Improving External Cause Coding in Hospital Discharge Data

  • Date: Nov 06 2007
  • Policy Number: 200710

Key Words: Information Technology, Health Care, Hospital Discharge, Health Records

This policy resolution supersedes APHA Position statement 9112 “Use of E Codes in Hospital Discharge Data” approved 1991. The resolution replaces the previous policy, which should be archived.

Injuries, both unintentional and intentional, remain one of the most neglected and costly public health problems in our society.1,2 Surveillance is the basis for the public health approach to assessing, preventing, and controlling injuries.1 Statewide hospital discharge databases are a core data set recommended for injury surveillance by state health departments.3 Hospital discharge data are coded using the current International Classification of Diseases Clinical Modification, which provides codes to specify both the nature of the injury (e.g., skull fracture) and the mechanism or external cause (e.g., bike collision with motor vehicle).4 Improved external cause-of-injury coding helps planners identify and address issues involving patient safety, such as elderly falls, motor vehicle crashes, suicide attempts, and other injuries that present a significant economic burden to the health care system.2,5,6 

Currently, hospitals routinely code injury according to the nature of the injury, and the external cause code is not consistently or uniformly included in hospital discharge databases.1,7,8 Limited progress has been made on this issue since 1990, with (as of 2005) only 26 states currently having a mandate for external cause coding. In states that have evaluated their systems, only 55% of statewide hospital emergency department data sets have an external cause code for more than 90% of injury records.9 Even when external cause codes are present, the use of nonspecific codes greatly limits their utility.10 

Both Healthy People 2010 objectives and the patient safety indicators promulgated by the Agency for Healthcare Research and Quality require external cause-coded data.5,11 Organizations such as the Council of State and Territorial Epidemiologists,12 the State and Territorial Injury Prevention Directors Association,13 the American Academy of Pediatrics,14 and the Suicide Prevention Action Network6 currently endorse improvements in external cause-of-injury coding. The costs of fully implementing external cause coding as part of hospital discharge data are minimal.15 

Recognizing that the federal data systems (UHDDS) and uniform billing (UB) procedures drive the submission of data to statewide hospital discharge databases, but that these procedures do not currently require the submission of external cause codes, APHA therefore—

1. Recommends that all states require external cause-of-injury codes be recorded in the hospital record for each hospital admission for which an injury is the principal diagnosis, and the first-listed external cause code should be related directly to the principal diagnosis.
2. Recommends that UHDDS and UB procedures require the submission of these data from statewide hospital discharge databases.
3. Recommends that data quality assurance programs at the state level be developed and implemented with an aim toward improving the completeness and accuracy of external cause-of-injury codes.
4. Recommends that professional organizations join with the APHA, the Council of State and Territorial Epidemiologists, the State and Territorial Injury Prevention Directors Association, the American Hospital Association, the American Academy of Pediatrics and the Suicide Prevention Action Network in endorsing the importance of complete and specific external cause coding in statewide hospital discharge databases.
5. Calls on the Centers for Disease Control and Prevention’s National Center for Injury Prevention and Control and National Center for Health Statistics to lead a national effort to develop a strategy to improve the completeness and specificity of external cause coding in hospital discharge databases which should include, at least—
a. Facilitation of a unified federal effort to address this issue involving agencies affected by this issue, such as the Agency for Healthcare Research and Quality, the Center for Medicaid and Medicare Services, and the National Highway Traffic Safety Administration;
b. Exploration of the use of UHDDS and UB procedures as a tool to address this issue;
c. Exploration of how other developed countries have approached getting complete and accurate external cause-of-injury coding;
d. Education of clinicians, coders, and hospital administrators on the importance of external cause coding to public health surveillance and prevention of injury and violence;
e. Promotion of the assessment of external cause coding completeness and specificity in statewide hospital discharge databases.


  1. Bonnie RJ, Fulco CE, Liverman CT (eds.). Reducing the Burden of Injury: Advancing Prevention and Treatment. Washington, DC: National Academy Press; 1999.
  2. Finkelstein EA, Corso PS, Miller TR, Associates. The Incidence and Economic Burden of Injuries in the United States. New York: Oxford University Press; 2006.
  3. Injury Surveillance Workgroup. Consensus Recommendations for Using Hospital Discharge Data for Injury Surveillance. Marietta, GA: State and Territorial Injury Prevention Directors Association; 2003. 
  4. International Classification of Diseases, Ninth Revision, Clinical Modification. Hyattsville, MD: National Center for Health Statistics; 1980. DHHS publication PHS 80-1260.
  5. Agency for Healthcare Research and Quality. Guide to Patient Safety Indicators, Version 3.0a. 2006. Available at: http://www.qualityindicators.ahrq.gov/archives/psi/psi_guide_v30a.doc. Accessed December 13, 2007.
  6. Suicide Prevention Action Network (SPAN). Strategies to Improve Non-Fatal Suicide Attempt Surveillance—Recommendations From an Expert Roundtable. Washington, DC: SPAN; 2006. 
  7. Heinen M, Hall MJ, Boudreault MA, Fingerhut LA. National Trends in Injury Hospitalizations 1979–2001. Washington, DC: National Center for Health Statistics; 2005.
  8. Coben JH, Steiner CA, Barrett M, et al. Completeness of cause of injury coding in healthcare administrative databases in the United States, 2001. Inj Prev. 2006;12:199–201. 
  9. Abellera J, Annest JL, Conn JM, Kohn M. How states are collecting and using cause of injury data: 2004 update to the 1997 report. A survey by The Council of State and Territorial Epidemiologists, Data Committee Injury Control and Emergency Health Services Section, American Public Health Association, and State and Territorial Injury Prevention Directors Association. Atlanta, GA: The Council of State and Territorial Epidemiologists; 2005. Available at: www.cste.org/pdffiles/newpdffiles/ECodeFinal3705.pdf. Accessed March 12, 2007.
  10. Lawrence BA, Miller TR, Weiss HB, Spicer RS. Issues in using state hospital discharge data in injury control research and surveillance. Accid Anal Prev. 2007;39:319–325. 
  11. US Department of Health and Human Services. Healthy People 2010: Understanding and Improving Health. 2nd ed. Washington, DC: U.S. Government Printing Office, 2000. Also available at: http://web.health.gov/healthypeople/document/.
  12. Council of State and Territorial Epidemiologists Position Statement. CSTE Position Statement 1988-7. Amending Hospital Discharge Summaries to Include External Cause of Injury Codes. Council of State and Territorial Epidemiologists Position Statement. Atlanta, GA: CSTE; 1988.
  13. State and Territorial Injury Prevention Directors Association. STIPDA Position Statement 07-INJ-01. Improving external cause of injury coding. State and Territorial Injury Prevention Directors Association. Atlanta, GA: STIPDA; 2004.
  14. Committee on Injury and Poison Prevention. The hospital record of the injured child and the need for external cause of injury codes. Pediatrics. 1999;103:524–526.
  15. Rivara FP, Morgan F, Bergman AB, Maier RV. Cost estimates for statewide reporting of injuries by E coding hospital discharge abstract database systems. Public Health Rep. 1990;105:635–638. 

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