disorder type

[Link] Chapter 15 – Rationale for Chapter 15

The American College of Rheumatology and European League Against Rheumatism
(ACR/EULAR) Diagnostic Criteria for Rheumatoid Arthritis (under development) was used to
inform the code hierarchy and content model attributes for Rheumatoid arthritis. Current
literature informed the change of title of ‘systemic connective tissue disorders’ to ‘non-
organ specific systemic autoimmune disorders’. The changes to vasculitis were based on the
classification of the Chapel Hill International Consensus Conference on the Nomenclature of
Systemic Vasculitis.

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The category ‘Dermatopolymyositis’ was changed to ‘Idiopathic inflammatory myopathies’
with a change of axes and introduction of further granularity.
The revisions to the classification of spondyloarthritis reflect current expert opinion with
comments from Dr Robert Landewé, with a separation of axial and peripheral. Together, the
axial and peripheral spondyloarthritis criteria cover the entire spectrum of what was
formerly called (undifferentiated) spondyloarthritis and (ankylosing) spondylitis. There is re-
arrangement of infective spondyloarthritis, with a secondary axis for the major types of
infective process, i.e. bacterial, fungal etc., and supplementary codes to be used for the
specific infection.
The new category for Auto-inflammatory syndromes is based on the work of the
International Society of Systemic Auto-inflammatory Disease (ISSAID).
3.2.16 Chapter 16 – Diseases of the genitourinary system

[Link] Chapter 16 – Structure of Chapter 16

Chapter 16 has specific sections for Diseases of the female genitourinary system, Diseases of
the male genitourinary system, Disorders of breast, Diseases of the urinary system and
Postprocedural disorders of the genitourinary system.
The general hierarchy of Chapter 16 consists of the following:
1st level - Broad category of body system
2nd level - Broad disease/disorder type (with some anatomy)
3rd level - Specific disease/disorder type (with some anatomy)

[Link] Chapter 16 – Rationale for chapter 16

The changes to Chapter 16 are aimed at increasing the clinical utility of the classification by
providing a more user-friendly hierarchical structure, increased international comparability
and standardisation of genitourinary conditions. This is accomplished by including the most
scientifically accurate and internationally agreed-upon terms and definitions provided by
various international stakeholders, including the WHO department of Reproductive Health
and Research, the International Federation of Gynaecology and Obstetrics (FIGO), National
Kidney Foundation and the Kidney Disease International Global Outcomes (KDIGO).
The chapter hierarchy is subdivided into Diseases of the Female Genital System, Diseases of
the Male Genital System and Diseases of the Urinary system. This architecture of the female
genital system and the male genital system was designed to improve the end-user
experience. The female genital system hierarchy is broken down into non-inflammatory and
inflammatory disorders, and then further divided by anatomical grouping in the order of
gynaecologic (and obstetric) examination (from external to internal genitalia), where
applicable. (Vulva, Vagina, Cervix, Uterus, Fallopian Tube, Ovary, Pelvic Cavity).
These groupings have further subdivisions for congenital and acquired abnormalities, as
appropriate.
To reflect the current scientific understanding for certain genitourinary conditions,
additional detail has been included for the following areas:

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Amenorrhea
Ovarian dysfunction
Female pelvic pain
Endometriosis
Adenomyosis
Female infertility
Male infertility
Early pregnancy loss
Pregnancy outcomes
The Kidney failure section of the classification has been revised to reflect the current
evidence-based definitions of acute kidney versus chronic kidney disease and the new
Kidney Disease (‘Improving Global Outcomes (KDIGO) definitions and staging system for
acute kidney failure’.)
3.2.17 Chapter 17 – Conditions related to sexual health

[Link] Chapter 17 – Structure of Chapter 17

New chapter in ICD-11 divided into major sections for:
Sexual dysfunctions
Sexual pain disorders
Gender incongruence
1st level - Broad category of condition
2nd level - Specific type of condition
3rd level - Specific disease/disorder

[Link] Chapter 17 – Rationale for Chapter 17

The chapter has been formulated to group sexually related conditions. This also allows
categorisation of gender identity related conditions without stigmatisation, while
maintaining recognition of these entities as real conditions so that related health
interventions can be accommodated within the health system.
3.2.18 Chapter 18 – Pregnancy, childbirth or the puerperium

[Link] Chapter 18 – Structure of Chapter 18

The general hierarchy of Chapter 18 consists of the following:
1st level - Broad category related to the stages of pregnancy, child
birth or the puerperium
2nd level - Specific disease/disorder type
3rd level - Further specificity of disease/disorder type

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[Link] Chapter 18 – Rationale for Chapter 18
The changes to this chapter are intended to increase the clinical utility of the classification
by providing a more user-friendly hierarchical structure. Increasing the international
comparability and standardisation of conditions related to pregnancy, childbirth and the
puerperium by including the most scientifically accurate and internationally agreed-upon
terms and definitions provided by various international stakeholders, such as the WHO
department of RHR, International Federation of Gynaecology and Obstetrics (FIGO), was
also a highly important aspect of the modifications. Particular attention was given to correct
integration of concepts and definitions of the International Committee Monitoring Assisted
Reproductive Technologies (ICMART).
The changes reflect the current understanding for certain conditions related to pregnancy,
childbirth and the puerperium. Additional specifications have been included for Early
pregnancy loss
3.2.19 Chapter 19 – Certain conditions originating in the perinatal period

[Link] Chapter 19 – Structure of Chapter 19

The general hierarchy of Chapter 19 consists of the following:
1st level - Broad category disease/disorder type and some anatomy
2nd level - Specific disease/disorder type
3rd level - Further specificity of disease/disorder type

3.2.20 Chapter 20 – Developmental anomalies

[Link] Chapter 20 – Structure of Chapter 20

Chapter 20 has undergone a major restructure with it now having four major sections
Structural developmental anomalies primarily affecting one body system
1st level - Broad category of anatomy
2nd level - Specific disease/disorder type
3rd level - Further specificity of disease/disorder type

Multiple developmental anomalies or syndromes

1st level - Broad category of anatomy
2nd level - Specific disease/disorder type
3rd level - Further specificity of disease/disorder type

Chromosomal anomalies, excluding gene mutations

1st level - Specific disease/disorder type
2nd level - Further specificity of disease/disorder type

Conditions with disorders of intellectual development as a relevant clinical feature

1st level - Non-syndromic vs syndromic conditions
2nd level - Further specificity of disease/disorder type

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[Link] Chapter 20 – Rationale for Chapter 20
The ICD–10 classification of developmental anomalies is covered by Chapter XVII: Q00-Q99
Congenital malformations, deformations and chromosomal abnormalities.
It is a very heterogeneous chapter, including malformations, genetic syndromes (with or
without malformations) and chromosomal anomalies. This leads to confusion between the
genetic origin of a disease and malformation. Therefore, all genetic syndromes without
structural developmental anomalies are excluded from this chapter and are reallocated to
appropriate chapters of the ICD-11, according to the affected body system(s).
The new chapter 20 has three main divisions:
• Structural developmental anomalies/malformations

• Multiple developmental anomalies and syndromes

• Chromosomal anomalies and genetic defects

The first division ‘Structural developmental anomalies/malformations’ includes isolated

conditions affecting only one body system. It is organised in sections corresponding to those
body systems, which are also classified in the other relevant chapters of ICD–11.
The second division ‘Multiple developmental anomalies and syndromes’ includes conditions
affecting several locations within one body system, or several body systems simultaneously.
Syndromes which can be said to affect one body system predominantly are assigned to
corresponding sections within this division. Syndromes which affect several body systems,
without one clearly predominating, are put together in a specific section at the end of the
division. There is also a section for Dysplasia syndromes due to inborn errors of metabolism,
all of them primarily classified in the chapter for metabolic diseases.
The third division ‘Chromosomal anomalies and genetic defects’ departs from the clinical
approach generally followed in the ICD and classifies developmental anomalies defined
genetically or cytogenetically, since there is no clear-cut distinction between genetics and
cytogenetics. We have started to include specific deletions and duplications corresponding
to a clear phenotype, knowing that many more will be described in the coming years. Future
ones will be added whenever necessary, during the post-publication revisions of the ICD–11.
A special problem is how to deal with diseases historically defined clinically but including a
chromosomal/genetic anomaly as aetiology. In some cases, there are several aetiologies for
the clinical entity, and not all of them are chromosomal anomalies: for instance, Silver-
Russell syndrome can be caused by a 11p15 duplication, a 7p11.2p13 duplication, but also
by maternal uniparental disomy of chromosome 7 or 11 and imprinting defects of 11p15. In
other cases, there is an overwhelming correspondence between the clinical entity and a
cytogenetic aetiology: for instance, Williams-Beuren syndrome corresponds to the 7q11.23
deletion.
Polyhierarchy is used in a restricted way within the frame of this chapter: once a disease is
assigned to a section, it is generally not secondarily classified elsewhere in the chapter. The
structure would otherwise become too intricate. On the other hand, all entities in this
chapter are to be classified in other chapters of ICD–11, when appropriate.

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3.2.21 Chapter 21 – Symptoms, signs or clinical findings, not elsewhere classified

[Link] Chapter 21 – Structure of Chapter 21

Chapter 21 is divided into major sections based on body systems. Each of these sections has
the following categories, as appropriate:
• Symptoms and signs

• Clinical findings

An additional section is located at the end of this chapter for Ill-defined and unknown
causes of mortality.

[Link] Chapter 21 – Rationale for Chapter 21

The different chapters of ICD–10 included several clinical manifestation categories, some of
them as asterisk codes. In order to simplify the structure, improve the use of
postcoordination, and also to remove ‘ill-defined’ conditions from organ chapters, several
former asterisk codes, additional detail for diverse conditions, and the said ill-defined
conditions have been moved here. All follow the main organisation by anatomy, and the
anatomical groupings have a secondary parent to the relevant organ chapter, improving the
user guidance.
3.2.22 Chapter 22 – Injury, poisoning or certain other consequences of external causes

[Link] Chapter 22 – Structure of Chapter 22

The general hierarchy of Chapter 22 consists of the following:
1st level - Broad category of anatomy (e.g. head; hip & thigh)
2nd level - Broad category of injury type (e.g. fracture; open wound
3rd level - Further specification

OR
1st level - Broad category of cause of injury
2nd level - Specific injury type
3rd level - Further specificity of injury type

[Link] Chapter 22 – Rationale for Chapter 22

The principles of the revision were:
• Maintain good back-compatibility with ICD–10, particularly by minimising change at the
former three-character level. Change at the former four-character level is more extensive
but has also been done with this principle in mind.

• Take account of the extensions to this chapter in clinical modifications of ICD–10 because:

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 – They are evidence of extensions required to serve clinical purposes in
identified situations.
– It is preferable to minimise incompatibilities with these classifications.
• Take account of classifications other than ICD that are in wide clinical use for conditions in
scope for this chapter.

• Take account of advice, solicited and proffered.

– Increased attention to distinctions pertinent to treatment choices and to

outcomes, including disability.
These include allowing identification of clinically and prognostically important aspects of
fractures (notably whether they extend into a joint) and organ/vessel injuries (degree).
Some conditions are much more important when bilateral, and in such instances side has
been proposed as precoordinated entities (e.g. injury of the eyes). The United States’ clinical
modification of ICD-10 (ICD-10-CM) was particularly valuable in this regard, as its injury
chapter makes many distinctions, beyond ICD–10, which follow or are consistent with
credible and widely used clinical classifications relevant to injury treatment and outcome.
Increased attention has been given to injury conditions specific to childhood (e.g. greenstick
and epiphyseal fractures) and to injury conditions that are indicative of possible intentional
injury (e.g. posterior rib fractures, ‘bucket-handle’ and ‘corner’ fractures).
The work was done with the awareness that this chapter is not primarily used to code the
Underlying Cause of Death.
The morbidity use case is particularly important for this chapter.
3.2.23 Chapter 23 – External causes of morbidity or mortality

[Link] Chapter 23 – Structure of Chapter 23

The general hierarchy of Chapter 23 consists of the following sections:
1st level - Intent of external cause (unintentional, intentional sel
f-harm, assault, undetermined intent and intent pending.)
2nd level - Broad category of the mechanism of the external cause
3rd level - More specific mechanism and objects/substances involved
in causing injury
4th level - Further characterisation of the external cause

Other sections include Exposure to extreme forces, Maltreatment, Legal intervention,

Armed conflict and Causes of health care related harm.

[Link] Chapter 23 – Rationale for Chapter 23

The main aim of the changes was to provide a more uniform coding structure while still
maintaining high compatibility with ICD–10. The changes to the traffic injury categories are
aimed at simplifying code selection, while the section on Operations of war and armed
conflicts has been revised to capture the more current situations of armed conflicts.
Another enhancement has been to produce a single, hierarchical list of noxious substances
to serve the Injury and External Causes chapters.

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All mechanisms/objects codable for all intents:
• More uniform code structure
• Revised ‘Intent’ dimension (N.B. Intent pending; ISH: suicidal/non-suicidal)
• Retain transport codes, but expand vehicle types
• Expanded Place of Occurrence codes
• Expanded and revised Activity dimension (N.B. work-relatedness)
• Revision of Complications of Medical & Surgical Care
• Expanded Legal/War Codes
• Improved provision for maltreatment syndromes
• Introduction of additional dimensions (optional)
• Revision of External Cause index, rules and guidelines
• Provide for Mortality, Morbidity, Lower Resource Settings, Research
Progress has been made on all of these points, though constrained in some respects,
particularly for the mortality use-case (due to the tight constraints on code-space combined
with the lack of provision for postcoordination/cluster-coding). A section on limitations is at
the end of these notes.
Notes provided here focus on several of these points; additional material will be provided
on other aspects on request. Comments are also provided here on the two main issues that
involve both the External Causes chapter and the Injury chapter (both also involve Chapter X
‘Extension codes’): substances; complications of care (Safety & Quality).
Transport
Four dimensions are implicit in the ICD–10 range V01-V89: injured person’s mode of
transport (e.g. motorcycle), whether the injurious event occurred in road traffic (if so, the
resulting injury is a road injury), the injured person’s role (e.g. passenger), and what other
type of vehicle was involved, if any (counterpart). All four dimensions are required for a
revised structure that is conceptually equivalent to the ICD–10 ‘transport accidents’ module
at four- character level.
All four dimensions have been precoordinated in the Unintentional transport injury module.
This produces a structure with high back-compatibility with ICD–10 at four-character level. It
preserves all top-level modes of transport categories (some now split) and the four
conceptual dimensions (mode; and for land transport modes: whether in traffic, transport
user role and counterpart).
In recognition of code-space limitations, and of the fact that most transport injury cases are
unintentional, precoordination of transport cases in the other main intent blocks
(intentional self-harm, assault, undetermined intent, and intent pending) is limited to intent
by mode of transportation. However, the other dimensions are available for optional use.
The revised transport block includes changes made to resolve problems identified with the
ICD– 10 transport section.

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 • Split several modes of transport to enable identification of important and emerging
types that cannot be identified in ICD–10.
• Refined and revised terms and definitions (for clarity, to fill gaps in the set provided
in ICD–10 and to improve comparability with terms used internationally for road
safety).
• Various other revisions (e.g. of types of vessel in water transport section). Note that
the coordination order has been altered from the equivalent in ICD–10, from: mode,
counterpart, then user role and traffic status combined to: mode, traffic status, user
role, counterpart.
The main reason for this change was to simplify the selection of ‘traffic accident’ categories,
which are frequently required when reporting road injury.
War and armed conflict
A revised classification is provided for inclusion as the expansion of intent category Armed
conflict (Operations of war in ICD–10). The classification largely follows the expansion of Y36
in the United States’ clinical modification of ICD–10 (ICD–10-CM). This follows the four-
character categories in ICD–10 and provides subdivisions, which follow inclusion notes given
in ICD–10. In addition, sub-categories are provided to distinguish whether the injured
person was military or civilian.
The rubric has been altered by the addition of ‘…and armed conflict’ to ‘Operations of war’,
and the inclusion term has been altered accordingly. ‘War’ and ‘civil insurrection’ (which
also formed part of the inclusion term) were not defined in ICD–10. The use of a term
broader than ‘war’ is considered desirable because war, in the sense of formally declared
armed conflicts between nation states (or subnational entities) has become uncommon.
Armed conflicts of a range of types and intensities, while tending to become less common,
remain much more numerous than wars. Restriction of use of this category to declared
wars, and/or to armed conflicts that meet a commonly used criterion of intensity (1,000 or
more battle-related deaths in a calendar year = war) was thought to be unduly restrictive.
The alternative proposed here is to also include injuries due to ‘Minor’ armed conflicts,
defined as those resulting in 25 to < 1,000 battle-related deaths in a calendar year.
Application of the definition is aided by the existence of a publicly accessible database listing
conflicts found to satisfy it.
Crossover issues
These are matters that affect both the injury and the external causes chapters, and other
parts of the ICD.
Toxic effects of substances
Toxic effects of noxious substances appear in ICD–10 at several points, in the Injury and
External Causes chapters, and in other chapters. Code lists at those points differ in
specificity and are not completely consistent. A design aim for ICD–11 is to produce a single,
hierarchical list of noxious substances to serve all of the purposes required for the Injury and
External Causes chapters. The benefits of this are: external source(s) can define-by-example
the inclusions of the ICD–11 list; and if the external source(s) are actively updated, then this
provides a way for the ICD–11 coverage of substances to remain current.

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The term ‘Harmful effects’ is used for all types of harm resulting from harmful chemical
effects of substances of all types. It is recognised that other terms, such as ‘toxic effect’,
‘poisoning’, ‘chemical corrosion’ and ‘envenomation’ are sometimes used in the context of
particular substances. These terms will be included as synonyms and subordinate terms
where in common use. A number of sources were consulted, including ICECI Objects &
Substances dimension; Anatomical Therapeutic Chemical (ATC) classification; TAG-IEG
advisory groups on drugs and poisons; Quality and safety TAG; SNOMED; IPCS INTOX.
The list has two main hierarchical levels.
The first, with 16 categories, is conceptually related to the code-list that is present in ICD–10
at X40-X49 (Accidental poisoning by and exposure to noxious substances) and the
equivalent points in the Intentional Self-harm and Undetermined intent code-blocks. The list
results from application of these principles:
• It should have only a few categories. This is necessary for practicability, especially in
the context of cause of death coding and because the block structure of the external
causes chapter has the effect that each additional category adds several rows.
• The categories should refer to substances or classes of substances that are important
causes of mortality or morbidity.
• As many as possible of the categories should be sufficiently specific so meaningful as
reporting groups. (By comparison, several categories in the ICD–10 blocks such as
X40-X49 are so broad as to be difficult to interpret).
• The several main contexts of exposure were kept in mind when specifying categories
(i.e. recreational/street use; clinical use; self-harm; industrial and other exposures).
The 16 categories, either alone or combined with others, allow backwards comparability
with eight of the ten categories in ICD–10 X40-X49 (and the equivalent groups in the ISH and
Undetermined intent blocks). The only exceptions are two residual groups: ‘…other gases
and vapours’ and ‘…other and unspecified chemicals and noxious substances’. The second
level provides categories (n=381), with about the same number and specificity of substances
that are provided for in the injury and external causes chapters of ICD–10. It includes all of
the categories of substances that are specified in the ‘Cause of harm’ component of the
Quality and Safety TAG classification.
Some categories have been added: to allow for pharmacological innovation and changes in
drug use (e.g. synthetic cannabinoids); to reflect additions to ICD–10 made in its clinical
modifications (e.g. more specificity concerning anticoagulants); to allow more specific
identification of prominent drugs (e.g. paracetamol); to provide for additional widely-used
recreational drugs (e.g. Cathinone, the main active agent in khat); and on advice from other
TAGs (e.g. types of substance added by the Safety and Quality TAG). We anticipate that
more categories will be added in future updates, to reflect changes in drug availability and
use.
A more comprehensive list of substances (a superset of the hierarchical list), with synonyms
for many of the entries, will be provided in Chapter X ‘Extension codes’. That list shares the
same hierarchical structure as the precoordinated codes. It also takes account of the ICD–11
Supplementary Classification of Contact Allergens prepared by the Dermatology TAG.

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Entries in the Extension codes substances list will be specified in terms of equivalent terms
in SNOMED-CT.
Complications of care (Quality and Safety)
This section briefly describes the model for coding complications of care that has been
developed by the Quality and Safety Topic Advisory Group (TAG).
The model has three parts, each of which must be coded. The postcoordinated codes for all
the parts must be designated as belonging to a cluster. The three concepts are:
1. The resultant injury or harm;
2. The cause of harm; and
3. The ‘Mode/Mechanism’ of harm. Classifications and code-sets have been developed
for (2) and (3) by the Quality and safety TAG. The categories have been entered into
the External Causes chapter. The resultant harm (1) is to be coded by using the most
appropriate disease or injury code from any part of ICD–11.
The construct would, in principle, fit well into ICD–11 as follows:
1. Resultant injury or harm. Code selected from anywhere in ICD–11.

2. The cause or ‘Mode’ of harm: Code selected from the relevant block in External Causes
chapter

3. ‘Mode/Mechanism’ of harm

Sanctioning rules lead coders to the subset of ‘Mode’ codes that are relevant, given the
selected ‘Cause’ (e.g. if ‘Cause’ is a drug, then the relevant ‘Modes’ are categories such as
overdose and underdose).
3.2.24 Chapter 24 – Factors influencing health status or contact with health services

This chapter should not be used for international comparison or for primary mortality
coding.

[Link] Chapter 24 – Structure of Chapter 24

This chapter has two major sections: - Reasons for contact with the health service - Factors
influencing health status
The general hierarchy of Chapter 24 consists of the following axis:
1st level - Broad category of a particular health status or service
2nd level - Specific condition

[Link] Chapter 24 – Rationale for Chapter 24

Initially, the Functioning Topic Advisory Group for ICD–11 (fTAG) was tasked with the review
of the Factors Chapter. They were to evaluate the necessity of each of the 801 codes and
propose a revised hierarchical structure for the essential content that would remain. This
content was to be both clinically relevant and use-friendly as well as allowing the necessary
space for expansion using the extension codes, as necessary. fTAG organised a review that
identified the major ‘types’ of codes as ‘diagnostic’, ‘interventional’, ‘contextual factors’ and

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‘other/debatable’. This review was combined with the general structure of the ICPC2
classification section on ‘social problems’ and a new organisation was designed that
combined the ICPC2 hierarchy with the ICD–11 codes. For the ICD-11 MMS, a shoreline
exercise was then undertaken on the new structure to decrease granularity seen as
unnecessary.
3.2.25 Chapter 25 – Codes for special purposes

[Link] Chapter 25 – Structure of Chapter 25

This chapter consists of two blocks:
• International provisional assignment of new diseases of uncertain aetiology,
containing the international emergency codes
• National provisional assignment of new diseases of uncertain aetiology, containing
codes for use by individual countries
3.2.26 Chapter 26 - Supplementary Chapter Traditional Medicine Conditions - Module 1

‘Traditional Medicine Module 1’ (TM1) chapter is a new supplementary chapter for optional
use in ICD, and as such is referred to as the ‘TM1 chapter’. The rationale for its inclusion in
ICD-11 is to enable Traditional Medicine health services and encounters to count and be
counted nationally and internationally. The Module in this chapter in its current form refers
to disorders and patterns which originated in ancient Chinese Medicine and developed
throughout history to incorporate contemporary science and technology. These disorders
and patterns are commonly used in China, Japan, Korea, United States of America, Australia,
Europe and elsewhere around the world. The classification rubrics represent a unified set of
harmonised Traditional Medicine disorders and patterns from national classifications from
China, Japan and Korea. Future Modules may be developed for other forms of Traditional
Medicine practices.
Scope:
This chapter has currently been designed for morbidity recording and reporting. It must not
be used for mortality coding and reporting.
Content and structure:
The content and structure of the TM1 Chapter represent a common language developed
jointly through the international cooperation of Traditional Medicine clinicians, researchers,
academics and classification experts to enable international comparability of practice and
reporting of morbidity in Traditional Medicine. Standardisation of this TM1 classification will
allow clinical documentation in different countries to incorporate the same concepts and
enable coders and users to extract comparable morbidity data from that documentation.
Coders must also be guided by rules which reflect the clinical diagnostic decision-making
process. However, the rules are relatively flexible to allow for national adaptations and
research questions concerning relationships between diseases, disorders and patterns to be
framed from a number of different angles.
The English terms do not necessarily represent the most common translation of the TM
terms in Chinese, Korean or Japanese. Where the best fit English TM translation resulted in
the same term as used in Western Medicine, it was necessary to indicate a difference

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between the Western Medicine (WM) concept and TM concept where the same term had
different definitions in TM and WM. This difference in definition is indicated by the use of
(TM1) for disorders and patterns throughout the TM chapter.
Terminology:
The Supplementary Chapter Traditional Medicine Conditions, Module 1, uses the terms
disorder and pattern to describe concepts. This is different from the concept descriptions in
the Western Medicine chapters which refer to diseases (clinical pictures) and syndromes
(clinical presentations). The TM1 chapter is divided into separate sections for disorder and
pattern to emphasise the independence of these concepts.
Definitions
A disorder in traditional medicine (disorder (TM1)) refers to a set of dysfunctions in any
body system which is judged from associated signs, symptoms or findings. Each disorder
(TM1) may be defined by its symptomatology, aetiological explanation based on traditional
medicine, course and outcome, treatment response or linkage to interacting environmental
factors. A disorder (TM1) is a clinical picture that is relatively stable and reflects the local
pathology and related specific manifestations commonly found in the anatomy and function
of the affected individuals.
A pattern in traditional medicine (pattern (TM1)) refers to the manifestation of the patient’s
health condition at a given moment in time including all findings which may include:
• Symptomatology: pattern of specific and non-specific signs, symptoms or unique
findings by traditional medicine diagnostic methods, including the taking of the
pulse, examination of the tongue, abdominal examination and other methods that
reflect the systemic response of the patient in a dysfunctional condition.
• Constitution: the characteristics of an individual, including structural and functional
characteristics, temperament, ability to adapt to environmental changes, or
susceptibility to various health conditions.
A pattern (TM1) is a clinical picture that is relatively temporary, reflects on the systemic
response of the patient and combined pattern of specific and non-specific manifestations
that usually hold a multifactorial relationship with the local pathology and the constitutional
traits of the patient. A pattern may show individual difference even in the individuals
affected by the same pathology that may be further analysed by the theoretical frame of
Traditional Medicine.
Traditional Medicine disorder and pattern are named after the body structures, causal
explanations, properties and severity which present for clinical investigation and diagnosis.
TM1 pattern may denote an individually different pattern (TM1) of systemic responses to
the WM disease or TM1 disorder. Pattern is a concept unique to TM1 and may be different
from TM1 disorder in the following ways:
Table 1: Characteristics of Traditional Medicine Disorders and Patterns

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 Distinguishing Disorder in Traditional Pattern in Traditional Medicine
Feature Medicine
Constant/ A clinical picture that is A clinical picture that is relatively
Temporary relatively constant temporary
throughout the duration of
that disorder
Constant Usually delivers Usually delivers information reflecting
Pathology/ information reflecting the the temporary overall manifestation or
Temporary constant pathology response of the patient
Response
Specific/ Non- A concept that summarises The combination of the manifestations
specific findings that are specific to that encompasses both specific
the pathologic process symptoms/signs and non-specific
under investigation findings
Linear/ May be applied for a time A pattern may be applied for a specific
Multifactorial span. A disorder coding time span, too. However, a pattern code
may be based on the main is based on the summarised whole
pathologic process which picture that may be observed in the
may show a causal patient based on the perspectives of
relationship with the main traditional medicine theories. A pattern
manifestations in the is recognized based on the analysis of
patient the systemic findings in the patient’s
body and mind which reflect the
pathologic processes, responses to the
pathologic processes, other concomitant
findings, and innate or acquired
constitutional traits of the patient
Commonality/ Used to describe the Used to describe the individual
Individuality general characteristics characteristics considered to be
considered to be relatively relatively specific to the patient at that
common to the population time
suffering from one
particular disorder
General/ Usually described with Usually described with terms of the
Theoretical general terms of anatomy traditional medicine theories that are
and physiology together used to summarise the underlying
with terms of signs and mechanism in the patient such as yin
symptoms and yang balance, cold and heat,
meridian, or constitution
3.2.27 Section V – Supplementary section for functioning assessment

This section is new. The list of 47 entities in this section is intended for assessment and
scoring in the context of ICD. It is using ICF functioning domains of high explanatory power
(ICF Annex 9). The categories are intended to be used as a set. The set has been defined in a
way that general and domain specific summary scores can be calculated using the WHO

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Disability Assessment Schedule 2.0 (WHO DAS 2.0) or the WHO Model Disability Survey
(MDS).
3.2.28 Chapter X - Extension Codes

This chapter is new. Extension codes are envisaged as providing the basis for
postcoordination of ICD–11 codes, being the repository for all codes in a linearisation that
are not eligible for use as stem codes.
The different lists provide additional codes for clinical use as well as for injury research,
device safety, drug safety, patient safety and cancer registration.
These codes are for optional use and will be used more likely in morbidity than in mortality.

3.3 Multiple Parenting

An entity may be correctly classified in two different places, e.g. by site or by aetiology. For
a disease like oesophageal cancer this would mean that it could be classified to cancers
(malignant neoplasms) or to conditions of the digestive system. In the same way, cerebral
ischaemic conditions could be classified to the vascular system – where the problem arises -
or to the nervous system – where the ischaemia impacts and manifests with symptoms.
Indications of multiple parenting:
• ‘Excludes’ or ‘Code elsewhere’ note
• Display of multiple parents in Foundation Component view
• Display of multiple parents in tabular list. Example for oesophageal cancer: primary
parent malignant neoplasm will appear in black and the digestive system for the
oesophageal cancer in grey
In the Foundation component, ‘excludes’ notes for these examples will mention possible
parents (multiple parents). However, for the tabulation of statistical outputs from any
tabular list, there can be only one parent for primary tabulation. When there are such
multiple parents, in the Foundation Component view both parents will be displayed the
same way. However, in a tabular list, the primary parent place will show the entity and its
parents in black, and the secondary possible parent in grey.
Every time an entity is parented elsewhere, it will continue to show the code from the
primary parent. The primary parent is sometimes referred to as the ‘Tabular list parent’.

3.4 The Content Model

The Content model is a structured framework that defines each entity found in the ICD in a
standard way. The purpose of the Content model is to present the background knowledge
that provides the basis for the description of each ICD entity in a systematic way to allow for
computerisation. ICD–11 holds all of its content in the Foundation Component. Here, every
entity is specified by a description, machine readable properties that have values, and one
or more parent-child relationship(s). Additional links provide information for
postcoordination. All of this multi-dimensional information is then combined to form a list
with mutually exclusive categories - the tabular lists. The Foundation Component includes

ICD-11 Reference Guide 315

information on where and how a certain entity is represented in a tabular list. An entity
might become a grouping, a category, or just a term that is, for example, listed in the index.
Each ICD entity can be seen from different dimensions. The Content Model represents each
one of these dimensions as a ‘property’.
The key components of the descriptions of disease are included as different properties
within the Content model. The main properties of the Content model are:
1. ICD Concept Title
2. Hierarchy, Type and Use
– Parent
– Type
– Use
3. Textual Definition(s)
– Description (short)
– Definition (long)
4. Terms
– Index terms
• Synonyms Inclusion terms
– Exclusion Terms
5. Clinical Descriptions
– Body System(s)
– Body Part(s) (Anatomical site(s))
– Manifestation Properties
• Signs and Symptoms
• Findings
– Causal Properties
– Aetiology Type
• Infection (agents)
• Injury (mechanisms)
– Risk Factors
– Genomic Characteristics
– Temporal Properties
– Severity Properties
– Functional Properties
– Specific Condition Properties
– Treatment Properties
– Diagnostic Criteria
For each ICD entity, various properties can be given if necessary to reach the correct coding
result. A coder can use the properties to better understand a condition and how to code it,
and the properties allow a coder to determine where a condition is placed. Only properties
that are absolutely necessary have been defined in order to avoid the necessity of frequent
updates. Additions of property values at the international level are managed through the

316 ICD-11 MMS

regular update cycle whenever coding problems indicate the necessity to do so. The
following is an example of the core properties:
ICD entity: Invasive ductal carcinoma of breast

Properties Value
Anatomy Breast
Morphology Invasive ductal carcinoma

The full range of different values for each given property is predefined using standard
terminologies and ontologies. This range of values is called a ‘Value set’.
Descriptions of ICD–11 entities inform analysts and translators about the meaning of an
entity and its descriptive characteristics. There are two different types of descriptions: a
short description (maximum of 100 words) that is available in both the content model and
the tabular list, and a detailed description with comprehensive detail at the level required
for each entity. The detailed description is labelled ‘additional information’ and appears only
in online electronic versions. Coders are cautioned not to use the descriptions for coding.
Coders must assign codes based on the diagnosis(es) documented by a clinician. However,
the descriptor information that is included for the individual entities of the ICD-11 provides
users of the ICD with clear insight regarding the intended meaning and scope of rubrics or
terms in the tabular list and the Foundation Component. The descriptors guide translators,
coders, and users of coded data. The goal is to enhance the comparability, consistency, and
interpretation of coded information for everyone, everywhere. There are four levels of
descriptor information in the ICD–11 content model:
• Fully Specified Term - This is an unambiguous title that does not assume context. For
example, ‘systemic illness with predominant gastrointestinal diarrhoeal symptoms
attributable to vibrio cholera’, as opposed to ‘cholera’ or ‘other’ (where the meaning of
other would have been clear from the hierarchical context).

• Short Description - The short description is a characterisation (maximum of 100 words) of

the entity that states things that are always true about a disease or condition and which are
necessary to understand the scope of the rubric. Descriptions do not necessarily contain
elements intended for use in common epidemiology or things that are clinical criteria.

• Additional Information - This is a text field that is not mandatory, but that may contain
additional information about, or characteristics of the diseases or conditions included in the
entity. This text field provides more context for the entity. For example, the most common
epidemiologic circumstances, putative or highly suspected aetiologic agents, or other
information that may not always be true but may be common, typical, or expected.

• Clinical or Diagnostic Criteria - It is intended to contain one or more scenarios of clinical

criteria and characteristics that would be sufficient to diagnose the condition(s) or
syndrome(s) of the given class or concept.

Such scenarios will contain multiple variations, or embedded logic to accommodate ‘x out of
n’ variations, that are necessary or useful to make the diagnosis. For example, a myocardial
infarction (MI) in high-resource diagnostic settings would typically include a longitudinal
pattern of cardiac enzymes, specific electrocardiogram changes, and stereotypical

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symptoms. However, only two out of these three needs to be present as there are such
things as ‘silent MIs’ (without symptoms) and similar variations.
It is expected that these scenarios will be divided over technology capabilities. For example,
diagnosing a myocardial infarction in the high-resource diagnostic settings would likely
involve different technology and criteria than in low-resource settings. ICD diagnostic
criteria draw on various WHO guidelines that have identified diagnostic rules. Extensions to
the ICD, as specialty linearisations, may use such diagnostic rules.
The ICD-11 architecture, and the future evolution of this component of information, could
eventually serve decision algorithms based on these criteria. Assignment of diagnoses and
conditions could automatically be proposed from data arising in electronic medical records.
Diagnostic criteria describes diagnostic methodology that determines how health providers
diagnose cases that are classified to an entity. It contains the core diagnostic information
necessary and sufficient to describe a category, and enables the digital representation of the
diagnostic algorithms using standardised terminology and other elements as appropriate.
There may be different sets of diagnostic criteria for different settings. Diagnostic criteria
will draw on the content of other attributes.

3.5 Language independent ICD entities

ICD-11 entities are language independent. All entities have a unique identifier or uniform
resource identifier (URI) and have a specific place in a hierarchy of groups, categories and
narrower terms. The maintenance of the ICD-11 on an international level is handled in the
English language but the content model of the ICD–11 is language independent and allows
binding of any desired language to the elements of its foundation. In this way, an
international translation base facilitates translations and multilingual browsing. The URI
remains valid independent of whether an ICD entity is still valid or has been retired. The
hierarchical structure of groups, categories, subcategories, and inclusions (parents, children
and narrower terms) serves also as a language independent backbone for translations of
ICD. This structure is essential when building an index in a local language. It helps (in
conjunction with the ICD translation platform) to identify the things that need to be
translated in order to be able to address ICD categories with terms reported in the local
language.

3.6 Innovation to mortality coding in ICD-11

Mortality coding instructions of ICD have matured over time and basically has been
maintained for ICD-11, while the text has been formatted using easier wordings to enhance
common understandings and standardised implementation. Major changes in the
classification have been incorporated in the mortality coding instructions.
New concepts or terminology of ICD-11, for instance postcoordination or cluster coding,
‘code also’ and ‘use additional code if desired’ instructions will function to capture further
information reported on the death certificate. In ICD-10 mortality coding, multiple cause
coding, several modification rules in Step M4, or certain flags used in automated coding
systems has been used to capture details reported on the death certificate and to facilitate
accurate selection of underlying cause. And in this sense, it is considered that the function
of postcoordination etc. has been embedded in ICD-10 mortality coding practice, while in

318 ICD-11 MMS

ICD-11 the concepts are more evident and several new instruction were added to inform on
how to apply these new concepts (see Part 2 of this Reference Guide).
The following table used in Step M1 for coding complications of diabetes mellitus is
provided for optional use. This list is not a complete list of possible complications of
diabetes mellitus, and is intended not to be updated but kept for users who are interested
in consistency between ICD-10 and ICD-11 coding.

ICD-11 Reference Guide 319

TUC diabetic complication If desired, postcoordination may be used to specify
in ICD-11 complication of diabetes mellitus
with mention of:
(ketoacidosis) 5C73 Acidosis
5C50.G Trimethylaminuria
MA18.Y Other specified abnormal findings of blood
chemistry
(renal complications) GB40-GB4Z Glomerular diseases
GB61 Chronic kidney disease
GB6Z Kidney failure, unspecified
MF54.0 Smooth contracted kidney
GB90.4Z Renal tubular function disorders, unspecified
(ophthalmic complications) 9A96.Z Anterior uveitis, unspecified
9B10.Z Cataract, unspecified
9B65.Z Posterior uveitis, unspecified
9B78.1 Background retinopathy and retinal vascular
changes
9B78.2 Other proliferative retinopathy
9B7Z Disorders of the retina, unspecified
(neurological 8C12 Certain specified mononeuropathies
complications)
8C1Z Mononeuropathy of unspecified site
8C0Z Polyneuropathy, unspecified
8C4Y Other specified disorders of nerve root, plexus or
peripheral nerves
8C7Y Other specified primary disorders of muscles
8D8Z Disorders of autonomic nervous system, unspecified
(peripheral circulatory BD40.0 Lower limb atherosclerosis
complications)
BD4Z Chronic arterial occlusive disease, unspecified
EE80.1 Necrobiosis lipoidica
MC85 Gangrene
(other specified ME60.2 Ulcer of skin of uncertain nature, specified as lower
complications) limb
FA2Z Inflammatory arthropathies, unspecified
MG30.5Z Chronic neuropathic pain, unspecified
when reported as the cause of:
(coma) MB20.1 Coma
(ophthalmic complications) 9C81.Z Palsy of unspecified ocular motor nerve

320 ICD-11 MMS

 TUC diabetic complication If desired, postcoordination may be used to specify
in ICD-11 complication of diabetes mellitus
9D90 Vision impairment including blindness
(neurological 8E7Y Other specified diseases of the nervous system
complications)
DA7Z Diseases of the stomach or the duodenum,
unspecified
(peripheral circulatory
complications)
(other specified 1A40 Gastroenteritis or colitis without specification of
complications) infectious agent
1G40-1G41 Sepsis
1C41 Bacterial infection of unspecified site
1F28 Dermatophytosis
1F2D Non-dermatophyte superficial dermatomycoses
1F23 Candidosis
3B20 Disseminated intravascular coagulation
5A41 Hypoglycaemia without associated diabetes
5C80.00 Primary hypercholesterolaemia
5C80.1 Hypertriglyceridaemia
5C80.2 Mixed hyperlipidaemia
5C80.Z Hyperlipoproteinaemia, unspecified
5C76 Hyperkalaemia
5D2Z Metabolic disorders, unspecified
8A42.Y Other specified acute disseminated
encephalomyelitis
8A42.Z Acute disseminated encephalomyelitis, unspecified
BA00.Z Essential hypertension, unspecified
BA01 Hypertensive heart disease
BA40-BA6Z Ischaemic heart diseases
BB40-BB4Z Acute or subacute endocarditis
BC0Z Heart valve diseases, unspecified
BC43.0Z Dilated cardiomyopathy, unspecified
BC43.Z Cardiomyopathy, unspecified
BC81.3 Atrial fibrillation
BC81.20 Cavotricuspid isthmus dependent macroreentry
tachycardia
BC81.2Z Macro reentrant atrial tachycardia, unspecified
BC60 Atrial premature depolarization

ICD-11 Reference Guide 321

TUC diabetic complication If desired, postcoordination may be used to specify
in ICD-11 complication of diabetes mellitus
BC61 Junctional premature depolarization
BC70 Ventricular premature depolarization
BC71.1 Ventricular fibrillation
BC80.20 Sick sinus syndrome
BC9Y Other specified cardiac arrhythmia
BC9Z Cardiac arrhythmia, unspecified
BD10-BD1Z Heart failure
BE2Z Diseases of the circulatory system, unspecified
8B00 Intracerebral haemorrhage
8B02 Nontraumatic subdural haemorrhage
8B03 Nontraumatic epidural haemorrhage
8B0Z Intracranial haemorrhage, unspecified
8B11 Cerebral ischaemic stroke
8B20 Stroke not known if ischaemic or haemorrhagic
8B22.Y Other specified cerebrovascular disease
8B2Z Cerebrovascular diseases, unspecified
8B25.1 Late effects of intracerebral haemorrhage
8B25.3 Late effects of other nontraumatic intracranial
haemorrhage
8B25.0 Late effects of cerebral ischemic stroke
8B25.4 Late effects of stroke not known if ischaemic or
haemorrhagic
8B25 Late effects of cerebrovascular disease
8D40.1 Neuropathy due to nutritional deficiency
8D40.2 Myopathy due to nutritional deficiency
8D40.Y Other specified neurological disorders due to
nutrient deficiency
8D40.Z Neurological disorders due to nutrient deficiency,
unspecified
BD30.20 Acute thromboembolic lower limb arterial
occlusion
BD30.0 Acute upper limb arterial occlusion
BD30.2 Acute lower limb arterial occlusion
BD70 Superficial thrombophlebitis
BD72 Venous thromboembolism
CA40.1 Viral pneumonia
CA40 Pneumonia

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 TUC diabetic complication If desired, postcoordination may be used to specify
in ICD-11 complication of diabetes mellitus
DA60-DA63.Z Ulcer of stomach or duodenum
ME24.Y Other specified clinical manifestations of the
digestive system
1B70.3 Ascending bacterial lymphangitis
1B70.Y Bacterial cellulitis or lymphangitis due to other
specified bacterium
1B70.Z Bacterial cellulitis or lymphangitis due to unspecified
bacterium
EB21 Pyoderma gangrenosum
EA3Z Unspecified skin disorder attributable to viral infection
EA89 Generalised eczematous dermatitis of unspecified
type
EH90 Pressure ulceration
FA26.2 Chondrocalcinosis
1B71 Necrotising fasciitis
GC08.Z Urinary tract infection, site and agent not specified
3.7 Innovation to morbidity coding in ICD-11
‘Present on Admission’
The inclusion of the new Extension codes in ICD-11 provides capacity for coding qualifying
information of linked stem codes. Among the new qualifying features is the particularly
important status display feature that allows for distinction of diagnoses present at
admission from diagnoses arising after hospital stay began.

3.8 Functioning section

An optional functioning section has been embedded in ICD-11 to enable the classification
and measurement of the impact of health conditions in terms of functioning. For further
information see section [Link].
Overall, the linkage between ICD-11 and ICF may assist with the following use cases:
• evaluation for general medical practice (e.g. work in capacity assessment)
• evaluation for social benefits (e.g. disability pension)
• payment or reimbursement purposes
• needs assessments (e.g. for rehabilitation, occupational assistance, long term care)
• outcome evaluation of interventions
Wherever full functioning reporting is desired and required, the ICF should be used.

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3.9 General features of ICD–11
The main structural innovation of ICD–11 is that it is built on a Foundation Component from
which the tabular list can be derived. The international reference tabular list is the statistical
classification for morbidity and mortality. Due to the addition of a Foundation Component,
and the electronic design of ICD-11, a new terminology had to be introduced that had not
been used in prior versions of ICD. (See Section 2.13 for further information.)
For more detail on the terminology of ICD-11, see Section [Link] Integrated use with
Terminologies.

3.10 Traditional Medicine conditions - Module 1 (TM1)

A large percentage of the world’s population uses some form of Traditional Medicine.
However, standardised data and information on health status of these users remain largely
absent from national and international health data collections. The use of Complementary
and Alternative Medicine (CAM) therapies has become a huge industry and is expected to
grow. As a result of this gap in information about TM and the size of the industry, resources
have been invested in the creation of a classification tool to allow data to be collected and
analysed.
ICD-11’s supplementary chapter on Traditional Medicine disorders and patterns is designed
to be integrated with coding of cases in conjunction with the Western Medicine concepts of
ICD Chapters 1-25.
As with other ICD chapters, the TM1 chapter is a tool for classifying, diagnosing, counting,
communicating and comparing TM conditions, it will also assist research and evaluation to
assess the safety and efficacy of TM. This chapter not judging TM practice or the efficacy of
any TM intervention.
This chapter must not be used in mortality coding.

3.11 Preparations for the Eleventh Revision

By 2003, it was becoming clear to the WHO and the Collaborating Centres that a further
revision of the ICD could not be long delayed. The extent to which ICD updating could
encapsulate emerging developments was limited by the structure of ICD–10, and some
issues needed extended development and discussion with expert groups. A special meeting
of Collaborating Centres in Helsinki in 2004 discussed the need for a revision and issues to
be addressed as part of the revision process. The 2004 WHO-FIC meeting subsequently
adopted a revision process work-plan which was progressively developed at ensuing
meetings.
In 2007, the WHO formally launched the revision process. Oversight has been provided
through a broad-based Revision Steering Group. Technical work has been undertaken by a
series of Technical Advisory Groups, with cross-cutting groups examining mortality,
morbidity and quality and safety issues. For the first time, a chapter on description of
diseases and patterns of diseases from a Traditional medicine standpoint has been included.
A Content Model, including a range of components for each ICD entity has been developed,
giving a rich foundation for the ICD. Other classifications and terminologies are linked or

324 ICD-11 MMS

included where possible to ensure ICD is aligned with them, and items used in other
members of the WHO Family of Classifications have been aligned wherever possible. The
more traditional statistical classification for mortality and morbidity is obtained from the
Foundation Component of ICD–11 as a Tabular list. Extension codes are used to limit
content volume but still allow detailed classification of disease entities. Supplementary
chapters and sections allow capturing on an optional basis information about traditional
medicine diagnoses and functioning. Based on the experiences with ICD-9 and ICD-10 an
updating mechanism was designed, that allows improvements in user guidance and
scientific updates without compromising the statistical use of the classification.
The revision of ICD-11 has taken place in several phases. First, a list of issues that were
known from the use of ICD-10 and that could not be solved in its classification structure was
compiled and possible solutions were formulated.
Second, input was received from many scientific groups in the key subject areas, with a
focus on clinical perspectives.
Finally, centralised editing occurred, aimed to adjust imbalances in content generated by
multiple, independently operating expert groups in the previous phase of the revision, and
to ensure the overall structure is consistent and practicable for users for mortality and
morbidity statistics. The final version also received input from field testing, Member State
comments, and ongoing submission and processing of proposals.

3.12 Annex A: ICD-11 Updating and Maintenance

This Annex describes the review process, the release cycles and the proposals workflow for
updating ICD-11.
Official releases of the ICD-11 classification are produced annually for international use in
mortality and morbidity (this is known as the ‘blue browser’). By contrast, the ICD-11
Foundation Component is continuously updated. The updating is carried out at different
levels with corresponding different frequencies.
The ICD-11 is being released in five-yearly ‘stable’ versions for international use (contains
updates that impact on the four- and five- character structure), unless urgent public health
needs require otherwise. The releases are supplemented with version identifiers that are
used for reporting in conjunction with the codes. Transition tables and materials showing
the differences are provided with every version.
Updates at a more detailed level than four- and five- characters can be published annually.
Small error corrections that serve to clarify meaning, indexing or errors, may be
communicated annually. Additions to the index can be done on an ongoing basis.
Mortality and morbidity rules will be updated in longer term cycles of every 10 years.
All countries that have implemented the ICD-11 are encouraged to adopt the updates in
order to ensure greatest possible standardisation of coding results. If a country for whatever
reason cannot implement a certain year of updates it shall at least ensure that the reported
data is in line with the most recent version of ICD-11.
The WHO has taken all reasonable precautions to verify the information contained in the
ICD and its different versions and editions. However, the ICD is being distributed without
warranty of any kind, either expressed or implied. The responsibility for the interpretation
and use of ICD lies with the user. In no event shall the WHO be liable for damages arising

ICD-11 Reference Guide 325

from its use.
The publisher of ICD-coded information is liable to ensure proper use of the ICD and present
clearly the methodology for data collection and mechanisms that were used to modify the
original data in order to indicate the comparability of the presented outcomes. For mortality
data, no deviation from the methodology indicated in the ICD is permitted.
For information on taxonomy and structuring see 1.2.
3.12.1 Background

Updating ICD-11 makes sure that ICD meets the needs of users in content and terminology.
Updating and decisions follow the principles laid out in 1.2.1 Taxonomy.
Updates include changes to chapters 01-24 of ICD, the supplementary chapter for
traditional medicine conditions (including the development of additional modules), the
supplementary section for functioning assessment, the extension codes, special views and
special tabulation lists, elements of the foundation of ICD, as well as changes to the
reference guide.
All proposals are entered on an online maintenance platform, for verification of
completeness, discussion and editing. The platform provides the infrastructure for routing
proposals to reviewers and experts, and for providing feedback to the original authors. The
maintenance platform also shows the final outcome of the proposal that has been entered
in the authoring platform and become part of the ICD. Any individual user of the
classification can submit a proposal for an update to the ICD. Such updates can refer to one
or more entities of the ICD. They may address the position of entities in a tabular list, in the
Foundation Component, and any element of the content model. The maintenance platform
of ICD-11 (known as the ‘orange browser’) is used for proposals and comments. Any input to
ICD-11 and its components requires proper referencing of sources, details of scientific
evidence, and permission from the owner of any copyright materials (where applicable).
The proposals will be reviewed by scientific experts and classification experts. The decision
regarding the outcome of a particular proposal will be based on the recommendations by
these experts.
A workflow between a mortality reference group (MRG) and a morbidity reference group
(MbRG), a medical scientific advisory committee (MSAC), and the overall overseeing
classification and statistics advisory committee (CSAC) will ensure that all aspects
concerning a proposal are considered. Reviews of the synthesis by classification experts
ensure suitability of the proposed changes to the diverse use cases of the ICD.
The process is based on consensus of the members of the CSAC about a proposed change.
All rounds of editing will be handled through electronic platforms. Where consensus cannot
be achieved, the proposal can either be deferred to subsequent cycles of editing pending
arbitration by the WHO or be solved in a face-to-face meeting of classification and content
experts. In all other cases, a consensus recommendation is given to WHO for final decision.
All proposals for change must be submitted through the proposal mechanism to ensure a
clear and transparent review of the proposed content. The different types of proposals that
may move through a workflow in order to ensure consistency, structural integrity, and

326 ICD-11 MMS

scientific correctness of the classification. The different workflows warrant proper use of the
available resources of the WHO Family of International Classifications WHO-FIC Network
and WHO. All changes are reported. Several steps may be needed for verification of
updates.
3.12.2 Updating Cycle

The updating is carried out at different levels with different frequencies. That will keep
stability for mortality and allow quicker updates for morbidity use.
• Updates that impact on international reporting (the four and five-character structure
of the stem codes) will be published every five years.
• Updates at a more detailed level can be published at annual rates and pending the
needs of clinical modifications also twice a year.
• Additions to the index can be done on an ongoing basis.
• Mortality and morbidity rules will be updated in a 10-year cycle.
• Other updates to the reference guide can be published at annual rates.

[Link] Types of proposals for ICD-11-MMS maintenance

After reviewing the established proposal types and criteria of ICD-10 and those used thus far
during ICD-11 Revision, taking into context the needs of ICD-11, the following proposal types
for ICD-11 are proposed (see Table below for impact on Morbidity and Mortality Statistics
(MMS)).
• Add new entity:
– to add an entity ‘below the shoreline’ (becoming an index entry in MMS)
– to add an entity ‘above the shoreline’ (becoming a category in MMS)
• Delete entity:
– applicable to an entity below the shoreline (removing an index term from the
MMS)
– applicable to an entity above the shoreline (removing a category from the
MMS)
• Change of Coding Status:
– moving an entity from the index into the MMS (e.g. giving it an individual
code), or an entity from the MMS to the index (e.g. eliminating the individual
code and directing it elsewhere)
• Content Enhancement including the following subtypes:
– Change of Preferred Term (title) (Changes to a code that affect the meaning
of that code are not allowed and will not be accepted. If a concept is

ICD-11 Reference Guide 327

 outdated and must be updated, or a new concept is necessary, the relevant
delete entity or add new entity proposal types, or both, must be used.)
– Addition / Deletion of a synonym
– Addition / Deletion of an exclusion
– Change of Description (Definition)
– Change of Additional Information (Long Definition)
– Correction of spelling or grammar (in any field)
– Addition / Deletion of a mandatory postcoordination combination of stem
codes
– Addition / Deletion of entity rubric content (does not allow change to
meaning)
• Structural Change including the following subtypes:
– Change a primary parent link
– Change a secondary parent link
• Reference Guide Change applicable to any text of the ICD-11 Reference Guide,
including coding rules and defaults, etc. Subtypes include:
– Correction of spelling or grammar
– Clarification of a rule
– Change to a rule (that effects data integrity), including changing a coding hint
• Proposals for clarification that do not require change to the classification
• Correction of inconsistency between volumes
Ideally, each proposal will specify if it relates to the foundation or to a classification,
including if it is for a national clinical modification or specialty linearisation. Tick boxes in the
proposals will allow to indicate the scope.
Not all authors will be familiar with these distinctions. The default may assume that the
proposal relates to the ICD-11 MMS, unless specified otherwise. Regardless, the CSAC will
need to determine if the item, once accepted, will be ‘above or below the shoreline’ in the
ICD-11 MMS.
Not all proposals will require the same level of scrutiny, as each may be considered in the
context of its impact on the statistical classification and the desirability for a scientifically
accurate and up-to-date classification. A ‘fast track’ to review urgently needed updates,
such as for national clinical modifications will be put in place as needed. Criteria and a
specific workflow exist for each ‘track’ used for proposals.
Table 1: Overview of ICD-11 maintenance proposal types and their potential impact on
MMS-collected data. List does not imply a hierarchy of prioritization. ‘X’ means applies.

328 ICD-11 MMS

 Proposal Type Major Minor None
Add new entity X X
Delete entity (+) X
Change of Coding Status X X
Content Enhancement
Change of Preferred Term (title) X X X
Addition/Deletion of a synonym X
Addition/Deletion of an exclusion X
Change of Description X X X
Change of Additional Information (Long Description - outside X
WHO)
Correction of a typo (in any field) X
Addition/Deletion of mandatory postcoordination combination of X
stem codes
Addition/Deletion of entity rubric content – no change to X
meaning
Structural Change
Change a primary parent X
Change a secondary parent X
Reference Guide change
Correction of a typo X
Clarification of a rule X
Change to a rule (that affects data integrity), including changing a X
coding hint

(+) Errors are deleted; obsolete terms and entities are not deleted as they assist with
mapping and coding as they may still be in use
Table 2: Groups responsible for maintenance of potential changes.

ICD-11 Reference Guide 329

 Proposal Type CSAC MSAC MRG MbRG FDGRG or
TM
Add new entity X X X X X+
Delete entity (+) X X X X X+
Change of Coding Status X X X X
Content Enhancement
Change of Preferred Term (title) X (X) X+
Addition/Deletion of a synonym** X+
Addition/Deletion of an exclusion**
Change of Description X X X X X+
Change of Additional Information (Long (X) X+
Description - outside WHO)
Correction of a typo (in any field)**
Addition/Deletion of mandatory X X X
postcoordination combination of stem codes
Structural Change
Change a primary parent X (X) X X X+
Change a secondary parent X X
Reference Guide change
Correction of a typo**
Clarification of a rule X X X X+
Change to a rule (that affects data integrity), X (X) X+ X+ X+
including changing a coding hint

(+) errors are deleted; obsolete terms and entities are not deleted as they assist with
mapping and coding as they may still be in use. (X) applies only in special situations. X+
applies only for the specific use case. ** WHO team
3.12.3 Proposal completeness

Any individual can submit a proposal for an update to the ICD. Proposals shall be provided in
the format of a short (approximately 500-words) explanation with references to
underpinning literature and evidence (publications in peer reviewed journals, or in official
meetings of WHO, its CC or NGO in official relationships). The proposal shall also visualize
the changes in the position and address potential impact on entities outside the proposal.
• The author has to register with full name and affiliation and declare any possible
conflict of interest.
• All proposals must have a clearly written and compelling rationale, with citations to
establish the proposals’ evidence base.
• Proposals that suggest adding entities must have a description, and a description of
the entity. This ensures the correct placement in the foundation. The rationale must

330 ICD-11 MMS

 have a scientific background, with references to publications in peer reviewed
journals, or in official meetings of WHO, its CC or NGO in official relationships.
• Proposals for new codes should include information about how the case would be
coded if the proposed new code is not accepted.
• Proposals with impact on the statistics must include a description or analysis of the
resulting impact like frequency.
• Proposals suggesting rule changes must come with an impact analysis.
• An incomplete proposal will be returned to the author.
• The proposal mechanism will not allow submitting proposals without rationale or
with missing description or definition, adequate to process the proposal.
3.12.4 Proposal Timelines

Proposals can be submitted at any time. No impact proposals are processed on an ongoing
basis, proposals requiring review by any of the groups and committees involved in the
workflow, are bundled every 28 February of a year and routed in the necessary workflow.
Proposals are processed in parallel by the relevant groups. Formal comments are provided
in two rounds (two months, one month) -offering the opportunity for edits in between.
Final decision about acceptance, rejection or ‘further discussion’ is taken at a teleconference
of the CSAC at the WHO-FIC annual meeting in October every year. Official releases are
published end of September for validity according to the updating cycle of the kind of
proposal, earliest being proposals for adoption in January of the following year (minimum
six months for translation, three months for formal dissemination, e.g. for clinical detail,
secondary parents or synonyms).

Proposal and Release Timelines

ICD-11 Reference Guide 331

3.12.5 Proposal Workflow

ICD maintenance is a process that requires broad expertise in statistics and medical science
as well as in different use cases. It has already been established that the structure
associated with ICD update and maintenance will be revised in line with new requirements
and efficient use of limited resources. The figure below shows the flow by which proposals
received through the update platform might move through the expert groups for review and
recommendation to WHO. A ‘proposal triage’ will initially review all proposals received to
ensure that they are complete and have been submitted correctly. The proposals will then
be forwarded to the appropriate next step(s). This triage may identify proposals that can or
must be processed in an accelerated process, such as due to the type of proposal or in cases
of extreme urgency. The proposed typology of proposals may help to identify the impact on
the classification which will, in turn, inform whether the proposal is an improvement or
clarification that can be implemented on an ongoing basis, or if the change must be queued
for implementation on the updating cycle. The threshold for considering proposals to the
foundation is low, allowing for simple rules to identify what is ‘receivable/actionable’
namely, if it is complete and correct, it may be considered. Consideration does not
guarantee acceptance.
The CSAC is composed of:
• WHO-FIC Collaborating centres and officially nominated technical representatives
from WHO member states. The participants and observers have specific knowledge
and expertise in the classifications
• Two cochairs from each Reference Group (Mortality Reference Group (MRG),
Morbidity Reference Group (MbRG) and Functioning and Disability Reference Group
(FDRG), Traditional Medicine Group (TMRG)) as well as two cochairs from the
Medical and Scientific Advisory Committee (MSAC) are also included ex officio, with
the right to comment but no right to vote.
• Additional experts may be invited to participate in CSAC meetings for commenting
on specific items.
All decisions are based on consensus. Terms of reference of the working groups are included
in the document that describes the conduct of the WHO Family of International
Classifications Network.

332 ICD-11 MMS

Proposal Workflow
Proposal Workflow see Conduct of the WHOFIC Network for ToR and Governance of the
different groups.
CSAC Small Group
This group consists of the CSAC co-chairs and secretariats, WHO staff and experts selected
by WHO.
The CSAC Small Group reviews each proposal and determines if the proposal is ready for
review by the full CSAC. The Small Group also makes a recommendation by consensus as to
whether the proposal should be accepted or rejected. If a proposal requires more
information or is incomplete, the CSAC Small Group may request further advice from MSAC
or other commit- tees and reference groups (C&RG) or send the proposal back to the
author. Sometimes, the Small Group, MSAC and/or a C&RG make a recommendation for a
modification to the original proposal, and this is recorded in the public comments section of
the proposal by the secretariat of the group. These comments and proposed modifications
are then considered by the full CSAC.
When a proposal is ready for review by the wider CSAC, the CSAC Secretariat records the
recommendation of the CSAC Small Group, and any suggested modifications and the
reasons for these, on the public comments section of the proposal and allocates the
proposal to have the status ‘CSAC Voting’. CSAC members can then indicate their agreement
and/or comment on the proposal, as modified by the CSAC Small Group, as applicable.
3.12.6 Changes that cannot be done during the normal updating process

Changes that create new structures that conflict with the existing structure or coding of a
current revision can be carried out only within a new revision of ICD and they include:

ICD-11 Reference Guide 333

 1. Changing an existing code of a category

2. Changing an existing grouping into a category if it has children in the linearisation (Allowing
this would force changing the codes of the children therefore it is not allowed)

3. Changing an existing category into a grouping if it has children in the linearisation (Same as
above)

4. Inserting a category in between two existing sibling categories. Categories to an existing

siblinghood needs to be entered at the end before the residuals.

5. Re-ordering of any kind will not be possible as the ordering would be based on the codes
which will not change.

6. Retiring an entity that contains children that are not retired and replacing it with another
entity that contains the old children. (This is not possible because the new entity cannot
keep the same code of the retired one and if we give a new code its code will not be
compatible with the children.)

7. Moving an existing category in a way that would imply changing its code. E.g. the category
2B01.2 cannot be moved which is under 2B01 as a child of 2B00

For Chapter X ‘Extension codes’ the only limitation is number 1 above. Any other change
could be done as the codes of Chapter X are not based on their hierarchical location.
3.12.7 Applicability and Intellectual Property

The following paragraph provides an extract of some of the legal regulations in relation to
ICD. It is noted that this text does not prejudge in any way the wording of any legal
arrangements that are made between WHO and other relevant parties. The binding official
version of the ICD license is available at [Link]
The ICD is the intellectual property of WHO and changes to the ICD are subject to
contractual arrangements and approval through the updating mechanism.
ICD-11 is licensed under the Creative Commons Attribution-NoDerivs 3.0 IGO license (CC BY-
ND 3.0 IGO, or the “ICD-11 License”, available at [Link]
nd/3.0/igo/). Under the terms of the License, you are NOT permitted to make “adaptations”
of ICD-11, as defined in the License. In that regard, and without otherwise limiting the terms
of the ICD-11 License, WHO provides the following clarifications:
• To prevent the dilution of ICD’s purpose to provide a definitive standard for identifying
health information, neither the Licensed Materials, nor any portion thereof, may be used for
the purpose of developing or promulgating a different standard.

• WHO does not consider incorporation of ICD-11 into a software product to be an

“adaptation”, provided that you do not do any of the following:

334 ICD-11 MMS

 –
a. Reproduce ICD-11 in part or whole and distribute it under a different
name or without attribution;
–
b. Reproduce and distribute ICD-11 in part or whole without the ICD-11
codes;
–
c. Reproduce ICD-11 in part or a whole without the ICD-11 URIs; or
–
d. Reproduce and distribute ICD-11, in part or whole, with any
combination of a-c above.
• Mappings or crosswalks between other classifications and terminologies and ICD-11 are not
covered by the ICD-11 License and are subject to a separate written agreement from WHO

• Adding data fields to ICD-11 concepts is permitted if such additions are clearly identified as
additions that do not originate from WHO.

• Web services for ICD coding and browsing and other software are available under a non-
exclusive, non-transferable and non-assignable royalty-free license to use and incorporate
the ICD-11 Software in computer applications or systems (the “Software License”). Such
computer applications or systems incorporating the ICD-11 Software, may be licensed to
users for commercial and non-commercial purposes. Users are not granted the right to sell
or license the ICD-11 Software as a standalone product. For the avoidance of any doubt the
ICD-11 Software is not licensed under the Creative Commons license for the ICD-11
described in Section 1, above.

The ICD may be translated into any language. For translation, interested parties (the
Translator) are requested to contact the WHO and comply with the relevant regulations and
receive written permission in a formal contract. Usually translation rights are granted only
to ministries of health.
The translations into the UN languages are a product of the WHO and all rights are vested
with WHO. Translations into other languages are a product of the Translator.
The Translator will use the WHO translation platform, thus allowing the WHO to verify
correctness and completeness of the translation.
WHO is automatically granted a perpetual and irrevocable, non-exclusive, world-wide,
royalty-free, sub-licensable right to use, change, adapt, translate, publish, and disseminate
such work product in any manner and in any format in conjunction with the work of WHO.
In some instances, users determine the need to change parts of the ICD in order to produce
a special version of ICD. Production of special versions requires a dedicated contractual
arrangement with WHO.
Such versions will be produced from the WHO production platform by WHO.
All changes or suggestions for changes to the ICD must be submitted to the WHO-ICD
maintenance platform (for details see 3.12 Annex A: ICD-11 Updating and Maintenance).

ICD-11 Reference Guide 335

Requests for production of a special version will be subject to the provision of resources
necessary for the WHO to generate the specialty version.
No publicity or advertising may be displayed in the coding or browsing pages. In case of
embedding of the classification in a local website, or running a local version, a link to the ICD
homepage at the WHO must be included.
No publicity or advertising may be displayed in the ICD print versions.
Ideally users will access the ICD online or through the web services provided by the WHO.
This will ensure proper joint use of the index, content model, and tabular lists and facilitate
dissemination of updates, where applicable. Any coding mechanism produced by 3rd parties
must provide the same coding results as the reference online coding tool.
For national and international recording and reporting, the most up to date version of the
ICD is to be used, as stipulated in the Nomenclature Regulations (1967).
Modifications for morbidity coding
The use of ICD in the specific context of the health care system of a country may require
detail that is not currently part of ICD-11, for example, due to specific settings or due to
reimbursement system requirements. Such changes will be subject to the same
international process as are all other changes to ICD and will then become part of the
Foundation Component and eventually of the Mortality and Morbidity Statistics (MMS),
ideally prior to their implementation in the requesting country.
A situation may arise, where a national government or a related national institution needs a
modification to be implemented immediately. In such circumstances, conflicts with the
current Foundation Component must be avoided, and the relevant changes will be subject
to special mechanisms for the international updating process. All countries planning to
produce modifications must make relevant contractual arrangements with WHO. This
includes regulations on distribution within and outside the respective country and the
resources necessary for the WHO to add such changes to the Foundation.
For developing a national modification of ICD-11 the following rules must be adhered to: 1.
Modifications will be agreed by the ICD-11 maintenance bodies before they are
implemented nationally. 2. Modifications must not impact on morbidity and mortality
statistics, and must not conflict with the Foundation. 3. Approval of all modifications will be
subject to consideration of whether suitable additional detail already exists in the
Foundation. 4. If a change is made to the international version of ICD-11 the respective
modification must incorporate the change as soon as possible.
Example
‘Diabetes Type 1’ in the WHO version of ICD-11 is classified to 5A10. A national modification
may require additional detail to be added to the ICD-11 codes. For example, ‘Diabetes Type
1, uncontrolled’ could be added as a subcategory to 5A10, as 5A10.1 Diabetes Type 1,
uncontrolled. However, when the mechanism of postcoordination provides the necessary
detail, the addition of a new subcategory may not be necessary.

336 ICD-11 MMS

3.13 Annex B: History of the development of the ICD
3.13.1 Early history

Sir George Knibbs, the eminent Australian statistician, credited François Bossier de Lacroix
(1706-1777), better known as Sauvages, with the first attempt to classify diseases
systematically (1). Sauvages’ comprehensive treatise was published under the title
Nosologia methodica. A contemporary of Sauvages was the great methodologist Linnaeus
(1707-1778), author of Genera morborum, a catalogue of diseases. More recently,
Moriyama et al (2) have referred to 16th century and 17th predecessors Fernel and
Sydenham. At the beginning of the 19th century, the classification of disease in most
general use was one by William Cullen (1710- 1790, of Edinburgh, which was published in
1785 under the title Synopsis nosologiae methodicae.
For all practical purposes, however, the statistical study of disease began a century earlier
with the work of John Graunt on the London Bills of Mortality published in 1662. The kind of
classification envisaged by this pioneer is exemplified by his attempt to estimate the
proportion of liveborn children who died before reaching the age of six, when no records of
age at death were available. He took all deaths and classed them using terms from the time,
such as thrush, convulsions, rickets, teeth and worms, abortives, chrysomes, infants, and
livergrown. Overlaid with these, he added to them deaths classed as smallpox, swinepox,
measles, and worms without convulsions. Despite the crudity of this classification, his
estimate of 36% mortality before the age of six years appears from later evidence to have
been a good one. While three centuries have contributed to the scientific accuracy of
disease classification, there are many who doubt the usefulness of attempts to compile
statistics of disease, or even causes of death, because of the difficulties of classification. To
these, one can quote Major Greenwood: ‘The scientific purist, who will wait for medical
statistics until they are nosologically exact, is no wiser than Horace’s rustic waiting for the
river to flow away’ (3).
Fortunately for the progress of preventive medicine, the General Register Office of England
and Wales, at its inception in 1837, found in William Farr (1807-1883) – its first medical
statistician. Farr was a man who not only made the best possible use of the imperfect
classifications of disease available at the time but laboured to secure better classifications
and international uniformity in their use.
Farr found Cullen’s classification in use in the public services. It had not been revised to
embody the advances in medical science, nor was it deemed by him to be satisfactory for
statistical purposes. Farr realised that small numbers that would result from a detailed
classification would not permit statistical inferences to be made. In the first Annual Report
of the Registrar General (4), therefore, he discussed the principles that should govern a
statistical classification of disease and urged the adoption of a uniform classification as
follows:
_The advantages of a uniform statistical nomenclature, however i
mperfect, are so obvious, that it is surprising no attention has bee
n paid to its enforcement in Bills of Mortality. Each disease has, i
n many instances, been denoted by three or four terms, and each term
has been applied to as many different diseases: vague, inconvenient
names have been employed, or complications have been registered ins

ICD-11 Reference Guide 337

tead of primary diseases. The nomenclature is of as much importance
in this department of inquiry as weights and measures in the physica
l sciences, and should be settled without delay._

Both nomenclature and statistical classification received constant study and consideration
by Farr in his annual ‘Letters’ to the Registrar General published in the Annual Reports of the
Registrar General. Farr did much to promote his classification but could not find general
acceptance (4). However, the utility of a uniform classification of causes of death was so
strongly recognised at the first International Statistical Congress, held in Brussels in 1853,
that the Congress requested William Farr and Genevan Marc d’Espine to prepare an
internationally applicable, uniform classification of causes of death.
At the next Congress, in Paris in 1855, Farr and d’Espine submitted two separate lists which
were based on very different principles. Farr’s classification was arranged under five groups:
epidemic diseases, constitutional (general) diseases, local diseases arranged according to
anatomical site, developmental diseases, and diseases that are the direct result of violence.
D’Espine classified diseases according to their nature (gouty, herpetic, haematic, etc.). The
Congress adopted a compromise list of 139 rubrics. In 1864, this classification was revised in
Paris on the basis of Farr’s model and was subsequently further revised in 1874, 1880, and
1886. Although this classification was never universally accepted, the general arrangement
proposed by Farr, including the principle of classifying diseases by aetiology followed by
anatomical site, survived as the basis of the International List of Causes of Death.
Importantly, the 1855 Congress also recommended that each country should ask for
information on causes of death from the doctor who had been attending the deceased, and
that each country should take measures to ensure that all deaths were verified by doctors
(4).
3.13.2 Adoption of the International List of Causes of Death

At its 1891 meeting in Vienna, the International Statistical Institute, the successor to the
International Statistical Congress, charged a committee chaired by Jacques Bertillon (1851-
1922), Chief of Statistical Services of the City of Paris, with the preparation of a classification
of causes of death. The committee’s report was presented and adopted at the meeting of
the International Statistical Institute in Chicago in 1893.
For main headings, Bertillon adopted the anatomical site rather than the nature of disease,
according to Farr’s plan. Bertillon’s list included defined diseases most worthy of study by
reason of their transmissible nature or their frequency of occurrence. In accordance with
the instructions of the Vienna Congress, Bertillon included three classifications: an abridged
classification of 44 titles; a classification of 99 titles; and a classification of 161 titles.
Bertillon also prepared some rules or guidelines on the resolution of problems; for example,
how statistical clerks should classify what is written without imputing what the doctor might
have meant (5). The ‘Bertillon Classification of Causes of Death’, as it was first called,
received general approval and was adopted by several countries, as well as by many cities.
The classification was first used in North America by Jesus E. Monjaras for the statistics of
San Luis de Potosi, Mexico (5). In 1898, the American Public Health Association, at its
meeting in Ottawa, Canada, recommended the adoption of the Bertillon Classification by

338 ICD-11 MMS

registrars of Canada, Mexico, and the United States of America. The Association further
suggested that the classification should be revised every ten years.
At the meeting of the International Statistical Institute at Christiania in 1899, Bertillon
presented a report on the progress of the classification, including the recommendations of
the American Public Health Association for decennial revisions. The International Statistical
Institute then adopted the following resolution (6): The International Statistical Institute,
convinced of the necessity of using comparable nomenclatures in the different countries:
_Learns with pleasure of the adoption by all the statistical off
ices of North America, by some of those of South America, and by som
e in Europe, of the system of cause of death nomenclature presented
in 1893; Insists vigorously that this system of nomenclature be adop
ted in principle and without revision, by all the statistical instit
utions of Europe; Approves, at least in its general lines, the syste
m of decennial revision proposed by the American Public Health Assoc
iation at its Ottawa session (1898); Urges the statistical offices w
ho have not yet adhered, to do so without delay, and to contribute t
o the comparability of the cause of death nomenclature._

The French Government therefore assembled in Paris, in August 1900, the first International
Conference for the Revision of the Bertillon or International List of Causes of Death.
Delegates from 26 countries attended this Conference. A detailed classification of causes of
death consisting of 179 groups and an abridged classification of 35 groups was adopted on
21 August 1900. The desire for decennial revisions was recognized, and the French
Government was requested to call the next meeting in 1910. In fact, the next conference
was held in 1909, and the Government of France called succeeding conferences in 1920,
1929, and 1938. Bertillon continued to be the guiding force in the promotion of the
International List of Causes of Death, and the revisions of 1900, 1910, and 1920 were carried
out under his leadership. As Secretary- General of the International Conference, he sent out
the provisional revision for 1920 to more than 500 people, asking for comments. His death
in 1922 left the International Conference without a guiding hand.
At the 1923 session of the International Statistical Institute, Michel Huber, Bertillon’s
successor in France, recognized this lack of leadership and introduced a resolution for the
International Statistical Institute to renew its stand of 1893 in regard to the International
Classification of Causes of Death and to cooperate with other international organisations in
preparation for subsequent revisions. The Health organisation of the League of Nations had
also taken an active interest in vital statistics and appointed a Commission of Statistical
Experts to study the classification of diseases and causes of death, as well as other problems
in the field of medical statistics. E. Roesle, Chief of the Medical Statistical Service of the
German Health Bureau and a member of the Commission of Statistical Experts, prepared a
monograph that listed the expansion in the rubrics of the 1920 International List of Causes
of Death that would be required if the classification were to be used in the tabulation of
statistics of morbidity. This careful study was published by the Health organisation of the
League of Nations in 1928 (7). In order to coordinate the work of both agencies, an
international ‘Mixed Commission’ was created with an equal number of representatives
from the International Statistical Institute and the Health organisation of the League of

ICD-11 Reference Guide 339

Nations. This Commission drafted the proposals for the Fourth (1929) and the Fifth (1938)
revisions of the International List of Causes of Death.
3.13.3 The Fifth Decennial Revision Conference

The Fifth International Conference for the Revision of the International List of Causes of
Death, like the preceding conferences, was convened by the Government of France and was
held in Paris in October 1938. The Conference approved three lists: a detailed list of 200
titles, an intermediate list of 87 titles and an abridged list of 44 titles. Apart from bringing
the lists up to date in accordance with the progress of science, particularly in the chapter on
infectious and parasitic diseases, and changes in the chapters on puerperal conditions and
on accidents, the Conference made as few changes as possible in the contents, number, and
even in the numbering of the items. A list of causes of stillbirth was also drawn up and
approved by the Conference.
As regards classification of diseases for morbidity statistics, the Conference recognised the
growing need for a corresponding list of diseases to meet the statistical requirements of
widely differing organisations, such as health insurance organisations, hospitals, military
medical services, health administrations, and similar bodies. The following resolution,
therefore, was adopted (8):

[Link] International Lists of Diseases

• In view of the importance of the compilation of international lists of diseases corresponding
to the international lists of causes of death: The Conference recommends that the Joint
Committee appointed by the International Institute of Statistics and the Health organisation
of the League of Nations undertake, as in 1929, the preparation of international lists of
diseases, in conjunction with experts and representatives of the organisations specially
concerned. Pending the compilation of international lists of diseases, the Conference
recommends that the various national lists in use should, as far as possible, be brought into
line with the detailed International List of Causes of Death (the numbers of the chapters,
headings and subheadings in the said List being given in brackets). The Conference further
recommended that the United States Government continue its studies of the statistical
treatment of joint causes of death in the following resolution (9):

– Death Certificate and Selection of Causes of Death where more than One Cause is
given (Joint Causes) The Conference,

• Whereas, in 1929, the United States Government was good enough to

undertake the study of the means of unifying the methods of
selection of the main cause of death to be tabulated in those cases
where two or more causes are mentioned on the death certificate,
• And whereas, the numerous surveys completed or in the course of
preparation in several countries reveal the importance of this
problem, which has not yet been solved,
• And whereas, according to these surveys, the international
comparability of death rates from the various diseases requires, not
only the solution of the problem of the selection of the main

340 ICD-11 MMS

 tabulated cause of death, but also the solution of several other
questions;
– Warmly thanks the United States Government for the work it has accomplished or
promoted in this connection;

• Requests the United States Government to continue its investigations during the next ten
years, in cooperation with other countries and organisations, on a slightly wider basis, and

• Suggests that, for these future investigations, the United States Government should set up a
subcommittee comprising representatives of countries and organisations participating in the
investigations undertaken in this connection.

3.13.4 Previous classifications of diseases for morbidity statistics

In the discussion so far, classification of disease has been presented almost wholly in
relation to cause-of-death statistics. Farr, however, recognized that it was desirable “to
extend the same system of nomenclature to diseases which, though not fatal, cause
disability in the population, and now figure in the tables of the diseases of armies, navies,
hospitals, prisons, lunatic asylums, public institutions of every kind, and sickness societies,
as well as in the census of countries like Ireland, where the diseases of all the people are
enumerated” (10). In his ‘Report on nomenclature and statistical classification of diseases’,
presented to the Second International Statistical Congress, he therefore included in the
general list of diseases most of those diseases that affect health as well as diseases that are
fatal. At the Fourth International Statistical Congress, held in London in 1860, Florence
Nightingale urged the adoption of Farr’s classification of diseases for the tabulation of
hospital morbidity in the paper, ‘Proposals for a uniform plan of hospital statistics’.
At the First International Conference to revise the Bertillon Classification of Causes of Death
in Paris in 1900, a parallel classification of diseases for use in statistics of sickness was
adopted. A parallel list was also adopted at the second conference in 1909. The extra
categories for non-fatal diseases were formed by subdivision of certain rubrics of the cause-
of-death classification into two or three disease groups, each of these being designated by a
letter. The translation in English of the Second Decennial Revision, published by the United
States Department of Commerce and Labor in 1910, was entitled International Classification
of Causes of Sickness and Death. Later revisions incorporated some of the groups into the
detailed International List of Causes of Death. The Fourth International Conference adopted
a classification of illness which differed from the detailed International List of Causes of
Death only by the addition of further subdivisions of 12 titles. These international
classifications of illnesses, however, failed to receive general acceptance, as they provided
only a limited expansion of the basic cause-of-death list.
In the absence of a uniform classification of diseases that could be used satisfactorily for
statistics of illness, many countries found it necessary to prepare their own lists. A Standard
Morbidity Code was prepared by the Dominion Council of Health of Canada and published in
1936. The main subdivisions of this code represented the 18 chapters of the 1929 Revision
of the International List of Causes of Death, and these were subdivided into some 380
specific disease categories. At the Fifth International Conference in 1938, the Canadian
delegate introduced a modification of this list for consideration as the basis for an
international list of causes of illness. Although no action was taken on this proposal, the
Conference adopted the resolution quoted above.

ICD-11 Reference Guide 341

In 1944, provisional classifications of diseases and injuries were published in both the United
Kingdom and the United States for use in the tabulation of morbidity statistics. Both
classifications were more extensive than the Canadian list, but, like it, followed the general
order of diseases in the International List of Causes of Death. The British classification was
prepared by the Committee on Hospital Morbidity Statistics of the Medical Research
Council, which was created in January 1942. It is entitled ‘A provisional classification of
diseases and injuries for use in compiling morbidity statistics’ (8). It was prepared with the
purpose of providing a scheme for collecting and recording statistics of patients admitted to
hospitals in the United Kingdom, using a standard classification of diseases and injuries, and
was used throughout the country by governmental and other agencies.
A few years earlier, in August 1940, the Surgeon-General of the United States Public Health
Service and the Director of the United States Bureau of the Census published a list of
diseases and injuries for tabulation of morbidity statistics (9). The code was prepared by the
Division of Public Health Methods of the Public Health Service in cooperation with a
committee of consultants appointed by the Surgeon-General. ‘The Manual for coding causes
of illness according to a diagnosis code for tabulating morbidity statistics’, consisting of the
diagnosis code, a tabular list of inclusions, and an alphabetical index, was published in 1944.
The code was used in several hospitals, in a large number of voluntary hospital insurance
plans and medical care plans, and in special studies by other agencies in the United States.
3.13.5 United States Committee on Joint Causes of Death

In compliance with the resolution of the Fifth International Conference, the American
Secretary of State in 1945 appointed the United States Committee on Joint Causes of Death
under the chairmanship of Lowell J. Reed, Professor of Biostatistics at Johns Hopkins
University. Members and consultants of this committee included representatives of the
Governments of Canada and the United Kingdom and the Health Section of the League of
Nations. Recognizing a trend, the committee decided that it would be advantageous to
consider classifications from the point of view of morbidity and mortality, since the problem
of joint causes pertained to both types of statistics.
The committee also took into account that part of the resolution on International Lists of
Diseases of the previous International Conference recommending that the ‘various national
lists in use should, as far as possible, be brought into line with the detailed International List
of Causes of Death’. It recognized that the classification of sickness and injury is closely
linked with the classification of causes of death. The view that such lists are fundamentally
different arises from the erroneous belief that the International List is a classification of
terminal causes, whereas it is in fact based upon the morbid condition that initiated the
train of events ultimately resulting in death. The committee believed that, in order to utilise
fully both morbidity and mortality statistics, not only should the classification of diseases for
both purposes be comparable, but if possible, there should be a single list.
Furthermore, an increasing number of statistical organisations were using medical records
involving both sickness and death. Even in organisations that compile only morbidity
statistics, fatal as well as non-fatal cases needed to be coded. A single list, therefore, greatly
facilitates their coding operations. It also provides a common base for comparison of
morbidity and mortality statistics.

342 ICD-11 MMS

A subcommittee was therefore appointed, which prepared a draft of a Proposed Statistical
Classification of Diseases, Injuries and Causes of Death. A final draft was adopted by the
committee after it had been modified on the basis of trials undertaken by various agencies
in Canada, the United Kingdom and the United States of America.
Table 1: ICD Revisions under the auspices of WHO

Revision Date of coming into effect Year of WHA adoption

6th Revision 1948 1948 (WHA1.36)
7th Revision 1 Jan 1958 May 1956 (WHА9.29)
8th Revision 1 Jan 1968 May 1966 (WHA19.44)
9th Revision 1 Jan 1979 May 1976 (WHA29.34)
10th Revision 1 Jan 1993 May 1990 (WHA43.24)
11th Revision 1 Jan 2022 May 2019 (WHA72.15)
3.13.6 Sixth Revision of the International Lists

The International Health Conference held in New York City in June and July 1946 (11)
entrusted the Interim Commission of the World Health Organisation with the responsibility
of ‘reviewing the existing machinery and of undertaking such preparatory work as may be
necessary in connection with: (i) the next decennial revision of ‘The International Lists of
Causes of Death’ (including the lists adopted under the International Agreement of 1934,
relating to Statistics of Causes of Death); and (ii) the establishment of International Lists of
Causes of Morbidity.’
To meet this responsibility, the Interim Commission appointed the Expert Committee for the
Preparation of the Sixth Decennial Revision of the International Lists of Diseases and Causes
of Death. This Committee, taking full account of prevailing opinion concerning morbidity
and mortality classification, reviewed and revised the above-mentioned proposed
classification which had been prepared by the United States Committee on Joint Causes of
Death.
The resulting classification was circulated to national governments preparing morbidity and
mortality statistics for comments and suggestions under the title, International Classification
of Diseases, Injuries, and Causes of Death. The Expert Committee considered the replies and
prepared a revised version incorporating changes to improve the utility and acceptability of
the classification. The Committee also compiled a list of diagnostic terms to appear under
each title of the classification. Furthermore, a subcommittee was appointed to prepare a
comprehensive alphabetical index of diagnostic statements classified to the appropriate
category of the classification. The Committee also considered the structure and uses of
special lists of causes for tabulation and publication of morbidity and mortality statistics and
studied other problems related to the international comparability of mortality statistics,
such as form of medical certificate and rules for classification. The International Conference
for the Sixth Revision of the International Lists of Diseases and Causes of Death was
convened in Paris from 26 to 30 April 1948 by the Government of France under the terms of
the agreement signed at the close of the Fifth Revision Conference in 1938. Its secretariat
was entrusted jointly to the competent French authorities and to the World Health
Organisation, which had carried out the preparatory work under the terms of the

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arrangement concluded by the governments represented at the International Health
Conference in 1946 (12).
The Conference adopted the classification prepared by the Expert Committee as the Sixth
Revision of the International Lists (13). It also considered other proposals of the Expert
Committee concerning the compilation, tabulation and publication of morbidity and
mortality statistics. The Conference approved the International Form of Medical Certificate
of Cause of Death, accepted the underlying cause of death as the main cause to be
tabulated, and endorsed the rules for selecting the underlying cause of death as well as the
special lists for tabulation of morbidity and mortality data. It further recommended that the
World Health Assembly should adopt regulations under Article 21(b) of the WHO
Constitution to guide Member States in compiling morbidity and mortality statistics in
accordance with the International Statistical Classification. In 1948, the First World Health
Assembly endorsed the report of the Sixth Revision Conference and adopted World Health
Organisation Regulations No. 1, devised based on the recommendations of the Conference.
The International Classification, including the Tabular List of Inclusions defining the content
of the categories, was incorporated, together with the form of the medical certificate of
cause of death, the rules for classification and the special lists for tabulation, into the
Manual of the International Statistical Classification of Diseases, Injuries, and Causes of
Death (22). The Manual consisted of two volumes, Volume 2 being an alphabetical index of
diagnostic terms coded to the appropriate categories. In the Sixth Revision, morbid
conditions resulting from injuries, poisonings and other external causes were classified
according to both the external circumstances giving rise to the injury and to the kind of
injury.
The adoption of this dual classification was regarded at the time as a bold step to deal with
the simultaneous interest in more than one aspect of injury. The Sixth Decennial Revision
Conference marked the beginning of a new era in international vital and health statistics.
Apart from approving a comprehensive list for both mortality and morbidity and agreeing on
international rules for selecting the underlying cause of death, it recommended the
adoption of a comprehensive programme of international cooperation in the field of vital
and health statistics. An important item in this programme was the recommendation that
governments establish national committees on vital and health statistics to coordinate the
statistical activities in the country, and to serve as a link between the national statistical
institutions and the World Health Organisation. It was further envisaged that such national
committees would, either singly or in cooperation with other national committees, study
statistical problems of public health importance and make the results of their investigations
available to the WHO.
3.13.7 The Seventh and Eighth Revisions

The International Conference for the Seventh Revision of the International Classification of
Diseases was held in Paris under the auspices of the WHO in February 1955 (14). In
accordance with a recommendation of the WHO Expert Committee on Health Statistics, this
revision was limited to essential changes and amendments of errors and inconsistencies
(15). The Eighth Revision Conference convened by the WHO met in Geneva, from 6 to 12
July 1965 (16). This revision was more radical than the Seventh but left unchanged the basic
structure of the Classification and the general philosophy of classifying diseases, whenever
possible, according to their aetiology rather than a particular manifestation. During the

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years that the Seventh and Eighth Revisions of the ICD were in force, the use of the ICD for
indexing hospital medical records increased rapidly and some countries prepared national
adaptations which provided the additional detail needed for this application of the ICD.
3.13.8 The Ninth Revision

The International Conference for the Ninth Revision of the International Classification of
Diseases, convened by the WHO, met in Geneva from 30 September to 6 October 1975 (17).
In the discussions leading up to the conference, it had originally been intended that there
should be little change other than updating of the classification. This was mainly because of
the expense of adapting data processing systems each time the classification was revised.
There had been an enormous growth of interest in the ICD and ways had to be found of
responding to this, partly by modifying the classification itself and partly by introducing
special coding provisions.
A number of representations were made by specialist bodies which had become interested
in using the ICD for their own statistics. Some subject areas in the classification were
regarded as inappropriately arranged and there was considerable pressure for more detail
and for adaptation of the classification to make it more relevant for the evaluation of
medical care, by classifying conditions to the chapters concerned with the part of the body
affected rather than to those dealing with the underlying generalised disease. At the other
end of the scale, there were representations from countries and areas where a detailed and
sophisticated classification was irrelevant, but which nevertheless needed a classification
based on the ICD in order to assess their progress in health care and in the control of
disease. The final proposals presented to and accepted by the Conference retained the basic
structure of the ICD, although with much additional detail at the level of the four-digit
subcategories, and some optional five-digit subdivisions. For the benefit of users not
requiring such detail, care was taken to ensure that the categories at the three-digit level
were appropriate.
For the benefit of users wishing to produce statistics and indexes oriented towards medical
care, the Ninth Revision included an optional alternative method of classifying diagnostic
statements, including information about both an underlying general disease and a
manifestation in a particular organ or site. This system became known as the dagger and
asterisk system. The Twenty Ninth World Health Assembly, noting the recommendations of
the International Conference for the Ninth Revision of the International Classification of
Diseases, approved the publication, for trial purposes, of supplementary classifications of
Impairments and Handicaps and of Procedures in Medicine as supplements to, but not as
integral parts of, the International Classification of Diseases.
3.13.9 The Tenth Revision

Even before the Conference for the Ninth Revision, the WHO had been preparing for the
Tenth Revision. It recognised that the great expansion in the use of the ICD necessitated a
thorough rethinking of its structure and an effort to devise a stable and flexible
classification, which should not require fundamental revision for many years to come. The
WHO Collaborating Centres for Classification of Diseases (see [Link]/classification)
were consequently called upon to experiment with models of alternative structures for ICD–
10.

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It had also become clear that the established ten-year interval between revisions was too
short. Work on the revision process had to start before the current version of the ICD had
been in use long enough to be thoroughly evaluated, mainly because the necessity to
consult so many countries and organisations made the process a very lengthy one. The
Director General of the WHO therefore wrote to the Member States and obtained their
agreement to postpone a 1985 Tenth Revision Conference until 1989, and to delay the
introduction of the Tenth Revision which would have been due in 1989. In addition to
permitting experimentation with alternative models for the structure of the ICD, this
allowed time for the evaluation of ICD-9, for example through meetings organised by some
of the WHO Regional Offices and through a survey organised at headquarters.
The International Conference for the Tenth Revision of the International Classification of
Diseases, attended by delegates from 43 Member States, was convened by the World
Health organisation in Geneva from 26 September to 2 October 1989. The United Nations,
the International Labour Organisation, and the WHO Regional Offices sent representatives
to participate in the Conference, as did the Council for International organisations of
Medical Sciences. Twelve other non-governmental organisations concerned with cancer
registration, the deaf, epidemiology, family medicine, gynaecology and obstetrics,
hypertension, health records, preventive and social medicine, neurology, psychiatry,
rehabilitation and sexually transmitted diseases were also invited.
Extensive preparatory activity had been devoted to a radical review of the suitability of the
structure of the ICD, essentially a statistical classification of diseases and other health
problems, to serve a wide variety of needs for mortality and health care data. Ways of
stabilizing the coding system to minimize disruption at successive revisions had been
investigated, as had the possibility of providing a better balance between the content of the
different chapters of the ICD. Even with a new structure, it was plain that one classification
could not cope with the extremes of the requirements. The concept had therefore been
developed of a ‘family’ of classifications, which would include the ICD for traditional
mortality and morbidity statistics, while needs for more detailed, less detailed or different
classifications and associated matters would be dealt with by other members of the family.
The potential for different members of the ‘family’ in the medico-social and multi-
dimensional assessment in relation not only to health but also to activities of daily living, as
well as the social and physical environment, was recognised. It was demonstrated that
effective information could be obtained through use of the ICD and the International
Classification of Impairments, Disabilities, and Handicaps (ICIDH) (18), and through use of
the codes from Chapter XXI of the Tenth Revision.
The main innovation in the Tenth Revision was the use of an alphanumeric coding scheme
of one letter followed by three numbers at the four-character level. This had the effect of
more than doubling the size of the coding frame in comparison with the Ninth Revision and
enabled the vast majority of chapters to be assigned a unique letter or group of letters, each
capable of providing 100 three-character categories. Of the 26 available letters, 25 had been
used, the letter U being left vacant for future additions and changes, and for possible
interim classifications to solve difficulties arising at the national and international level
between revisions.
Another important innovation was the creation towards the end of certain chapters of
categories for postprocedural disorders. These identified important conditions that

346 ICD-11 MMS

constituted a medical care problem in their own right. Postprocedural conditions that were
not specific to a particular body system continued to be classified in the chapter on ‘Injury,
poisoning and certain other consequences of external causes’. The Revision included
definitions, standards, and reporting requirements related to maternal mortality and to
fetal, perinatal, neonatal and infant mortality. It was published in three volumes: one
containing the Tabular List, a second containing all related definitions, standards, rules and
instructions, and a third containing the Alphabetical Index.
The Tenth Revision Conference discussed the difficulties experienced during the extended
period of use of the Ninth Revision, related to the emergence of new diseases and the lack
of an updating mechanism to accommodate them. It recognised that it would not be
feasible to hold revision conferences more frequently than every 10 years. It also recognised
that any changes introduced during the lifetime of the Tenth Revision would need to be
considered carefully in relation to their impact on analyses and trends.
3.13.10 The WHO Family of International Classifications

Although the ICD is suitable for many different applications, it does not serve all the needs
of its various users. It does not provide sufficient detail for some specialties and sometimes
information on different attributes of health conditions may be needed. Also, the ICD is not
useful to describe functioning and disability as aspects of health and does not include a full
array of health interventions or reasons for encounter. Foundations laid by the International
Conference on ICD–10 in 1989 provided the basis for the development of a ‘family’ of health
classifications. This was given added momentum during the 1990s by the development of
the International Classification of Functioning, Disability and Health (ICF) (19), approved by
the World Health Assembly in 2001.
In 2001, the WHO Family of International Classifications (WHO-FIC) was created. At the core
of the Family are its reference classifications, currently the ICD and the ICF; the International
Classification of Health Interventions (ICHI), now under development, is the third reference
classification. The WHO-FIC also includes derived classifications, which provide additional
detail to core classifications or are rearrangements or aggregations of terms in core
classifications; the WHO has licensed several countries to develop national modifications of
the ICD as derived classifications. As well, the WHO-FIC includes related classifications to
cover health functions which are not (or are only partially) covered by other WHO-FIC
members. The WHO-FIC is supported by a network of Collaborating Centres, based on the
former Collaborating Centres for the ICD and the ICF, but continuously expanded by the
addition of new centres.
Table 2: Evolution of ICD

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 Iteration Year Document Note
0 1891 Bertillon Classification of Causes Drafted by International Statistical
of Death Institute
1 1900 Bertillon/International List of First International Conference for
Causes of Death Revision of List of Causes of Death
2 1910 International List of Causes of 179 titles, call for revision every 10
Death years
3 1920 International List of Causes of
Death
4 1929 International List of Causes of Drafted jointly by International
Death Statistical Institute and Health
organisation of the League of
Nations
5 1938 International List of Causes of 200 titles, additions to infectious
Death and parasitic
6 1948 International Classification of Recognition of classification of
Diseases, Injuries, and Causes of disease and injury, in addition to
Death causes of death
7 1955 International Classification of
Diseases, Injuries, and Causes of
Death
8 1965 International Classification of
Diseases, Injuries, and Causes of
Death
9 1976 International Classification of Trial of supplement on
Diseases, Injuries, and Causes of Impairments and Handicaps, and
Death Procedures in Medicine
10 1990 International Statistical Introduction of alpha-numeric
Classification of Diseases and coding scheme, postprocedural
Related Health Problems disorders; regular interim updates
11 2019 International Statistical Postcoordination (cluster coding);
Classification of Diseases and addition of Traditional Medicine,
Related Health Problems adverse events coding
3.13.11 Updating of ICD between revisions

As foreshadowed at the Tenth Revision conference, updating of the tenth revision of ICD
commenced in 2000. Updating proposals came from, and were carefully considered by, the
WHO and Collaborating Centres, including the impact on trends. The updating process has
allowed an extended life for the Tenth Revision while maintaining its clinical and scientific
currency.
3.13.12 Major Steps in the ICD-11 Revision

The revision of ICD-11 has taken place in several phases. First; a list of issues that were
known from the use of ICD-10 and that could not be solved in its classification structure was

348 ICD-11 MMS

compiled and possible solutions were formulated. Second; input was received from many
scientific groups in the key subject areas, with a focus on clinical perspectives.
Finally, centralised editing occurred, aimed at adjusting imbalances in content generated by
multiple, independently operating expert groups in the previous phase of the revision, and
at ensuring consistency and practicability of the overall structure for mortality and
morbidity statistics.
The final version also received input from field testing, Member State comments, and
ongoing submissions and processing of proposals.
3.13.13 Preparations for the Eleventh Revision

By 2003, it was becoming clear to the WHO and the Collaborating Centres that a further
revision of the ICD could no longer be delayed. The extent to which ICD updating could
encapsulate emerging developments was limited by the structure of ICD–10, and some
issues needed extended development and discussion with expert groups. A special meeting
of Collaborating Centres in Helsinki in 2004 discussed the need for a revision and issues to
be addressed as part of the revision process. The 2004 WHO-FIC meeting subsequently
adopted a revision process work-plan which was progressively developed at ensuing
meetings.
In 2007, the WHO formally launched the revision process. Oversight has been provided
through a broad-based Revision Steering Group. Technical work has been undertaken by a
series of Topic Advisory Groups, with cross-cutting groups examining mortality, morbidity
and quality and safety issues. For the first time, a chapter on description of diseases and
patterns of diseases from a traditional medicine standpoint has been included.
A Content Model, including a range of components for each ICD entity has been developed,
giving a rich foundation for the ICD. Other classifications and terminologies are linked or
included where possible to ensure ICD is aligned with them, and items used in other
members of the WHO Family of Classifications have been aligned wherever possible. The
more traditional statistical classification for mortality and morbidity is obtained from the
Foundation Component of ICD–11 as a tabular list. Extension codes are used to limit content
volume but still allow detailed classification of disease entities. Supplementary chapters and
sections allow capturing on an optional basis information about traditional medicine
diagnoses and functioning. Based on the experiences with ICD-9 and ICD-10 an updating
mechanism was designed, that allows improvements in user guidance and scientific updates
without compromising the statistical use of the classification.

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3.13.14 References for history of ICD
1. Knibbs G.H. The International Classification of Disease and Causes of Death and its
revision. Medical journal of Australia, 1929, 1:2-12.
2. Moriyama IM, Loy RM, Robb-Smith AHT. History of the statistical classification of
diseases and causes of death. Rosenberg HM, Hoyert DL, eds. Hyattsville, MD:
National Center for Health Statistics. 2011.
3. Greenwood M. Medical statistics from Graunt to Farr. Cambridge, Cambridge
University Press, 1948.
4. First annual report. London, Registrar General of England and Wales, 1839, p. 99.
5. Bertillon J. Classification of the causes of death (abstract). In: Transactions of the
15th International Congress on Hygiene Demography. Washington, 1912.
6. International list of causes of death. The Hague, International Statistical Institute,
1940.
7. Roesle E. Essai d’une statistique comparative de la morbidité devant servir à établir
les listes spéciales des causes de morbidité. Geneva, League of Nations Health
organisation, 1928 (document C.H. 730)
8. Medical Research Council, Committee on Hospital Morbidity Statistics. A provisional
classification of diseases and injuries for use in compiling morbidity statistics.
London, Her Majesty’s Stationery Office, 1944 (Special Report Series No. 248).
9. US Public Health Service, Division of Public Health Methods. Manual for coding
causes of illness according to a diagnosis code for tabulating morbidity statistics.
Washington, Government Publishing Office, 1944 (Miscellaneous Publication No. 32).
10. Sixteenth annual report. London, Registrar General of England and Wales, 1856, App.
p.73.
11. Official Records of the World Health Organisation, 1948, 11, 23.
12. Official Records of the World Health Organisation, 1948, 2, 110.
13. Manual of the international statistical classification of diseases, injuries, and causes
of death. Sixth revision. Geneva, World Health Organisation, 1949.
14. Report of the International Conference for the Seventh Revision of the International
Lists of Diseases and Causes of Death. Geneva, World Health Organisation, 1955
(unpublished document WHO/HA/7 Rev. Conf./17 Rev. 1.
15. Third Report of the Expert Committee on Health Statistics. Geneva, World Health
organisation, 1952 (WHO Technical Report Series, No. 53).
16. Report of the International Conference for the Eighth Revision of the International
Classification of Diseases. Geneva, World Health Organisation, 1965 (unpublished
document WHO/ICD9/74.4.
17. Manual of the international statistical classification of diseases, injuries, and causes
of death, Volume 1. Geneva, World Health Organisation, 1977.
18. International Classification of Impairments, Disabilities, and Handicaps. Geneva,
World Health Organisation, 1980.
19. International Classification of Functioning, Disability and Health. Geneva, World
Health organisation, 2001
20. Eleventh revision of the International Classification of Diseases, Report by the
Director-General, 2019,
[Link]

350 ICD-11 MMS

3.14 Annex C: Annexes for Mortality Coding
3.14.1 International form of medical certificate of cause of death

The International Form of Medical Certificate of Cause of Death

ICD-11 Reference Guide 351

Additional data that might be necessary for the reporting system of countries can be added
to the certificate. The form has a Frame A that serves to report the cause(s) of death, the
sequence of causes, the duration of diseases until death, and other conditions contributing
to death. Causes of death should be reported with the best available detail. For example,
‘birth depression’ for a newborn child that died, should be complemented by the reason for
the birth depression, as intrapartum asphyxia, or prepartum hypoxaemia.
The Frame B is designed to help to report detail that is relevant to coding and epidemiology
analyses for deaths due to external causes, maternal deaths, perinatal deaths, and deaths
due to postprocedural conditions. It complements the information in Frame A. The
complete reporting of the causes of death is based on an accurate examination of the dead
body, the assessment of local circumstances and insight available from health records.
Correct establishment of a cause of death and completion of the death certificate requires
training that should start at medical school and be refreshed in regular education
programmes. Also important is the practical experience in death certification that is gained
under the supervision of more experienced colleagues. It is noted that medical certifiers
that establish the cause of death may not always be available. Certification by non-
physicians may result in a changed pattern of the reported causes of death.
Where the dead body is no longer available for examination, for example due to low
coverage of medical staff or traditional rapid burial procedures, a verbal autopsy may
provide some limited information on the cause of death. In such a case, a sequence of
causes that led to death will rarely be identified, and causes identified with verbal autopsy
should be reported separately to those available from formal death certification process.
3.14.2 Quick reference guide for the International form of medical certificate of cause of
death (MCCD flyer)
Cause of death information serves
• epidemiology and prevention
• managing health care
• comparing health in different populations

Certification of death is one of the first steps in getting an overview of the health of people.
The diseases or conditions recorded on a death certificate represent the best medical
opinion. A properly completed cause-of-death certificate provides a description of the
order, type and association of events that have resulted in the death. The diagnoses
reported on the certificate are coded with the International Classification of Diseases. The
filling in of the cause-of-death certificate is independent of the revision of ICD. This coded
data is analyzed and used both nationally and internationally no matter what language was
used to complete the certification.
Cause of Death on the certificate - how to fill in?
Frame A: Death certificates may look different in most countries. But the section on the
cause of death is identical worldwide. Frame A has two parts, called Part 1 and Part 2, and a
section to record the time interval between the onset of each condition and the date of
death.
Part 1 - is used for diseases or conditions that form part of the sequence of events leading
directly to death. The immediate (direct) cause of death is entered on the first line, 1(a).

352 ICD-11 MMS

There must always be an entry on line 1(a). The entry on line l(a) may be the only condition
reported in Part I of the certificate. Where there are two or more conditions that form part
of the sequence of events leading directly to death, each event in the sequence should be
recorded on a separate line.
In any case you must record the disease, injury or external cause that resulted in the death.
Do not record only the mode of dying, such as cardiac arrest, respiratory failure or heart
failure.
Try to be as specific as you can. “Unknown” cause of death should be recorded in cases
where thorough testing or autopsy examination the cause of death cannot be determined.
Stating “Unknown” is better than any speculation on the possible cause of death.
Always fully spell out all terms. Abbreviations can be interpreted in different ways. Terms
such as “suspected” or “possible” are ignored in evaluation of the entries. For example
“suspected Diabetes” will be interpreted as “Diabetes”. The four lines may not provide
enough space for the chain of events. Do not waste space with unnecessary words. Some
clinical terms are very vague. For example, “tumour” does not specify behaviour (see also
last page of this flyer).
Duration - is the time interval between the onset of each condition that is entered on the
certificate (not the time of diagnosis of the condition), and the date of death. The duration
information is useful in coding certain diseases and also provides a useful check on the order
of the reported sequence of conditions.
Part 2 - is used for conditions that do not belong in Part 1 but their presence contributed to
death.
Frame B: Some detail is frequently forgotten in Part 1 and 2 (Frame A). Separate detailed
questions ask for detail such as previous surgery, mode of death or place of occurrence.
Frame B is not shown in this information sheet. It is self-explanatory.
Cause of Death on the certificate - step by step
• Start at line 1(a), with the immediate (direct) cause, then go back in time to
preceding conditions until you get to the one that started the sequence of events.
You will get very close to the time the patient was healthy.
• Now, you should have reported the underlying or originating cause on the lowest
used line and a sequence of events leads from the underlying cause up to the
immediate (direct) cause in the first line 1(a).
• Finally, record the time interval between the onset of each condition entered on the
certificate and the date of death. Where the time or date of onset is not known you

ICD-11 Reference Guide 353

 should record a best estimate. Enter the unit of time (minutes, hours, days, weeks,
months, years).

Example
• Write clearly and do not use abbreviations.
• Be sure the information is complete.
• Do not speculate on the cause of death.
• Do not fill in laboratory results or statements like “found by partner” (there may be
separate fields on the form for this kind of information).
• One condition per line should be sufficient.
Frequently used ill-defined terms

354 ICD-11 MMS

 Term Instruction
Accident Specify circumstances. Specify intent, as car accident, suicidal, or
assault. Specify place of occurrence.
Alcohol, drugs Specify use: long term or single, addiction
Complication of Specify disease that was the reason for surgery
surgery
Dementia Specify cause: e.g. due to Alzheimer disease, cerebrovascular, Lewy
body
Hepatitis Specify course, etiology: acute or chronic, alcoholic. If viral (specify
type A, B, C..)
Infarction Specify site: heart, brain… Specify cause: arteriosclerotic, thrombotic,
embolic
Infection Specify: primary or secondary, causative organism. If primary: specify
bacterial, viral, fungal or parasitic. If secondary: specify the primary
infection
Leukaemia Specify: type e.g. myeloid, monocytic, lymphoid, also whether acute
or chronic
Pneumonia Specify: primary, aspiration, cause, causative organism. If due to
immobility: specify the cause of immobility
Pulmonary Specify cause of embolism. If postsurgical or due to immobility,
embolism indicate the disease that was a cause for surgery or of immobility
Renal failure Specify: acute, chronic or terminal, underlying cause of insufficiency,
such as arteriosclerosis or infection. If due to immobility: specify the
cause of immobility
Thrombosis Specify: arterial or venous. Specify: the blood vessel. If postsurgical or
immobility: specify disease that was a cause for surgery or immobility
Tumour Specify: behaviour, location, metastases
Urinary tract Specify: site in the urinary tract, causative organism, underlying cause
infection of infection. If due to immobility: specify the cause of immobility
3.14.3 Suggested additional details of perinatal deaths

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Suggested Additional Details Perinatal Deaths
Workflow diagram of steps SP1 to SP8, and to Steps M1 to M4 for mortality coding.

356 ICD-11 MMS

ICD-11 Reference Guide 357
Workflow
3.14.4 Workflow diagram for mortality coding

Workflow
3.14.5 Priority ranking of Nature-of-Injury codes

The priority ranking of nature of injury codes is produced to standardise and facilitate
coding of the main injury. The list was created with substantial input from the International
Collaborative Effort (ICE) on Injury Statistics. The initial list was introduced in 2011 after
testing in several countries, and updates made to correct errors in the initial list.
(1 = Highest priority rank)

358 ICD-11 MMS

 Code Title Rank
NA00 [Superficial injury of head] 6
NA01 [Open wound of head] 6
NA02 [Fracture of skull or facial bones]
NA02.0 [Fracture of vault of skull] 3
NA02.1 [Fracture of base of skull] 4
NA02.2 [Orbital fracture] 6
NA02.3 [Fracture of nasal bones] 6
NA02.4 [Fracture of maxilla] 6
NA02.5 [Fracture of zygoma] 6
NA0D.02 [Enamel-dentin fracture] 6
NA02.7 [Fracture of mandible] 6
NA02.8 [Multiple fractures involving skull or facial bones] 3
NA02.Y [Fracture of other specified skull or facial bones] 4
NA02.Z [Fracture of skull or facial bones, part unspecified] 3
NA03 [Dislocation or strain or sprain of joints or ligaments of head]
NA03.0 [Dislocation of jaw] 5
NA03.1 [Dislocation of septal cartilage of nose] 6
NA0D.12 [Extrusive luxation of tooth] 6
NA03.3 [Strain or sprain of jaw] 6
NA03.Y [Dislocation or sprain of other specified joints or ligaments of 6
head]
NA03.Z [Dislocation or strain or sprain of joints or ligaments of head, 6
unspecified]
NA04 [Injury of cranial nerves] 6
NA05 [Injury of blood vessels of head] 5
NA06 [Injury of eye or orbit]
NA06.0 [Eyelid trauma] 6
NA06.1 [Penetrating wound of orbit with or without foreign body] 6
NA06.2 [Retained foreign body following penetrating wound of orbit] 6
NA06.3 [Traumatic orbital haemorrhage] 6
NA06.4 [Injury of conjunctiva or corneal abrasion without mention of 6
foreign body]
NA06.5 [Trauma to the iris sphincter] 6
NA06.6 [Traumatic injuries of the retina] 6
NA06.7 [Traumatic retinal haemorrhage] 6
NA06.80 [Retained intraocular magnetic foreign body, unilateral] 6
NA06.81 [Retained intraocular nonmagnetic foreign body, unilateral] 6

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Code Title Rank
NA06.82 [Closed eyeball trauma, unilateral] 6
NA06.83 [Closed eyeball trauma, bilateral] 6
NA06.84 [Penetrating wound of eyeball without foreign body, unilateral] 6
NA06.85 [Avulsion of eye, unilateral] 5
NA06.86 [Avulsion of eye, bilateral] 5
NA06.87 [Ocular laceration or rupture with prolapse or loss of intraocular 6
tissue, unilateral]
NA06.88 [Ocular laceration or rupture with prolapse or loss of intraocular 6
tissue, bilateral]
NA06.89 [Penetrating injury of eyeball, bilateral] 6
NA06.8A [Perforating injury of eyeball, bilateral] 6
NA06.8B [Retained intraocular magnetic foreign body, bilateral] 6
NA06.8C [Retained intraocular nonmagnetic foreign body, bilateral] 6
NA06.8D [Ocular laceration without prolapse or loss of intraocular tissue, 6
unilateral]
NA06.8E [Ocular laceration without prolapse or loss of intraocular tissue, 6
bilateral]
NA06.8Y [Other specified traumatic injury to eyeball] 6
NA06.8Z [Traumatic injury to eyeball, unspecified] 6
NA06.9 [Contusion of eyeball or orbital tissues] 6
NA06.A [Injury of lens] 6
NA06.Y [Other specified injury of eye or orbit] 6
NA06.Z [Injury of eye or orbit, unspecified] 6
NA07 [Intracranial injury]
NA07.0 [Concussion] 6
NA07.1 [Traumatic intracerebral haemorrhage] 2
NA07.2 [Traumatic cerebral oedema] 1
NA07.3 [Diffuse brain injury] 1
NA07.4 [Focal brain injury] 2
NA07.5 [Traumatic epidural haemorrhage] 2
NA07.6 [Traumatic subdural haemorrhage] 2
NA07.7 [Traumatic subarachnoid haemorrhage] 2
NA07.8 [Traumatic haemorrhage in brain tissue] 2
NA07.Y [Other specified intracranial injury] 2
NA07.Z [Intracranial injury, unspecified] 2
NA08 [Crushing injury of head]
NA08.0 [Crushing injury of brain] 1
NA08.1 [Crushing injury of face] 5

360 ICD-11 MMS

 Code Title Rank
NA08.2 [Crushing injury of skull] 1
NA08.3 [Crushed scalp] 1
NA08.Y [Other specified crushing injury of head] 1
NA08.Z [Crushing injury of head, unspecified] 1
NA09 [Traumatic amputation of part of head]
NA09.0 [Avulsion of scalp] 6
NA09.1 [Traumatic amputation of ear] 6
NA09.2 [Traumatic amputation of nose] 4
NA09.3 [Traumatic amputation of lip] 4
NA09.Y [Other specified traumatic amputation of part of head] 4
NA09.Z [Traumatic amputation of part of head, unspecified] 4
NA0A [Certain specified injuries of head]
NA0A.0 [Complex wounds to the head] 2
NA0A.1 [Injury of muscle, fascia or tendon of head] 6
NA0A.2 [Traumatic rupture of ear drum] 6
NA0A.3 [Multiple injuries of head] 4
NA0A.Y [Other specified injuries of head] 6
NA0B [Injury of the auricle] 3
NA0C [Injury of middle or inner ear] 3
NA0D.0 [Injury of hard dental tissues and pulp] 6
NA0Z [Injuries to the head, unspecified] 3
NA20 [Superficial injury of neck] 6
NA21 [Open wound of neck]
NA21.0 [Laceration without foreign body of neck] 5
NA21.1 [Laceration with foreign body of neck] 5
NA21.2 [Puncture wound without foreign body of neck] 5
NA21.3 [Puncture wound with foreign body of neck] 5
NA21.4 [Open bite of neck] 5
NA21.5 [Multiple open wounds of neck] 5
NA21.Y [Other specified open wound of neck] 6
NA21.Z [Open wound of neck, unspecified] 6
NA22 [Fracture of neck] 3
NA23 [Dislocation or strain or sprain of joints or ligaments at neck
level]
NA23.0 [Traumatic rupture of cervical intervertebral disc] 6
NA23.1 [Dislocation of cervical vertebra] 3
NA23.2 [Dislocation of other or unspecified parts of neck] 3

ICD-11 Reference Guide 361

Code Title Rank
NA23.3 [Multiple dislocations of neck] 3
NA23.4 [Strain or sprain of cervical spine] 5
NA23.5 [Strain or sprain of thyroid region] 6
NA23.Y [Other specified dislocation or strain or sprain of joints or 3
ligaments at neck level]
NA23.Z [Dislocation or strain or sprain of joints or ligaments at neck 3
level, unspecified]
NA30 [Concussion or oedema of cervical spinal cord] 5
NA31 [Certain specified injuries of cervical spinal cord] 3
NA3Z [Injury of cervical spinal cord, unspecified] 3
NA40 [Injury of nerve root of cervical spine] 6
NA41 [Injury of brachial plexus] 6
NA42 [Injury of peripheral nerves of neck] 6
NA43 [Injury of cervical sympathetic nerves] 6
NA44 [Injury of phrenic nerve] 5
NA4Y [Injury of other specified nerves at neck level] 5
NA4Z [Injury of nerves at neck level, unspecified] 5
NA60 [Injury of blood vessels at neck level]
NA60.0 [Injury of carotid artery] 1
NA60.1 [Injury of vertebral artery] 2
NA60.2 [Injury of external jugular vein] 3
NA60.3 [Injury of internal jugular vein] 3
NA60.4 [Injury of multiple blood vessels at neck level] 1
NA60.Y [Injury of other specified blood vessels at neck level] 1
NA60.Z [Injury of blood vessels at neck level, unspecified] 1
NA61 [Injury of muscle, fascia or tendon at neck level] 6
NA62 [Crushing injury of neck] 3
NA63 [Traumatic amputation at neck level] 1
NA64 [Multiple injuries of neck] 3
NA6Y [Other specified injuries to the neck] 4
NA6Z [Injuries to the neck, unspecified] 5
NA80 [Superficial injury of thorax] 6
NA81 [Open wound of thorax] 5
NA82 [Fracture of rib, sternum or thoracic spine]
NA82.0 [Fracture of thoracic vertebra] 5
NA82.1 [Multiple fractures of thoracic spine] 5
NA82.2 [Fracture of sternum] 6

362 ICD-11 MMS

 Code Title Rank
NA82.3 [Fracture of rib] 6
NA82.4 [Multiple fractures of ribs] 5
NA82.5 [Flail chest] 2
NA82.Y [Other specified fracture of rib, sternum or thoracic spine] 5
NA82.Z [Fracture of rib, sternum or thoracic spine, unspecified] 5
NA83 [Dislocation or strain or sprain of joints or ligaments of thorax]
NA83.0 [Traumatic rupture of thoracic intervertebral disc] 6
NA83.1 [Dislocation of thoracic vertebra] 5
NA83.2 [Dislocation of other or unspecified parts of thorax] 5
NA83.3 [Strain or sprain of ligaments of thoracic spine] 6
NA83.4 [Strain or sprain of ribs or sternum] 6
NA83.Y [Other specified dislocation or strain or sprain of joints or 6
ligaments of thorax]
NA83.Z [Dislocation or strain or sprain of joints or ligaments of thorax, 6
unspecified]
NA90 [Concussion or oedema of thoracic spinal cord] 4
NA91 [Certain specified injuries of thoracic spinal cord] 4
NA9Z [Injury of thoracic spinal cord, unspecified] 5
NB00 [Injury of nerve root of thoracic spine] 5
NB01 [Injury of peripheral nerves of thorax] 5
NB02 [Injury of thoracic sympathetic nerves] 5
NB0Y [Injury of other specified nerves at thorax level] 5
NB2Y [Other specified injury of nerves or spinal cord at thorax level] 5
NB2Z [Injury of nerves or spinal cord at thorax level, unspecified] 5
NB30 [Injury of blood vessels of thorax]
NB30.0 [Injury of thoracic aorta] 1
NB30.1 [Injury of innominate or subclavian artery] 5
NB30.2 [Injury of superior vena cava] 1
NB30.3 [Injury of innominate or subclavian vein] 3
NB30.4 [Injury of pulmonary blood vessels] 1
NB30.5 [Injury of intercostal blood vessels] 4
NB30.6 [Injury of multiple blood vessels of thorax] 3
NB30.Y [Injury of other specified blood vessels of thorax] 4
NB30.Z [Injury of unspecified blood vessels of thorax] 4
NB31 [Injury of heart] 2
NB32 [Injury of other or unspecified intrathoracic organs]
NB32.0 [Traumatic pneumothorax] 3

ICD-11 Reference Guide 363

Code Title Rank
NB32.1 [Traumatic haemothorax] 3
NB32.2 [Traumatic haemopneumothorax] 3
NB32.3 [Certain injuries of lung] 2
NB32.4 [Injury of bronchus] 2
NB32.5 [Injury of thoracic trachea] 2
NB32.6 [Injury of pleura] 4
NB32.7 [Multiple injuries of intrathoracic organs] 1
NB32.Y [Other specified injury of other or unspecified intrathoracic 2
organs]
NB32.Z [Unspecified injury of unspecified intrathoracic organs] 2
NB33 [Crushing injury of thorax or traumatic amputation of part of 3
thorax]
NB34 [Injury of muscle, fascia or tendon at thorax level] 6
NB35 [Multiple injuries of thorax] 3
NB3Y [Other specified injuries to the thorax] 6
NB3Z [Injuries to the thorax, unspecified] 3
NB50 [Superficial injury of abdomen, lower back or pelvis] 6
NB51 [Open wound of abdomen, lower back or pelvis] 6
NB52 [Fracture of lumbar spine or pelvis]
NB52.0 [Fracture of lumbar vertebra] 6
NB52.10 [Fracture of sacrum without disruption of pelvic ring] 6
NB52.11 [Fracture of coccyx] 6
NB52.12 [Fracture of ilium without disruption of pelvic ring] 6
NB52.13 [Fracture of acetabulum without disruption of pelvic ring] 5
NB52.14 [Fracture of pubis without disruption of pelvic ring] 6
NB52.15 [Fracture of ischium without disruption of pelvic ring] 5
NB52.1Y [Fracture of other specified pelvic bone without disruption of 5
posterior arch of pelvic ring]
NB52.1Z [Fracture of unspecified pelvic bone without disruption of 5
posterior arch of pelvic ring]
NB52.2 [Fracture of the pelvic ring with incomplete disruption of 5
posterior arch]
NB52.3 [Fracture of pelvic ring with complete disruption of posterior 5
arch]
NB52.4 [Multiple fractures of lumbar spine or pelvis] 5
NB52.Y [Other specified fracture of lumbar spine or pelvis] 5
NB52.Z [Fracture of lumbar spine or pelvis, unspecified] 5

364 ICD-11 MMS

 Code Title Rank
NB53 [Dislocation or strain or sprain of joints or ligaments of lumbar
spine or pelvis]
NB53.0 [Traumatic rupture of lumbar intervertebral disc] 6
NB53.1 [Dislocation of lumbar vertebra] 6
NB53.2 [Dislocation of sacroiliac or sacrococcygeal joint without 6
disruption of pelvic ring]
NB53.3 [Dislocation of other or unspecified parts of lumbar spine or 5
pelvis without disruption of pelvic ring]
NB53.4 [Traumatic rupture of symphysis pubis without disruption of 6
pelvic ring]
NB53.5 [Strain or sprain of lumbar spine] 6
NB53.6 [Strain or sprain of sacroiliac joint] 6
NB52.Y [Other specified fracture of lumbar spine or pelvis] 6
NB52.Z [Fracture of lumbar spine or pelvis, unspecified] 5
NB60 [Concussion or oedema of lumbar spinal cord] 6
NB61 [Concussion or oedema of sacral spinal cord] 6
NB62 [Certain specified injuries of lumbar spinal cord] 6
NB63 [Certain specified injuries of sacral spinal cord] 6
NB6Z [Injury of spinal cord at abdomen, lower back or pelvis level, 6
unspecified]
NB70 [Injury of nerve root of lumbar spine] 6
NB71 [Injury of nerve root of sacral spine] 6
NB72 [Injury of cauda equina] 6
NB73 [Injury of lumbosacral plexus] 6
NB74 [Injury of lumbar, sacral or pelvic sympathetic nerves] 6
NB75 [Injury of peripheral nerve of abdomen, lower back or pelvis] 6
NB7Y [Other specified injury of nerves at abdomen, lower back or 5
pelvis level]
NB7Z [Injury of nerves at abdomen, lower back or pelvis level, 5
unspecified]
NB90 [Injury of blood vessels at abdomen, lower back or pelvis
level]
NB90.0 [Injury of abdominal aorta] 1
NB90.1 [Injury of inferior vena cava] 1
NB90.2 [Injury of coeliac artery] 3
NB90.3 [Injury of mesenteric artery]
NB90.4 [Injury of portal or splenic vein] 2
NB90.5 [Injury of renal blood vessels] 5

ICD-11 Reference Guide 365

Code Title Rank
NB90.6 [Injury of iliac blood vessels] 3
NB90.7 [Injury of multiple blood vessels at abdomen, lower back or 2
pelvis level]
NB90.Y [Injury of other specified blood vessels at abdomen, lower back 5
or pelvis level]
NB90.Z [Injury of unspecified blood vessel at abdomen, lower back or 5
pelvis level]
NB91 [Injury of intra-abdominal organs] 3
NB92 [Injury of urinary or pelvic organs] 5
NB93 [Crushing injury or traumatic amputation of part of abdomen,
lower back or pelvis]
NB93.0 [Crushing injury of external genital organs] 6
NB93.1 [Crushing injury of other or unspecified parts of abdomen, lower 5
back or pelvis]
NB93.2 [Traumatic amputation of external genital organs] 4
NB93.3 [Traumatic amputation of other or unspecified parts of 3
abdomen, lower back or pelvis]
NB94 [Injury of muscle, fascia or tendon of abdomen, lower back or 6
pelvis]
NB95 [Injury of intra-abdominal organ with pelvic organ] 3
NB96 [Other multiple injuries of abdomen, lower back or pelvis] 4
NB97 [Certain specified injuries of abdomen, lower back or pelvis] 6
NB98 [Injury to female genital organ without specification of injury 5
type]
NB99 [Injury to male genital organ without specification of injury type] 5
NB9Y [Other specified injuries to the abdomen, lower back, lumbar 4
spine or pelvis]
NB9Z [Injuries to the abdomen, lower back, lumbar spine or pelvis, 4
unspecified]
NC10 [Superficial injury of shoulder or upper arm] 6
NC11 [Open wound of shoulder or upper arm]
NC11.0 [Laceration without foreign body of shoulder or upper arm] 6
NC11.1 [Laceration with foreign body of shoulder or upper arm] 6
NC11.2 [Puncture wound without foreign body of shoulder or upper 6
arm]
NC11.3 [Puncture wound with foreign body of shoulder or upper arm] 6
NC11.4 [Open bite of shoulder or upper arm] 6
NC11.5 [Multiple open wounds of shoulder or upper arm] 6
NC11.Y [Other specified open wound of shoulder or upper arm] 5

366 ICD-11 MMS

 Code Title Rank
NC11.Z [Open wound of shoulder or upper arm, unspecified] 5
NC12 [Fracture of shoulder or upper arm]
NC12.0 [Fracture of clavicle] 6
NC12.1 [Fracture of scapula] 5
NC12.2 [Fracture of upper end of humerus] 5
NC12.3 [Fracture of shaft of humerus] 5
NC12.4 [Fracture of lower end of humerus] 6
NC12.5 [Multiple fractures of clavicle, scapula or humerus] 5
NC12.Y [Other specified fracture of shoulder or upper arm] 5
NC12.Z [Fracture of shoulder or upper arm, unspecified] 5
NC13 [Dislocation or strain or sprain of joints or ligaments of shoulder 6
girdle]
NC14 [Injury of nerves at shoulder or upper arm level] 6
NC15 [Injury of blood vessels at shoulder or upper arm level]
NC15.0 [Injury of axillary artery] 3
NC15.1 [Injury of brachial artery] 3
NC15.2 [Injury of axillary or brachial vein] 5
NC15.3 [Injury of superficial vein at shoulder or upper arm level] 5
NC15.4 [Injury of multiple blood vessels at shoulder or upper arm level] 5
NC15.Y [Injury of other specified blood vessels at shoulder or upper arm 5
level]
NC15.Z [Injury of unspecified blood vessel at shoulder or upper arm 5
level]
NC16 [Injury of muscle, fascia, tendon or bursa at shoulder or upper 6
arm level]
NC17 [Crushing injury of shoulder or upper arm] 5
NC18 [Traumatic amputation of shoulder or upper arm] 3
NC19 [Multiple injuries of shoulder or upper arm] 5
NC1Y [Other specified injuries to the shoulder or upper arm] 6
NC1Z [Injuries to the shoulder or upper arm, unspecified] 6
NC30 [Superficial injury of forearm] 6
NC31 [Open wound of forearm] 6
NC32 [Fracture of forearm] 5
NC33 [Dislocation or strain or sprain of joints or ligaments of elbow] 6
NC34 [Injury of nerves at forearm level] 6
NC35 [Injury of blood vessels at forearm level]
NC35.0 [Injury of ulnar artery at forearm level] 6
NC35.1 [Injury of radial artery at forearm level] 5

ICD-11 Reference Guide 367

Code Title Rank
NC35.2 [Injury of vein at forearm level] 5
NC35.3 [Injury of multiple blood vessels at forearm level] 5
NC35.Y [Injury of other specified blood vessels at forearm level] 6
NC35.Z [Injury of unspecified blood vessel at forearm level] 6
NC36 [Injury of muscle, fascia, tendon or bursa at forearm level] 6
NC37 [Crushing injury of forearm] 6
NC38 [Traumatic amputation of forearm] 4
NC39 [Multiple injuries of forearm] 4
NC3Y [Other specified injuries to the elbow or forearm] 6
NC3Z [Injuries to the elbow or forearm, unspecified] 5
NC50 [Injury to fingernail] 5
NC51 [Superficial injury of wrist or hand] 6
NC52 [Open wound of wrist or hand] 6
NC53 [Fracture at wrist or hand level]
NC53.0 [Fracture of scaphoid bone of hand] 6
NC53.1 [Fracture of other carpal bone] 6
NC53.2 [Fracture of first metacarpal bone] 6
NC53.3 [Fracture of other metacarpal bone] 6
NC53.4 [Multiple fractures of metacarpal bones] 6
NC53.5 [Fracture of thumb bone] 6
NC53.6 [Fracture of other finger bone] 6
NC53.7 [Multiple fractures of fingers] 6
NC53.Y [Fracture at other specified part of wrist or hand level] 5
NC53.Z [Fracture at wrist or hand level, unspecified] 5
NC54 [Dislocation or strain or sprain of joints or ligaments at wrist or 6
hand level]
NC55 [Injury of nerves at wrist or hand level] 6
NC56 [Injury of blood vessels at wrist or hand level]
NC56.0 [Injury of ulnar artery at wrist or hand level] 6
NC56.1 [Injury of radial artery at wrist or hand level] 5
NC56.2 [Injury of superficial palmar arch] 6
NC56.3 [Injury of deep palmar arch] 6
NC56.4 [Injury of blood vessel of thumb] 6
NC56.5 [Injury of blood vessel of other finger] 6
NC56.6 [Injury of multiple blood vessels at wrist or hand level] 6
NC56.Y [Injury of other specified blood vessels at wrist or hand level] 5
NC56.Z [Injury of unspecified blood vessel at wrist or hand level] 5

368 ICD-11 MMS

 Code Title Rank
NC57 [Injury of muscle, fascia or tendon at wrist or hand level] 6
NC58 [Crushing injury of wrist or hand] 6
NC59 [Traumatic amputation of wrist or hand]
NC59.0 [Traumatic amputation of thumb] 6
NC59.1 [Traumatic amputation of other single finger] 6
NC59.2 [Traumatic amputation of two or more fingers alone] 6
NC59.3 [Combined traumatic amputation of finger with other parts of 6
wrist or hand]
NC59.4 [Traumatic amputation of hand at metacarpal level] 6
NC59.Z [Traumatic amputation of wrist or hand, unspecified] 4
NC5A [Multiple injuries of wrist or hand] 5
NC5Y [Other specified injuries to the wrist or hand] 5
NC5Z [Injuries to the wrist or hand, unspecified] 5
NC70 [Superficial injury of hip or thigh] 6
NC71 [Open wound of hip or thigh] 6
NC72 [Fracture of femur]
NC72.0 [Fracture of head of femur] 3
NC72.1 [Fracture of upper epiphysis of femur] 3
NC72.2 [Fracture of neck of femur] 3
NC72.3 [Fracture of trochanteric section of femur] 3
NC72.4 [Subtrochanteric fracture of femur] 3
NC72.5 [Fracture of shaft of femur] 4
NC72.6 [Fracture of lower end of femur] 4
NC72.7 [Multiple fractures of femur] 4
NC72.8 [Fractures of other parts of femur] 4
NC72.Y [Other specified fracture of femur] 4
NC72.Z [Fracture of femur, unspecified] 4
NC73 [Dislocation or strain or sprain of joint or ligaments of hip] 6
NC74 [Injury of nerves at hip or thigh level]
NC74.0 [Injury of sciatic nerve at hip or thigh level] 6
NC74.1 [Injury of femoral nerve at hip or thigh level] 6
NC74.2 [Injury of cutaneous sensory nerve at hip or thigh level] 5
NC74.3 [Injury of multiple nerves at hip or thigh level] 5
NC74.Y [Injury of other specified nerves at hip or thigh level] 6
NC74.Z [Injury of unspecified nerve at hip or thigh level] 6
NC75 [Injury of blood vessels at hip or thigh level]
NC75.0 [Injury of femoral artery] 4

ICD-11 Reference Guide 369

Code Title Rank
NC75.1 [Injury of femoral vein at hip or thigh level] 5
NC75.2 [Injury of greater saphenous vein at hip or thigh level] 6
NC75.3 [Injury of multiple blood vessels at hip or thigh level] 5
NC75.Y [Injury of other specified blood vessels at hip or thigh level] 6
NC75.Z [Injury of unspecified blood vessel at hip or thigh level] 6
NC76 [Injury of muscle, fascia, tendon or bursa at hip or thigh level] 6
NC77 [Crushing injury of hip or thigh] 5
NC78 [Traumatic amputation of hip or thigh] 3
NC79 [Multiple injuries of hip or thigh] 5
NC7Y [Other specified injuries to the hip or thigh] 5
NC7Z [Injuries to the hip or thigh, unspecified] 5
NC90 [Superficial injury of knee or lower leg] 6
NC91 [Open wound of knee or lower leg] 6
NC92 [Fracture of lower leg, including ankle] 5
NC93 [Dislocation or strain or sprain of joints or ligaments of knee] 6
NC94 [Injury of nerves at lower leg level] 6
NC95 [Injury of blood vessels at lower leg level]
NC95.0 [Injury of popliteal artery] 5
NC95.1 [Injury of anterior tibial artery] 6
NC95.2 [Injury of posterior tibial artery] 6
NC95.3 [Injury of peroneal artery] 6
NC95.4 [Injury of greater saphenous vein at lower leg level] 5
NC95.5 [Injury of lesser saphenous vein at lower leg level] 6
NC95.6 [Injury of popliteal vein] 6
NC95.7 [Injury of multiple blood vessels at lower leg level] 5
NC95.Y [Injury of other specified blood vessels at lower leg level] 6
NC95.Z [Injury of unspecified blood vessel at lower leg level] 5
NC96 [Injury of muscle, fascia, tendon or bursa at lower leg level]
NC96.0 [Injury of Achilles tendon] 6
NC96.1 [Injury of other muscle, fascia or tendon of posterior muscle 6
group at lower leg level]
NC96.2 [Injury of muscle, fascia or tendon of anterior muscle group at 6
lower leg level]
NC96.3 [Injury of muscle, fascia or tendon of peroneal muscle group at 6
lower leg level]
NC96.4 [Injury of multiple muscles, fasciae or tendons at lower leg level] 6
NC96.5 [Injury of bursa of knee] 5

370 ICD-11 MMS

 Code Title Rank
NC96.Y [Injury of other specified muscle, fascia, tendon or bursa at 5
lower leg level]
NC96.Z [Injury of unspecified muscle, fascia, tendon or bursa at lower 6
leg level]
NC97 [Crushing injury of lower leg]
NC97.0 [Crushing injury of knee] 6
NC97.Y [Crushing injury of other specified part of lower leg] 5
NC97.Z [Crushing injury of lower leg, unspecified] 5
NC98 [Traumatic amputation of lower leg]
NC98.0 [Traumatic amputation of right lower leg at knee level] 3
NC98.1 [Traumatic amputation of left lower leg at knee level] 3
NC98.2 [Traumatic amputation at knee level, bilateral] 3
NC98.3 [Traumatic amputation at level between right knee and ankle] 3
NC98.4 [Traumatic amputation at level between left knee and ankle] 3
NC98.5 [Traumatic amputation at level between knee and ankle, 3
bilateral]
NC98.Y [Other specified traumatic amputation of lower leg] 4
NC98.Z [Traumatic amputation of lower leg, unspecified] 4
NC99 [Multiple injuries of lower leg] 5
NC9Y [Other specified injuries to the knee or lower leg] 5
NC9Z [Injuries to the knee or lower leg, unspecified] 5
ND10 [Injury to toenail] 6
ND11 [Superficial injury of ankle or foot] 6
ND12 [Open wound of ankle or foot] 6
ND13 [Fracture of foot, except ankle] 6
ND14 [Dislocation or strain or sprain of joints or ligaments at ankle or 6
foot level]
ND15 [Injury of nerves at ankle or foot level] 6
ND16 [Injury of blood vessels at ankle or foot level]
ND16.0 [Injury of dorsal artery of foot] 6
ND16.1 [Injury of plantar artery of foot] 5
ND16.2 [Injury of dorsal vein of foot] 6
ND16.3 [Injury of multiple blood vessels at ankle or foot level] 6
ND16.Y [Injury of other specified blood vessels at ankle or foot level] 6
ND16.Z [Injury of unspecified blood vessel at ankle or foot level] 6
ND17 [Injury of muscle, fascia or tendon at ankle or foot level] 6
ND18 [Crushing injury of ankle or foot]
ND18.0 [Crushing injury of ankle] 6

ICD-11 Reference Guide 371

Code Title Rank
ND18.1 [Crushing injury of toe] 5
ND18.2 [Crushing injury of other parts of ankle or foot] 6
ND18.Z [Crushing injury of ankle or foot, unspecified] 6
ND19 [Traumatic amputation of ankle or foot]
ND19.0 [Traumatic amputation of right foot at ankle level] 4
ND19.1 [Traumatic amputation of left foot at ankle level] 4
ND19.2 [Traumatic amputation of foot at ankle level, bilateral] 4
ND19.3 [Traumatic amputation of right foot at metatarsal level] 6
ND19.4 [Traumatic amputation of left foot at metatarsal level] 6
ND19.5 [Traumatic amputation of foot at metatarsal level, bilateral] 6
ND19.6 [Traumatic amputation of one toe] 6
ND19.7 [Traumatic amputation of two or more toes] 6
ND19.8 [Traumatic amputation of other parts of foot] 6
ND19.Z [Traumatic amputation of ankle or foot, unspecified] 6
ND1A [Multiple injuries of ankle or foot] 5
ND1Y [Other specified injuries to the ankle or foot] 5
ND1Z [Injuries to the ankle or foot, unspecified] 5
ND30 [Superficial injuries involving multiple body regions] 6
ND31 [Open wounds involving multiple body regions] 5
ND32 [Fractures involving multiple body regions] 3
ND33 [Dislocations, strains or sprains involving multiple body 5
regions]
ND34 [Crushing injuries involving multiple body regions] 5
ND35 [Traumatic amputations involving multiple body regions] 5
ND36 [Other injuries involving multiple body regions, not elsewhere 3
classified]
ND37 [Unspecified multiple injuries] 2
ND50 [Fracture of spine, level unspecified] 5
ND51 [Other injuries of spine or trunk, level unspecified]
ND51.0 [Dislocation or strain or sprain of unspecified joint or ligament of 6
trunk]
ND51.1 [Injury of unspecified nerve, spinal nerve root or plexus of 4
trunk]
ND51.2 [Injury of spinal cord, level unspecified] 3
ND51.3 [Injury of unspecified muscle, fascia or tendon of trunk] 6
ND51.4 [Crushing injury of spine or trunk, level unspecified] 5
ND51.Y [Other specified injuries of spine or trunk, level unspecified] 5
ND51.Z [Unspecified injuries of spine or trunk, level unspecified] 5

372 ICD-11 MMS

 Code Title Rank
ND52 [Fracture of arm, level unspecified] 5
ND53 [Other injuries of arm, level unspecified] 6
ND54 [Fracture of leg, level unspecified] 5
ND55 [Other injuries of leg, level unspecified] 6
ND56 [Injury of unspecified body region]
ND56.0 [Superficial injury of unspecified body region] 6
ND56.1 [Open wound of unspecified body region] 5
ND56.2 [Fracture of unspecified body region] 5
ND56.3 [Dislocation or strain or sprain of unspecified body region] 6
ND56.4 [Injury of nerve of unspecified body region] 6
ND56.5 [Injury of blood vessel of unspecified body region] 5
ND56.6 [Injury of muscles or tendons of unspecified body region] 6
ND56.7 [Crushing injury of unspecified body region] 2
ND56.8 [Traumatic amputation of unspecified body region] 2
ND56.9 [Injury complicating pregnancy] 6
ND56.Y [Other specified injury of unspecified body region] 6
ND56.Z [Unspecified injury to unspecified part of trunk, limb or body 6
region]
ND57 [Secondary effect of trauma] 6
ND5Y [Other specified injuries to unspecified part of trunk, limb or 6
body region]
ND5Z [Injuries to unspecified part of trunk, limb or body region, 6
unspecified]
ND70 [Foreign body on external eye]
ND70.0 [Foreign body in cornea] 6
ND70.1 [Foreign body in conjunctival sac] 6
ND70.2 [Foreign body in multiple parts of external eye] 6
ND70.Y [Foreign body in other specified part of external eye] 6
ND70.Z [Foreign body on external eye, unspecified] 5
ND71 [Foreign body in ear] 6
ND72 [Foreign body in respiratory tract] 5
ND73 [Foreign body in alimentary tract]
ND73.0 [Foreign body in mouth] 6
ND73.1 [Foreign body in oesophagus] 6
ND73.2 [Foreign body in stomach] 6
ND73.3 [Foreign body in small intestine] 5
ND73.4 [Foreign body in colon] 5

ICD-11 Reference Guide 373

Code Title Rank
ND73.5 [Foreign body in anus or rectum] 6
ND73.Y [Foreign body in other specified part of alimentary tract] 6
ND73.Z [Foreign body in alimentary tract, unspecified] 6
ND74 [Foreign body in genitourinary tract]
ND74.0 [Foreign body in urethra] 6
ND74.1 [Foreign body in bladder] 6
ND74.2 [Foreign body in vulva or vagina] 5
ND74.3 [Foreign body in uterus, any part] 6
ND74.Y [Foreign body in other specified part of genitourinary tract] 6
ND74.Z [Foreign body in genitourinary tract, unspecified] 5
ND7Z [Effects of foreign body entering through natural orifice, 6
unspecified]
ND90 [Burn of head or neck except face]
ND90.0 [Burn of head or neck except face, epidermal burn] 6
ND90.1 [Burn of head or neck except face, superficial partial thickness 6
burn]
ND90.2 [Burn of head or neck except face, deep partial thickness burn] 6
ND90.3 [Burn of head or neck except face, full thickness burn] 3
ND90.4 [Burn of head or neck except face, deep full thickness or 3
complex burn]
ND90.Z [Burn of head or neck except face, depth of burn unspecified] 6
ND91 [Burn of face except eye or ocular adnexa]
ND91.0 [Burn of face except eye or ocular adnexa, epidermal burn] 6
ND91.1 [Burn of face except eye or ocular adnexa, superficial partial 6
thickness burn]
ND91.2 [Burn of face except eye or ocular adnexa, deep partial thickness 6
burn]
ND91.3 [Burn of face except eye or ocular adnexa, full thickness burn] 3
ND91.4 [Burn of face except eye or ocular adnexa, deep full thickness or 3
complex burn]
ND91.Z [Burn of face except eye, depth of burn unspecified] 6
ND92 [Burn of trunk except perineum or genitalia]
ND92.0 [Burn of trunk except perineum or genitalia, epidermal burn] 6
ND92.1 [Burn of trunk except perineum or genitalia, superficial partial 6
thickness burn]
ND92.2 [Burn of trunk except perineum or genitalia, deep partial 6
thickness burn]
ND92.3 [Burn of trunk except perineum or genitalia, full thickness burn] 3

374 ICD-11 MMS

 Code Title Rank
ND92.4 [Burn of trunk except perineum or genitalia, deep full thickness 3
or complex burn]
ND92.Z [Burn of trunk except perineum or genitalia, depth of burn 6
unspecified]
ND93 [Burn of perineum or genitalia]
ND93.0 [Burn of perineum or genitalia, epidermal burn] 6
ND93.1 [Burn of perineum or genitalia, superficial partial thickness burn] 6
ND93.2 [Burn of perineum or genitalia, deep partial thickness burn] 6
ND93.3 [Burn of perineum or genitalia, full thickness burn] 3
ND93.4 [Burn of perineum or genitalia, deep full thickness or complex 3
burn]
ND93.Z [Burn of perineum or genitalia, depth of burn unspecified] 6
ND94 [Burn of shoulder or arm, except wrist or hand]
ND94.0 [Burn of shoulder or arm, except wrist or hand, epidermal burn] 6
ND94.1 [Burn of shoulder or arm, except wrist or hand, superficial 6
partial thickness burn]
ND94.2 [Burn of shoulder or arm, except wrist or hand, deep partial 6
thickness burn]
ND94.3 [Burn of shoulder or arm, except wrist or hand, full thickness 5
burn]
ND94.4 [Burn of shoulder or arm, except wrist or hand, deep full 5
thickness or complex burn]
ND94.Z [Burn of shoulder or arm except wrist or hand, depth of burn 6
unspecified]
ND95 [Burn of wrist or hand]
ND95.0 [Burn of wrist or hand, epidermal burn] 6
ND95.1 [Burn of wrist or hand, superficial partial thickness burn] 6
ND95.2 [Burn of wrist or hand, deep partial thickness burn] 6
ND95.3 [Burn of wrist or hand, full thickness burn] 5
ND95.4 [Burn of wrist or hand, deep full thickness or complex burn] 5
ND95.Z [Burn of wrist or hand, depth of burn unspecified] 6
ND96 [Burn of hip or leg, except ankle or foot]
ND96.0 [Burn of hip or leg, except ankle or foot, epidermal burn] 6
ND96.1 [Burn of hip or leg, except ankle or foot, superficial partial 6
thickness burn]
ND96.2 [Burn of hip or leg, except ankle or foot, deep partial thickness 6
burn]
ND96.3 [Burn of hip or leg, except ankle or foot, full thickness burn] 5

ICD-11 Reference Guide 375

Code Title Rank
ND96.4 [Burn of hip or leg, except ankle or foot, deep full thickness or 5
complex burn]
ND96.Z [Burn of hip or leg except ankle or foot, depth of burn 6
unspecified]
ND97 [Burn of ankle or foot]
ND97.0 [Burn of ankle or foot, epidermal burn] 6
ND97.1 [Burn of ankle or foot, superficial partial thickness burn] 6
ND97.2 [Burn of ankle or foot, deep partial thickness burn] 6
ND97.3 [Burn of ankle or foot, full thickness burn] 5
ND97.4 [Burn of ankle or foot, deep full thickness or complex burn] 5
ND97.Z [Burn of ankle or foot, depth of burn unspecified] 6
ND99.1 [Chemical burn due to skin contact with corrosive substance] 6
ND99 [Acute skin injury due to skin contact with corrosive substance] 6
ND9Y [Burns of external body surface, other specified site] 6
ND9Z [Burns of external body surface, unspecified site] 6
NE00 [Burn of eye or ocular adnexa] 6
NE01 [Burn of respiratory tract] 3
NE02 [Burn of other internal organs] 3
NE0Z [Burns of unspecified internal organ] 6
NE10 [Burns of multiple body regions] 6
NE11 [Burn of unspecified body region] 6
NE2Z [Burns, unspecified] 3
NE40 [Superficial frostbite] 6
NE41 [Frostbite with tissue necrosis] 6
NE42 [Frostbite involving multiple body regions] 6
NE4Z [Frostbite, unspecified] 5
NF00 [Effects of radiation, not elsewhere classified] 6
NF01 [Effects of heat]
NF01.0 [Heat stroke] 3
NF01.1 [Heat syncope] 6
NF01.2 [Heat exhaustion due to fluid depletion] 6
NF01.3 [Heat fatigue, transient] 6
NF01.Y [Other specified effects of heat] 6
NF01.Z [Effects of heat, unspecified] 5
NF02 [Hypothermia] 3
NF03 [Other effects of reduced temperature]
NF03.0 [Chilblains] 5

376 ICD-11 MMS

 Code Title Rank
NF03.1 [Immersion hand or foot] 6
NF03.Y [Other specified effects of reduced temperature] 4
NF03.Z [Unspecified effects of reduced temperature] 4
NF04 [Effects of air pressure or water pressure]
NF04.0 [Otitic barotrauma] 5
NF04.1 [Sinus barotrauma] 4
NF04.2 [Caisson disease] 5
NF04.3 [Effects of high-pressure fluids] 6
NF04.Y [Other specified effects of air pressure or water pressure] 6
NF04.Z [Effects of air pressure or water pressure, unspecified] 5
NF05 [Asphyxiation] 1
NF06 [Effects of strenuous physical exercise]
NF06.0 [Exertional heat stroke] 3
NF06.1 [Post exercise postural hypotension] 6
NF06.2 [Post exertional dehydration] 6
NF06.3 [Exercise muscle cramp] 6
NF06.Y [Other specified effects of strenuous physical exercise] 6
NF06.Z [Effects of strenuous physical exercise, unspecified] 6
NF07 [Effects of other deprivation]
NF07.0 [Effects of hunger] 3
NF07.1 [Effects of thirst] 5
NF07.2 [Exhaustion due to exposure] 6
NF07.Y [Other specified effects of deprivation] 6
NF07.Z [Effects of other deprivation, unspecified] 6
NF08 [Effects of certain specified external causes]
NF08.0 [Effects of lightning] 4
NF08.1 [Drowning or nonfatal submersion] 2
NF08.2 [Effects of vibration] 6
NF08.3 [Motion sickness] 6
NF08.4 [Effects of electric current] 3
NF0Y [Other specified effects of external causes] 6
NF0Z [Unspecified effects of external causes] 6
NF2Y [Other specified injury, poisoning or certain other consequences 6
of external causes]
NF2Z [Unspecified injury, poisoning or certain other consequences of 6
external causes]
3.14.6 List of ill-defined conditions

ICD-11 Reference Guide 377

Use this table in Step SP7. Conditions in this table are considered ill-defined and are not for
use as underlying cause of death.

Code or Category title

Chapter
BD10-BD1Z Heart failure in BD10- specified as acute (XT5R)
BA2Z Hypotension, unspecified
BE2Y Other specified diseases of the circulatory system
BE2Z Diseases of the circulatory system, unspecified
CB41.0 Acute respiratory failure
CB41.2 Respiratory failure, unspecified as acute or chronic
KB2D Respiratory failure of newborn
KB2E Respiratory arrest of newborn
Chapter 21 Symptoms, signs or clinical findings, not elsewhere classified; except
conditions listed below:
MA15 Microbiological findings in blood, blood-forming organs, or the
immune system
MG43 Symptoms or signs concerning food or fluid intake
MG44.1 Lack of expected normal physiological development
MH11 Sudden infant death syndrome
MH15 Sudden unexpected death in epilepsy
3.14.7 List of conditions that can cause HIV disease

This list to be used to support the Special instructions on accepted and rejected sequences
Steps SP3-SP4 to assess the sequence for deaths where HIV is reported on the death
certificate. Note that this list is not complete and should be considered indicative. Accept
HIV due to:

378 ICD-11 MMS

 Code Category
Malignant neoplasms
2B50-2E2Z Malignant neoplasms, except primary neoplasms of
lymphoid, haematopoietic, central nervous system or related
tissues
Certain anaemias or
other erythrocyte
disorders
3A00-3A03 Nutritional or metabolic anaemias
3A10-3A4Z Haemolytic anaemias
3A60-3A6Z Pure red cell aplasia
3A50 Thalassaemias
3A51 Sickle cell disorders or other haemoglobinopathies
3A70 Aplastic anaemia
3A71 Anaemia due to chronic disease
3A72 Sideroblastic anaemia
3A73 Congenital dyserythropoietic anaemia
3A90 Anaemia due to acute disease
3A9Y Other specified anaemias and erythrocyte disorders
3A9Z Anaemias or other erythrocyte disorders, unspecified
3B10-3B6Z Coagulation defects, purpura or other haemorrhagic or
related conditions

ICD-11 Reference Guide 379

Certain disorders due to substance use or addictive
behaviours
6C43 Disorders due to use of opioids
6C44 Disorders due to use of
sedatives, hypnotics or
anxiolytics
6C45 Disorders due to use of cocaine
6C46 Disorders due to use of
stimulants including
amphetamines,
methamphetamine or
methcathinone
6C48 Disorders due to use of caffeine
6C49 Disorders due to use of
hallucinogens
6C4C Disorders due to use of MDMA
or related drugs, including MDA
6C4D Disorders due to use of
dissociative drugs including
ketamine and phencyclidine
[PCP]
6C4E Disorders due to use of other
specified psychoactive
substances, including
medications
6C4F Disorders due to use of multiple
specified psychoactive
substances, including
medications
6C4G Disorders due to use of
unknown or unspecified
psychoactive substances
6C4Y Other specified disorders due to
substance use
6C4Z Disorders due to substance use,
unspecified
Laboratory evidence of HIV
MA14.0 Laboratory evidence of human
immunodeficiency virus
Certain
injuries

380 ICD-11 MMS

 Certain disorders due to substance use or addictive
behaviours
Head Neck Thor Abdom Upper Forear Wri Hip Lower Ank
ax en arm m st leg le
Han Foo
d t
Open NA01 NA21 NA8 NB51 NC11 NC31 NC71 NC91
wound 1
Fracture NA02 NA22 NA8 NB52 NC12 NC32 NC72 NC92
2
Injury of NA05 NA60 NB90 NC15 NC35 NC5 NC75 NC95 ND
blood 6 16
vessels
Injury of NB91
organs NB92
Crushing NA08 NA62 NB33 NB93 NC17 NC37 NC5 NC77 NC97 ND
injury 8 18
Traumat NA09 NA63 NC18 NC38 NC59 NC78 NC9 ND19
ic 8
amputat
ion
Lacerati NA0A. NA61 NB34 NB94.3 NC16. NC36. NC76. NC96.
on of 11 .1 .1 NB94.4 01 01 01 01
muscle, NB94.5 NC16. NC36. NC76. NC96.
fascia or 11 11 11 11
tendon NC16. NC36. NC76. NC96.
21 21 21 21
NC16. NC36. NC76. NC96.
31 31 31 31
NC16. NC36.
41 41
NC36.
51
Multiple NA0A. NA64 NB35 NB95 NC19 NC39 NC5 NC79 NC99 ND
injuries 3 NB96 A 1A
Other or NA0A. NA6Y NB3Y NB97 NC1Y NC3Y NC5 NC7Y NC9Y ND
certain 0 NB98 Y 1Y
specifie NA0A. NB99
d Y NB9Y
injuries
Injuries, NA0Z NA6Z NB3Z NB9Z NC1Z NC3Z NC5 NC7Z NC9Z ND
unspecif Z 1Z
ied

ICD-11 Reference Guide 381

 Multiple Unspecified part Arm Leg Unspecified body
body of trunk, limb etc. region
injuries
Superficial ND53.Y ND55
injury
Open wound ND31 ND51.Y ND53.Y ND55 ND56.1
Fracture ND32 ND50 (Spine) ND52 ND54 ND56.2
Dislocations, ND33 ND53.Y ND55
strains or
sprains
Crushing injury ND34 ND55 ND56.7
Traumatic ND35 ND51.Y ND53.Y ND55 ND56.8
amputation
Other specified ND36 ND51.Y ND53.Y ND55 ND56.5 (Blood
injuries vessel) ND56.Y
Injuries, ND37 ND51.Z ND53.Z ND55 ND56.Z
unspecified
Certain injuries (continued)
ND70-ND7Z Effects of foreign body entering through natural
orifice
ND90-NE2Z Burns
NE80 Injury or harm arising following infusion,
transfusion or therapeutic injection, not
elsewhere classified
Certain causes of healthcare related
harm or injury
PK80-PK8Z Surgical or other medical procedures associated
with injury or harm in diagnostic or therapeutic
use
PL11.0 Cut, puncture or tear, as mode of injury or harm
PL11.4 Failure of sterile precautions, as mode of injury
or harm
PL14.4 Other problem associated with transfusion
3.14.8 List of conditions that can cause diabetes mellitus

This list to be used to support the Special instructions on accepted and rejected sequences
Steps SP3-SP4 to assess the sequence for deaths where diabetes mellitus is reported on the
death certificate.

382 ICD-11 MMS

 5A10 Type 1 diabetes mellitus
1D82.1 Cytomegaloviral pancreatitis
5B52 Acute malnutrition in infants, children or
adolescents
5B71 Protein deficiency
5B7Z Unspecified undernutrition
5A11 Type 2 diabetes mellitus
5A70 Cushing syndrome
5B52 Acute malnutrition in infants, children or
adolescents
5B71 Protein deficiency
5B7Z Unspecified undernutrition
5A12 Malnutrition-related diabetes
mellitus
5B52 Acute malnutrition in infants, children or
adolescents
5B71 Protein deficiency
5B7Z Unspecified undernutrition
5A13 Diabetes mellitus, other specified
type or 5A14 Diabetes mellitus, type
unspecified
1D82.1 Cytomegaloviral pancreatitis
1D80.4 Pancreatitis due to mumps virus
2C10 Malignant neoplasm of pancreas
2D81 Malignant neoplasm metastasis in pancreas
2E92.8 Benign neoplasm of pancreas
2E92.9 Benign neoplasm of endocrine pancreas
4A40-4A4Z Nonorgan specific systemic autoimmune
disorders
5A02 Thyrotoxicosis
5A03 Thyroiditis
5A60.0 Acromegaly or pituitary gigantism
5A70 Cushing syndrome
5B52 Acute malnutrition in infants, children or
adolescents (for 5A14 only)
5B71 Protein deficiency (for 5A14 only)
5B7Z Unspecified undernutrition (for 5A14 only)
5C58.1 Porphyrias
5C64.1 Disorders of iron metabolism

ICD-11 Reference Guide 383

 5A10 Type 1 diabetes mellitus
5D41 Postprocedural hypoinsulinaemia
6C40.1 Harmful pattern of use of alcohol
6C40.2 Alcohol dependence
8A01.10 Huntington disease
8A03 Ataxic disorders
8A0Z Movement disorders, unspecified
8C71 Myotonic disorders
CA25 Cystic fibrosis
DC31 Acute pancreatitis
DC32 Chronic pancreatitis
DC3Z Diseases of pancreas, unspecified
JA63.2 Diabetes mellitus arising in pregnancy
KA62.8 Congenital rubella syndrome
LD20-LD2Z Multiple developmental anomalies or
syndromes
LD40.0 Complete trisomy 21
LD50.0 Turner syndrome
LD50.3 Klinefelter syndrome
LD52.1 Male with double or multiple Y
LD53 Structural anomalies of chromosome Y
LD54 Male with sex chromosome mosaicism
LD5Y Other specified sex chromosome anomalies
LD7Y Other specified chromosomal anomalies,
excluding gene mutations
NB91.4 Injury of pancreas
NE60 Harmful effects of drugs, medicaments or
biological substances, not elsewhere
classified
PL00 Drugs, medicaments or biological substances
associated with injury or harm in therapeutic
use
3.14.9 List of conditions to be considered obvious consequences of surgery and other
invasive medical procedures

The list in this section contains conditions that might develop as complications to surgery or
other invasive medical procedures. This does not mean that the conditions on the list should
always be considered as complications, and the following restrictions apply:
• Do not consider a condition on the list as a complication of a surgery or an invasive medical
procedure if the surgery or procedure was carried out more than four weeks before death.

384 ICD-11 MMS

 • Do not consider a condition on the list as a complication of a surgery or an invasive
procedure if there is evidence that the condition was present before the surgery or invasive
procedure was carried out.

• Do not consider a condition flagged with ‘OCPR’ (Other Cause of Procedure Required) as a
complication of surgery or an invasive procedure unless the certificate reports another
condition of the same site that was treated by surgery or some other invasive procedure.

• Do not consider a condition flagged with ‘DSAP’ (Duration Stated, developed After
Procedure) as a complication unless there is clear evidence that the condition developed
after the surgery or invasive procedure.

• Note that adhesions should be considered as complications of surgery or an invasive

procedure in the same site or region, even after more than four weeks since the date of the
surgery or invasive procedure. If the procedure was performed more than one year before
death, use the codes for sequelae of medical care.

ICD-11 Reference Guide 385

[Link] List of conditions to be considered direct consequences of surgery

386 ICD-11 MMS

 Infections Flag
Abscess OCPR
Bacteraemia
Fistula OCPR, and for a procedure of the same site
or region only
Gas gangrene
Infection, haemolytic
Infection NOS DSAP
Infection in surgical wound
Sepsis
Septic
Haemorrhage, haemolysis Flag
Coagulopathy, consumption
Disseminated intravascular coagulation
(DIC)
Haemorrhage NOS
Haemorrhage, gastrointestinal OCPR
Haemorrhage, intra-abdominal OCPR
Haemorrhage, rectal OCPR
Haemorrhage, surgical wound
haemorrhage, specified site For a procedure of the same site or region
only
Haematemesis OCPR
Haematoma OCPR
Haemothorax OCPR
Haemolysis
Melaena OCPR
Cardiac complications Flag
Arrest, cardiac
Arrhythmia NOS DSAP
Asystole
Block, cardiac DSAP
Failure/insufficiency, cardiac
Fibrillation, atrial DSAP
Fibrillation, ventricular
Infarction (myocardial)
Ischaemia, myocardial (acute)
Rupture, myocardial

ICD-11 Reference Guide 387

Infections Flag
Cerebrovascular and other cerebral Flag
complications
Apoplexy DSAP
Damage, brain (anoxic) DSAP
Embolism, cerebral DSAP
Haemorrhage, cerebral/intracranial DSAP
Infarction, cerebral DSAP
Ischaemia, cerebral/cerebrovascular DSAP
Lesion, cerebral/cerebrovascular DSAP
Meningitis DSAP
Oedema, cerebral DSAP
Stroke DSAP
Thrombosis, cerebral DSAP
Other vascular complications Flag
Arrest, circulatory
Embolism (arterial)
Embolism, fat/air
Embolism, air
Embolism, pulmonary
Embolism, venous
Failure/insufficiency, circulatory
Hypotension
Infarction, pulmonary
Infarction (any site)
Occlusion (any site)
Phlebitis (any site)
Phlebothrombosis (any site)
Thrombophlebitis (any site)
Thrombosis, arterial
Thrombosis, venous
Thrombosis NOS (any site)
Respiratory complications Flag
Adult respiratory distress syndrome (ARDS)
Alkalosis and acidosis, respiratory
Arrest, respiratory
Aspiration
Atelectasis

388 ICD-11 MMS

 Infections Flag
Bronchitis DSAP
Effusion, pleura
Empyema OCPR
Fistula, bronchopleural or oesophageal OCPR
Failure/insufficiency, pulmonary
Failure/insufficiency, respiratory
Mediastinitis
Obstruction, upper airway OCPR
Oedema, laryngeal OCPR
Oedema/hypostasis, pulmonary
Pneumonia
Pneumothorax OCPR
Gastrointestinal complications Flag
Abscess, intra-abdominal OCPR
Constipation OCPR
Dilatation, gastric OCPR
Disorder, circulatory, gastrointestinal OCPR
Embolism, mesenterial OCPR
Failure, hepatic DSAP
Fistula, biliary/ bowel/rectovaginal OCPR
Ileus OCPR
Ischaemia, intestinal OCPR
Necrosis, gastrointestinal OCPR
Obstruction, bowel (mechanical) OCPR
Peritonitis OCPR
Ulcer, gastrointestinal (stress) OCPR
Volvulus OCPR
Renal and urinary complications Flag
Anuria
Failure/insufficiency, renal
Fistula, urinary OCPR
Infection, urinary
Pyelonephritis DSAP
Retention, urine
Stricture, urethra OCPR
Uraemia
Urosepsis

ICD-11 Reference Guide 389

Infections Flag
Other complications Flag
Adhesions For a procedure of the same site or region
only
Compartment syndrome OCPR
Complication(s) NOS
Crisis, thyrotoxic DSAP
Displacement, prosthesis
Failure, (multi)organ
Gangrene
Insufficiency, anastomosis OCPR
Necrosis, fat/wound OCPR
Seizures (epileptic) DSAP
Shock NOS
Shock, anaphylactic
Ulcer, decubitus

[Link] List of conditions to be considered direct consequences of other invasive

medical procedures

390 ICD-11 MMS

 Obvious consequences of cardiac catheterization PK80.11
Cardiac procedure for repair of congenital anomaly associated
with injury or harm, percutaneous approach, PK80.15 Other
cardiac procedure associated with injury or harm, percutaneous
approach
Sepsis, septic shock
Bacteraemia
MRSA
Fungal sepsis
Fungaemia
Vascular catheter or port infection
Septic thrombophlebitis
Infectious endocarditis
Myocardial infarction Only if indicated as
following the
catheterization
Coronary thrombosis Only if indicated as
following the
catheterization
Coronary embolism Only if indicated as
following the
catheterization
Coronary rupture Only if indicated as
following the
catheterization
Cardiac arrest
Cardiac embolism
Cholesterol embolic syndrome
Pulmonary embolism
Haemorrhage
Blood loss
Haemoperitoneum
Cardiogenic shock Only if indicated as
following the
catheterization
Hypotensive shock Only if indicated as
following the
catheterization

ICD-11 Reference Guide 391

Obvious consequences of aspiration of fluid PK81.2 Aspiration or
drainage of body cavity or fluid collection associated with injury
or harm in therapeutic use
Haemothorax If aspiration or
puncture of the same
site
Haemorrhage If aspiration or
puncture of the same
site

Obvious consequences of biopsy PK81.4 Bone marrow aspiration

or biopsy associated with injury or harm in therapeutic use,
PK81.5 Biopsy procedure, not elsewhere classified, associated
with injury or harm in therapeutic use
Haemorrhage If of the same site
Pneumothorax If of the same site
Adhesions If of the same site

Obvious consequences of kidney dialysis PK81.6 Dialysis

associated with injury or harm in therapeutic use
Sepsis, septic shock
Bacteraemia
MRSA
Infectious endocarditis
Fungal sepsis
Fungaemia
Vascular catheter or port infection
Septic thrombophlebitis
Peritonitis
Pneumonia
Hypotension (during dialysis)
Hypovolemic shock
Haemorrhage

Obvious consequences of feeding tube, PEG PK81.8 Insertion of

tube associated with injury or harm in therapeutic use
Aspiration pneumonia
Abdominal wound infection
Abdominal wall infection

392 ICD-11 MMS

 Obvious consequences of resuscitation PK81.E Cardiopulmonary
resuscitation associated with injury or harm in therapeutic use
Rib fracture(s)

Other surgical or medical procedures PK8Y Other specified

surgical or other medical procedures associated with injury or
harm in diagnostic or therapeutic use
Obvious consequences of Intravenous line/artery catheter
Sepsis, septic shock
Bacteraemia
MRSA
Fungal sepsis
Fungaemia
Vascular catheter or port infection
Septic thrombophlebitis If infection of
catheter/port site
Infectious endocarditis If infection of
catheter/port site
Cellulitis If infection of
catheter/port site
Abscess If infection of
catheter/port site
Haematoma If infection of
catheter/port site
Haemorrhage If infection of
catheter/port site
Haemothorax If infection of
catheter/port site

Obvious consequences of bone marrow transplant

Sepsis, septic shock
Bacteraemia
MRSA
Fungal sepsis
Fungaemia
Necrotizing fasciitis
Thrombocytopenia
Graft vs host disease

Obvious consequences of radiological procedures and therapy

ICD-11 Reference Guide 393

 Pericarditis If radiation of the
same site
Restrictive lung disease If radiation of the
same site
Small bowel obstruction If radiation of the
same site
Cervical myelitis If radiation of the
same site
(Interstitial) fibrosis If radiation of the
same site
Osteonecrosis If radiation of the
same site
Mucositis If radiation of the
same site
Fistula If radiation of the
same site
Stricture or scarring If radiation of the
same site

Obvious consequences of urinary catheterization PK93.10

Gastroenterology or urology devices associated with injury or
harm, urinary catheter
Urinary tract infection
Urosepsis
3.14.10 List of conditions unlikely to cause death

Use this table in Step SP8 Conditions in this table are unlikely to cause death.
Unlikely to cause death

394 ICD-11 MMS

3.14.11 List of categories limited to, or more likely to occur in, female persons

ICD-11 Reference Guide 395

Code Title
1C14 Obstetrical tetanus
1F23.10 Vulvovaginal candidosis
2B58.1 Leiomyosarcoma of uterus
2B5C Endometrial stromal sarcoma, primary site
2B5D.0 Malignant mixed epithelial mesenchymal tumour of ovary
2B5D.1 Malignant mixed epithelial and mesenchymal tumour of corpus uteri
2B5F.0 Sarcoma, not elsewhere classified of uterus
2B5G Myosarcoma of uterus, part not specified
2C65 Hereditary breast and ovarian cancer syndrome
2C70-2C7Z Malignant neoplasms of female genital organs
2E05 Malignant neoplasm metastasis in female reproductive system
2E66 Carcinoma in situ of cervix uteri
2E67.0 Carcinoma in situ of endometrium
2E67.1 Carcinoma in situ of vulva
2E67.2 Carcinoma in situ of vagina
2E67.3 Carcinoma in situ of other or unspecified female genital organs
2E86.0 Leiomyoma of uterus
2E88 Benign endometrial stromal tumour
2F31 Non-mesenchymal benign neoplasms of uterus
2F32 Benign neoplasm of ovary
2F33 Benign neoplasm of other or unspecified female genital organs
2F76 Neoplasms of uncertain behaviour of female genital organs
2F96 Neoplasms of unknown behaviour of female genital organs
4A45.2 Antiphospholipid syndrome in pregnancy
5A71.0 46,XX disorders of sex development induced by androgens of foetal origin
5A71.1 46,XX disorders of sex development induced by androgens of maternal origin
5A80 Ovarian dysfunction
5D44 Postprocedural ovarian failure
6E20 Mental or behavioural disorders associated with pregnancy, childbirth and
the puerperium, without psychotic symptoms
6E21 Mental or behavioural disorders associated with pregnancy, childbirth or the
puerperium, with psychotic symptoms
6E2Z Mental or behavioural disorders associated with pregnancy, childbirth and
the puerperium, unspecified
BD75.2 Vulval varices
EA83.00 Lichen simplex of vulva
EA87.1 Dermatitis or eczema of female genitalia

396 ICD-11 MMS

 Code Title
EB60.0 Lichen sclerosus of vulva
ED61.11 Vulval melanotic macule
ED70.1 Female pattern hair loss
ED70.31 Postpartum telogen effluvium
EE40.10 Stretch marks of pregnancy
EK02.13] Irritant contact dermatitis of vulva
FB83.10 Premenopausal idiopathic osteoporosis
FB83.11 Postmenopausal osteoporosis
FC01.9 Postoophorectomy osteoporosis
GA00- Diseases of the female genital system
GA6Z
GB23.4 Galactorrhoea not associated with childbirth
GC04.1 Fistulae involving female genital tract
GC04.2 Ureteral fistula
GC40- Female pelvic floor dysfunction
GC4Z
GC50.10 Absent or diminished bladder sensation associated with pelvic organ
prolapse
GC51 Female Genital Mutilation
GC70 Postoperative adhesions of vagina
GC71 Prolapse of vaginal vault after hysterectomy
GC77 Postprocedural nonmenstrual uterine bleeding
GC78 Postprocedural acute female pelvic inflammatory disease
HA01.0 Female sexual arousal dysfunction
HA20 Sexual pain-penetration disorder
JA00-JB6Z Pregnancy, childbirth or the puerperium
KA83.9 Neonatal vaginal or uterine haemorrhage
LA90.32 Uterine arteriovenous malformations
LB40-LB4Z Structural developmental anomalies of the female genital system
LD2A.1 46,XY gonadal dysgenesis
LD2A.4 46,XY disorder of sex development due to androgen resistance
LD50.0 Turner syndrome
LD50.1 Karyotype 47,XXX
LD50.2 Mosaicism, lines with various numbers of X chromosomes
LD50.Y Other specified number anomalies of chromosome X
LD50.Z Number anomalies of chromosome X, unspecified
LD90.4 Rett syndrome

ICD-11 Reference Guide 397

Code Title
MF30- Symptoms, signs or clinical findings involving the female genital system
MF3Y
MF60- Clinical findings in specimens from female genital organs
MF6Z
MG24.01 Fear of breast cancer female
MG24.D Fear of complications of pregnancy
MG24.E Fear of sexually transmitted disease female
MG24.F Fear of female genital or breast disease
NB92.4 Injury of ovary
NB92.5 Injury of fallopian tube
NB92.6 Injury of uterus
NB93.02 Crushing injury of vulva
NB93.24 Traumatic amputation of entire vulva
NB93.25 Traumatic amputation of part of vulva
NB98 Injury to female genital organ without further specification
ND56.9 Injury complicating pregnancy
ND74.2 Foreign body in vulva or vagina
ND74.3 Foreign body in uterus, any part
PK80.5 Gynaecological or breast procedure associated with injury or harm in
therapeutic use
PK80.7 Obstetric procedure associated with injury or harm in therapeutic use
PK96 Obstetric or gynaecological devices, implants or grafts associated with injury
or harm
QA00.9 Gynaecological examination
QA09.4 Special screening examination for neoplasm of cervix
QA21.0 Contact with health services for postcoital contraception
QA21.2 Contact with health services for insertion of contraceptive device
QA21.4 Contact with health services for menstrual extraction
QA21.6 Surveillance of contraceptive device
QA30.00 Contact with health services for gamete intrafallopian transfer
QA30.01 Contact with health services for procreative management by artificial
insemination
QA30.02 Contact with health services for medically assisted sperm insemination
QA30.0Y Contact with health services for other specified assisted insemination
QA30.0Z Contact with health services for unspecified assisted insemination
QA30.1 Contact with health services for assisted reproductive technology
QA30.2 Contact with health services for other assisted fertilisation methods

398 ICD-11 MMS

 Code Title
QA30.Y Other specified contact with health services for medically assisted
reproduction
QA40 Pregnancy examination or test
QA41 Pregnant state
QA42 Supervision of normal pregnancy
QA43 Supervision of high-risk pregnancy
QA45 Antenatal screening
QA46 Outcome of delivery
QA48 Postpartum care or examination
QA49 Problems related to unwanted pregnancy
QA4A Problems related to multiparity
QA4B Contact with health services for menopausal counselling
QB51.C Presence of contraceptive device
QB62.5 Attention to artificial vagina
QD31 Contact with health services for concerns about body image related to
pregnancy
QF01.10 Acquired absence of female genital organs
3.14.12 List of categories limited to, or more likely to occur in, male persons

ICD-11 Reference Guide 399

Code Title
1A70.00 Gonorrhoea of penis
1D80.1 Orchitis due to mumps virus
1F23.11 Candida balanoposthitis
2B55.2 Rhabdomyosarcoma of male genital organs
2B59.2 Liposarcoma of male genital organs
2C80-2C8Z Malignant neoplasms of male genital organs
2E06 Malignant neoplasm metastasis in male genital organs
2E67.4 Carcinoma in situ of penis
2E67.5 Carcinoma in situ of prostate
2E67.6 Carcinoma in situ of other or unspecified male genital organs
2F34 Benign neoplasm of male genital organs
2F77 Neoplasms of uncertain behaviour of male genital organs
2F97 Neoplasms of unknown behaviour of male genital organs
5A81 Testicular dysfunction or testosterone-related disorders
5D45 Postprocedural testicular hypofunction
BD75.1 Scrotal varices
EA83.01 Lichen simplex of male genitalia
EA87.0 Dermatitis or eczema of male genitalia
EB60.1 Lichen sclerosus of penis
EC92.0 Penoscrotodynia
ED61.10 Penile melanotic macule
GA80-GB0Z Diseases of the male genital system
HA01.1 Male erectile dysfunction
HA03 Ejaculatory dysfunctions
LB50-LB5Z Structural developmental anomalies of the male genital system
LD2A.0 Ovotesticular disorder of sex development
LD2A.2 Testicular agenesis
LD2A.3 46,XY disorder of sex development due to a defect in testosterone
metabolism
LD50.3 Klinefelter syndrome
LD52 Number anomalies of chromosome Y
LD53 Structural anomalies of chromosome Y
LD54 Male with sex chromosome mosaicism
MA14.1B Prostate specific antigen positive
MF40- Symptoms, signs or clinical findings involving the male genital system
MF4Y

400 ICD-11 MMS

 Code Title
MF70- Clinical findings in specimens from male genital organs
MF7Z
MG24.02 Fear of genital cancer male
MG24.G Fear of sexually transmitted disease male
MG24.H Fear of genital disease male
NB93.00 Crushing injury of penis
NB93.01 Crushing injury of testes or scrotum
NB93.20 Traumatic amputation of entire penis
NB93.21 Traumatic amputation of part of penis
NB93.22 Traumatic amputation of entire testes or scrotum
NB93.23 Traumatic amputation of part of testes or scrotum
NB97.1 Fractured penis
NB99 Injury to male genital organ without further specification
QA09.5 Special screening examination for neoplasm of prostate
QB82 Contact with health services for routine or ritual circumcision
QF01.11 Acquired absence of male genital organs
3.14.13 Collection of instructions with coding examples related maternal mortality

Overview (See Section [Link])

The International form of medical certificate of cause of death (See Mortality Annex 3.14 is
structured to allow reporting on obstetric causes, the time elapsed between the obstetric
event and the person’s death, and whether the pregnancy contributed to death. Use all
information available on the death certificate. When information provided is ambiguous it is
recommended to verify where possible, while means of verification may vary among
countries according to different legal systems or profiles in maternal mortality. Additional
information may be obtained through clinical summaries of medical institutions, verbal
autopsy reports, or by certain verification processes which may require not only queries to
the certifier but also establishing an inquiry system to analyse specific cases.
Following concepts related to statistical tabulation of maternal mortality is provided in
Section 2.25.5 Standards and reporting requirements related for maternal mortality.

ICD-11 Reference Guide 401

 • [Link] Maternal death
• [Link] Late Maternal death
• [Link] Comprehensive maternal death
• [Link] Direct and indirect obstetric deaths
• [Link] Death occurring during pregnancy, childbirth and puerperium
• [Link] Recording requirements of maternal mortality
• [Link] International reporting of maternal mortality
• [Link] Numerator, denominator, and ratios of published maternal mortality
Briefly the underlying cause of death categories for Maternal Mortality is summarized in the
table below:

JB00 -JB60, JB63.-, JB61.- Late Maternal JB62.- Sequealae of

JB64.-, JB6Y, 1C14 death obstetric
Maternal death conditions
Deceased was at the time of death, more than 42 days but one year or more
pregnant: and within 42 days less than one year before the death
before the death before the death

On a death certificate usually the timespan is recorded in day unit where 42 days are
included in maternal death and 43 days are included in late maternal death. In a
mathmatical explanation, this means exactly 42 days are included in maternal death, while
for example 42 days and one hour is included in late maternal death. Also note that JB61.-
and JB62.- includes deaths due to any obstetric cause. The obstetric cause reported
including cause unknown (JB60) is postcoordinated to JB61.- or JB62.- to retain information
on the cause. Coding instructions are provided to select the UCOD and capture further
details in a cluster.
Coding instructions for maternal mortality
For coding of maternal mortality, follow the general coding instructions.
To assign the correct multiple cause code for a certificate with mention of pregnancy, first
use the coding tool to assign a specific code for each condition reported. Categories out of
Chapter 18 may also be assigned. When a condition suggests it is an obstetric condition, by
using certain modifiers such as ‘obstetric’ or ‘maternal’, search if there is a direct match of
the diagnosis reported. The coding tool also supports coding by providing the icon ‘J’ ( ) for
certain condition that have a compatible category for maternal conditions.

402 ICD-11 MMS

 Example 1
1 (a) Pulmonary oedema CB01
(b) Mitral valve insufficiency, pregnancy JB64.4/BB61.Z
(c)
(d)
2

Mitral valve insufficiency nos is coded to BB61.Z, however assign JB64.4/BB61.Z because it is
described as ‘pregnancy’.

Example 2
1 (a) Pulmonary oedema CB01
(b) Mitral valve insufficiency BB61.Z
(c)
(d)
2 XX completed weeks of gestation

Code mitral valve insufficiency to BB61.Z. Pregnancy is mentioned in Part 2 and it is

considered that pregnancy contributed to death. Apply Step M4 and code the underlying
cause of death to JB64.4 Diseases of the circulatory system complicating pregnancy,
childbirth or the puerperium. For greater specificity, also add the code for BB61.Z Mitral
valve insufficiency, unspecified to the cluster (JB64.4/BB61.Z).
Structure of Chapter 18 and other related categories
The following categories are used for deaths due to an obstetric event occurring within 42
days after termination of pregnancy:
• JA00 - JB4Z, 1C14: Direct obstetric causes
• JB63.-, JB64.-: Maternal diseases classifiable elsewhere but complicating pregnancy
• JB60 is used when a woman dies during pregnancy, labor, delivery or the puerperium
and the only information provided is ‘maternal’ or ‘obstetric’ death. If obstetric
cause of death is specified, do not use JB60 but code to the appropriate category.
• JB6Y is used for other specified obstetric conditions not elsewhere classified
Category JB61.- is used for death of a woman due to an obstetric cause but more than 42
days but less than one year after termination of pregnancy.
Category JB62.- is used for death of a woman due to an obstetric cause of one year or more
after termination of pregnancy.
JB6Z is used when both obstetric condition is unspecified, and the time elapsed between the
obstetric event and death is unknown. Note that this code is not to be used for underlying
cause of death (See section 2.19.4 Special instructions on surgery and other medical
procedures (Step M4)) .
Determining whether pregnancy contributed to death

ICD-11 Reference Guide 403

Consider pregnancy contribute to death when pregnancy, puerperium or childbirth is
reported in Part 1 or Part 2;or is reported elsewhere and the answer to the question “Did
the pregnancy contribute to death?” is yes, unknown, or is unstated.
Determining the time elapsed
The time elapsed between the obstetric event and the death is determined by the duration
reported for the obstetric cause. If duration is unknown or unspecified, use the information
in Frame B of the death certificate. When duration is unknown or unstated, but pregnancy
contributed to death, it is assumed that the death occurred within 42 days after the
obstetric event.
Selecting the underlying cause of death for maternal mortality (See Section 2.19.7)
For coding of maternal mortality, follow general coding instructions.
After assigning a code for each condition reported (See Coding instructions for maternal
mortality in Section [Link]) apply the selection and modification instructions in the normal
way starting from SP1 as same as other causes of death.
Then, apply Steps SP1 to SP8 and M1 to M3 and M4 for Surgery, Injury, External causes, and
Poisoning, then Step M4 for maternal mortality (See also section 2.19.7.
Typical cases of maternal mortality
Normally the sequence reported is accepted in general (See Section 2.16.2), however,
several relations may be rejected, and may have other specific instructions as summarized
below.

Example 3 Duration
1 (a) Hypovolemic shock 1 hour
(b) Postcesarean hemorrhage 2 hours
(c) Uterine vessel injury during cesarean section 2 hours
(d)
2

The deceased was pregnant: Yes, within 42 days of death; Pregnancy contributed to death:
Yes
Both hypovolemic shock and postcaesarean hemorrhage can be caused by Uterine vessel
injury during cesarean section coded to JB0D.3 Other complications of obstetric surgery or
procedures and is the tentative starting point (Step SP3). As no other special instruction
apply, and the death was within 42 days after the obstetric cause, JB0D.3 is the underlying
cause of death.

404 ICD-11 MMS

 Example 4
1 (a) Pulmonary oedema CB01
(b) Mitral valve insufficiency, pregnancy JB64.4/BB61.Z
(c)
(d)
2

Pulmonary oedema can be caused by mitral regurgitation in pregnancy which is the

tentative starting point (Step SP3). As no other special instruction apply, and the death was
within 42 days of after the obstetric cause, JB64.4 is the underlying cause of death. For
greater specificity, also add the code for BB61.Z Mitral valve insufficiency, unspecified to the
cluster (JB64.4/BB61.Z).

Example 5
1 (a) Haemorrhage MG27
(b) Cervical cancer 2C77.Z
(c)
(d)
2 Treatment delayed because of pregnancy

The deceased was pregnant: Yes, at the time of death; Pregnancy contributed to death:
unstated
Cervical cancer is the tentative starting point (Step SP3). Pregnancy is mentioned in Part 2
and it is considered that pregnancy contributed to death. Apply Step M4 and code the
underlying cause of death to JB64.Y Other specified maternal diseases classifiable elsewhere
but complicating pregnancy, childbirth or the puerperium. For greater specificity, also add
the code 2C77.Z Malignant neoplasms of cervix uteri, unspecified to the cluster.
(JB64.Y/2C77.Z)

Example 6
1 (a) Hepatic failure DB99.7
(b) Dengue haemorrhagic fever 5 days 1D21
(c)
(d)
2 Additional information: 40 days postpartum

The deceased was pregnant: Yes, within 42 days of death; Pregnancy contributed to death:
unstated
Dengue with warning signs is the tentative starting point (Step SP3). Pregnancy is mentioned
in Part 2 and it is considered that pregnancy contributed to death. Apply Step M4 and code
the underlying cause to JB63.5 Other viral diseases complicating pregnancy, childbirth or the
puerperium. For greater specificity, also add the code for 1D21 Dengue with warning signs
to the cluster. (JB63.5 /1D21 )

ICD-11 Reference Guide 405

 Example 7
1 (a) Disseminated intravascular coagulation 3B20
(b) Obstetric hemorrhage JA4Z
(c) Postpartum uterine atony JA43.1
(d) Abruptio placentae JA8C.Z
2

The deceased was pregnant: Yes, within 42 days of death; Pregnancy contributed to death:
Yes
All DIC, obstetric hemorrhage, and postpartum uterine atony can be caused by Abruptio
placentae JA8C.Z and that is the tentative starting point. As DIC is reported and this gives
greater specificity apply Step M2 and code to JA8C.0 Premature separation of placenta with
coagulation defect. As no other special instructions apply, and the death was within 42 days
after the obstetric cause, JA8C.0 is the underlying cause of death.
Extraction and examples of special instructions on maternal mortality
Followings are special instructions specific to categories in Chapter 18. For instructions of
each step refer to corresponding sections.
SP3 & SP4 Accepted and rejected sequences of maternal mortality (see Section 2.17.6,
2.17.7 and [Link])
Do not accept Ectopic pregnancy (JA01.-) and Molar pregnancy (JA02.-) as due to other
causes.

Consequence condition Causal condition

JA01.- Ectopic pregnancy Do not accept other causes
JA02.- Molar pregnancy

Do not accept Hypertensive disorders in pregnancy, childbirth, or the puerperium (JA20-

JA21, JA23-JA25) as due to other causes.

Consequence condition Causal condition

JA20-JA21, JA23-JA25 Hypertensive disorders in pregnancy, Do not accept other
childbirth, or the puerperium causes

Do not accept Maternal care related to placenta praevia or low lying placenta (JA8B.-) as
due to other causes.

Consequence condition Causal condition

JA8B.- Maternal care related to placenta praevia or low lying Do not accept other
placenta causes

406 ICD-11 MMS

 Example 8
1 (a) Hypovolemic shock 1 day MG40.1
(b) Obstetric haemorrhage 1 day JA4Z
(c) Placenta praevia 1 day JA8B.1
(d) Pneumonia 4 days CA40.Z
2

The deceased was pregnant: Yes, at the time of death; Pregnancy contributed to death: Yes
Placenta praevia cannot be caused by pneumonia and this sequence is rejected by the
special instructions on the accepted and rejected sequence. There is an acceptable
sequence which is hypovolemic shock caused by obstetric haemorrhage, in its turn caused
by placenta praevia, and JA8B.1 is the tentative starting point (Step SP4). As no other special
instructions apply, and the death was within 42 days after the obstetric cause, JA8B.1 is the
underlying cause of death.
SP5 - Terminal cause of death when no sequence (See Section 2.17.8)

Example 9
1 (a) Amniotic fluid embolism JB42.1
(b)
(c)
(d)
2

There is no sequencing ending with the teminal cause of death in Part one. Amniotic fluid
embolism JB42.1 is the tentative starting point (Step SP5), and as no other special
instructions apply it is also the underlying cause of death.
SP8 - Conditions unlikely to cause death of maternal mortality (See Section 2.17.11 and
Mortality Annex 3.14)

ICD-11 Reference Guide 407

 Code Title
JA65.3 Low weight gain in pregnancy
JA65.4 Pregnancy care of habitual aborter
JA66 .- Clinical findings on antenatal screening of mother
JA8D .- Maternal care related to false labour
JB00.0 Preterm labour without delivery
JB46.0 Retracted nipple associated with childbirth
JB46.2 Other and unspecified disorders of breast associated with childbirth
JB46.3 Agalactia
JB46.4 Hypogalactia
JB46.5 Suppressed lactation
JB46.6 Galactorrhea
JB46.7 Other and unspecified disorders of lactation

Example 10
1 (a) Galactorrhoea in puerperium 10 days JB46.6
(b)
(c)
(d)
2 Puerperal sepsis after cesarean section 6 days JB40.0

Galactorrhoea in puerperium JB46.6 is the tentative starting point (Step SP5), but it is in the
‘List of conditions considered unlikely to cause death’. There is another condition on the
certificate, Puerperal sepsis after cesarean section, which is not in the ‘List of conditions
considered unlikely to cause death’. Disregard galactorrhoea in perperium by Step SP8 and
restart the selection procedure from Step SP1. Puerperal sepsis after cesarean section is
selected as the underlying cause of death.
M1 – If the conditions specified in the right-hand column apply, then use the code in bold as
the new tentative underlying cause (See Section 2.18.1 and 2.19.3)

TUC is with mention of: code to:

JA24.- Pre-eclampsia JA25.- Eclampsia JA25.-

408 ICD-11 MMS

 TUC is when reported as the cause of: code
to:
JA61.0 Varicose veins of lower extremity in JB42.2 Obstetric blood-clot JB42.2
pregnancy embolism
JA61.1 Genital varices in pregnancy
JA61.2 Superficial thrombophlebitis in
pregnancy
JA61.4 Haemorrhoids in pregnancy

TUC is when reported as the cause of: code to:

JA65.2 Excessive JA20 - JA20-JA2Z Oedema, proteinuria, or JA20 -
weight gain in hypertensive disorders in pregnancy, childbirth, or JA20-JA2Z
pregnancy the puerperium

TUC is with mention of: code

to:
JA65.3 Low weight JB64.2 Endocrine, nutritional or metabolic diseases JB64.2
gain in pregnancy complicating pregnancy, childbirth or the puerperium

TUC is when reported as the cause of: code to:

JA65.4 Pregnancy care of habitual JA00 - JA0Z Abortive outcome of JA00 -
aborter pregnancy JA0Z

TUC is when reported as the cause of: code to:

JA65.5 Retained intrauterine contraceptive JA00 - JA0Z Abortive outcome of JA00 -
device in pregnancy pregnancy JA0Z
JA88.1 Infection of amniotic sac JA88.1
and membranes
JB00 .- Preterm labour or JB00 .-
delivery

TUC is with mention of: code

to:
JA65.7 Subluxation of JB04 - JB06 Obstructed labour due to JB04 -
symphysis pubis in pregnancy, malposition or malpresentation of fetus, JB06
childbirth or the puerperium maternal pelvic abnormality or due to other
causes

ICD-11 Reference Guide 409

TUC is when reported as the cause of: code
to:
JA67.4 Spinal and epidural JA67.2 Central nervous system JA67.2
anaesthesia-induced headache during complications of anaesthesia during
pregnancy pregnancy

TUC is with mention of: code

to:
JA80.- Maternal care related JB04 - JB06 Obstructed labour due to JB04 -
to multiple gestation malposition or malpresentation of foetus, JB06
maternal pelvic abnormality, or other causes
JA81.- Maternal care related JB0D.3 Other complications of obstetric JB0D.3
to complications specific to surgery or procedures
multiple gestation
JB42.1 Amniotic fluid embolism JB42.1

TUC is when reported as the cause of: code

to:
JA82.- Maternal care for known JA43.- Postpartum haemorrhage JA43.-
or suspected malpresentation
of fetus
JA83.- Maternal care for known JB04 - JB06 Obstructed labour due to JB04 -
or suspected disproportion malposition or malpresentation of foetus, JB06
maternal pelvic abnormality, or other causes
JA84.- Maternal care for known JB09 - JB0A Perineal laceration during JB09 -
or suspected abnormality of delivery and other obstetric trauma JB0A
pelvic organs
JA85.- Maternal care for known JB0D.- Certain specified complications of JB0D.-
or suspected fetal abnormality labour or delivery, not elsewhere classified
or damage
JA86.- Maternal care for other JB40.- Infections in the puerperium JB40
known or suspected fetal
problems

TUC is with mention of: code

to:
JA82.- Maternal care for known or JA83.- Maternal care for known or JA83.-
suspected malpresentation of fetus suspected disproportion

410 ICD-11 MMS

 TUC is with mention of: code
to:
JA83.Z Maternal care for known or JA83.0 Maternal care for disproportion JA83.0
suspected disproportion, unspecified due to deformity of maternal pelvic
bones
JA83.1 Maternal care for disproportion JA83.1
due to generally contracted pelvis
JA83.2 Maternal care for disproportion JA83.2
due to inlet contraction of pelvis
JA83.3 Maternal care for disproportion JA83.3
due to outlet contraction of pelvis

TUC is when reported as the cause of: code

to:
JA87.- Maternal care JA8C.- Maternal care related to premature JA8C.-
related to separation of placenta
polyhydramnios
JB03.- Long labour JB03.-
JB04 - JB06 Obstructed labour due to malposition JB04 -
or malpresentation of foetus, maternal pelvic JB06
abnormality, or other causes
JA43.- Postpartum haemorrhage JA43.-
JB0D.- Certain specified complications of labour or JB0D.-
delivery, not elsewhere classified
JB40.- Infections in the puerperium JB40.-
JB42.1 Amniotic fluid embolism JB42.1

TUC is when reported as the cause of: code

to:
JA88.0 Oligohydramnios JA43.- Postpartum haemorrhage JA43.-
JA88.Y Other specified disorders of JA88.1 Infection of amniotic sac or JA88.1
amniotic fluid and membranes membranes
JA88.Z Disorders of amniotic fluid JB03.- Long labour JB03.-
and membranes, unspecified
JB40.- Infections in the puerperium JB40.-
JB0D.- Certain specified complications of JB0D.-
labour or delivery, not elsewhere
classified

ICD-11 Reference Guide 411

TUC is with mention of: code
to:
JA89.3 Premature rupture JA88.1 Infection of amniotic sac or membranes JA88.1
of membranes
JB03.- Long labour JB03.-
JA43.- Postpartum haemorrhage JA43.-
JB0D.- Certain specified complications of labour or JB0D.-
delivery, not elsewhere classified
JB40.- Infections in the puerperium JB40.-
JB42.1 Amniotic fluid embolism JB42.1

TUC is when reported as the cause of: code

to:
JA8A.0 Placental transfusion JA8C.- Maternal care related to premature JA8C.-
syndromes separation of placenta
JA8A.1 Malformation of placenta JA42.- Intrapartum haemorrhage JA42.-
JA8A.Y Other specified maternal JA43.- Postpartum haemorrhage JA43.-
care related to placental disorders
JA8A.Z Maternal care related to JB0D.- Certain specified complications of JB0D.-
placental disorders, unspecified labour or delivery, not elsewhere classified
JB40.- Infections in the puerperium JB40.-

TUC is when reported as the cause of: code

to:
JA8A.2 Morbidly JA8B.1 Placenta praevia with haemorrhage JA8B.1
adherent placenta
JA8B.0 Placenta praevia specified as without JA8B.0
haemorrhage
JA8B.Z Maternal care related to placenta praevia or JA8B.Z
low lying placenta, unspecified

TUC is when reported as the cause of: code

to:
JA8E Maternal care related to JB0D.- Certain specified complications of labour JB0D.-
prolonged pregnancy or delivery, not elsewhere classified

412 ICD-11 MMS

 TUC is when reported as the cause of: code
to:
JB00.- Preterm labour or JA8C.- Maternal care related to premature JA8C.-
delivery separation of placenta
JB01.- Failed induction of JA42.- Intrapartum haemorrhage JA42.-
labour
JB02.- Abnormalities of forces JA43.- Postpartum haemorrhage JA43.-
of labour
JB03.- Long labour JB04 - JB06 Obstructed labour due to JB04 -
malposition or malpresentation of foetus, JB06
maternal pelvic abnormality, or other causes
JB07.- Labour or delivery JB0D.- Certain specified complications of labour JB0D.-
complicated by foetal distress or delivery, not elsewhere classified
JB08.- Labour or delivery JB40.- Infections in the puerperium JB40.-
complicated by umbilical cord
complications

TUC is with mention of: code

to:
JB04.- Obstructed labour due to JB05.- Obstructed labour due to JB05.-
malposition or malpresentation of fetus maternal pelvic abnormality

TUC is when reported as the code

cause of: to:
JB09.2, JB09.3, JB09.Z Third, fourth or unspecified JA43.- Postpartum JA43.-
degree perineal laceration during delivery haemorrhage
JB40.- Infections in the JB40.-
puerperium

TUC is when reported as the cause of: code

to:
JB0C.5 Spinal and epidural JB0C.3 Central nervous system JB0C.3
anaesthesia-induced headache during complications of anaesthesia during
labour and delivery labour or delivery

ICD-11 Reference Guide 413

TUC is when reported as the cause of: code
to:
JB0D.0 Maternal distress during labour and JA43 Postpartum haemorrhage JA43
delivery
JB0D.1 Shock during or following labour and JB40 Infections in the JB40
delivery puerperium

TUC is when reported as the cause code

of: to:
JB0D.2 Pyrexia during labour, not elsewhere JB40 Infections in the JB40
classified puerperium

TUC is when reported as the cause of: code

to:
JB0D.4 Delayed delivery after artificial JB0D.4 Delayed delivery after artificial JA43.-
rupture of membranes rupture of membranes
JB0D.5 Delayed delivery after JB0D.- Certain specified complications JB0D.-
spontaneous or unspecified rupture of of labour or delivery, not elsewhere
membranes classified
JB40.- Infections in the puerperium JB40.-

TUC is when reported as the cause of: code

to:
JB0D.6 Vaginal delivery JA8A.2 Morbidly adherent placenta JA8A.2
following previous caesarean
section
JB0A.1 Rupture of uterus during labour JB0A.1
JB0A.2 Postpartum inversion of uterus JB0A.2
JA43.- Postpartum haemorrhage JA43.-
JB0D.- Certain specified complications of JB0D.-
labour or delivery, not elsewhere classified
JB40.- Infections in the puerperium JB40.-

414 ICD-11 MMS

 TUC is when reported as the cause code
of: to:
JB41.0 Superficial thrombophlebitis in the JB42.2 Obstetric blood-clot JB42.2
puerperium embolism
JB41.2 Haemorrhoids in the puerperium
JB41.Y Other venous complications in the
puerperium
JB41.Z Venous complication in the puerperium,
unspecified

TUC is when reported as the cause of: code

to:
JB43.3 Spinal and epidural JB43.2 Central nervous system JB43.2
anaesthesia-induced headache during complications of anaesthesia during the
the puerperium puerperium

M1 - Conditiions of maternal mortality not to be used as UCOD (See Section [Link] for
details)

TUC is:
JA05.- Complications following abortion, ectopic Code to: Abortive outcome of
or molar pregnancy pregnancy of JA00-JA04

TUC is:
JB65 Sequelae of complication of pregnancy, Code to: JB62.- Death from sequelae
childbirth or the puerperium of obstetric causes

M1 - Conditions of maternal mortality not to be used as UCOD under certain condition

(See Section 2.18.1 and [Link])

TUC is:
JA80 Maternal care related to Not to be used for the underlying cause of death, if a
multiple gestation more specific complication is reported.
Code to: the more specific complication.
If there is no specific complication, code to JB0Z
Complications of labor or delivery, unspecified

ICD-11 Reference Guide 415

 TUC is:
JB20 - JB2Z Not to be used for the underlying cause of death, if a more specific
Delivery complication is reported.
Code to: code to the more specific complication of JB0C.- to JB0D.- or
JB0Y. If no complication is reported code to JB0Z.

Example 11
1 (a) Subarachnoid haemorrhage 9 days 8B01.2
(b) Eclampsia during pregnancy 10 days JA25.0
(c) Severe pre-eclampsia 11 days JA24.1
(d)
2

The deceased was pregnant: Yes, at the time of death; Pregnancy contributed to death: Yes
Severe pre-eclampsia is the tentative underlying cause according to Step SP3. There is a
special instruction on ‘Pre-eclampsia’ reported with mention of ‘eclampsia’. Apply this
instruction and select JA25.0 as the tentative underlying cause. As no other special
instructions apply, and the death was within 42 days after the obstetric cause, JA25.0 is the
underlying cause of death.
M2 - Specificity (See Section 2.18.2))

Example 12
1 (a) Heart failure 1 day BD1Z
(b) Hypovolemic shock 2 days MG40.1
(c) Fourth degree perineal laceration 2 days JB09.3
(d) Perineal laceration during delivery 2 days JB09.Z
2

The deceased was pregnant: Yes, within 42 days of death; Pregnancy contributed to death:
Yes
Perineal laceration during delivery (JB09.Z) is the tentative starting point by Step SP3.
However, there is a category that provides more precise information about this condition
which is fourth degree perineal laceration (JB09.3). Apply Step M2 and select JB09.3 as the
underlying cause of death.
M4 - Special instructions on surgery and other medical procedures (See Section 2.18.4 and
2.19.4)

416 ICD-11 MMS

 Example 13
1 (a) Postoperative haemorrhage NE81.0Z
(b) Caesarean section JB22.Z
(c)
(d)
2

The deceased was pregnant: Yes, at the time of death; Pregnancy contributed to death: Yes
Reason for surgery: Prolonged labour
Caesarean section JB22.Z is the tentative by Step SP3. And the reason why the caesarean
section was performed was stated as prolonged labour. Code JB03.Z Long labour,
unspecified as the underlying cause of death.

Example 14
1 (a) Septic shock 1 day 1G41
(b) Postpartum cardiomyopathy 1 month JB44.3
(c) Emergency caesarean section 1 month JB22.1
(d)
2

The deceased was pregnant: Yes, within 42 days of death; Pregnancy contributed to death:
Yes
Emergency caesarean section JB22.1 is the tentative underlying cause by Step SP3. The
reason for caesarean section is not reported but the complication is. Code the complication,
postpartum cardiomyopathy JB44.3 as the underlying cause of death.
M4 – Special instructions on maternal mortality (See Section 2.19.7
Terms used here in the instruction is as follows:
• Certain maternal diseases: JA00.- to JB4Z, JB60, JB6Y, 1C14
• Maternal diseases classified elsewhere: JB63 (infections), JB64 (other)
• Injury or external causes: Chapter 22 or Chapter 23
• Other conditions: other than above
Maternal diseases - If the tentative underlying cause (TUC) is ‘certain maternal diseases’ and
the deceased was pregnant at the time of death, within 42 days before death, or the
duration is unknown or unstated, keep the TUC. - If the TUC is ‘maternal diseases classified
elsewhere’ keep the TUC and postcoordinate the code for the specific disease classified
elsewhere from Chapter 01-19. - If the TUC is JB61.0, JB61.Z, JB62.0 or JB62.Z, keep it and its
post-coordinated code, if any, as the TUC. - If the TUC is ‘certain maternal diseases’ or
maternal diseases classified elsewhere’ but the deceased was pregnant in more than 42
days but less than one year before death, then code to JB61.- as the TUC and add the code
for the specific maternal disease to the cluster.

ICD-11 Reference Guide 417

Other conditions or indirect obstetric causes - If the TUC is JB61.1 or JB62.1, keep it and its
post-coordinated code if any as the TUC. - If the TUC is ‘other conditions’, and the
pregnancy contributed to death, and the deceased was pregnant at the time of death,
within 42 days before death, or the duration is unknown or unstated, code to JB63.- or
JB64.- as appropriate and add the specific ‘other condition’ to the cluster. - If the TUC is
‘other conditions’, and the pregnancy did not contribute to death, but the deceased was
pregnant at the time of death, within 42 days before death, keep the TUC and add XT0S
Pregnancy to the cluster. - If the TUC is ‘other conditions’, and the pregnancy did not
contribute to death, and the deceased was pregnant in more than 42 days before death, or
the duration is unknown or unstated, keep the TUC.
See ‘Determining whether pregnancy contributed to death’ in section [Link] to decide
whether pregnancy contributed to death from the information on the death certificate.
Injury or external causes - If the TUC is ‘injury or external cause’, and the deceased was
pregnant at the time of death, within 42 days before death, keep the TUC and add XT03
Pregnancy to the cluster. - If the TUC is ‘injury or external cause’, and the deceased was
pregnant in more than 42 days before death, or the duration is unknown or unstated, keep
the TUC.
3.14.14 Target list of causes of death for verbal autopsy

The use of this list is two-fold. For computer-coding VA (CCVA) algorithms that assign broad
text labels for causes of death, this list could serve as a coding list, such that the CCVA
program could directly code the death to one of these labels, and this table provides the
related ICD-11 codes. Alternatively, this list could serve as a tabulation list for other VA
cause of death assignment methods such as physician coding or expert algorithms, which
have the potential to directly assign specific text labels for causes of death with their
individual ICD-11 codes. In such situations, the detailed coded data from these methods
could then be aggregated for tabulation according to the code groups, to enable comparison
with computer derived diagnosis. In other situations, the specifically ICD-11 coded data
from physician coded VA or expert algorithms could be aggregated and analysed using other
tabulation lists such as the WHO Mortality Lists or the Global Health Estimates/Global
Burden of Disease categories. In all situations, coded data from VA should be specifically
labelled according to the data source and the type of coding approach used, and separately
tabulated for each data source/coding method. Column 1 contains the code for the verbal
autopsy entity. Column 2 lists the related titles hyperlinked to the ICD-11 codes that would
be used if the condition labelled by column 2 were coded to ICD-11.

418 ICD-11 MMS

 Verbal autopsy code Verbal autopsy title
VAs-01 Infectious and parasitic diseases
VAs-01.01 Sepsis
VAs-01.02 Acute respiratory infection, including
pneumonia
VAs-01.03 HIV/AIDS related death
VAs-01.04 Diarrheal diseases
VAs-01.05 Malaria
VAs-01.06 Measles
VAs-01.07 Meningitis and encephalitis
VAs-01.08 Tetanus
VAs-01.09 Pulmonary tuberculosis
VAs-01.10 Pertussis
VAs-01.11 Haemorrhagic fever
VAs-01.12 Dengue fever
VAs-01.13 Coronavirus disease (COVID-19)
VAs-01.99 Unspecified infectious disease
Non-communicable diseases
VAs-98 Other and unspecified non-
communicable disease
VAs-02 Neoplasms
VAs-02.01 Oral neoplasms
VAs-02.02 Digestive neoplasms
VAs-02.03 Respiratory neoplasms
VAs-02.04 Breast neoplasms
VAs-02.05 Female reproductive neoplasms
VAs-02.06 Male reproductive neoplasms
VAs-02.99 Other and unspecified neoplasms
VAs-03 Nutritional and endocrine disorders
VAs-03.01 Severe anaemia
VAs-03.02 Severe malnutrition
VAs-03.03 Diabetes mellitus
VAs-04 Diseases of the circulatory system
VAs-04.01 Acute cardiac disease
VAs-04.02 Stroke
VAs-04.03 Sickle cell with crisis
VAs-04.99 Other and unspecified cardiac disease
VAs-05 Respiratory disorders

ICD-11 Reference Guide 419

Verbal autopsy code Verbal autopsy title
VAs-05.01 Chronic obstructive pulmonary disease
(COPD)
VAs-05.02 Asthma
VAs-06 Gastrointestinal disorders
VAs-06.01 Acute abdomen
VAs-06.02 Liver cirrhosis
VAs-07 Renal disorders
VAs-07.01 Renal failure
VAs-08 Mental and nervous system disorders
VAs-08.01 Epilepsy
VAs-09 Pregnancy childbirth and puerperium-
related disorders
VAs-09.01 Ectopic pregnancy
VAs-09.02 Abortion-related death
VAs-09.03 Pregnancy-induced hypertension
VAs-09.04 Obstetric haemorrhage
VAs-09.05 Obstructed labour
VAs-09.06 Pregnancy-related sepsis
VAs-09.07 Anaemia of pregnancy
VAs-09.08 Ruptured uterus
VAs-09.99 Other and unspecified maternal cause
VAs-10 Neonatal causes of death
VAs-10.01 Prematurity or low birth weight
VAs-10.02 Birth asphyxia
VAs-10.03 Neonatal pneumonia
VAs-10.04 Neonatal sepsis
VAs-10.05 Neonatal tetanus
VAs-10.06 Congenital malformation
VAs-10.99 Other and unspecified perinatal cause of
death
VAs-11 Stillbirths
VAs-11.01 Fresh stillbirth
VAs-11.02 Macerated stillbirth
VAs-12 External causes of death
VAs-12.01 Road traffic accident
VAs-12.02 Other transport accident
VAs-12.03 Accidental fall

420 ICD-11 MMS

 Verbal autopsy code Verbal autopsy title
VAs-12.04 Accidental drowning and submersion
VAs-12.05 Accidental exposure to smoke, fire and
flames
VAs-12.06 Contact with venomous animals and
plants
VAs-12.07 Accidental poisoning and exposure to
noxious substance
VAs-12.08 Intentional self-harm
VAs-12.09 Assault
VAs-12.10 Exposure to force of nature
VAs-12.99 Other and unspecified external cause of
death
VAs-99 Cause of death unknown
3.15 Annex D: Differences between ICD-10 and ICD-11
3.15.1 Chapter 01 – Differences between ICD–10 and ICD–11 in Chapter 01

The chapter includes more infectious items then in the past. Also, influenza has been moved
from the respiratory to the infectious diseases chapter. Tuberculosis, leprosy have been
grouped under ‘Mycobacterial diseases’, because identification, course, and treatment are
similar. Prion diseases have been moved to the Nervous system.
Table 1: Comparison of ICD-10 block structure with ICD-11 equivalent structure

ICD-11 Reference Guide 421

 ICD-10 block heading ICD-11 equivalent structure
A00-A09 Intestinal infectious diseases Gastroenteritis or colitis of infectious origin
A15-A19 Tuberculosis Part of the grouping - Mycobacterial diseases
A20-28 Certain zoonotic bacterial Certain zoonotic bacterial diseases
diseases
A30-A49 Other bacterial diseases Other bacterial diseases
A50-A64 Infections with a predominantly Predominantly sexually transmitted infections
sexual mode of transmission
A65-A69 Other spirochaetal diseases Part of the grouping - Other specified bacterial
diseases
A70-A74 Other diseases caused by Part of the grouping – Other bacterial diseases
chlamydiae
A75-A79 Rickettsioses Part of the grouping – Other bacterial diseases
A80-A89 Viral infections of the central Viral infections of the central nervous system
nervous system
A92-A99 Arthropod-borne viral fevers Split into two groups - Other arthropod-borne
and viral haemorrhagic fevers viral fevers and Certain zoonotic viral diseases
B00-B09 Viral infections characterized by Viral infections characterised by skin or
skin and mucous membrane lesions mucous membrane lesions
B15-B19 Viral hepatitis Viral hepatitis
B20-B24 Human immunodeficiency virus Human immunodeficiency virus disease
[HIV] disease
B25-B34 Other viral diseases Certain other viral diseases
B35-B49 Mycoses Mycoses
B50-B64 Protozoal diseases Part of the grouping - Parasitic diseases
B65-B83 Helminthiases Part of the grouping - Parasitic diseases
B85-B89 Pediculosis, acariasis and other Part of the grouping - Parasitic diseases
infestations
B90-B94 Sequelae of infectious and Sequelae of infectious diseases
parasitic diseases
B95-B98 Bacterial, viral and other Now part of extension codes for organisms
infectious agents
B99-B99 Other infectious diseases Certain other disorders of infectious origin
3.15.2 Differences between ICD–10 and ICD–11 in Chapter 02

The most significant change to the hierarchy of Chapter 02 is the inclusion of certain
morphology types within the chapter (previously found in ICD–10, Appendix A). There are
now precoordinated codes consisting of both morphology and site. Other types of
morphology and greater site specificity not included in Chapter 02 are found in the Chapter
X, Extension codes, and can be used for postcoordination.

422 ICD-11 MMS

Other changes include: grouping together all neoplasms of brain and central nervous system
regardless of behaviour; grouping together all haematopoietic and lymphoid tissues; and
the addition of the new group Malignant mesenchymal neoplasms. The previous ICD–10
group Neoplasms of uncertain or unknown behaviour has been split into two separate
groups - Neoplasms of uncertain behaviour and Neoplasms of unknown behaviour.
Table 1: Comparison of ICD-10 block structure with ICD-11 equivalent structure

ICD-10 block heading ICD-11 equivalent structure

C00-C97 Malignant Neoplasms of brain or central nervous system
neoplasms
Neoplasms of haematopoietic or lymphoid tissues
Malignant neoplasms, except of lymphoid,
haematopoietic, central nervous system or related
tissues
D00-D09 In situ neoplasms In situ neoplasms, except of lymphoid, haematopoietic,
central nervous system or related tissues
D10-D36 Benign neoplasms Benign neoplasms, except of lymphoid, haematopoietic,
central nervous system or related tissues
D37-D48 Neoplasms of Neoplasms of uncertain behaviour, except of lymphoid,
uncertain or unknown haematopoietic, central nervous system or related
behaviour tissues
Neoplasms of unknown behaviour, except of lymphoid,
haematopoietic, central nervous system or related
tissues
3.15.3 Differences between ICD–10 and ICD–11 in Chapter 03

ICD–10, Chapter 03 Disease of the blood and blood-forming organs and certain disorders
involving the immune mechanism has been split into two chapters: one for diseases of
blood or blood-forming organs (Ch. 03) and the other for disorders of the immune system
(Ch. 04). In ICD-10 there were five major sections for blood disorders which have now been
reclassified into three sections in ICD-11.
A broad grouping Anaemias and other erythrocyte disorders now contains, Nutritional
anaemias, Haemolytic anaemias and Aplastic and other anaemias with subdivisions for
acquired and congenital.
Table 1: Comparison of ICD-10 block structure with ICD-11 equivalent structure

ICD-11 Reference Guide 423

 ICD-10 block heading ICD-11 equivalent structure
D50-D53 Nutritional Part of the grouping - Anaemias and other erythrocyte
anaemias disorders
D55-D59 Haemolytic Part of the grouping - Anaemias and other erythrocyte
anaemias disorders
D60-D64 Aplastic and other Part of the grouping - Anaemias and other erythrocyte
anaemias disorders
D65-D69 Coagulation Coagulation defects, purpura and other haemorrhagic and
defects, purpura and other related conditions
haemorrhagic conditions
D70-D77 Other diseases of Concepts redistributed to one of the following groupings:
blood and blood-forming Anaemias and other erythrocyte disorders Coagulation
organs defects, purpura and other haemorrhagic and related
conditions or Diseases of spleen
D80-D89 Certain disorders Move to Chapter 04 ‘Diseases of the immune system’
involving the immune
mechanism
3.15.4 Differences between ICD–10 and ICD–11 in Chapter 04

ICD–10, Chapter 03 ‘Diseases of the blood and blood-forming organs and certain disorders
involving the immune mechanism’ has been split into two chapters: one for diseases of
blood or blood-forming organs (Ch. 03) and the other for disorders of the immune system
(Ch. 04). This new chapter (Ch. 04) was created to better capture the complexity of the
disease processes of the immune system.
Table 1: Comparison of ICD-10 block structure with ICD-11 equivalent structure

ICD-10 block heading ICD-11 equivalent structure

D80-D89 Certain disorders involving the Primary immunodeficiencies
immune mechanism
Acquired immunodeficiencies
Autoinflammatory disorders
Allergic or hypersensitivity conditions
Immune system disorders involving white
cell lineages
Certain disorders involving the immune
system
Diseases of thymus
3.15.5 Differences between ICD–10 and ICD–11 in Chapter 05

Changes and additions have been made to Diabetes mellitus with the inclusion of categories
for Intermediate hyperglycaemia (including Impaired glucose regulation) and Insulin-
resistance syndromes. Nutritional disorders section incorporates current terminology and
contains a detailed classification for vitamin and mineral deficiencies as well as for obesity.

424 ICD-11 MMS

The Metabolic disorders section also includes more detail and the organisation of the
various types of metabolic disorders has been improved.
Table 1: Comparison of ICD-10 block structure with ICD-11 equivalent structure in Chapter 5

ICD-11 Reference Guide 425

 ICD-10 block heading ICD-11 equivalent structure
E00-E07 Disorders of thyroid Disorders of the thyroid gland or thyroid hormones
gland system. The structure for this section has not changed
but has been revised to better reflect current disease
processes.
E10-E14 Diabetes mellitus Diabetes mellitus (Specifies the ‘type’ of diabetes
mellitus i.e. Type 1, Type 2, other and unspecified.
‘Diabetic’ complications are primarily parented to their
respective body system chapter).
E15-E16 Other disorders of Other disorders of glucose regulation or pancreatic
glucose regulation and internal secretion – has remained unchanged.
pancreatic internal secretion
E20-E35 Disorders of other This block has been unbundled and the sections
endocrine glands renamed to better reflect the conditions classified
within each entity:
Disorders of the parathyroid and parathyroid hormone
system
Disorders of the pituitary hormone system
Disorders of the adrenal glands and adrenal hormone
system
Disorders of the gonadal hormone system
Certain disorders of puberty
Polyglandular dysfunction
Disorders of lipoprotein metabolism and certain
specified lipidaemias
E40-E46 Malnutrition Undernutrition - Two new subsections have been
added for Undernutrition based on anthropometric or
clinical criteria and Undernutrition due to specific
nutrient deficiencies
E50-E64 Other nutritional Part of the grouping - Undernutrition
deficiencies
E65-E68 Obesity and other Overweight, obesity or specific nutrient excesses
hyperalimentation
E70-E90 Metabolic disorders Metabolic disorders with subsections based on
aetiology
3.15.6 Differences between ICD–10 and ICD–11 in Chapter 06

Changes to this chapter include restructuring of the hierarchy, the inclusion of more current
terminology, and specific groupings for single episodes of harmful use, harmful pattern of
use, dependence, intoxication, and withdrawal by substance type.
In the ICD–10, the numbers of large groupings, or ‘blocks’, of disorders was artificially
constrained by the decimal coding system used in the classification, such that it was only
possible to have a maximum of ten major groupings of disorders within the mental and

426 ICD-11 MMS

behavioural disorder chapter (corresponding to the digits 0 to 9). This meant that some
groupings were created that were not based on clinical utility or scientific evidence. In the
ICD–10, for example, one block (F30-F39) is devoted to Mood (affective) disorders, while
Anxiety disorders represent only a portion of a broad and heterogeneous block (F40- F49)
called ‘Neurotic, stress-related, and somatoform disorders’. Another block ? ‘Behavioural
syndromes associated with physiological disturbances and physical factors’ ? unites
disorders that are unrelated in terms of clinical symptoms and symptomatology except that
they have something to do with the body.
Given the constrained structural parameters of the ICD–10, the developers of the
classification provided a reasonable set of diagnostic groupings. However, the more flexible
structural characteristics of ICD–11 make it possible to incorporate key features based on
available scientific evidence and current practice for more optimal nosology.
Table 1: Comparison of ICD-10 block structure with ICD-11 equivalent structure

ICD-11 Reference Guide 427

 ICD-10 block heading ICD-11 equivalent structure
F00-F09 Organic, including Neurocognitive disorders
symptomatic, mental disorders
F10-F19 Mental and Part of the grouping - Disorders due to substance use or
behavioural disorders due to addictive behaviours
psychoactive substance use
F20-F29 Schizophrenia, Schizophrenia or other primary psychotic disorders
schizotypal and delusional
disorders
F30-F39 Mood (affective) Mood disorders
disorders
F40-F48 Neurotic, stress- Anxiety or fear-related disorders
related and somatoform
disorders
F50-F59 Behavioural syndromes Redistributed between Feeding or eating disorders,
associated with physiological Mental or behavioural disorders associated with
disturbances and physical pregnancy, childbirth and the puerperium and new
factors chapters for Sleep disorders and Sexual health
F60-F69 Disorders of adult Personality disorders and related traits
personality and behaviour
F70-F79 Mental retardation Part of the grouping - Neurodevelopmental disorders
F80-F89 Disorders of Part of the grouping - Neurodevelopmental disorders
psychological development
F90-F98 Behavioural and Part of the grouping - Neurodevelopmental disorders
emotional disorders with onset
usually occurring in childhood
and adolescence
F99-F99 Unspecified mental Unspecified residual for the chapter
disorder
3.15.7 Chapter 07 is a new addition to ICD–11 and was not found in past editions

Table 1: Comparison of ICD-10 block structure with ICD-11 equivalent structure

428 ICD-11 MMS

 ICD-10 previous location ICD-11 equivalent structure
Codes from Mental Health and Nervous system Insomnia disorders
chapters
Concept not in ICD-10 Sleep-related movement disorders
Codes from Mental Health and Nervous system Hypersomnolence disorders
chapters
Codes from Neurology and Endocrine chapters Sleep-related breathing disorders
Codes from Mental health chapter Parasomnia disorders
Codes from Neurology chapter Disorders of the sleep-wake
schedule
Codes from Neurology chapter Certain specified sleep disorders
3.15.8 Differences between ICD–10 and ICD–11 in Chapter 08

There has been a major restructuring and movement of previous ICD–10 concepts in this
chapter. A number of new concepts have also been added. Cerebrovascular diseases have
been moved to the Neurology chapter and multiply parented to the Circulatory chapter.
Transient Ischaemic attack (TIA) is now also located under Cerebrovascular diseases and
appears in Diseases of the nervous system.
ICD–11 sees a major overhaul in the organisation of the blocks which make up the
neurology chapter. The restrictive decimal coding system of the ICD–10, with its capacity to
contain only 11 blocks of disorders per chapter, resulted in blocks containing miscellaneous
neurological entities which did not logically fit together, such as the episodic and
paroxysmal disorders block, containing headache disorders, epilepsy, transient ischaemic
attacks and sleep disorders. The ICD–11 now positions headache disorders, epilepsy and
cerebrovascular disorders at block level, and sleep disorders at chapter level (Chapter 07).
Not only has the structure of the neurological chapter changed, but the approach to
classification also integrates current clinical practice and advancements in the
understanding of neurological diseases. In the time since the ICD–10 was published,
enormous progress in the fields of genetics, molecular biology and medical technologies
have been made. An increase in the number of codes is inevitable when one reflects on the
recent knowledge gain in neurology, so a balance between comprehensiveness, clinical
utility and maintaining a public health approach is the aim. The working groups tackled this
issue by considering the more common disorders to appear in the chapter, with less
common aetiological variations of these disorders being subject to a ‘double coding’
technique. One major change which illustrates the advancement of knowledge is the
addition of a block entitled ‘Paraneoplastic and autoimmune disorders of the nervous
system’. This block contains immune-mediated neurological diseases, a field in which
knowledge has exploded in recent years. A second example of how the new version reflects
molecular biological advancement is through awarding Prion diseases block status despite
their rarity. Previously, they featured as part of the infections of the central nervous system
block, but research interest after the major public health issue in Europe in the 1990s has
led to new variants of prion diseases being discovered.
Table 1: Comparison of ICD-10 block structure with ICD-11 equivalent structure

ICD-11 Reference Guide 429

 ICD-10 block heading ICD-11 equivalent structure
G00-G09 Inflammatory This section is now located in Chapter 1 in a new block
diseases of the nervous called Non-viral infections of the central nervous system
system
G10-G14 Systemic atrophies Split between the Movement disorders and Motor neuron
primarily affecting the disease and related disorders
central nervous system
G20-G26 Extrapyramidal and Movement disorders
movement disorders
G30-G32 Other degenerative Neurocognitive disorders
diseases of the nervous
system
G40-G47 Episodic and Epilepsy and seizures, Headache disorders and
paroxysmal disorders cerebrovascular blocks. Sleep disorders are now a stand-
alone chapter (Ch. 07)
G50-G59 Nerve, nerve root Disorders of nerve root, plexus and peripheral nerves
and plexus disorders
G60-G64 Polyneuropathies Polyneuropathy, Mononeuropathy and Hereditary
and other disorders of the neuropathy
peripheral nervous system
G70-G73 Diseases of Diseases of neuromuscular junction and muscle
myoneural junction and
muscle
G80-G83 Cerebral palsy and Cerebral palsy
other paralytic syndromes
G90-G99 Other disorders of Other disorders of the nervous system - the following
the nervous system have been moved out to their own grouping: Diseases of
the autonomic nervous system, Disorders of cerebrospinal
fluid pressure and flow, Spinal cord disorders excluding
trauma
A81 Atypical virus infections Prion diseases
of central nervous system
3.15.9 Differences between ICD–10 and ICD–11 in Chapter 09

There have been major changes to the structure and hierarchy of this chapter for ICD–11.
The aetiology/manifestation convention (dagger/asterisk) of ICD–10 has not been kept in
ICD–11.
Table 1: Comparison of ICD-10 block structure with ICD-11 equivalent structure

430 ICD-11 MMS

 ICD-10 block heading ICD-11 equivalent structure
H00-H06 Disorders of eyelid, Disorders of the ocular adnexa or orbit
lacrimal system and orbit
H10-H13 Disorders of conjunctiva Disorders of conjunctiva
H15-H22 Disorders of sclera, Redistributed between the groupings Disorders of
cornea, iris and ciliary body the eyeball – anterior segment and Disorders of the
eyeball – posterior segment
H25-H28 Disorders of lens Disorders of lens
H30-H36 Disorders of choroid and Separate categories under Disorders of the eyeball –
retina posterior segment
H40-H42 Glaucoma Glaucoma or glaucoma suspect
H43-H45 Disorders of vitreous Redistributed between the groupings Disorders of
body and globe the eyeball –posterior segment and Disorders of the
eyeball affecting both anterior and posterior
segments
H46-H48 Disorders of optic nerve Disorders of the visual pathways or centres
and visual pathway
H49-H52 Disorders of ocular Redistributed between the groupings Strabismus or
muscles, binocular movement, ocular motility and Disorders of refraction or
accommodation and refraction accommodation
H53-H54 Visual disturbances and Visual impairment
blindness
H55-H59 Other disorders of eye Redistributed between the groupings Nystagmus
and adnexa and Postprocedural disorders of eye or ocular
adnexa
3.15.10 Differences between ICD–10 and ICD–11 in Chapter 10

This chapter has retained a similar structure as in ICD–10, with only minor changes.
Table 1: Comparison of ICD-10 block structure with ICD-11 equivalent structure

ICD-11 Reference Guide 431

 ICD-10 block ICD-11 equivalent structure
heading
H60-H62 Diseases of Diseases of external ear
external ear
H65-H75 Diseases of Diseases of middle ear or mastoid
middle ear and
mastoid
H80-H83 Diseases of Diseases of inner ear
inner ear
H90-H95 Other Redistributed into the groupings Disorders with hearing
disorders of ear impairment, Disorders of ear, not elsewhere classified and
Postprocedural disorders of ear or mastoid process
3.15.11 Differences between ICD–10 and ICD–11 in Chapter 11

There has been some restructuring and regrouping throughout this chapter, with new
concepts based on medical advancements over the last 20 years added. Medical
terminology has been updated. The sections on Hypertension and Heart valve diseases have
been expanded. Heart valve diseases have moved from a classification based on aetiology
(rheumatic/non-rheumatic) followed by valve type and disease physiology; to a hierarchy
led by valve type, then disease physiology, followed by aetiology, in keeping with current
clinical practice. Non-rheumatic valve disease has therefore been moved from ‘Other forms
of heart disease’ to the heart valve disease section. Acute rheumatic fever has been moved
to Chapter 1.
Cerebrovascular diseases have been moved to the Neurology Chapter (08) as their primary
parent with the Circulatory Chapter being a secondary parent.
Table 1: Comparison of ICD-10 block structure with ICD-11 equivalent structure in Chapter 11

432 ICD-11 MMS

 ICD-10 block heading ICD-11 equivalent structure
I00-I02 Acute rheumatic Moved to Chapter 01 Infectious diseases
fever
I05-I09 Chronic rheumatic Heart valve diseases - Change in hierarchy for the
heart diseases classification of heart valve disorders to heart valve type and
then by aetiology
I10–I15 Hypertensive Hypertensive diseases - Remains relatively the same with
diseases expansion of some categories, essential hypertension now
includes subcategories for diastolic/systolic hypertension
I20–I25 Ischaemic heart Ischaemic heart diseases - Change in terminology for AMI to
diseases reflect STEMI/NSTEMI only. Inclusion of timeframe for old
AMI. Expansion of complications following and AMI. New
section for ‘Diseases of coronary artery’ to include coronary
atherosclerosis, coronary artery aneurysm, dissection, fistula
I26–I28 Pulmonary heart Pulmonary heart disease or diseases of pulmonary circulation
disease and diseases of - Expansion of some categories (e.g. pulmonary
pulmonary circulation hypertension) to include new concepts, particularly
pulmonary hypertension.
I30–I52 Other forms of This block category title no longer exists in ICD-11 and the
heart disease concepts within have been made distinct entities and
expanded to include new terminology and disease processes
I60–I69 Cerebrovascular Reclassified to Chapter 08 Diseases of the nervous system
diseases
I70–I79 Diseases of Diseases of capillaries has been moved into Diseases of skin
arteries, arterioles and
capillaries
I80–I89 Diseases of veins, This section has been separated into two main blocks:
lymphatic vessels and Diseases of veins and Disorders of lymphatic vessels and
lymph nodes, not lymph nodes. Oesophageal varices and Haemorrhoids have
elsewhere classified been reclassified to Chapter 13 Diseases of the digestive
system - Vascular disorders of the oesophagus and Vascular
disease of anus and anal canal, respectively
I95–I99 Other and Marked expansion of the postprocedural disorders section
unspecified disorders of with new codes for postprocedural disorders following repair
the circulatory system of congenital anomalies.
3.15.12 Differences between ICD–10 and ICD–11 in Chapter 12

There has been some restructuring and regrouping of this chapter, with new concepts
added and the inclusion of updated and current terminology.

ICD-11 Reference Guide 433

 • A new section, Inhalational, occupational and environmental lung disease has been
added to improve the classification of respiratory disorders according to their
aetiology.
• Sleep disorders of breathing and respiratory control have been moved into the new
chapter of Sleep disorders (Chapter 7) and secondarily parented to the Respiratory
Chapter.
• Cystic fibrosis has been moved to the Respiratory Chapter and multi-parented to
Chapter 05 ‘Endocrine, nutritional or metabolic diseases’.
Table 1: Comparison of ICD-10 block structure with ICD-11 equivalent structure in Chapter 12

ICD-10 block heading ICD-11 equivalent structure

J00-J06 Acute upper Upper respiratory tract disorders section, Infectious diseases
respiratory infections by infectious agent
J09-J18 Influenza and Lung infections
pneumonia
J20-J22 Other acute Combined into the grouping - Lung infections
lower respiratory
infections
J30-J39 Other diseases Combined into the grouping - Upper respiratory tract disorders
of upper respiratory
tract
J40-J47 Chronic lower Certain lower respiratory tract diseases
respiratory diseases
J60-J70 Lung diseases Lung diseases due to external agents
due to external agents
J80-J84 Other Respiratory diseases principally affecting the lung interstitium
respiratory diseases
principally affecting the
interstitium
J85-J86 Suppurative and Combined into the grouping - Lung infections
necrotic conditions of
lower respiratory tract
J90-J94 Other diseases Pleural, diaphragm and mediastinal disorders
of pleura
J95-J99 Other diseases Certain diseases of the respiratory system Postprocedural
of the respiratory respiratory disorders have been moved to a grouping of their
system own. Mediastinal and diaphragm disorders were moved to the
section for Pleural, diaphragm and mediastinal disorders
3.15.13 Differences between ICD–10 and ICD–11 in Chapter 13

There has been a major restructuring and change of the previous ICD-10 concepts in this
chapter. Detailed anatomical groups were added to the hierarchy, such as ‘Diseases of
duodenum’, ‘Diseases of the anal canal’ or ‘Diseases of the pancreas’. Independent
categories for functional gastrointestinal disorders and inflammatory bowel diseases have

434 ICD-11 MMS

also been included to cover broad anatomical sites. Additional dimensions are available
from the clinical findings section in Chapter 21 and Chapter X ‘Extension Codes’ for use in
postcoordination. For example, with and without haemorrhage, with and without
obstruction, with and without ascites, laterality and greater site specificity, etc.
Although ICD-10 included diseases of the oral cavity, salivary glands and jaws, the
corresponding section of Chapter 13 in ICD-11 has been improved in structure and content
to include diseases and disorders of the orofacial complex.
Table 1: Comparison of ICD-10 block structure with ICD-11 equivalent structure

ICD-10 block heading ICD-11 equivalent structure

K00-K14 Diseases of oral Diseases or disorders of orofacial complex
cavity, salivary glands and
jaws
K20-K31 Diseases of Now in two groups – Diseases of oesophagus and
oesophagus, stomach and Diseases of the stomach or the duodenum
duodenum
K35-K38 Diseases of appendix Diseases of appendix
K40-K46 Hernia Hernia
K50-K52 Noninfective Now in two groups – Gastritis, under Diseases of stomach
enteritis and colitis and Certain noninfectious colitis or proctitis
K55-K64 Other diseases of Redistributed to various new groups based on anatomical
intestines sites
K65-K67 Diseases of Diseases of peritoneum
peritoneum
K70-K77 Diseases of liver Diseases of liver
K80-K87 Disorders of Now in two groups – Diseases of gallbladder or biliary
gallbladder, biliary tract and tract and Diseases of pancreas
pancreas
K90-K93 Other diseases of Redistributed to various groups including Postprocedural
the digestive system disorders of digestive system and Clinical findings in the
digestive system
3.15.14 Differences between ICD–10 and ICD–11 in Chapter 14

Chapter 14 has undergone major restructuring, with the addition of more detailed entities.
The terminology has been updated to be more current. Detail has come from the fusion of
the American, British and German dermatological terminologies.
Table 1: Comparison of ICD-10 block structure with ICD-11 equivalent structure

ICD-11 Reference Guide 435

 ICD-10 block heading ICD-11 equivalent structure
L00-L08 Infections of the skin Certain skin disorders attributable to infection or
and subcutaneous tissue infestation
L10-L14 Bullous disorders Renamed Immunobullous diseases of the skin and
included under inflammatory dermatoses
L20-L30 Dermatitis and eczema Dermatitis and eczema
L40-L45 Papulosquamous Papulosquamous dermatoses (included under
disorders inflammatory dermatoses)
L50-L54 Urticaria and erythema Part of groupings – Urticaria, angioedema and other
urticarial disorders and Inflammatory erythemas and
other reactive inflammatory dermatoses
L55-L69 Radiation-related Dermatoses provoked by light or UV radiation
disorders of the skin and
subcutaneous tissue
L60-L75 Disorders of skin Disorders of the epidermis and epidermal appendages
appendages
L80-L99 Other disorders of the Redistributed to various groups throughout the
skin and subcutaneous tissue restructured Skin chapter
3.15.15 Differences between ICD–10 and ICD–11 in Chapter 15

The blocks in this chapter have been reordered, and a new block - Auto-inflammatory
syndromes has been added to the Immune Chapter and secondarily parented to here. The
area of spinal conditions has been restructured and renamed to Conditions associated with
the spine.
Table 1: Comparison of ICD-10 block structure with ICD-11 equivalent structure

436 ICD-11 MMS

 ICD-10 block heading ICD-11 equivalent structure
M00-M25 Arthropathies Arthropathies
M30-M36 Systemic Moved to Chapter 04 ‘Diseases of the immune system’
connective tissue disorders
M40-M54 Dorsopathies Conditions associated with the spine
M60-M79 Soft tissue Soft tissue disorders
disorders
M80-M94 Osteopathies Osteopathies or chondropathies
and chondropathies
M95-M99 Other disorders Redistributed to various groupings including Certain
of the musculoskeletal and specified acquired deformities of musculoskeletal system or
connective tissue connective tissue, not elsewhere classified and
Postprocedural musculoskeletal disorders, not elsewhere
classified
3.15.16 Differences between ICD–10 and ICD–11 in Chapter 16

Chapter 16 has been reordered to distinguish diseases of the female genital system, the
male genital system, and the urinary system. There is more specificity within the areas of
Amenorrhea, Ovarian dysfunction, Female pelvic pain, Endometriosis, Adenomyosis, Female
infertility, Male infertility, Early pregnancy loss, and Pregnancy outcomes reflecting current
scientific understanding. The hierarchy is now divided into non-inflammatory disorders and
inflammatory disorders, which are further divided by anatomical groupings. These groupings
are in an order followed by gynaecological and obstetric examinations i.e. from external to
internal genitalia. Neoplasms of the urinary system are primarily located in Chapter 02
‘Neoplasms’, Structural developmental anomalies of the urinary system are primarily
located in Chapter 20 and Symptoms, signs or clinical findings involving the urinary system
are primarily located in Chapter 21.
All diseases relating to the kidney are now classified under the main category for ‘Diseases
of the urinary system’. Acute kidney failure and chronic kidney disease now incorporates the
currently used staging classification as proposed by Kidney Disease | Improving Global
Outcomes (KDIGO).
The classification of Glomerular diseases has been restructured and is now divided into
clinical features/syndromes. A new block has been added for Cystic and dysplastic kidney
disease, originally, classified in ICD-10 to Chapter 17 ‘Congenital malformations,
deformations and chromosomal abnormalities’, with relevant entities grouped together and
based on the 2015 KDIGO guidelines.
Table 1: Comparison of ICD-10 block structure with ICD-11 equivalent structure

ICD-11 Reference Guide 437

ICD-10 block heading ICD-11 equivalent structure
N00-N08 Glomerular Glomerular diseases - Classified to Diseases of the urinary
diseases system. This section is now classified according to clinical
features or syndromes. Still includes: Nephritic syndrome
Nephrotic syndrome Isolated proteinuria and albuminuria. The
subdivisions describing morphology typically determined by
biopsy have been moved to Chapter 21 under Clinical findings
of the urinary system. Electron microscopy and
immunofluorescence findings subdivisions have been removed
from proteinuria with morphological lesion. This is now
classified to Isolated proteinuria and albuminuria.
N10-N16 Renal-tubulo- Renal-tubulo-interstitial diseases - Classified to Diseases of the
interstitial diseases urinary system. Section remains relatively the same. Tubular
and cortical necrosis has been unbundled from acute renal
failure to be a distinct codable entity classified to this section.
N17-N19 Renal failure Kidney failure - Classified to Diseases of the urinary system.
Acute renal failure is no longer a bundled concept which
previously identified the acute kidney damage i.e. acute tubular
necrosis.
N20-N23 Urolithiasis Urolithiasis - Classified to Diseases of the urinary system.
Subdivided into upper urinary tract (includes kidney and ureter)
and lower urinary tract (includes bladder and urethra). Renal
colic has been reclassified to Chapter 21 Symptoms, signs and
clinical findings involving the urinary system
N25-N29 Other Certain specified disorders of kidney or ureter - Classified to
disorders of kidney and Diseases of the urinary system. Reclassification of disorders
ureter relating to the size of the kidney to Chapter 21 Symptoms, signs
or clinical findings involving the urinary system - Macroscopic
changes of size of the kidney
N30-N39 Other Certain specified diseases of urinary system – remains similar to
diseases of urinary ICD-10
system
N40-N51 Diseases of Diseases of male genital organs– remains similar to ICD-10
male genital organs
N60-N64 Disorders of Disorders of breast– remains similar to ICD-10
breast
N70-N77 Inflammatory Inflammatory disorders of the female genital tract - Classified to
diseases of female Diseases of the female genital system.
pelvic organs
N80-N98 Noninflammatory disorders of female genital tract – Classified
Noninflammatory to Diseases of the female genital system
disorders of female
genital tract

438 ICD-11 MMS

 ICD-10 block heading ICD-11 equivalent structure
N99 Other disorders of Other disorders of the genitourinary system – Postprocedural
the genitourinary disorders of the genitourinary system has been moved out of
system this section to be a grouping of its own
3.15.17 Chapter 17 is a new addition to ICD–11 and was not found in past editions

Table 1: Comparison of ICD-10 block structure with ICD-11 equivalent structure

ICD-10 previous location ICD-11

equivalent
structure
Codes from Mental Health category F52 Sexual dysfunction, not Sexual
caused by organic disorder or disease dysfunctions
Codes from Mental Health category F52 Sexual dysfunction, not Sexual pain
caused by organic disorder or disease and Genitourinary category N94 disorders
Pain and other conditions associated with female genital organs and
menstrual cycle
Codes from Mental Health category F64 Gender identity disorders Gender
incongruence
3.15.18 Differences between ICD–10 and ICD–11 in Chapter 18

The chapter has been reordered but content remains similar to that in ICD–10. There have
been some changes and additions made to the sections Maternal care related to the fetus
and amniotic cavity and possible delivery problems and Complications of labour and
delivery. Additional specifications have been included for “Early pregnancy loss”. A new
section Obstetric haemorrhage has been added to enable all types of haemorrhage to be
grouped together.
Table 1: Comparison of ICD-10 block structure with ICD-11 equivalent structure

ICD-11 Reference Guide 439

 ICD-10 block heading ICD-11 equivalent structure
O00-O08 Pregnancy with abortive outcome Abortive outcome of pregnancy
O10-O16 Oedema, proteinuria and Oedema, proteinuria, or hypertensive
hypertensive disorders in pregnancy, disorders in pregnancy, childbirth, or the
childbirth and the puerperium puerperium
O20-O29 Other maternal disorders Certain specified maternal disorders
predominantly related to pregnancy predominantly related to pregnancy
O30-O48 Maternal care related to the fetus Maternal care related to the fetus,
and amniotic cavity and possible delivery amniotic cavity or possible delivery
problems problems
O60-O75 Complications of labour and Complications of labour or delivery
delivery
O80-O84 Delivery Delivery
O85-O92 Complications predominantly Complications predominantly related to
related to the puerperium the puerperium
O94-O99 Other obstetric conditions, not Certain obstetric conditions, not
elsewhere classified elsewhere classified
3.15.19 Differences between ICD–10 and ICD–11 in Chapter 19

There has been some reordering of this chapter but it remains similar to that in ICD–10.
There is new grouping for Neurological disorders specific to the perinatal or neonatal period
and an expansion of codes for gestational age of the newborn.
Table 1: Comparison of ICD-10 block structure with ICD-11 equivalent structure

440 ICD-11 MMS

 ICD-10 block heading ICD-11 equivalent structure
P00-P04 Fetus and newborn fetus or newborn affected by maternal factors or by
affected by maternal factors and complications of pregnancy, labour or delivery
by complications of pregnancy,
labour and delivery
P05-P08 Disorders related to Disorders of newborn related to length of gestation
length of gestation and fetal or fetal growth
growth
P10-P15 Birth trauma Birth injury
P20-P29 Respiratory and Split into two groups: Respiratory disorders specific
cardiovascular disorders specific to the perinatal or neonatal period; Cardiovascular
to the perinatal period disorders present in the perinatal or neonatal period
P35-P39 Infections specific to the Infections of the fetus or newborn
perinatal period
P50-P61 Haemorrhagic and Haemorrhagic or haematological disorders of fetus or
haematological disorders of fetus newborn
and newborn
P70-P74 Transitory endocrine and Transitory endocrine or metabolic disorders specific
metabolic disorders specific to to fetus or newborn
fetus and newborn
P75-P78 Digestive system Digestive system disorders of fetus or newborn
disorders of fetus and newborn
P80-P83 Conditions involving the Split into two groups: Disorders involving the
integument and temperature integument of fetus or newborn; Disturbances of
regulation of fetus and newborn temperature regulation of newborn
P90-P96 other disorders Certain disorders originating in the perinatal period –
originating in the perinatal period Block 91 other disturbances of cerebral status of
newborn has been moved into a new grouping
Neurological disorders specific to the perinatal or
neonatal period
3.15.20 Differences between ICD–10 and ICD–11 in Chapter 20

This chapter has undergone major restructuring including a title change from Congenital
malformations, deformations and chromosomal abnormalities to Developmental anomalies.
All genetic syndromes without structural developmental anomalies have been reallocated to
appropriate chapters of the ICD, according to the affected body system(s).
Table 1: Comparison of ICD-10 block structure with ICD-11 equivalent structure

ICD-11 Reference Guide 441

ICD-10 previous location ICD-11 equivalent structure
Q00-Q07 Congenital Structural developmental anomalies of the nervous
malformations of the system - A grouping under Structural developmental
nervous system anomalies primarily affecting one body system
Q10-Q18 Congenital Split into four separate groups under Structural
malformations of eye, ear, developmental anomalies primarily affecting one body
face and neck system:
Structural developmental anomalies of the eye, eyelid or
lacrimal apparatus
Structural developmental anomalies of the ear
Structural developmental anomalies of the face, mouth or
teeth
Structural developmental anomalies of the neck
Q20-Q28 Congenital Structural developmental anomalies of the circulatory
malformations of the system - A grouping under Structural developmental
circulatory system anomalies primarily affecting one body system
Q30-Q34 Congenital Structural developmental anomalies of the respiratory
malformations of the system - A grouping under Structural developmental
respiratory system anomalies primarily affecting one body system
Q35-Q37 Cleft lip and cleft Clefts of lip, alveolus or palate is a subsection in the
palate grouping Structural developmental anomalies of the face,
mouth or teeth
Q38-Q45 Other congenital Structural developmental anomalies of the digestive tract
malformations of the - A grouping under Structural developmental anomalies
digestive system primarily affecting one body system
Q50-Q56 Congenital Split into two separate groups under Structural
malformations of genital developmental anomalies primarily affecting one body
organs system: Structural developmental anomalies of the female
genital system; Structural developmental anomalies of the
male genital system
Q60-Q64 Congenital Structural developmental anomalies of the urinary system
malformations of the urinary - A grouping under Structural developmental anomalies
system primarily affecting one body system
Q65-Q79 Congenital Structural developmental anomalies of the skeleton
malformations and
deformations of the
musculoskeletal system
Q80-Q89 Other congenital Redistributed to various groupings within the new
malformations structure of the chapter
Q90-Q99 Chromosomal Chromosomal anomalies, excluding gene mutations
abnormalities, not elsewhere
classified
3.15.21 Differences between ICD–10 and ICD–11 in Chapter 21

442 ICD-11 MMS

This chapter has undergone major restructuring with the high level hierarchy now in line
with the ICD chapters. Certain clinical forms previously located in other chapters as asterisk
codes are now located here. A new category has been added for Findings of microorganism
resistant to antimicrobial drugs.
Table 1: Comparison of ICD-10 block structure with ICD-11 equivalent structure

ICD-11 Reference Guide 443

ICD-10 block heading ICD-11 equivalent structure
R00-R09 Symptoms and signs Split into two groupings: Symptoms, signs or clinical
involving the circulatory and findings of the circulatory system; Symptoms, signs or
respiratory systems clinical findings of the respiratory system
R10-R19 Symptoms and signs Symptoms, signs or clinical findings of the digestive
involving the digestive system system or abdomen
and abdomen
R20-R23 Symptoms and signs Symptoms, signs or clinical findings involving the skin
involving the skin and
subcutaneous tissue
R25-R29 Symptoms and signs Split into two groupings: Symptoms, signs or clinical
involving the nervous and findings of the nervous system; Symptoms, signs or
musculoskeletal systems clinical findings of the musculoskeletal system
R30-R39 Symptoms and signs Symptoms, signs or clinical findings of the
involving the urinary system genitourinary system - part of the grouping
Symptoms, signs or clinical findings of the
genitourinary system
R40-R46 Symptoms and signs Reorganised into various subsections under Mental or
involving cognition, perception, behavioural symptoms, signs or clinical findings
emotional state and behaviour
R47-R49 Symptoms and signs Symptoms, signs or clinical findings of speech or voice
involving speech and voice
R50-R69 General symptoms and General symptoms, signs or clinical findings
signs
R70-R79 Abnormal findings on Included in the grouping Symptoms, signs or clinical
examination of blood, without findings of blood, blood-forming organs or the
diagnosis immune system
R80-R82 Abnormal findings on Clinical findings on examination of urine, without
examination of urine, without diagnosis under the grouping Symptoms, signs or
diagnosis clinical findings involving the urinary system
R83-R89 Abnormal findings on Clinical findings in specimens from other specified
examination of other body fluids, organs, systems and tissues under the grouping
substances and tissues, without General symptoms, signs or clinical findings
diagnosis
R90-R94 Abnormal findings on Split into two subsections: Abnormal diagnostic
diagnostic imaging and in imaging results not elsewhere classified; Abnormal
function studies, without results of function studies of other organs and
diagnosis systems in the grouping Abnormal results not
elsewhere classified
R95-R99 Ill-defined and unknown Ill-defined and unknown causes of mortality
causes of mortality
3.15.22 Differences between ICD–10 and ICD–11 in Chapter 22

444 ICD-11 MMS

The high level categories have only a few changes. Changes are mainly at the lower
character level and include additions of more specific categories of injury types and body
location of the injury. There are no longer separate codes for burns and for corrosions. They
are all together under Burns. Additional dimensions are available from Chapter X Extension
codes, for postcoordination to add further detail such as laterality, or depth of burn. Major
changes have been made to the section for complications of medical and surgical care. The
Quality and Safety TAG has revised the coding of health care related injuries and events. The
concept of a mechanical complication of a device is now classified as an external cause of
harm.
Table 1: Comparison of ICD-10 block structure with ICD-11 equivalent structure

ICD-11 Reference Guide 445

ICD-10 block heading ICD-11 equivalent structure
S00-S09 Injuries to the head Injuries to the head
S10-S19 Injuries to the neck Injuries to the neck
S20-S29 Injuries to the thorax Injuries to the thorax
S30-S39 Injuries to the Injuries to the abdomen, lower back, lumbar spine or
abdomen, lower back, lumbar pelvis
spine and pelvis
S40-S49 Injuries to the Injuries to the shoulder or upper arm
shoulder and upper arm
S50-S59 Injuries to the elbow Injuries to the elbow or forearm
and forearm
S60-S69 Injuries to the wrist Injuries to the wrist or hand
and hand
S70-S79 Injuries to the hip and Injuries to the hip or thigh
thigh
S80-S89 Injuries to the knee Injuries to the knee or lower leg
and lower leg
S90-S99 Injuries to the ankle Injuries to the ankle or foot
and foot
T00-T07 Injuries involving Injuries involving multiple body regions
multiple body regions
T08-T14 Injuries to unspecified Injuries to unspecified part of trunk, limb or body region
part of trunk, limb or body
region
T15-T19 Effects of foreign Effects of foreign body entering through natural orifice
body entering through natural
orifice
T20-T32 Burns and corrosions Burns
T33-T35 Frostbite Frostbite
T36-T50 Poisoning by drugs, Now included under the main grouping Harmful effects
medicaments and biological of substances
substances
T51-T65 Toxic effects of Now included under the main grouping Harmful effects
substances chiefly of substances
nonmedicinal as to source
T66-T78 Other and unspecified Other or unspecified effects of external causes
effects of external causes
T79 Certain early Other or unspecified effects of external causes
complications of trauma
Now included under the main grouping

446 ICD-11 MMS

 ICD-10 block heading ICD-11 equivalent structure
T80-T88 Complications of Injury or harm arising from surgical or medical care, not
surgical and medical care, not elsewhere classified
elsewhere classified
T90-T98 Sequelae of injuries, Redistributed to the specific body grouping as index
of poisoning and of other terms. Sequelae will now be indicated by an cluster
consequences of external identifying the condition that is the sequelae, a code
causes from Chapter 24 QC50 and the original injury.
3.15.23 Differences between ICD–10 and ICD–11 in Chapter 23

The primary axis for all external causes except exposure to extreme forces of nature,
maltreatment, legal intervention, armed conflict and health care related harm or injury is
now based on ‘intent’. The codes are a combination of intent, followed by mechanism and
object or substance involved in occurrence of injury. There has been an expansion in the
areas of vehicle types, places of occurrence, types of activities, legal/war codes, and
substances. The areas of Complications of medical and surgical care and Maltreatment
syndromes have been revised and improved. Additional dimensions are available from
Chapter X Extension codes, for use in postcoordination. Further, the categories for sequelae
of external causes have been removed and such cases are primarily coded to the
appropriate categories describing the event, resulting in increases in the frequencies of the
specific categories.
An extension code can be used in postcoordination where such sequelae need to be
identified separately.
Table 1: Comparison of ICD-10 block structure with ICD-11 equivalent structure

ICD-11 Reference Guide 447

 ICD-10 block heading ICD-11 equivalent structure
V01-X59 Accidents Redistributed to the main groupings of Unintentional
cause, Intentional self-harm, Assault and Unknown
intent
X60-X84 Intentional self-harm Intentional self-harm
X85-Y09 Assault Assault
Y10-Y34 Event of Undetermined intent
undetermined intent
Y35-Y36 Legal intervention Split into two groups: Legal intervention; Armed conflict
and operations of war
Y40-Y84 Complications of Causes of health care related harm or injury
medical and surgical care
Y85-Y89 Sequelae of external Redistributed to the specific external cause grouping as
causes of morbidity and index terms. Sequelae will now be indicated by a cluster
mortality identifying the condition that is the sequelae, a code
from Chapter 24 QC50 and the original external cause
code.
Y90-Y98 Supplementary Entities from this block are now found in either Chapter
factors related to causes of 21 Symptoms, signs and clinical findings (e.g. blood
morbidity and mortality alcohol level findings) or have been added to Section X
classified elsewhere ‘Extension codes’ (e.g. nosocomial condition)
3.15.24 Differences between ICD–10 and ICD–11 in Chapter 24

This chapter has undergone reorganisation and is divided into two main sections: Reasons
for contact with the health system and Factors influencing health status. There has been an
expansion of the section related to reproduction with the addition of a new section Contact
with health services for reproductive management. There is also a new section for health
care related adverse events that occur but do not result in any harm to the patient.
Table 1: Comparison of ICD-10 block structure with ICD-11 equivalent structure

448 ICD-11 MMS

 ICD-10 block heading ICD-11 equivalent structure
Z00-Z13 Persons encountering Contact with health systems for purposes of
health services for examination and examination or investigation – a section under the
investigation grouping Reasons for contact with the health
system
Z20-Z29 Persons with potential Contact with or exposure to communicable
health hazards related to diseases – a section under the grouping Reasons for
communicable diseases contact with the health system
Z30-Z39 Persons encountering Contact with health services for reasons associated
health services in circumstances with reproduction diseases – a section under the
related to reproduction grouping Reasons for contact with the health
system
Z40-Z54 Persons encountering Split into two new sections, under Reasons for
health services for specific contact with the health system: Contact with health
procedures and health care services for specific surgical interventions; Contact
with health services for nonsurgical interventions
not involving devices
Z55-Z65 Persons with potential Reorganised and now appear under main grouping
health hazards related to of Factors influencing health status
socioeconomic and psychosocial
circumstances
Z70-Z76 Persons encountering Reorganised and now appear under main grouping
health services in other of Factors influencing health status
circumstances
Z80-Z99 Persons with potential Reorganised and now appear under main grouping
health hazards related to family and of Factors influencing health status
personal history and certain
conditions influencing health status
3.15.25 Differences between ICD–10 and ICD–11 in Chapter 25

Diseases formerly coded here have been moved to their primary places within ICD–11. New
codes for use as international provisional codes have been included.
Table 1: Comparison of ICD-10 block structure with ICD-11 equivalent structure

ICD-11 Reference Guide 449

ICD-10 block heading ICD-11 equivalent structure
U00-U49 Provisional assignment Split into two new sections: International provisional
of new diseases of uncertain assignment of new diseases of uncertain aetiology;
aetiology or emergency use National provisional assignment of new diseases of
uncertain aetiology
U82-U85 Resistance to Moved to Chapter 21 with the new title Finding of
antimicrobial and antineoplastic microorganism resistant to antimicrobial drugs
drugs
3.16 Annex E: Referred Value Sets
• Section [Link] Hypertension due to other conditions refers to 3 Value Sets:
Endocrine neoplasms
Renal neoplasms
Carcinoid tumours

• Section [Link] Sepsis refers to 6 Value Sets:

Conditions that impair the immune system
Wasting Diseases
Diseases causing paralysis - sepsis
Serious respiratory conditions
Serious injuries
Diseases of infectious origin

• Section [Link] Embolism refers to 6 Value Sets:

Venous thrombosis
Phlebitis or thrombophlebitis
Valvular heart disease
Childbirth
Operation
Embolic

• Section [Link] Pneumonia refers to 6 Value Sets:

Conditions that impair the immune system
Wasting Diseases
Diseases causing paralysis
Serious respiratory conditions
Conditions that affect the process of swallowing
Serious injuries

• Section [Link] Common secondary conditions refers to 3 Value Sets:

Wasting Diseases
Diseases causing paralysis

450 ICD-11 MMS

 Serious injuries

• Section [Link] Secondary peritonitis refers to 1 Value Set:

Secondary peritonitis and unspecified peritonitis

• Section 3.14.10 List of conditions unlikely to cause death refers to 1 Value Set:
Unlikely to cause death

• Section 3.14.14 Target list of causes of death for verbal autopsy refers to 65 Value
Sets:
Sepsis
Acute respiratory infection, including pneumonia
HIV/AIDS related death
Diarrheal diseases
Malaria
Measles
Meningitis and encephalitis
Tetanus
Pulmonary tuberculosis
Pertussis
Haemorrhagic fever
Dengue fever
Coronavirus disease (COVID-19)
Unspecified infectious disease
Other and unspecified non-communicable disease
Oral neoplasms
Digestive neoplasms
Respiratory neoplasms
Breast neoplasms
Female reproductive neoplasms
Male reproductive neoplasms
Other and unspecified neoplasms
Severe anaemia
Severe malnutrition
Diabetes mellitus
Acute cardiac disease
Stroke
Sickle cell with crisis
Other and unspecified cardiac disease
Chronic obstructive pulmonary disease (COPD)
Asthma
Acute abdomen
Liver cirrhosis
Renal failure
Epilepsy
Ectopic pregnancy
Abortion-related death

ICD-11 Reference Guide 451

 Pregnancy-induced hypertension
Obstetric haemorrhage
Obstructed labour
Pregnancy-related sepsis
Anaemia of pregnancy
Ruptured uterus
Other and unspecified maternal cause
Prematurity or low birth weight
Birth asphyxia
Neonatal pneumonia
Neonatal sepsis
Neonatal tetanus
Congenital malformation
Other and unspecified perinatal cause of death
Fresh stillbirth
Macerated stillbirth
Road traffic accident
Other transport accident
Accidental fall
Accidental drowning and submersion
Accidental exposure to smoke, fire and flames
Contact with venomous animals and plants
Accidental poisoning and exposure to noxious substance
Intentional self-harm
Assault
Exposure to force of nature
Other and unspecified external cause of death
Cause of death unknown

452 ICD-11 MMS