CHEST Original Research


Trends in Bronchiectasis Among Medicare
Beneficiaries in the United States,
2000 to 2007
Amy E. Seitz, MPH; Kenneth N. Olivier, MD, MPH; Jennifer Adjemian, PhD;
Steven M. Holland, MD; and D. Rebecca Prevots, PhD, MPH

Background: Bronchiectasis is a potentially serious condition characterized by permanent and
abnormal widening of the airways, the prevalence of which is not well described. We sought
to describe the trends, associated conditions, and risk factors for bronchiectasis among adults
aged  65 years.
Methods: A 5% sample of the Medicare outpatient claims database was analyzed for bronchiectasis
trends among beneficiaries aged  65 years from 2000 to 2007. Bronchiectasis was identified using
International Classification of Diseases, Ninth Revision, Clinical Modification claim diagnosis
codes for acquired bronchiectasis. Period prevalence was used to describe sex- and race/ethnicity-
specific rates, and annual prevalence was used to describe trends and age-specific rates. We esti-
mated trends using Poisson regression and odds of bronchiectasis using multivariate logistic
Results: From 2000 to 2007, 22,296 people had at least one claim for bronchiectasis. The 8-year
period prevalence of bronchiectasis was 1,106 cases per 100,000 people. Bronchiectasis increased
by 8.7% per year. We identified an interaction between the number of thoracic CT scans and
race/ethnicity; period prevalence varied by a greater degree by number of thoracic CT scans
among Asians compared with whites or blacks. Among people with one CT scan, Asians had a
2.5- and 3.9-fold higher period prevalence compared with whites and blacks.
Conclusions: Bronchiectasis prevalence increased significantly from 2000 to 2007 in the Medicare
outpatient setting and varied by age, sex, and race/ethnicity. This increase could be due to a true
increase in the condition or an increased recognition of previously undiagnosed cases.
CHEST 2012; 142(2):432–439

Abbreviations: APC 5 annual percentage change; CMS 5 Centers for Medicare & Medicaid Services; ICD-9-CM 5
International Classification of Diseases, Ninth Revision, Clinical Modification; PNTM 5 pulmonary nontuberculous
mycobacterial disease; SAF 5 standard analytic file

B ronchiectasis is an uncommon, but potentially
serious condition related to abnormal widening
erly clear mucus, can lead to bronchiectasis.1,2 Symp-
toms of bronchiectasis include, but are not limited
of the airway passages. Recurrent lung infections; to, hemoptysis, chronic cough, sputum production,
foreign objects in the airways; and defective lung and shortness of breath. 2-4 Bronchiectasis treat-
clearance mechanisms, such as the inability to prop- ment is aimed at minimizing further damage to the
airways through inflammation reduction, infection
Manuscript received August 31, 2011; revision accepted January 10,
Affiliations: From the Epidemiology Unit (Ms Seitz and Correspondence to: Amy E. Seitz, MPH, National Institute of
Drs Olivier, Adjemian, and Prevots) and Laboratory of Clinical Allergy and Infectious Diseases, National Institutes of Health,
Infectious Diseases (Ms Seitz and Drs Olivier, Adjemian, Holland, 8 W Dr, MSC 2665, Bethesda, MD 20892; e-mail: seitza@niaid.
and Prevots), National Institute of Allergy and Infectious Dis-
eases, National Institutes of Health, Bethesda, MD. © 2012 American College of Chest Physicians. Reproduction
Funding/Support: This research was supported by the Intramu- of this article is prohibited without written permission from the
ral Research Program of the National Institutes of Health, National American College of Chest Physicians. See online for more details.
Institute of Allergy and Infectious Diseases. DOI: 10.1378/chest.11-2209

432 Original Research

Downloaded From: by Emilio Vera on 02/27/2017

18 by state.8-12 mine how representative the 5% sample was relative to the US as well as associations with diseases such as rheuma.4 per 100. prevalence estimates were not assessed because age is a time- ditions. Materials and Methods Results Databases and Populations The study population included . We assessed potential bias resulting from this case defini- use of CT scans has been increasing.8 Other studies have general US census population aged  65 years in 2000 to deter- also shown high rates for women and older adults. and some patients may Medicare beneficiary (e-Appendix 1). Age-specific period CT scans are being ordered for a variety of con. population.14 Bronchiectasis.1 (Environmen- increased opportunity for detecting incidental findings. This record included count variables to indicate the number of claims with bronchiectasis. such as rheumatoid arthritis and nontuberculous myco- provide an optimal resource for studying bronchi. race.3. The 1 month from 2000 through 2007.3 Treat. prevention.0 (bronchiectasis without acute found an increasing trend in bronchiectasis-associated exacerbation). include annual demographic and enrollment information for each ment is usually long term. Bronchiectasis claims were identified by International toid arthritis and humoral immunodeficiencies. use data set is not linkable to identifying information. only one prior and trends of bronchiectasis and to describe comorbid condi- tions and geographic patterns over the 8-year period. diagnostic capacity for detecting previously unrecog.14 and the Medi. leaving open questions of generalizability and con. Additionally. and (3) no enroll- of bronchiectasis in Hong Kong was found to be ment in a health maintenance organization.000 adults. (2) aged  65 years. age.6 The hospital admission rate year were met: (1) residency within the 50 United States or the District of Columbia. To describe the most common conditions associated with bron- care Part B population aged  65 years represents chiectasis in this population.publications. conditions as the percentage with both bronchiectasis and the rent study to estimate the prevalence and trends for condition of interest divided by the percentage with the condition bronchiectasis in an outpatient population that is of interest among the general population.15. We calculated age. We used ArcInfo. individual cases were considered if the patient had at least one founders regarding access to care.3 cases of bronchiectasis define the denominator population. individual and each year. Ninth Revision.7 suggesting a high age.1 (bronchiectasis the Agency for Healthcare Quality and Research and with acute exacerbation). The denominator SAFs bia were represented. tal Systems Research Institute. Analysis was study estimated bronchiectasis prevalence for the completed using SAS. and racial distribution in the study population to the prevalence in Asian countries. For example. and bronchopulmonary hygiene. Inc) to map the period prevalence such as bronchiectasis. associated hospitalizations were highest among women number of thoracic CT scans. benefit from surgical resection of the lung or lung Data Analysis and Ethical Review transplantation. that study Analysis by racial or ethnic group used the racial/ethnic categories was limited to an inpatient population in select states.17.6 To our knowledge. Because bronchiectasis is a chronic condition. bacterial infection.chestnet. we assessed diagnosis claims among about 91% of the total US population aged  65 years. ficiaries from all 50 states and the District of Colum- tional outpatient health-care providers. version 9.20 We calculated the prevalence ratio for these ectasis in the United States. and 494. sex.chestnet. and CT scan use (e-Appendix 1). Medicare bene- carrier SAFs contain claims-level information from CHEST / 142 / 2 / AUGUST 2012 433 Downloaded From: http://journal. with higher rates among women was included in the analysis if all of the following criteria in that and older individuals.2 (SAS Institute Inc) statistical United States. 494.publications. 2 million unique We analyzed a 5% sample of the carrier and the denominator individuals enrolled in Medicare Part B for at least standard analytic files (SAFs) obtained from CMS. The 5% sam- ple was randomly selected from all carrier claims by CMS.and sex-specific annual prevalence of Because prior studies reported a high prevalence of bronchiectasis and used Poisson regression to determine signifi- cance of annual trends from 2000 to 2007 (e-Appendix 1).8. We undertook the cur. This study was not representative of the US population most affected by considered human subject research by the National Institutes of Health Office of Human Subjects Protection because the limited- this condition.19 people with bronchiectasis (e-Appendix 1). the primary or secondary claim of bronchiectasis in the time period of interest. software. 60 years. However.3. bronchiectasis among older people6. if more thoracic and constructed a multivariate logistic regression model to assess race. We used the Medicare Denominator database to mated a prevalence of 52. An individual’s annual record per 100.000 people in 1990. The demographic distribution journal.16 and the tion by comparing overall demographics and specific outcomes observed increase in bronchiectasis could reflect to those that would result from a case definition of at least two an artifact of increased CT scan use with improved bronchiectasis claims (e-Appendix 1). We calculated 8-year prevalence estimates from 2000 to 2007 nized this increased scanning would result in an dependent variable. sex.13 Classification of Diseases.6.2 The current prevalence of bronchiectasis is not We analyzed claims from 2000 to 2007 to estimate prevalence well described. and comorbid conditions of interest. A single summary record was created for each hospitalizations from 1993 to 2006. and people aged . sex. identifying the most the Medicare Part B outpatient databases from the common primary diagnosis claims and describing the frequency Centers for Medicare & Medicaid Services (CMS) of conditions with known or suspected associations with bronchi- ectasis. We compared the 16.ashx?url=/data/journals/chest/24699/ by Emilio Vera on 02/27/2017 . version 9. This retrospective cohort study esti. Clinical Modification We previously analyzed hospital discharge data from (ICD-9-CM) codes 494 (bronchiectasis). defined by CMS.

000 person-years.0. thoracic CT scans. These individuals included 13. and blacks were 2. The APC was similar for prevalence compared with whites and blacks. We identified a statistically sig.and 3. with period preva. 7. 1.000 person-years). Using a logistic regression model containing vari. and women aged 80 to 84 years had 100. 7.21-23 we used the case definition The overall average annual prevalence of bron- of at least one bronchiectasis claim in the period of chiectasis in the physician outpatient setting was interest.971 women between the state with the highest period prevalence (63%).700] cases people with one claim of bronchiectasis and people per 100.467-1.chestnet.36.3% (95% CI.092-1. age of approximately five claims per person during A threefold increased prevalence was observed this period. utilization behaviors.70%-9. CT scans and race/ethnicity.112 claims of bronchiectasis ectasis among women compared with men (OR. (8.58%) and women people who had two to three scans. Period prevalence for Asians was the highest average annual prevalence (537 [95% CI. 1.3%) per year during the same period.0 and 3. respectively (Fig 1).32-1.000 population) and the state with the lowest with two or more claims of bronchiectasis. with bronchiectasis compared with those without Figure 1.2%-12. 1. and an inter. was representative of the entire US population action term for number of thoracic CT scans and race. Within men (9.5.74% (95% CI. Within each of thoracic CT scans.60%) (Fig 4). No clear pattern of clus- sex remained the same (e-Appendix 1). 95% CI. 1. 95% CI. Asians had a 2.106 100. 7.40). 488 [95% increased prevalence relative to men (Fig 3). higher than for blacks or whites within each stratum 523-551] cases per 100. Prevalence increased with age (95% CI. 370 (95% CI. The APC alence estimates for Asians compared with whites for thoracic CT scans increased by 10. but the prevalence (Montana. we identified a 36% increase in the odds of bronchi- We identified 117.publications. 2000 to 2007. the annual percentage change (APC) of lence among Asians varying to a greater degree than bronchiectasis was 8.121) cases of bronchiectasis per up to 85 years. aged  65 years.10%.79%). from 2000 to 2007 from 22. the relative prev. The demographics differed significantly between (Massachusetts. Conditions identified as higher among people ables for sex.3.296 people for an aver. that for whites and blacks. women had a 1. age group up to age 85 years. 367-374) cases of bronchiectasis per The overall 8-year period prevalence was 1.9-fold higher period from 2000 through 2007. 339-637] cases overall pattern of period and annual prevalence by per 100.583 [95% CI. race.70%. To reduce the tering by geographic region at the state level was evi- possibility of bias due to differences in health-care dent (Fig 2).000 population).80%-9. nificant interaction between the number of thoracic 1. Bronchiectasis period prevalence by sex and race/ethnicity among people with two or three thoracic CT scans. Among people with one representing a significant increase in bronchiectasis CT scan.ashx?url=/data/journals/chest/24699/ by Emilio Vera on 02/27/2017 .000 people. 8. 434 Original Research Downloaded From: http://journal.64%-10. 95% CI. 1.

Map of bronchiectasis period prevalence. Figure 2.chestnet. we further identi. bronchiectasis from the initial screening of all claims (PNTM). In a focused comparison with conditions suspected The prevalence ratio of PNTM among individuals with to be associated with bronchiectasis. Average annual prevalence of bronchiectasis by age and sex. cough. bronchiectasis compared with those without bronchi- fied pulmonary nontuberculous mycobacterial disease ectasis was twofold greater among women than men.chestnet. as each having an increased prevalence among peo- ness of breath. 2000 to 2007. 2000 to 2007.publications. rheumatoid arthritis.publications. ple with bronchiectasis in both men and women. Figure 3. and other respiratory distress. and lung malignancies were acute bronchitis. unspecified pneumonia.ashx?url=/data/journals/chest/24699/ by Emilio Vera on 02/27/2017 . CHEST / 142 / 2 / AUGUST 2012 435 Downloaded From: http://journal.

52) 75. IgG defi ciency.35 327 (2.87) 6.764 (0.09 4.046 (60.23) 7. blacks.96) 36.52) 2.97) 38.112 (7.ashx?url=/data/journals/chest/24699/ by Emilio Vera on 02/27/2017 .0 disordersb Data are presented as No. a1-antitrypsin deficiency. PNTM 5 pulmonary nontuberculous mycobacterial disease.61) 207.29 pulmonary fibrosisa Lung malignancies 1.981 (28. Figure 4. the absolute prevalence and prevalence ratio for most of the conditions for We analyzed CMS databases to describe nationally people with and without bronchiectasis was similar representative patterns of prevalence and trends of bron- for whites.02 disease Other genetic 177 (2.757) RP (n 5 13.14) 15.92 arthritis Postinflammatory 2.878) RP PNTM 217 (2.06) 89. with among people with and without bronchiectasis was the highest prevalence ratio among whites.110 (65. Interestingly.778 (34. RP 5 relative prevalence.211 (0.34) 13.83 1.5 752 (5. aPostinflammatory pulmonary fibrosis: International Classification of Diseases. common variable immunodefi ciency.325) (n 5 842.publications. ratios by sex.53) 1.29 Rheumatoid 636 (7. people with bronchiectasis.080 ( (5.975 (35. unless otherwise indicated. situs inversus.13) 1.494 (6. about 20% (4.80) 1. Ninth Revision. and rheumatoid arthritis have PNTM than those without bronchiectasis.74) 49. lung malignancies.976 (0. bCongenital cartilage defi ciency.260 (3.13) 2. allergic bronchopulmonary aspergillosis.447 (5.58) 2.749 (12.chestnet.06) 43.54 Inflammatory bowel 186 (2.196 (3.15) 12. Among similar for men and women (Table 1).16) 2.95) 2.64) 2.44) 6.21) 329.20 1. (%).21 252 (1. we then grouped these comorbid con- ditions across sex groups and looked at racial/ethnic Discussion differences. Clinical Modification code 515.46 9. 2000 to 2007 Men Women Individuals With Individuals Without Individuals With Individuals Without Bronchiectasis Bronchiectasis Bronchiectasis Bronchiectasis Condition (n 5 8.20) 62. and Asians (Table 2).507) had Because we saw little difference in the prevalence none of the comorbidities listed in Tables 1 and 2.971) (n 5 1. People with chiectasis in the older adult US outpatient population.621 (24.564 (4.61) 480 (0.38) 638 (0.410 (1. Trend in annual prevalence of bronchiectasis by sex. Table 1—Comorbid Conditions by Men and Women for People With and Without Bronchiectasis.47) 2. 436 Original Research Downloaded From: http://journal.156.67 Acute bronchitis 5.64) 29. The prevalence ratio of postinflammatory pulmonary bronchiectasis were 50 to 75 times more likely to fibrosis.

ashx?url=/data/journals/chest/24699/ by Emilio Vera on 02/27/2017 . Although some Asian of this increase is likely due to increasing use of CT scans since 2000. such as those due to infectious or inflammatory conditions.84) (n 5 166.8 This large number of undiagnosed cases indicates a need for greater awareness of this 55.5-fold increased prevalence aPostinflammatory pulmonary fibrosis: International Classification of Diseases.59 1.626) 37 (0. Acute bronchitis The racial and ethnic categories of white. black. common variable immunodeficiency.89 3. These findings are consis- Bronchiectasis 33. Bron- (n 5 33. the prevalence among those with Other genetic disordersb bronchiectasis compared with the general popula- pulmonary fibrosisa Rheumatoid arthritis tion was strikingly higher. Bronchiectasis 12. Clinical Modification code 515. We used comorbid conditions to identify patterns of possible underlying pathogenic processes.12) 2.62) (n 5 1. Although PNTM was a rela- tively rare condition even among people with bron- Inflammatory bowel disease chiectasis (2%-5%). Based on the number of cases identified in this anal- 49.99 2. suggesting an important Lung malignancies Postinflammatory interaction between bronchiectasis and PNTM.13 RP ysis and extrapolating to the 2007 US population aged  65 years.354) 56 (0.23) 10 (0.03) 9. relative to whites. some studies suggested a high prevalence in Asian countries.6. allergic bronchopulmonary aspergillosis.736 (64. Bronchiectasis comorbidities.64) 1. and prevalence increased with age for both sexes.05) conditions (rheumatoid arthritis or inflammatory With bowel disease) and infectious conditions (PNTM) among people with bronchiectasis than for those without bronchiectasis. unless otherwise indicated.409 (5.225 (4. The reasons for the increased likelihood of a 476.67 2. Bronchiectasis One study identified a high proportion of asymptom- bCongenital cartilage deficiency.963 (9.69) 176 (0.67) 194 (33.67 pared with whites or blacks varied by CT scan use.7.83 13.93) and racial/ethnic groups. we estimate that .81) 9 (1.005 (19.11) 2.724.05 8.813 (3.45) 40 (6.74) 92 (15.83) 7.735) Bronchiectasis 986 (0.publications.95 7.10-12 People identified as Without Asian had a 1.89) Prevalence estimates were higher for inflammatory (n 5 19. which tended to be similar across sex 558 (51.17) Table 2—Comorbidities by Race/Ethnicity for People With and Without Bronchiectasis.569 (7.34) 5.638 (31. The increased prevalence With among Asians has not been previously described for the US population.79) 28 (0.345 (27. IgG deficiency.05 2. with the greatest relative prevalence Black among people with a higher number of CT scans. however.58 2.09) 885 (2.08) Without chiectasis prevalence increased significantly from 2000 to 2007 among both men and women.55 2.000 unique cases of bronchiectasis were assessed by a physician Bronchiectasis 10.057 (10.23 8. 380 (64.384 (1.45 condition.06 5.922 (34.20) 18 (1.37) 6.295 (3.10 that is. the prevalence was greater for Asians compared with whites and blacks.55) CHEST / 142 / 2 / AUGUST 2012 437 Downloaded From: http://journal. situs inversus.publications.05) (n 5 587) 32 (5.35) 406 (2.00) (n 5 1. and Condition Asian encompass a wide variety of ethnicities and may PNTM serve as surrogates for unidentified behavioral risk factors or genetic susceptibility because associations journal. the burden of recognized disease nonetheless clearly increased from 2000 to 2007. Ninth Revision.64) in the older adult US population in that year.32 2.04) 100.06) 86.8 Of note is our finding that the relative prevalence for Asians com- 75.376 (4.84) 19.94 2.700 (5.08 2.44 3. the burden of disease was greater among women than among men. 190. This increased prevalence among the Asian subgroup was not explained by differences in the prevalence of Data are presented as No.62 1.91) 122 (11.11) tent with previous studies. suggesting that a large proportion of undiagnosed cases may exist.35) 368 (34.949 (5. See Table 1 legend for expansion of abbreviations.82) 66.839) 902 (4.15) bronchiectasis diagnosis among Asians with increased Without CT scan use are not clear but may warrant further White research.67) 24 (2. RP 1 Overall.666 (0.49) 1. (%). a -antitrypsin deficiency.chestnet.4.89) 467 (2. 2000 to 2007 atic individuals with bronchiectasis among individuals With with a chest CT scan in a health screening program.23) 129 (12.63) 265 (0.53) 1 (0.156 (0. with increasing CT scan use.chestnet. RP 2.

Tsang KW. 2 million adults aged  65 years For example. or other unknown factors. we did not look at geographic patterns Ms Seitz: contributed to the study concept and design.29 Addi. data nization coverage. Choi YW. statistical and epidemiologic analyses. revision. and preparation of the tionally. et al. 2006. we are more likely to be underestimating the true 2. NIH intramural research program. However. the current study results.346(18): unable to determine the detailed clinical pathology 1383-1393. Tohoku J Exp Med. codes are primarily used for billing purposes and Role of sponsors: This research was completed as part of the only secondarily for epidemiologic research. Because we were limited to ICD-9-CM codes. data acqui- on smaller geographic subunits. Clin Pulm Med. Barker AF. and approval of the final version. therefore. Chronic cough due to bronchiectasis: ACCP prevalence. et al. 1953.ashx?url=/data/journals/chest/24699/ by Emilio Vera on 02/27/2017 . Rosen MJ. Chest. final edit. 6. Additional information: The e-Appendix can be found in the Medicare reimbursement may affect coding30 and. Wynn-Williams N. and approval of the final version. authors and do not necessarily reflect those of the US Depart- ferences in regional billing practices or changes in ment of Health and Human Services. Barker AF.24. this rep- applies to the diverse groups included in the category.25 Although we ognition of previously undiagnosed cases or a true identified Asians as having the highest prevalence increase in incidence. revision. final edit. an overall higher prevalence for women and Asians.7(4): Conclusions 268-274. future studies could explore analyses by Asian subgroup. we do not interpretation of results. between specific human leukocyte antigen alleles and increasing prevalence may be due to increased rec- bronchiectasis have been identified. 2005. The use of ICD-9-CM codes Financial/nonfinancial disclosures: The authors have reported for identifying cases of bronchiectasis and comorbid to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be dis- conditions is also a limitation in our study. 2010. given the relative rarity of 1. 7. Dr Adjemian: contributed to the interpretation of results and There are limitations inherent in the use of Medi. Kwak HJ. N Engl J Med. Differences in these populations.137(4):969-978. apply to the comorbidity analysis because we were 3. drafting of the manuscript. acquisition and management. or by urban or rural region. economic burden of bronchiectasis. Bronchiectasis. 438 Original Research Downloaded From: http://journal. such as by county sition and management. excluding individuals with health maintenance orga. The authors had full control in the design of the study. final edit. Dif. revision. The views expressed in this article are those of the cases of bronchiectasis has not been validated. and manuscript preparation. Overall. Bronchiectasis: update of an orphan this condition and only recent awareness of its impact. revision. Fall A. “Supplemental Materials” area of the online article. ectasis in the outpatient Medicare population and 12(4):205-209. Edelsberg J. 5. Moon JY. Bardana EJ Jr. and approval of the final interpreting these results is the potential bias from version.1(4821):1194-1199. are unknown. The increased prevalence among Asians was observed 8. The lack of geographic clustering could indicate Acknowledgments that bronchiectasis has little or no association with Author contributions: Ms Seitz and Dr Prevots had full access geographic variables that exist on a statewide scale. Int J Tuberc Lung Dis. variation. CT scan use. Oster G. statistical and epidemiologic analyses. ethnic tation of results.chestnet. High prevalence of at all levels of thoracic CT scan use and was greatest bronchiectasis in adults: analysis of CT findings in a health with four to six scans across the 8-year period. Prevalence and We observed an increasing prevalence of bronchi.publications. Native Hawaiian and Pacific Islanders provides further evidence for the increased burden have a variety of different risk factors compared with among Asians and women and identifies an increas- Asian Americans. Limitations using ICD-9-CM codes also evidence-based clinical practice guidelines. One exam. we are unsure how broadly this increased awareness of this condition. and manuscript especially with regard to socioeconomic or health preparation. Dr Prevots: contributed to the study concept and design. Weycker D. and approval of the care claims data for epidemiologic final edit. This screening program. interpretation of results. know whether there may be geographic patterns that Dr Olivier: contributed to the study concept and design. However. drafting of the manuscript. BMJ. analysis of the data.26-28 Although Medicare data are not ing trend in the elderly outpatient population in the subdivided by the ethnic groups that comprise the United States.222(4):237-242. final edit. Spencer D. 1988. resentative study of . 2006. Bronchiectasis: a study centred on Bedford and its environs. final version. revision. 129(suppl 1):122S-131S. Am Rev Respir Dis. to all of the data in the study and take responsibility for the integ- rity of the data and the accuracy of the data analysis. highlighting the need for of bronchiectasis. ple of a limitation that should be considered while Dr Holland: contributed to the interpretation of results and man- uscript preparation. Paediatric bronchiectasis in Europe: what now and where next? Paediatr Respir Rev. disease. associated with the ICD-9-CM comorbidity code. 4. and approval of the final version.8(6):691-702. 2004. Bronchiectasis: not an orphan disease in the East. Tipoe GL. we may be over- estimating or underestimating the true prevalence of References bronchiectasis. Asian population. manuscript preparation. consequently. interpre- depend on local coding practices. and manuscript preparation. the use of ICD-9-CM codes for identifying manuscript. 2002. status. ICD-9-CM cussed in this article.

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