Death By...?

As the song 'American Pie' starts off...

"...long, long, time ago, I can still remember, when..."

It might have been 2002, and I was at an NHCAA conference in San Diego in June, perhaps. NHCAA stands for Nation Health Care Anti-fraud Association, I was there with another co-worker.

This is the annual convention and draws people from all types of fraud departments: State Insurance, Federal Law Enforcement, Commercial insurers, and from companies like mine Blue Cross Blue Shield plans across the nation. I think it runs 4 days.

Birds of a feather flock together, and after one day or so of presentations, a group of us from us went to one of the malls, Fashion Mall, I think.

It was accessible by the trolley, which is part of San Diego's mass transit system. There was trolley stop right behind the hotel,

San Diego the, and maybe still, uses an honor system fro paying the fare. You buy a ticket and show it, if asked to an enforcement individual, who might be on the trolley, or asking you for the ticket as you get off. But there not always there.

There are no turnstiles like the N.Y.C. subway. The trolley runs at ground level, powered by pantograph wires overhead. The ride is as smooth as a baby's bottom, because I think the trolley's wheels are rubber.

The station stops are almost sidewalks. You can walk across the tracks to the other side with no chance of any danger.

Being the New Yorker, I am I marveled at the system, especially the honor system for fare collection. I felt proud of myself when I was confronted at a bus stop for my ticket by uniformed fare enforcers. They almost seemed surprised I had one. I wasn't playing the wise guy, conniving New Yorker to beat the fare.

So, here we are at the Fashion Mall, and I can't get over the trolley and the ability to walk across, or along the tracks. 

Being who I am, I envisioned getting killed by a trolley. Further, I wondered how they would code the accident using the ICD-10 manual, International Classification of Diseases: Death by trolley? Death by trolley going uptown? Downtown? Electric trolley? Diesel powered?

I kept this patter up as we went to and from the Fashion Mall. "Death by trolley." A woman from the Louisiana Blue Cross Blue Shield thought this was quite funny. They don't come across many New Yorkers whose accent make then sound like a gangster, thinking out loud on how to code an unusual death. We can he a handful. We stayed in touch. Somewhat. 

Don't laugh, the ICD-10 manual is thick with codes to uses for all kinds of diseases. Toward the back are a series of alphanumeric codes that attempt to assign a code to an event causing death that is not a medical death. Maybe something like a car accident.

But the codes can be quite granular, and an event might need several codes to capture the cause of death, as we will see. 

The world runs on statistics, and having a uniform coding system for cause of death allows for research into causes. Medical reasons are understandable. Other types of events that might cause death are varied as well: violence, suicide, accidents by all sorts of conveyances, crime, there is quite a list.

There was quite a bit of teeth gnashing on how to code the deaths from the World Trade Center, the Pentagon, and Shanksville, Pennsylvania. Hijacked 767s not using a runway to land causing death was a coding challenge. Did NYC have a sudden surge in homicides? Oh boy.

I immediately thought of the investigator from Louisiana (who is now a manager of the unit) when I was putting the posting together about the assistant night club manager who was crushed to death by a piano that was accidently hydraulically lifting itself to the ceiling while he was on top of a stripper making whoopee. The assistant manger was crushed to death, and the screaming stripper was found the next morning with bruises, but otherwise not physically hurt. A janitor discovered the scene the following morning when he came in to start cleaning.

Being stuck for hours under a corpse on top of you while you're on a piano pressed against he ceiling, had to leave some mental damage. Eventually, more coding.

The woman from Louisiana was still working for the Blue Cross Blue Shield plan, which made me wonder how young was she when I was going on about "death by trolley?" No matter.

We connected via LinkedIn. I linked her to the blog posting about the assistant night club manager killed in a very unusual manner, and asked her if she'd use the ICD-10 book and code the event for me. The book is expensive and I have no need to have one.

She admitted she was not a coder (there are certified coders as a profession) but took a stab with T14.8, crushed, severe, unspecified site. Certainly fits.

I also asked her if she could also code the Central Park carriage accident where a young man fell out of the carriage attempting to help his mother when the carriage was tipped over because the horse felt a charge of stray electricity in its hoof from the pavement, and ran off. The young man hit his head on the pavement and died. Lots of news there. Louisiana passed on that one, but was a bit astonished that I still brought up "death by trolley" after all thee years. 

The coding of unusual deaths still niggled in my brain. It got me thinking. How would they code that? Why not ask AI? Well, ChatGPT reveals how much can go into capturing all the elements of a death precipitated by a horse feeling a stray electrical charge in its hoof and running off while tipping the carriage over, causing a passenger to fall out and fatally crack their skull on the pavement. You got to admit, a lot went into having a very bad day.

ChatGPT:

"If you mean the scenario you describe is unusually specific, but it actually fits the transport-accident classification quite well. The key external-cause code

"The best fit is:

"V80.02XA — Occupant of animal-drawn vehicle injured by fall from or being thrown from animal-drawn vehicle in non-collision accident, initial encounter.

"That category specifically includes an overturning animal-drawn vehicle without a collision, which is essentially what happened when the horse bolted and tipped the carriage.

"For a death certificate/mortality coding, however, the coding works somewhat differently. The CDC says that transportation accidents are classified primarily according to the victim's mode of transportation, and the underlying-cause code is generally selected at the three-character level rather than using the full clinical 7-character injury code.

"So the mortality coding would likely center on:

V80 — Animal-rider or occupant of animal-drawn vehicle injured in transport accident

with the circumstances further described in the record.

"But there is another important part

The actual cause of death would be the fatal head injury—not the horse's electrical sensation. For example, if the medical examiner determined that the passenger died from a traumatic skull fracture and brain injury, the medical cause would be something along the lines of:

Fatal traumatic brain injury due to skull fracture from fall onto pavement

and the V80 code supplies the external circumstances.

"The electrical charge that startled the horse is an additional causal circumstance. ICD-10 mortality coding is designed to capture the chain of events, and the CDC specifically notes that when transportation is involved, the transportation accident is coded as an external cause.

"So, in plain English, your hypothetical could be represented as:

Horse receives stray electrical shock → horse bolts → carriage overturns → passenger is thrown/falls from carriage → strikes head on pavement → fatal skull/brain injury.

"ICD-10-CM external cause: V80.02XA (for the injury encounter)
Underlying mortality classification: V80 (animal-drawn vehicle transport accident)

"One wrinkle: because you specifically said “death precipitated by a horse feeling a stray electrical charge in its hoof,” there may be an argument for separately coding the electrical event. If you're asking this because you're trying to reconstruct how an actual historical death would have been coded, I can dig into the ICD-10 Index and show exactly how the electrical shock → runaway horse → overturned carriage → skull fracture chain would be coded on a death certificate.

"Factoring in the electrical charge causing the bolting:

"Yes — the electrical shock is a separate part of the causal chain, and I would distinguish it from the carriage accident.

"If the horse itself received an accidental electrical shock from, say, a live wire or electrified rail, the ICD-10-CM external-cause category for the human victim is not simply “electrocution.” The passenger was not electrically shocked; the electricity caused the horse to bolt, which caused the transport accident.

"So I would code the chain approximately as:

"Electrical current → horse startled/bolts → animal-drawn carriage overturns → passenger thrown out → fatal head injury.

"The passenger's principal external-cause code would remain in V80, for an occupant of an animal-drawn vehicle injured in a non-collision accident. The ICD-10-CM classification specifically has V80.0 for someone injured by falling from or being thrown from an animal-drawn vehicle in a non-collision accident.

"But if you're asking what code describes the electrical event itself, that's where it gets interesting. The appropriate electrical-current code depends on what supplied the current—for example, a power transmission line, electrical wiring, railway equipment, etc. ICD-10-CM has separate external-cause categories for those circumstances.

"And there's an important distinction:

• Person receives electric shock: an electrical-injury code such as W85–W87 may apply, depending on the source.
• Horse receives shock and a person is subsequently killed: the electrical event is an antecedent circumstance, while the person's injury is the consequence of the animal-drawn-vehicle accident.

"The CDC's mortality guidance emphasizes that the external-cause classification follows the circumstances that produced the fatal injury, and transportation accidents are separately classified.

"If this is for the historical death you have in mind, I can go one step further and find the exact ICD-10 code for “horse struck by electric current” and then construct the complete death-certificate causal sequence.

"Horse struck by electrical current makes it:

"Ah — if you mean the horse itself was struck by an electrical current, rather than the passenger, then I would not use an ICD-10-CM “electric shock” code as though the horse were the patient. ICD-10-CM is a classification for human morbidity/mortality.

"For the human death, however, the electrical event can be described as an antecedent circumstance. The ICD-10-CM Index identifies “Exposure — electric current” as W86.8, with the more specific W86.8XXA being “Exposure to other electric current, initial encounter.”

"But in your exact scenario:

Horse's hoof contacts stray electrical current → horse bolts → carriage overturns → passenger is thrown → passenger sustains fatal skull fracture

"I would not make W86.8 the principal external-cause code for the passenger, because the passenger wasn't exposed to the electricity.

"The most natural coding description would be:

V80 — occupant of animal-drawn vehicle injured in transport accident

with the electrical current recorded as the precipitating circumstance.

"And I think this is what you were getting at originally: “death precipitated by a horse receiving an electrical shock”, rather than “death by electrocution.” That's an important distinction."

WOW! You can see there are a lot of events, and sequence of events, to consider. I watch some of those British detective shows and there's one called 'The Coroner' where a verdict comes in: "Death by misadventure."  How boring. 

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Okay, perhaps the most unusual death ever is the woman in NYC who opened her car door and fell into a manhole because the cover had been dislodged. She fell to the bottom of the manhole and was scalded to death.

ChatGPT

"On May 19, 2026, a 56-year-old woman died after stepping out of her Mercedes-Benz SUV and falling 10 feet into an uncovered manhole on East 52nd Street near Fifth Avenue in Midtown Manhattan. 

"Incident Details: Dislodged Cover: Surveillance video reviewed by Con Edison and the NYPD showed that a multi-axle truck turned onto the street and drove over the manhole cover roughly 12 minutes prior to the incident, unseating and dislodging it.

"Legal and Official Response: City agencies and Con Edison opened joint safety investigations, and the victim's family subsequently filed a lawsuit regarding the hazardous, uncovered condition of the street.

"If you mean how I would code this event in ICD-10-CM I would treat the fatal thermal/steam injury as the principal injury with the fall into the manhole as an external-cause code. The exact burn code cannot be finalized from the narrative alone because the anatomic burn sites and degree of burn are not specified. For 2026 ICD-10-CM, the CDC guidelines say burn codes should identify the site and degree, and that separate codes should be assigned for separate burn sites. Likely coding structure: Coding element ICD-10-CM approach Primary injury coded to the documented body site(s) and burn degree. Add T31 if the percentage of total body surface area burned is documented/needed Steam exposure— exposure to ignition of highly flammable materials / hot vapors/steam category should be verified against the final 2026 tabular listing. 

"An appropriate W17/W18.- fall code depending on the documented mechanics of the fall Cardiac arrestI46.9 may describe cardiac arrest, but it generally would not be the underlying cause of death when the arrest resulted from the fatal thermal injury assuming the medical examiner determined this was an accident. The CDC's ICD-10-CM index specifically recognizes burn from steam as a thermal burn and directs coding according to the burn site.

"If this is for a death certificate that's slightly different from hospital ICD-10-CM coding. Based on the facts you supplied, the causal chain would conceptually be: 

"Underlying cause: Accidental fall into an uncovered utility manhole → exposure to extremely hot steam → severe thermal/scald burns → cardiac arrest → death,. not code “cardiac arrest” as the underlying cause simply because she went into cardiac arrest. Cardiac arrest is the terminal mechanism; the fatal injury that precipitated it is what matters for the causal sequence. Also, I would not assign a specific T20/T21/T22/T23/T24/T25/T26/T27/T28 code from this narrative alone, because doing so would require knowing where she was burned and the documented degree. The CDC specifically cautions that T30 (unspecified body region) should rarely be used when the burn site can be determined. 

"If you want, I can also turn this into a complete ICD-10-CM code set (principal diagnosis + secondary diagnosis + external-cause codes) and identify the most likely specific codes for the steam exposure and 10-foot fall using the 2026 code set."

That's okay. I don't blame Louisiana for taking a hard pass on that one. They did however come up with a code for the next one.

Yes Virginia, there is one more.

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Now, for the cherry on top. The pièce de resistance: How would ChatGPT ICD-10 code the horny assistant manager who climbed on top of a piano while having sex with a stripper underneath him, who accidently (we think it was his foot) tripped the "on" switch with his foot, and was oblivious to the piano rising to the top, crushing and killing him against the ceiling, and leaving the stripper in hysterics until the morning?

The description of the circumstances of the death were described to ChatGPT as stated above. Initially, the little AI guy thought I was pulling their leg—thought it was fiction. On no, mon ami, this actually happened. ChatGPT thought I was writing a screenplay:

ChatGPT:

"If this is for a fictional story, the cause-of-death certificate version could get considerably more darkly funny while still sounding authentically medical."

No, this happened. Not fiction Thus, I got:

"Ah—understood. If this was a real death, then I should treat it as an actual medical-coding question rather than a fictional scenario.

"For the circumstances you describe, ICD-10-CM would not code him as “horny,” nor would the fact that he was having sex be the principal diagnosis. The coding would center on the fatal traumatic injury and its accidental mechanism.

"The exact code depends on the injuries documented by the medical examiner/autopsy. For the external cause, the scenario sounds particularly consistent with caught/crushed between a moving and stationary object. ICD-10-CM specifically has the W23 category for being caught, crushed, jammed, or pinched between objects; the classification distinguishes moving/stationary-object circumstances.

"So, in plain English, the death certificate/coding narrative might be along the lines of:

Cause of death:

Multiple traumatic injuries due to crushing/entrapment between a mechanically elevated piano and the ceiling.

Manner of death:

Accident (assuming the medical examiner concluded that the activation was unintentional).

"The piano rising while he was on it is an unusually important detail because the external-cause code should describe what actually produced the injury, rather than simply calling it an unspecified accident. CDC describes ICD-10-CM external-cause codes as a framework for classifying both the mechanism and intent of injuries.

"And I wouldn't assign a psychiatric diagnosis from the word “hysterics” describing the stripper's reaction. Nor would I infer intoxication, sexual disorder, or anything else unless the actual medical/legal record establishes it.

"If you give me the actual injuries listed in the autopsy or death certificate (you can redact names and identifying information), I can tell you much more precisely how I'd map the case to the current FY2026 ICD-10-CM codes. The CDC has the FY2026 code set and official coding guidelines available."

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I followed up with stating the cause of death was getting crushed by the piano against the ceiling. I offered that my Blue Cross Blue Shield contact suggested: "T14.8, crushed, severe, unspecified cite." Would this fit?

ChatGPT:

"Yes— T14.8 is a defensible description of the injury if all you know is “crush injury, unspecified body region.” The ICD-10-CM inclusion terms for T14.8 explicitly include “crush injury NOS.”

"But there are two important qualifications:

1. “T14.8” by itself isn't a billable ICD-10-CM code. For a clinical encounter, it expands to something such as T14.8XXA (initial encounter), T14.8XXD, or T14.8XXS, depending on the circumstances.
2. It isn't the best description of the mechanism of this particular death. ICD-10-CM has W23.2 — “caught, crushed, jammed or pinched between a moving and stationary object.” A person crushed between a rising piano and a stationary ceiling is remarkably close to that wording.

"So I'd distinguish them this way:

What you're trying to code	Likely approach
The injury itself	T14.8 can encompass an unspecified crush injury
How the injury happened	W23.2 is much more specific
Underlying fatal injuries	Specific S-codes would be preferable if the autopsy identifies the injuries (e.g., skull, chest, abdominal, etc.)

"And there's a subtle issue with your contact's wording: “T14.8, crushed, severe, unspecified cite” isn't the official long description. The official-style description is “Other injury of unspecified body region,” with crush injury NOS as an inclusion term.

"So if you're asking, “Was the Blue Cross contact completely off base?” — no. T14.8 does encompass an unspecified crush injury. But if you're asking, “Is T14.8 the most informative ICD-10-CM coding for a man who was specifically crushed between a rising piano and a ceiling?” — probably not. The mechanism and the specific injuries would ordinarily allow substantially more precise coding.

"One other distinction: if you're dealing with an actual death certificate, rather than an insurance claim/clinical diagnosis, the medical examiner's cause and manner of death are a separate matter from selecting an ICD-10-CM diagnosis code for billing."

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ChatGPT has done an admirable job of dissecting the events that lead to the death. They are a talkative little guy. They accorded my Louisiana contact an "E" for effort, but basically tell them to keep their day job. Which is fine. A manager of Fraud Investigations is an important role in society.

Paul Simon has sung, "there are 50 ways to leave your lover." There are waaaay more ways to code your demise.

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