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HEAD
E23.7 Pituitary Dysfunction S09.93XA Face
HEART R49.
I25.10 Coronary Atherosclerosis, NOS H90.3 Bilat I25.810 Coronary Atherosclerosis, unspec graft H90.41 RT R23.0 Cyanosis H90.42 LT R60.0 Localized Edema H90.5 Unspec R60.1 Generalized R60.9 Unspec I11.9 Hypertensive Cardiovascular Disease R00.2 Palpitations Z01.810 Pre-op Cardiovascular exam
- ICD-10 ICD-
- R40.20 Coma, unspecified J05.
- S06.0X0A Concussion, unspecified J04.
- G40.101 Convulsion-Focal J06.
- G40.309 Convulsion-Grand Mal. K00.
- S09.93XA S19.9XXA Face & neck injury K02.
- R51 Headache J34.
- G06.0 Intracranial Abscess R43. G91.0 Hydrocephalus see below
- C70.0 Meningioma R43.
- Z85.841 Personal Hx malignant of brain R43.
- R55 Syncope E04. R93.0 Skull & Head Non-specific Abn. Fngs on x-ray S19.9XXA Neck - H91. - HEART R49.
- R94.31 Abnormal EKG E05.
- I20.9 Angina, NOS E03.
- I49.9 Cardiac Dysrhythmia M26.
- R01.1 Cardiac Murmur,Undiagnosed M27.
- I51.7 Cardiomegaly C79.
- R07.89 Chest Pressure/Tightness R09.
- I50.9 CHF R22.
- Q24.5 Coronary Artery Anomaly M54.
- I25.10 Coronary Atherosclerosis, native vessel E21. - C Z01.811 Pre-op Respiratory exam - E04. - R
- ICD- - GALLBLADDER, BILIARY, LIVER M54.
- R74.8 Abnormal Labs/Liver or pancreas M50.
- R93.3 Abnormal xray findings abdomen M54.
- R63.0 Anorexia R29.
- M54.9 Backache M51.25-M51.
- K80.50 Bile Duct calculus w/o cholecystitis Q76.
- C24.9 Biliary Ca, primary NOS C72.
- R93.2 Biliary Tract - Abn Fngs on x-ray C41.
- R09.89 Bruit G58.
- R07.9 Chest pain M54.
- K81.0 Cholecystitis, acute w/o mention calculus M54.
- K81.1 Cholecystitis, Chronic M54.
- K81.9 Cholecystitis, NOS R29. - Cholesterolosis, GB M41.
- K74.60 Unsp Cirrhosis M48.06-M48.
- K74.69 Other M47.
- K70.0 Fatty Liver, Alcoholic Q76.
- K76.0 Fatty Liver, non-alcohloic M43.
- C23 Gallbladder Ca M54.24-M54,
- K80.00 Gallbladder calculus w/o cholecystitis M54.14-M54.
R12 Heartburn ICD-
S36.112A Hematoma/Contusion Liver C22.0-C22.8 Hepatoma I71. R16.0 Hepatomegaly I81. R17 Jaundice, not newborn R09. K76.9 Liver Disease I65. R94.5 Liver Scan Abnormal I87. K83.1 Obstruction CBD I73.
K70.10 Pancreatic Ca, Body
R60.0 Localized R60.1 Generalized R60.9 Unspecified
C25.0 Pancreatic Ca, Head R C25.9 Pancreatic Ca, NOS I72. C25.2 Pancreatic Ca, Tail I80. K55.9 Pancreatitis M79.601 RT Arm K82.2 Perforation GB M79.602 LT Arm
T81.4XXA Post-Op Infection/abscess, NOS
M79.603 Unspec Arm S36.00XA Splenic Injury M79.604 RT Leg R16.1 Splenomegaly M79.605 LT Leg
B19.9 Viral Hepatitis NOS
M79.606 Unspec Leg M79.609 Unspec Limb M79.
STOMACH I
ICD-
R93.5 Abdominal Area- Abn. Fngs on x-ray C16.9 Stomach Cancer I72. K63.5 Polyp/Polyps I82. K28.9 Ulcer K29.00 Acute Gastritis I72. K29.80 Doudenitis w/o obstruction I71. K29.60 Gastrostomy complication, unspecified I71. K44.9 Hiatal Hernia K46.9 Hernia unspecified site I12. K66.9 Unspecified disorder of Peritoneum K85.9 Pancreatitis, acute NOS K92.0 Hematemesis R19. L08.9 Fistula - Any R10. R19.7 Diarrhea L03. R93.3 GI Tract - Abn. Fngs on x-ray K35. T18.9XXA Foreign Body, Ingested K35. Z93.1 Gastrostomy status R18. C81. C77.
URINARY TRACT/KIDNEYS C48.
Abnormal lab- Kidney C48. R19.00 Abdominal - pelvis swelling, mass, lump C85. N17.9 Acute Renal Failure R16. D30.00 Unspec Benign Neo Kidney D30.01 RT D30.02 LT R93. N18.9 Chronic renal failure NOS C17. R31.9 Hematuria R19. I12.9 Hypertensive renal disease w/CKD Stage I thru IV, Unspec K52. N13.30 Hydronephrosis (Unspec) T18.9XXA N13.1 Hydronephrosis w/Ureteral Stricture, NEC R93. N13.2 Hydronephrosis w/Renal and Ureteral Calculous Obstr. K46. I10 Hypertension NOS K56. N28.81 Hypertrophy kidney K56. R39.14 Incomplete Bladder emptying K63. N20.0 Kidney Stone K28. N20.2 Kidney Stone w/Ureteral Stone Z93. N12 Pyelonephritis, Unspec Z80. N13.6 Pyonephrosis K31.
R10.
B
SOFT TISSUE D64.
L02.21-* Abscess L03.31-* Cellulitis Cellulitis and Abscess - Trunk M89.
- 6th Character 1 = Abd Wall, 2 = Back (expect buttock), 3 = Chest Wall, 4 = Groin, 5 = Perineum, 6 = Umbilicus, 9 = Unspec
M71.50 Bursitis E83. L03.90 Cellulitis Cellulitis and Abscess, unspec site I L02,91 Abscess R60.0-R60.9 Edema E05. see below Foreign Body, superficial Face,Neck, Scalp E05. S00.05XA Scalp E83. S00.35XA Nose E03. S00.451A RT Ear C85. S00.452A LT E83. S00.459A Unspec E21. S00.551A Lip R41. S00.552A Oral Cavity E10. S00.95XA Unspec part of the Head E11. S10.15XA Throat S10.95XA Unspec part of the Neck
All shown as Initial Encounter A = 7th character If Subsequent Encounter replace with "D"; If Sequela, replace with "S" M67.40 Ganglion, Unspecified I96 Gangrene
M79.069 Unspec Limb Limb Pain R59. M79.60-* Entire Arm C85. M79.64-* Hand/Metacarpals M79.67-* Foot/Metarsals *6th Character 1 = RT, 2 = LT, 3 = Unspec
M79.62-* Upper Arm/Humerus R63. M79.63-* Forearm/Ulna, Radius R63. M79.65-* Thigh/Femur R53. M79.66-* Lower Leg/Tibia, Fibula R23. *6th Character 1 = RT, 2 = LT, 9 = Unspec R19. R60.0-R60.
M79.60-* Entire Leg R62. M79.64-* Fingers/Phalanges R62. M79.67-* Toes/Phalanges R50. *6th Character 4 = RT, 5 = LT, 6= Unspec R M79.89 Limb Swelling R11. G58.9 Mononeuritis, Causalgia, unspecified R11.
R20.9 Numbness
R53.1 Weakness R53.81 Malaise R53.83 Fatigue S61.229A Unspec Open Wound - Finger N S61.02-A* Thumb only R41. S61.12-A* Thumb incl Nail R06. *6th Character 1 = RT, 2 = LT, 9 = Unspec R40. S61.220A RT Index Finger only R63.
S61.221A LT S61.222A RT Middle Finger only R11. S61.223A LT S61.224A RT Ring Finger only S61.225A LT S61.226A RT Little Finger only S61.227A LT
Z
Z93.
S91.329A Open wound - Foot Z93.2 (^) Revised : 2012
S61.429A Open wound - Hand Z03. S31.020A Open wound - multiple-unspecified sites Z D49.2 Soft Tissue Tumor Z R22.9 Swelling, Mass, Lump Z
M65.9 Tenosynovitis Z L97.1-- * Ulcer, thigh Z01. L97.2--* Ulcer, calf Z01.
L97.3--* Ulcer, ankle Z01. L97.4--* Ulcer, heel and midfoot L97.5--* Ulcer, other part of foot L97.8--* Ulcer, other part LE **5th character 0 = Unspec Side 1 = RT 2 = LT 6th character 1 = Ltd Skin Breakdown 2 = Fat layer Exposed 3 = Necrosis Muscle 4 = Necrosis Bone 9 = Unspec Severity
F18.
F19.
JOINT F10.
ACL tear Ankle Sprain Arthritis, unspecified site Z91. Chondrocalcinosis Z91. Disorder of bone and cartilage Z91. Meniscus Tear Neoplasm - site unspecified Rheumatoid Arthritis Sprain Unspecified site Tear Rotator Sprain Patella - degenration of articular cartilage
N95.0 Postmenopausal bleeding N94.89 Unspec symptom female genital organs R10.2 Pelvic and Perineal Pain N89.8 Vaginal Bleeding/Non-inflammatory disease Vagina, NEC
ENT
Acute laryngitits, + obstruction Acute laryngitits, w/o obstruction Acute Upper Respiratory Infection Anodontia Dental Caries Deviated Nasal Septum Disturbance - Smell/Taste Aosmia Parosmia Parageusia Face & neck injury
Goiter, unspecified Hearing Loss - Unspecific Hoarseness Hyperthyroidism Hypothyroidism Jaw Closure - Abnormality Jaw Pain Metastatic. Thyroid. CA Nasal Congestion Neck Mass Neck Pain Parathyroid disorder Sensorineural Hearing Loss
Sinusitis Sore Throat (viral NES) Speech Disorder Stridor Superior glenoid labrum lesion Throat Pain, sore throat Thyroid CA Thyroid nodule Thyroid Scan or Uptake Abnormal Thyroid, enlarged Tinnitus TM Joint Disease Toothache Unspecified supraglottis, + obstruction Unspecified supraglottis, w/o obstruction Vertigo SPINE
Back pain Cervical intervertebral disc w/o myelopathy Cervical Radiculitis Loss of height Lumbar intervertebral disc w/o myelopathy Lumbosacral region, Spondylolysis Malignant Neoplasm Spinal Cord Malignant Neoplasm Vertebra Nerve root or plexus disorder Pain C spine Pain L spine (Lumbago) Pain T spine Posture, abnormal Scoliosis amd kyphoscoliosis, idiopathic Spinal Stenosis - Lumbar Spondy. Comp. Spinal Cord Spondylolisthesis Spondylolisthesis, degenerative Thoracic intervertebral disc w/o myelopathy Thoracic/Lumbosacral Radiculitis
ESOPHAGUS
Achalasia Cancer Esophagus Dysphagia, Unspecified Heartburn Reflux-Gastro Esophageal
COLON
Abdominal Area - Abn. Fngs on x-ray Anal - Rectal Polyp
Bloody Stool (Melena) Colon Cancer
Constipation, unspecified Constipation, Other Diarrhea NOS Diverticulosis Diverticulitis Enteritis-diarrhea GI tract - Abn. Fngs on x-ray Hemorrhage rectum and anus Hernia unspecified site
Obstruction - mechanical Other functional disorder of intestine Polyp/Polyps Rectal Cancer
ABDOMEN SIGNS & SYMPTOMS
Abdominal Pain, Unspecified Site
Abdominal or pelvis swelling, mass, lump- Unspec Site
Abdominal tenderness, Unspecified Site Rebound Abdominal Tenderness, Unspec Site Abdominal tenderness, RUQ Rebound Abdominal Tenderness, RUQ Abdominal Tenderness, LUQ Rebound Abdominal Tenderness, LUQ Abdominal Tenderness, RLQ Rebound Abdominal Tenderness, RLQ Abdominal Tenderness, LLQ Rebound Abdominal Tenderness, LLQ Periumbilic Rebound Abdominal Tenderness Epigastric Rebound Abdominal Tenderness Generalized Rebound Abdominal Tenderness
**code 4th character ICD- 0 = Unspecified 1 = Right Upper Quadrant 2 = Left Upper Quadrant 3 = Right Lower Quadrant 4 = Left Lower Quadrant 5 = Periumbilic 6 = Epigastric 7 = Generalized 9 = Other specified sites (multiple sites)
Colic
SYSTEMIC DISEASE
AIDS
Anemia
Disorder of bone and cartilage
Hypercalcemia Hypertension
Hyperthyroidism
Hypocalcemia Hypothyroidism Lymphoma Other disorder of calcium metabolism Parathyroid disorder Senility/Debility (Age) Type I Diabetes Type II Diabetes mellitus
LYMPHATIC
Lymphadenopathy Lymphoma - Mal
GENERAL SYMPTOMS & SIGNS OF ILLNESS
Abnormal Weight Gain Abnormal Weight Loss Chronic fatigue syndrome Cyanosis Diarrhea Edema
Failure to Thrive, adult Failure to Thrive, infant Fever Jaundice Nausea - Alone Nausea with Vomiting
Other malaise & fatigue Renal Failure, Unspecified Senility/Debility (Age) Tachypnea Transient alteration of awareness Underweight
Vomiting - Alone *not for ultrasound
STAND ALONE "V" CODES
Follow up exam fracture Gastrostomy status Ileostomy status (^) Revised : 2012
FEMALE - PREGNANCY
Antenatal Care High risk pregnancy, unspec Pregnancy, Size/Dates discrepancy, Unspecified Ectopic, unspec
Spontaneous Ab, s mention complication Hemmorhage in early pregnancy Placenta Previa, s hemmorhage, Antepartum Placenta Previa, with hemmorhage, unspec Other antepartum hemmorhage Post-term pregnancy - ie, between 40 - 42 weeks Prolonged Pregnancy - ie, greater than 42 weeks Infections in GU tract in pregnancy
Maternal Diabetes Twin gestation, uncomplicated Twin gestation, antepartum complication unspec Abdominal Pain - apply appropiate 5th digit !!!**
MALE GENITAL
Benign neo Male genital tract, NOS
Fistula - Any Hydrocele Unspecified disorder male genital organs Pelvic and Perineal pain Infertility - Male Orchitis, epididymitis
BPH
Cyst of Prostate Prostate Hyperplasia, Unspec Prostate Cancer Prostatitis, acute Prostatitis, chronic Prostatitis, NOS Scrotal Mass Scrotal Trauma Scrotal Varicocele Spermatocele Testicular Ca Testicular pain Testicular torsion
