1
© Copyright 2015 Revised 8/15/15
LEUKEMIA/MDS
0 - Not having achieved remission 1 - In remission 2 - In relapse
Leukemia,
LYMPHOID 0 - Acute lymphoblastic leukemia 1- Chronic lymphocytic leukemia of B-cell type 3 - Prolymphocytic leukemia of B-cell type 4 - Hairy cell leukemia 5 - Adult T-cell lymphoma/leukemia (HTLV-1-associated) 6 - Prolymphocytic leukemia of T-cell type A - Mature B-cell leukemia Burkitt-type Z - Other lymphoid leukemia 9 - Unspecified
C91.
Unspecified Malignant Neoplasms of
LYMPHOID, HEMATO POIETIC & RELATED TISSUE
0 - Multifocal and multisystemic (disseminated) Langerhans-cell histiocytosis 2 - Malignant mast cell tumor 4 - Sarcoma of dendritic cells (accessory cells) 5 - Multifocal and unisystemic Langerhans-cell histiocytosis 6 - Unifocal Langerhans-cell histiocytosis A - Histiocytic sarcoma Z - Other specified 9 - Unspecified
C96.
0 -Not having achieved remission 1 - In remission 2 - In relapse
Leukemia,
MYELOID
0 - Acute myeloblastic leukemia 1 - Chronic myeloid leukemia, BCR/ABL- positive 2 - Atypical chronic myeloid leukemia, BCR/ABL-negative 3 - Myeloid sarcoma 4 - Acute promyelocytic leukemia 5 - Acute myelomonocytic leukemia 6 -Acute myeloid leukemia with 11q23- abnormality A - Acute myeloid leukemia with multilineage dysplasia Z - Other myeloid leukemia 9 - Unspecified
C92.
0 - Acute monoblastic/monocytic leukemia 1 - Chronic myelomonocytic leukemia 3 - Juvenile myelomonocytic leukemia Z - Other monocytic leukemia 9 - Unspecified
0 - Not having achieved remission 1- In remission 2– In relapse
Leukemia,
MONOCYTIC C93.
0 - Not having achieved remission 1 - In remission 2 - In relapse
Other Leukemias of
SPECIFIED CELL TYPE 0 - Acute erythroid leukemia 2 - Acute megakaryoblastic leukemia 3 - Mast cell leukemia 4 - Acute panmyelosis with myelofibrosis 8 - Other specified leukemias
STOP 6 - Myelodysplastic disease, not classified
C94.
0 - Not having achieved remission 1- In remission 2– In relapse
C95. Leukemia of UNSPECIFIED CELL TYPE
0 - Acute 1 - Chronic 9 - Unspecified
MYELODYSPLASTIC SYNDROME (MDS)
0 - Not having achieved remission 1- 1 2– 2
2 - Refractory anemia with excess of blasts
STOP
Use T45.1X code for adverse effect, if applicable
D46.
0 - Refractory anemia without ring sideroblasts, so stated 1 - Refractory anemia with ring sideroblasts A - Refractory cytopenia with multilineage dysplasia B - Refractory cytopenia with multilineage dysplasia and ring sideroblasts C - Myelodysplastic syndrome with isolated del(5q) chromosomal abnormality 4 - Refractory anemia, unspecified Z - Other myelodysplastic syndromes 9 - Unspecified
0 - Not having achieved remission 1 - In remission 2 – In relapse
Multiple Myeloma & Malignant
PLASMA CELL NEOPLASM
C90.
0 - Multiple Myeloma 1 - Plasma cell leukemia 2 - Extramedullary plasmacytoma 3 - Solitary plasmacytoma
2
© Copyright 2015 Revised 8/15/15
B-CELL LYMPHOMA
Lymphoma,
FOLLICULAR
0 - Unspecified site 1 - Head, neck, face 2 - Intrathoracic 3 - Intra-abdominal 4 - Axilla and upper limb 5 - Inguinal region and lower limb 6 -Intrapelvic 7 -Spleen 8 - Multiple-sites 9 - Extranodal and solid organ site
0 - Grade I 1 - Grade II 2 - Grade III unspecified 3 - Grade IIIa 4 - Grade IIIb 5 - Diffuse follicle center lymphoma 6 - Cutaneous follicle center lymphoma 8 - Other types lymphoma 9 - Unspecified
C82.
Lymphomas, MALIGNANT IMMUNOPROLIFERATIVE & OTHER B-CELLS
0 - Waldenstrom macroglobulinemia 2 - Heavy chain disease 3 - Immunoproliferative small intestinal disease 4 - Extranodal marginal zone B-cell lymphoma of mucosa-
associated lymphoid tissue [MALT-lymphoma] 8 - Other malignant immunoproliferative diseases 9 - Unspecified.
C88.
Lymphoma,
HODGKIN 0 - Nodular lymphocyte predominant 1 - Nodular sclerosis classical 2 - Mixed cellularity classical 3 - Lymphocyte-depleted classical 4 - Lymphocyte-rich classical 7 - Other classical 9 - Unspecified
0 - Unspecified site 1 - Head, neck, face 2 - Intrathoracic 3 - Intra-abdominal 4 - Axilla and upper limb 5 - Inguinal region and lower limb 6 -Intrapelvic 7 -Spleen 8 - Multiple-sites 9 - Extranodal and solid organ site
C81.
Lymphoma,
NON-FOLLICULAR 0 - Unspecified site 1 - Head, neck, face 2 - Intrathoracic 3 - Intra-abdominal 4 - Axilla and upper limb 5 - Inguinal region and lower limb 6 -Intrapelvic 7 -Spleen 8 - Multiple-sites 9 - Extranodal and solid organ site
0 - Small cell B-cell Lymphoma 1 - Mantle cell Lymphoma 3 - Diffuse Large B-cell lymphoma 5 - Lymphoblastic (diffuse lymphoma) 7 - Burkitt lymphoma 8 - Other non-follicular Lymphoma (includes PEL/ intravascular) 9 - Unspecified
C83.
Lymphoma,
OTHER NON-HODGKIN 0 - Unspecified site
1 - Head, neck, face 2 - Intrathoracic 3 - Intra-abdominal 4 - Axilla and upper limb 5 - Inguinal region and lower limb 6 -Intrapelvic 7 -Spleen 8 - Multiple-sites 9 - Extranodal and solid organ site
1 - Unspecified B-cell lymphoma 2 - Mediastinal (thymic) large B-cell 8 - Other specified types of non-Hodgkin’s 9 - Unspecified
C85.
Lymphoma, Other
SPECIFIED T/NK-CELL 0 - Extranodal NK/T-cell lymphoma, nasal type 1 - Hepatosplenic T-cell lymphoma 2 - Enteropathy-type (intestinal) T-cell lymphoma 3 - Subcutaneous panniculitis-like-T-cell lymphoma 4 - Blastic NK-cell lymphoma 5 - Angiommunoblastic T-cell lymphoma 6 - Primary cutaneous CD-30-positive T-cell proliferations
C86.
LYMPHOMA,
MATURE T/NK CELL
0 - Unspecified site 1 - Head, neck, face 2 - Intrathoracic 3 - Intra-abdominal 4 - Axilla and upper limb 5 - Inguinal region and lower limb 6 -Intrapelvic 7 -Spleen 8 - Multiple-sites 9 - Extranodal and solid organ site
0 - Mycosis Fungoides 1 - Sezary Disease 4 - Peripheral T-cell, not classified 6 - Anaplastic Large cell AKL-positive 7 - Anaplastic Large cell AKL-negative A - Cutaneous T-cell, unspecified Z- Other 9 - Unspecified
C84.
3
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Other Diseases W/Participation of
LYMPHORETICULAR/ RETICULOHISTIOCYTIC TISSUE 1 - Hemophagocytic lymphohistiocytosis 2 - Hemophagocytic syndrome, infection-associated (Use additional code to identify infectious agent or disease) 3 - Other histiocytosis syndromes
D76.
0 - Histiocytic and mast cell tumors of uncertain behavior 1 - Chronic myeloproliferative disease 2 - Monoclonal gammopathy 3 - Essential (hemorrhagic) thrombocythemia 4 - Osteomyelofibrosis 9 - Unspecified
Neoplasms of Uncertain Behavior of
LYMPHOID, HEMA-TOPOIETIC & RELATED TISSUE
Z - Other specified neoplasms
1- Post-transplant lymphoproliferative disorder (PTLD) 9 - Other specified neoplasms
For MYELOFIBROSIS, use D75.81
D47.
STOP
Other & Unspecified Diseases of
BLOOD & BLOOD-FORMING ORGANS (MYELOFIBROSIS)
0 - Familial erythrocytosis 1 - Secondary polycythemia 9 - Unspecified
8 - Other specified diseases of blood and blood- forming organs
1- MYELOFIBROSIS (Code first underlying disorder such as neoplasm. If applicable, code for associated therapy-related MDS and for adverse effects to identify drug)
2 - Heparin induced thrombocytopenia (HIT) 9 - Other specified diseases of blood and blood-forming organs
STOP
D75.
MYELOFIBROSIS D75.81
MYELOPROLIF/MGUS
Malignant Neoplasm of
ADRENAL GLAND 0 - Unspecified 1 - Right 2 - Left
0 - Cortex 1- Medulla 9 -Unspecified
C74. Malignant Neoplasm of
KIDNEY, EXCEPT RENAL PELVIS 1 - Right kidney 2 - Left kidney 9 - Unspecified
C64.
MALIGNANT NEOPLASMS OF BONE & ARTICULAR CARTILAGE
0 - Unspecified 1 - Right 2 - Left
0 - Scapula & long bones of upper limb 1- Short bones of upper limb 2 - Long bones of lower limb 3 - Short bones of lower limb 8 - Overlapping 9 - Unspecified
Use additional code to identify major osseous defect, if applicable (M89.7)
C40. Malignant Neoplasm of
BONE & CARTILAGE OF LIMBS
Malignant Neoplasm of
BONE & ARTICULAR CARTILAGE OF OTHER & UNSPECIFIED SITES 0 - Bones of skull and face 1 - Mandible 2 - Vertebral column 3 - Ribs, sternum and clavicle 4 - Pelvic bones, sacrum and coccyx 9 - Unspecified
C41.
4
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MALIGNANT NEOPLASMS OF PERIPHERAL NERVES & AUTONOMIC NERVOUS SYSTEM
Malignant Neoplasm of
RETROPERITONEUM & PERITONEUM 0 - Retroperitoneum 1 - Specified parts of peritoneum 2 - Unspecified peritoneum 8 - Overlapping sites of retroperitoneum & peritoneum
C48.
Malignant Neoplasm of Other
CONNECTIVE & SOFT TISSUE
1 - Upper limb, including shoulder 2 - Lower limb, including hip
0 - Unspecified 1 - Right 2 - Left
0 - Head, face & neck 3 - Thorax 4 - Abdomen 5 - Pelvis 6 - Trunk, unspecified 8 - Overlapping sites 9 - Unspecified
C49.
STOP
1 - Upper limb, including shoulder 2 - Lower limb, including hip
0 - Unspecified 1 - Right 2 - Left
C47. Malignant Neoplasm of
PERIPHERAL NERVES 0 - Head, face & neck 3 - Thorax 4 - Abdomen 5 - Pelvis 6 - Trunk, unspecified 8 - Overlapping sites 9 - Unspecified
STOP
FUNCTIONAL DISORDERS OF POLYMORPHONUCLEAR NEUTROPHILS
D71
5
© Copyright 2015 Revised 8/15/15
SECONDARY & UNSPECIFIED SITES
Malignant
NEUROENDOCRINE TUMORS
0– Duodenum 1- Jejunum 2- Ileum 9– Unspecified
0- Appendix 1- Cecum 2- Ascending
colon 3- Transverse
colon
4- Descending colon
5- Sigmoid colon 6- Rectum 9- Large intestine, unspecified
0- Bronchus/Lung 1- Thymus 2- Stomach 3- Kidney
4- Foregut NOS 5- Midgut NOS 6- Hindgut NOS 8- Other sites
STOP 0- Unspecified
site
9- Other sites
1- Small intestine
2- Appendix, large
intestine, and rectum
STOP 1 - Malignant poorly differentiated neuroendocrine tumors 8 - Other malignant neuroendocrine tumors
0- Malignant
Carcinoid Tumors
C7A. Secondary Malignant Neoplasm of
OTHER & UNSPECIFIED SITES
0 - Unspecified urinary organs 1 - Bladder 9 - Other urinary organs
1- Bladder and other and unspecified urinary organs
0 - Kidney & Renal Pelvis 6 - Ovary 7 - Adrenal gland
2 - Skin 9 - Unspecified
1 - Breast 2 - Genital organs 9 - Other
0 - Unspecified 1 - Right 2 - Left
3– Brain and cerebral meninges
4– Other & unspecified parts of nervous system
0 - Unspecified 9 - Other
5– Bone and bone marrow 1 - Bone 2 -Bone marrow
8– Other specified sites
STOP
C79.
1 –Brain 2– Cerebral meninges
Malignant Neoplasm of
OTHER & ILL-DEFINED SITES
0 - Unspecified 1 - Right 2 - Left
0 - Head, face & neck 1- Thorax 2 - Abdomen 3 - Pelvis 8 -Other specified ill-defined sites
4 - Upper limb 5- Lower limb
STOP
C76.
6
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DRUG-INDUCED PHENOMENON
D70.1 AGRANULOCYTOSIS SECONDARY TO CANCER CHEMOTHERAPY
OTHER SECONDARY THROMBOCYTOPENIA
D69.59
* Due to drugs, EtOH, alloimmunization; NOT ITP
DRUG (OPIATE) INDUCED CONSTIPATION
K59.09
ANEMIA DUE TO ANTINEOPLASTIC CHEMOTHERAPY
D64.81
DRUG-INDUCED CUSHING'S SYNDROME
E24.2 DRUG-INDUCED ADRENOCORTICAL INSUFFICIENCY
E27.3
STOP 0 - With cholestasis 2 - With acute hepatitis
TOXIC LIVER DISEASE
0 - Without coma 1 -With coma
1 - With hepatic necrosis
This is for toxic effects due to drug; Does Not include ETOH
K71.
0 - Drug-induced 1 - Alcoholic 2 - Due to other toxic agents 9 - Unspecified (as used for AIDS)
Other & Unspecified POLYNEUROPATHIES
1 -Critical illness 2 - Radiation-induced 9 - Other
8 - Other specified
STOP
G62.
ORAL MUCOSITIS, ULCERATIVE
0 -Unspecified 1 - Due to antineoplastic therapy 2 - Due to other drugs 3 - Due to radiation 9 - Other
K12.3
POLYNEUROPATHY IN DISEASES CLASSIFIED ELSEWHERE (Includes myeloma induced neuropathy)
G63
DRUG-INDUCED PHENOMENON
DRUG (OPIATE) INDUCED CONSTIPATION
K59.09
AGRANULOCYTOSIS DUE TO NON-CHEMOTHERAPY DRUG
D70.2
7
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METABOLISM
OBESITY
E66.01: MORBID (SEVERE) OBESITY
DUE TO EXCESS CALORIES
E66.3: OVERWEIGHT
Disorders of ADRENAL GLAND
1 - Primary adrenocortical insufficiency 2 - Addisonian crisis 3 - Drug-induced adrenocortical insufficiency
E27. 0 - Rickets, active 9 - Unspecified
E55. VIT. D DEFICIENCY
BONE HEALTH: OSTEOPOROSIS W/O CURRENT FRACTURE
0 - Age-Related 8 - Other (includes drug induced/Steroids)
M81.
HYPERLIPEDMIA 0 - Pure hypercholesterolemia 1 - Pure hyperglyceridemia 2 - Mixed hyperlipidemia 5 - Unspecified
E78.
E76.01 HURLER’S SYNDROME
Disorders of FATTY-ACID METABOLISM 0 - Unspecified 2 - Disorders of ketone metabolism 9 - Other Disorders
1 - Disorders of fatty-acid oxidation
0 - Long chain/very long chain acyl CoA dehydrogenase deficiency
1 - Medium chain acyl CoA dehydrogenase deficiency
2 - Short chain acyl CoA dehydrogenase deficiency
3 - Glutaric aciduria type II 4 - Muscle carnitine palmitoyltransferase
deficiency 8 - Other
E71.3
STOP
PEROXISOMAL DISORDERS 0 - Unspecified 3 - Other group 2 peroxisomal disorders
1 - Disorders of peroxisome biogenesis
0 - Zellweger syndrome 1 - Neonatal adrenoleukodystrophy 8 - Other
E71.5
STOP
0 - Childhood cerebral X-linked adrenoleu-kodystrophy
1 - Adolescent X-linked adrenoleu-kodystrophy
2 - Adrenomyeloneuropathy 8 - Other 9 - Unspecified
2 - X-linked adrenoleu-kodystrophy
4 - Other peroxisomal
disorders
0 - Rhizomelic chondrodysplasia punctata 1 - Zellweger-like syndrome 2 - Other group 3 peroxisomal disorders 8 - Other peroxisomal disor-
E77.1 DEFECTS IN GLYCOPROTEIN DEGRADATION
D83.1 COMMON VARIABLE IMMUNODEFICIENCY WITH PREDOMINANT IMMUNOREGULATORY T-CELL DISORDERS (IPEX)
8
© Copyright 2015; Revised 8/15/15
TYPE 2 DM
E11.65: W/ HYPERGLYCEMIA
E11.42: W/ DIABETIC POLYNEUROPATHY
E11.9: W/O COMPLICATIONS
DIABETES MELLITUS
Diabetic complications are complex and can be added electronically by using the follow-ing key words: kidney, ophthalmic, or neuro-logic complications
TYPE 2 DIABETES MELLITUS
E10: TYPE 1
E08: DUE TO UNDERLYING CONDITION
E09: DRUG OR CHEMICAL INDUCED
E11: TYPE 2
E13: OTHER SPECIFIED
*Diabetes codes are complex; Need to look up; Key words: kidney, ophthalmic, neurological, circulatory, skin
TYPE 2 DM WITH DIABETIC POLYNEUROPATHY
E11.42
TYPE 1 DM WITH DIABETIC POLYNEUROPATHY
E10.42
POSTERIOR REVERSIBLE ENCEPHALOPATHY SYNDROME
I67.83
POLYNEUROPATHY IN DISEASES CLASSIFIED ELSEWHERE
G63
*Code malignancy elsewhere
0 - Drug-induced 1 - Alcoholic 2 - Due to other toxic agents 9 - Unspecified (Myeloma/Amyloid)
Other & Unspecified POLYNEUROPATHIES
G62.
NEUROLOGY
Disorders of MAGNESIUM & CALCIUM METABOLISM
E83.51: HYPO-CALCEMIA
E83.42: HYPO-MAGNESEMIA
E83.52: HYPER-CALCEMIA
FLUIDS & ELECTROLYTES
0 - Hyperosmolality & Hypernatremia 1 - Hypoosmolality and hyponatremia 2 - Acidosis 3 - Alkalosis 4 - Mixed disorder of acid-base balance 5 - Hyperkalemia 6 - Hypokalemia 8 - Other electrolyte & acid/base disorder
Disorders of FLUID, ELECTROLYTE & ACID/BASE BALANCE
0 - Unspecified 1- Transfusion associated circulatory overload 9 - Other
7 - Fluid Overload
STOP
E87.
9
© Copyright 2015; Revised 8/15/15
0 - With cholestasis 2 - With acute hepatitis
TOXIC LIVER DISEASE
0 - Without coma 1 -With coma
1 - With hepatic necrosis
STOP
* This code is for toxic effects due to drug; Does Not include ETOH
K71.
0 - Fatty (change of) liver, not elsewhere classified 1 - Chronic passive congestion of liver 2 - Central hemorrhagic necrosis of liver 3 - Infarction of liver 4 - Peliosis hepatis 5 - Hepatic veno-occlusive disease 6 - Portal hypertension 7 - Hepatorenal syndrome
Other Diseases of LIVER
K76.
Other non-infective GASTROENTERITIS & COLITIS
0 - Gastroenteritis and colitis due to radiation 1 - Toxic gastroenteritis and colitis 2 - Allergic and dietetic gastroenteritis and colitis
K52.
0 - With esophagitis 9 - Without esophagitis
GASTRO-ESOPHAGEAL REFLUX DISEASE
K21.
DYSPHAGIA 0 - Unspecified 1– Oral phase 2 - Oropharyngeal phase 3 - Pharyngeal phase 4 - Pharyngoesophageal phase 9 - Other
R13.1
0 - First degree 1 - Second degree 2 - Third degree 3 - Fourth degree
HEMORRHOIDS K64.
0 - Malignant 8 - Other
ASCITES R18.
GI
ANOREXIA R63.0
ENTERCOLITIS DUE TO COLOSTRIDIUM DIFFICILE
A04.7
K92.81 GASTROINTESTINAL MUCOSITIS (ULCERATIVE)
ORAL MUCOSITIS (ULCERATIVE)
0 - Unspecified 1– Due to antineoplastic therapy 2 - Due to other drugs 3 - Due to radiation 9 - Other oral mucositis (ulcerative)
K12.3
1 - Fecal 9 - Other
4 - Other impaction of intestine
STOP
K56. PARALYTIC ILEUS & INTESTINAL OBSTRUTION W/O HERNIA
0 - Paralytic Ileus 1 - Intussusception 2 - Volvulus 3 - Gallstone Ileus 5 - Intestinal adhesions [bands] w/obstruction (post- procedural & post-infection) 7 - Illeus, unspecified
0 - Unspecified 9 - Other
6 - Other & unspecified intestinal obstruction
10
© Copyright 2015; Revised 8/15/15
PAIN IN THROAT R07.0
ABDOMINAL & PELVIC PAIN
0 - Upper abdomen unspecified 1– Right upper quadrant 2 - Left upper quadrant 3 - Epigastric pain
STOP
0 - Lower abdomen unspecified 1– Right lower quadrant 2 - Left lower quadrant 3 - Periumbilical pain
R10.
3 - Pain localized to lower abdomen
1 - Pain localized to Upper Abdomen
0 - Acute abdomen 2 - Pelvic and Perineal pain
PAIN
G89.3: NEOPLASM RELATED
PAIN (ACUTE) (CHRONIC)
G89.29: OTHER CHRONIC PAIN
LIMB PAIN
0 - Pain in limb, unspecified
2 - Upper arm 3 - Forearm 5 - Thigh 6 - Lower leg
4 - Hand & fingers 7 - Foot & toes
1 - Right arm 2 - Left arm 3 - Arm unspecified 4 - Right leg 5 - Left leg 6 - Leg unspecified 9 - Unspecified limb
1 - Right 2 - Left 9 - Unspecified limb
1 - Right hand or foot 2 - Left hand or foot 3 - Unspecified hand or foot 4 - Right finger or toe 5 - Left finger or toes 6 - Unspecified finger or toe
M79.6
JOINT PAIN 0 - Unspecified joint
1 - Shoulder 2 - Elbow 3 - Wrist 5 - Hip 6 - Knee 7 - Ankle & foot joints
1 - Right 2 - Left 9 - Unspecified
STOP
M25.5
DORSALGIA 0 - Unspecified side 1– Right side 2 - Left side
STOP
M54.
3 - Sciatica 4- Lumbago with sciatica
5- Low back pain
PAIN
HEADACHE R51
This code excludes atypical face pain, migraine and other
headache syndromes, trigeminal neuralgia.
GI (continued
CONSTIPATION 1 – Slow transit 9 - Other (including Opiate-induced constipation in therapeutic use)
K59.0
0 - Nausea 2 - Nausea with vomiting, unspecified
NAUSEA & VOMITING
0 - Unspecified 1 -Without nausea 2 - Projectile vomiting
1 - Vomiting
STOP
R11.
DIARRHEA UNSPECIFIED
R19.7
11
© Copyright 2015; Revised 8/15/15
COUGH RO5
BREATHING ABNORMALITIES
R06.2: WHEEZING
RO6.01: ORTHOPNEA
RO6.02: SHORTNESS OF BREATH
R06.4: HYPERVENTILATION
R06.6: HICCOUGH
R06.81: APNEA (Sleep apnea)
MALIGNANT PLEURAL EFFUSION
J91.0
OBSTRUCTIVE SLEEP APNEA (ADULT & PEDIATRIC)
G47.33
0 - With acute lower respiratory infection 1 - With (acute) exacerbation 9 - Unspecified
Other COPD J44.
ASTHMA 0– Uncomplicated 1 - With acute exacerbation 2 - With status asthmaticus
2 - Mild intermittent 3 - Mild persistent 4 - Moderate persistent 5 - Severe persistent
J45.
0 - Unilateral pulmonary emphysema [MacLeod's syndrome] 1 - Panlobular 2 - Centrilobular 8 - Other 9 - Unspecified
EMPHYSEMA J43.
ASPERGILLOSIS 0 - Invasive pulmonary 1 - Other pulmonary 2 - Tonsillar 7 - Disseminated 9 - Unspecified
8 - Other
B44.
STOP
1- Allergic bronchopulmonary 9 - Other forms
LUNG/RESPIRATORY
ACUTE RESPIRATORY DISTRESS SYNDROME
J80
J06. ACUTE UPPER RESPIRATORY INFECTIONS OF MULTIPLE/UNSPECIFIED SITES 0 - Acute laryngopharyngitis 9 - Unspecified
PULMONARY EMBOLISM W/O ACUTE COR PULMONALE
0 - Septic pulmonary embolism 2 – Saddle embolus of pulmonary artery 9 - Other
I26.9
1 - Solitary pulmonary nodule 8 - Other nonspecific abnormal finding of lung field Including multiple pulmonary nodules
Abnormal Findings on DIAGNOSTIC
IMAGING OF LUNG R91. IDIOPATHIC
INTERSTITIAL PNEUMONIA 1 - Not otherwise specified 2 - Idiopathic pulmonary fibrosis 3 - Idiopathic non-specific interstitial pneumonitis 4 - Acute interstitial pneumonitis 5 - Respiratory bronchiolitis interstitial lung disease 6 - Cryptogenic organizing pneumonia
J84.11
12
© Copyright 2015; Revised 8/15/15
OTHER SECONDARY THROMBOCYTOPENIA
D69.59
* Due to drugs, EtOH, alloimmunization; NOT ITP
LYMPHO- CYTOPENIA
D72.810
LEUKEMOID REACTION
D72.823
BLOOD
PULMONARY EMBOLISM W/O ACUTE COR PULMONALE
0 - Septic pulmonary embolism 2 - Saddle embolus of pulmonary artery 9 - Other
I26.9
HEPATIC THROMBOSIS
I81: PORTAL VEIN THROMBOSIS
I82.0: BUDD-CHIARI SYNDROME
Other
COAGULATION DEFECTS 0 - Von Willebrand's disease 1- Hereditary factor XI deficiency 2 -Hereditary deficiency of other clotting factors 4 - Acquired coagulation factor deficiency 8 - Other specified coagulation defects 9 - Unspecified
D68. Hemorrhagic Disorders due to
CIRCULATING ANTI-COAGULANTS
3 - Hemorrhagic
disorder due to circulating anticoagulants
1- Hemorrhagic disorder due to intrinsic circulating anticoagulants, antibodies, or inhibitors
2 - Hemorrhagic disorder due to extrinsic
circulating anticoagulants
1 - Acquired hemophilia 2 - Antiphospholipid
antibody with hem-orrhagic disorder
8 - Other Hemorrhagic disorder due to intrinsic circulat- ing anticoagulants, antibodies, or inhibitors
STOP
D68.
1- Activated protein C resistance 2 - Prothrombin gene mutation 9 - Other primary thrombophilia
5 - Primary thrombophilia
6 - Other thrombophilia
1- Antiphospholipid syndrome 2 - Lupus anticoagulant syndrome 9 - Other thrombophilia
D68. Other Coagulation Defects,
THROMBOPHILIA
D72.810: LYMPHOCYTOPENIA
D72.823: LEUKEMOID REACTION
D70.1: AGRANULOCYTOSIS SECONDARY TO CANCER CHEMOTHERAPY
D70.9: NEUTROPENIA,UNSPECIFIED
WHITE BLOOD CELL DISORDERS
D70.2: AGRANULOCYTOSIS DUE TO NON- CHEMOTHERAPY DRUG
0 – Congenital agranulocytosis 1 - Agranulocytosis secondary to cancer chemotherapy (Code also underlying neoplasm. Use additional code for adverse effect, if applicable, to identify drug.) 2 - Other drug-induced agranulocytosis (Use additional code for adverse effect, if applicable, to identify drug) 3 - Neutropenia due to infection 4 - Cyclic neutropenia 8 - Other 9 - Unspecified
NEUTROPENIA
Use additional code for any associated fever & mucositis
D70.
Functional Disorders of
POLYMORPHONUCLEAR NEUTROPHILS
D71
13
© Copyright 2015; Revised 8/15/15
Other specified diseases with
PARTICIPATION OF LYMPHORETICULAR AND RETICULOHISTIOCYTIC TISSUE
1 - Hemophagocytic lymphohistiocytosis 2 - Hemophagocytic syndrome, infection-associated 3 - Other histiocytosis syndromes
D76.
BLOOD (continued)
IMMUNODEFICIENCY ASSOCIATED W/OTHER MAJOR DEFECTS 0 - Wiskott-Aldrich syndrome 1 - Di George's syndrome 2 - Immunodeficiency with short-limbed stature 3 - Immunodeficiency following hereditary defective response to Epstein-Barr virus 4 - Hyperimmunoglobulin E [IgE] syndrome 8 - Other 9 - Unspecified
D82.
IMMUNODEFICIENCES
0 - SCID with reticular dysgenesis 1 - SCID with low T- and B-cell numbers 2 - SCID with low or normal B-cell numbers 3 - Adenosine deaminase [ADA] deficiency 4 - Nezelof's syndrome 5 - Purine nucleoside phosphorylase [PNP] deficiency 6 - Major histocompatibility complex class I deficiency 7 - Major histocompatibility complex class II deficiency 9 - Unspecified
1 - Biotin-dependent carboxylase deficiency
0 - Biotinidase deficiency
8 - Other 9 - Unspecified
STOP
8 - Other combined immunodefi-ciencies
9 - Other combined Immunodeficiencies
D81. COMBINED IMMUNODEFICIENCIES
STOP
ENDOCRINE
HYPOFUNCTION AND OTHER DISORDERS OF THE PITUITARY GLAND 0 - Hypopituitarism 1 - Drug-induced hypopituitarism 2 - Diabetes insipidus 3 - Hypothalamic dysfunction, not elsewhere classified 6 - Other disorders of pituitary gland 7 - Disorder of pituitary gland, unspecified
E23.
TESTICULAR DYSFUNCTION
0 - Testicular hyperfunction 1 - Testicular hypofunction 8 - Other 9 - Unspecified
E29.
0- Without crisis or storm 1- With crisis or storm
0 - With diffuse goiter 1 - With toxic single thyroid nodule 2 - With toxic multinodular goiter 3 - From ectopic thyroid tissue 4 - Thyrotoxicosis factitia 8 - Other 9 - Unspecified
E05. THYROTOXICOSIS [HYPERTHYROIDISM]
Other
HYPOTHYROIDISM 0 - Congenital hypothyroidism with diffuse goiter 1 - Congenital hypothyroidism without goiter 2 - Due to medicaments and other exogenous substances 3 - Postinfectious hypothyroidism 4 - Atrophy of thyroid (acquired) 5 - Myxedema coma 8 - Other specified hypothyroidism 9 - Unspecified
E03.
14
© Copyright 2015; Revised 8/15/15
ANEMIAS
D59. Hemolytic Anemia,
ACQUIRED 0 -Drug-induced autoimmune (Use additional code for adverse effects, if applicable, to identify drug) 1 - Other autoimmune 2 - Drug-induced non-autoimmune (Use additional code for adverse effects, if applicable, to identify drug) 3 - Hemolytic-uremic syndrome (Use additional code to identify associated: E. coli, Pneumoncoccal pneumonia, or Shigella dysenteriae) 4 - Other non-autoimmune 5 - Paroxysmal nocturnal hemoglobinuria (Marchiafava-Micheli) 6 - Hemoglobinuria due to hemolysis from other external causes 8 - Other acquired hemolytic anemias 9 - Unspecified
0 –Alpha 1 - Beta 2 - Delta-beta 3 - Minor 4 - HPFH (Hereditary persistence of fetal hemoglobin) 5 - Hemoglobin E-beta 8 - Other 9 - Unspecified
THALASSEMIA D56.
1 - Drug-induced aplastic anemia (If applicable, use additional code for adverse effects to identify drug) 2 - Aplastic anemia due to other external agents (If applicable, code first toxic effects of substance chiefly non-medicinal as to source (T51-T65) 3 - Idiopathic aplastic anemia 9 - Unspecified
Other Aplastic Anemias & Other BONE MARROW FAILURE SYNDROMES
1 - Constitutional (pure) red blood cell aplasia 9 - Other constitutional aplastic anemia
0– Constitutional aplastic anemia
1- Pancytopenia
0 - Antineoplastic chemotherapy induced
pancytopenia 1 - Other drug-induced
pancytopenia 8 - Other pancytopenia
2 - Myelophthisis 9- Other specified aplastic anemias
& other bone marrow failure
syndrome
8 - Other specified aplastic anemias & other bone marrow failure syndromes
STOP
STOP
D61.
0 - Secondary to blood loss (chronic) 1 - Sideropenic dysphagia 8 - Other iron deficiency anemias 9 - Unspecified
Anemia,
IRON DEFICIENCY D50.
Anemia in
CHRONIC DISEASES CLASSIFIED ELSEWHERE
0 - Anemia in neoplastic disease (Code first neoplasm) 1 - Anemia in chronic kidney disease (Code first underlying CKD) 8 - Anemia in other chronic diseases classified elsewhere (Code first underlying disease such as: - Hypothyroidism - Tuberculosis)
D63.
0 - Hereditary sideroblastic anemia 1 - Secondary sideroblastic anemia due to disease 2 - Secondary sideroblastic anemia due to drugs and toxins 3 - Other sideroblastic anemias 4 - Congenital dyserythropoietic anemia 9 - Unspecified
OTHER ANEMIAS
8 –Other specified anemias
1- Anemia due to anti-neoplastic chemotherapy 9 -Other specified anemias
STOP
D64.
ANEMIA DUE TO ANTINEOPLASTIC CHEMOTHERAPY
D64.81
0 - In neoplastic disease 1 - In chronic kidney disease 8 - In other chronic diseases
ANEMIA IN CHRONIC DISEASES
D63.
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ESSENTIAL (PRIMARY) HYPERTENSION
I10 NON VERERTIGINOUS DIZZINESS
R42
CACHEXIA R64
CHILLS W/O FEVER R68.83
DEHYDRATION E86.0
UNSPECIFIED PROTEIN-CALORIE MALNUTRITION
E46
0 - Idiopathic 1 - Orthostatic 2 - Due to drugs
HYPOTENSION I95.
0 - Localized 1 - Generalized 9 - Unspecified
EDEMA R60.
0 - Localized 1 - Generalized
ENLARGED LYMPH NODES
R59.
0 - Ataxic gait 1 - Paralytic gait 2 - Difficulty in walking
ABNORMALITIES OF GAIT & MOBILITY
1 - Unsteadiness on feet
8 - Other abnormalities of gait & mobility
STOP
R26.
2 - Drug Induced 9 - Unspecified
FEVER OF UNKNOWN ORIGIN
1 - Fever presenting with conditions classified elsewhere 2 - Post procedural fever 3 - Post vaccination fever 4 - Febrile nonhemolytic transfusion reaction
8 - Other specified fever
STOP
R50.
CONSTITUTIONAL
SLEEP DISORDERS
G47.33: OBSTRUCTIVE SLEEP APNEA
(ADULT) (PEDIATRIC)
G25.81: RESTLESS LEGS SYNDROME
SLEEP DISORDERS
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ESSENTIAL (PRIMARY) HYPERTENSION
I10
ACUTE KIDNEY FAILURE
0 - With tubular necrosis 1 - With acute cortical necrosis 2 - With medullary necrosis 8 - Other 9 - Unspecified
N17.
1 - Stage 1 2 - Stage 2 (mild) 3 - Stage 3 (moderate) 4 - Stage 4 (severe) 5 - Stage 5 6 - End stage renal disease
CHRONIC KIDNEY DISEASE (CKD)
N18.
0 - Gross hematuria 1 - Benign essential microscopic hematuria
HEMATURIA
*Use code forcystitis/ glomerunephritis if present)
R31.
DYSURIA R30.0
INCONTINENCE/ UTI
0 - Urinary tract infection, site not specified 3 - Stress incontinence (female/male)
1 - Urge incontinence 2 - Incontinence without sensory awareness 3 - Post-void dribbling 4 - Nocturnal enuresis 5 - Continuous leakage 6 - Mixed incontinence
1 - Overflow incontinence
8 - Other specified urinary incontinence
STOP
4 - Other specified urinary incontinence
9 - Other incontinence
N39.
0 - Unspecified 1- Transfusion associated circulatory overload 9 - Other
0 - Hyperosmolality & Hypernatremia 1 - Hypoosmolality and hyponatremia 2 - Acidosis 3 - Alkalosis 4 - Mixed disorder of acid-base balance 5 - Hyperkalemia 6 - Hypokalemia 8 - Other electrolyte & acid/base disorder
7 - Fluid Overload
STOP
E87. Disorders of FLUID, ELECTROLYTE & ACID/BASE BALANCE
RENAL/GU
CALCULUS OF KIDNEY & URETER
0 - Calculus of kidney 1 - Calculus of ureter 2 - Calculus of kidney with calculus of ureter
N20.
0 - Localized 1 - Generalized 9 - Unspecified
EDEMA R60.
CYSTITIS
0 - Acute 1 - Interstitial cystitis (chronic) 2 - Other chronic cystitis 3 - Trigonitis 4 - Irradiation cystitis
0 - Without hematuria 1 - With hematuria
N30.
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1 - Right 2 - Left 9 - Unspecified
L03.
A04. BACTERIAL INTESTINAL INFECTIONS
0 - Enteropathogenic Escherichia coli infection 1 - Enterotoxigenic Escherichia coli infection 2 - Enteroinvasive Escherichia coli infection 3 - Enterohemorrhagic Escherichia coli infection 4 - Other intestinal Escherichia coli infections 5 - Campylobacter enteritis 6 - Enteritis due to Yersinia enterocolitica 7 - Enterocolitis due to Clostridium difficile 8 - Other specified bacterial intestinal infections
CANDIDIASIS 0 - Candidal stomatitis 1 - Pulmonary candidiasis 2 - Candidiasis of skin and nail 3 - Candidiasis of vulva and vagina 5 - Candidal meningitis 6 - Candidal endocarditis 7 - Candidal sepsis 9 - Unspecified
1- Candidal cystitis and urethritis 2 - Candidal balanitis 9 - Other urogenital candidiasis
4 - Other urogenital sites
STOP
8 - Other sites 1- Candidal esophagitis 2 - Candidal enteritis 3 - Candidal cheilitis 4 - Candidal otitis externa 9 - Other sites
B37.
ZOSTER (HERPES) 0 - Zoster encephalitis 1 - Zoster meningitis 7 - Disseminated 8 - With other complications 9 - Without complications
1- Postherpetic geniculate ganglionitis 2 - Postherpetic trigeminal neuralgia 3 - Postherpetic polyneuropathy 4 - Postherpetic myelitis 9 - Other postherpetic nervous system involvement
2 - With other nervous system involvement
STOP
0 - Unspecified 1– Conjunctivitis 2 - Iridocyclitis 3 - Keratitis 4 - Scleritis 9 - Other herpes zoster eye
3 - Ocular disease
B02.
STOP
3 - Trunk 1 - Cellulitis 2 - Acute lymphangitis
1 - Abdominal wall 2 - Back (except
buttock) 3 - Chest wall 4 - Groin 5 - Perineum 6 - Umbilicus 7 - Buttock 9 - Unspecified part
8 - Other sites
0 - Cellulitis 1 - Acute lymphangitis
1 - Head (except face) 8 - Other sites
9 - Unspecified
1 - Cellulitis 2 - Acute lymphangitis
1 - Cellulitis 2 - Acute lymphangitis
1 - Right axilla 2 - Left axilla 3 - Right upper limb 4 - Left upper limb 5 - Right lower limb 6 - Left lower limb 9 - Unspecified part
2 - Face & Neck 1 - Face 2 - Neck
1 - Cellulitis 2 - Acute lymphangitis
0 - Finger & toe 1 - Right 2 - Left 9 - Unspecified
1 - Other parts of limb
1 - Cellulitis of finger 2 - Acute lymphangitis of finger 3 - Cellulitis of toe 4 - Acute lymphangitis of finger
L03. CELLULITIS & ACUTE LYMPHANGITIS
RESPIRATORY SYNCYTIAL VIRUS PNEUMONIA
J12.1
INFECTIOUS DISEASES
ASPERGILLOSIS 0 - Invasive pulmonary 1 - Other pulmonary 2 - Tonsillar 7 - Disseminated 9 - Unspecified
8 - Other
B44.
STOP
1- Allergic bronchopulmonary 9 - Other forms
B25. CYTOMEGALOVIRAL DISEASE
0 - Cytomegaloviral pneumonitis 1 - Cytomegaloviral hepatitis 2 - Cytomegaloviral pancreatitis 8 - Other cytomegaloviral diseases 9 - Cytomegaloviral disease, unspecified
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TOXOPLASMOSIS
0 - Oculopathy
1 - Hepatitis 2 - Meningoencephalitis 3 - Pulmonary toxoplasmosis 9 - Unspecified
STOP
8 - With other organ involvement
0 - Unspecified 1 - Chorioretinitis 9 - Other
1 - Myocarditis 2 - Myositis 3 - Tubulo-interstitial nephropathy 9 - Other organ involvement
B58.
2 - Drug Induced 9 - Unspecified
FEVER OF UNKNOWN ORIGIN
1 - Fever presenting with conditions classified elsewhere 2 - Post procedural fever 3 - Post vaccination fever 4 - Febrile nonhemolytic transfusion reaction
8 - Other specified fever
STOP
R50.
PSYCHIATRIC
0 - Mild 1 - Moderate 2 - Severe without psychotic features 3 - Severe with psychotic features 4 - In partial remission 5 - In full remission
MAJOR DEPRESSIVE DISORDER, SINGLE EPISODE
F32.
1 - PTSD
REACTION TO SEVERE STRESS
0 - Unspecified 1 -With depressed mood 2 - With anxiety 3 - With anxiety & depressed mood 4 - With disturbance of conduct 5 - With disturbance of emotions & conduct 9 - With other symptoms
2 - Adjustment disorders
0 - Unspecified 1 -Acute 2 - Chronic
F43.
0 - Panic disorder [episodic paroxysmal anxiety] without agoraphobia 1 - Generalized anxiety disorder
ANXIETY DISORDERS F41.
CARDIOLOGY
1 - Left ventricular failure 9 - Unspecified
HEART FAILURE
0 - Unspecified 1 -Acute 2 - Chronic 3 - Acute on chronic
I50.
2 - Systolic CHF 3 - Diastolic CHF 4 - Combined systolic & diastolic CHF
STOP
ATRIAL FIBRILLATION & FLUTTER
0 - Paroxysmal atrial fibrillation 1 - Persistent atrial fibrillation 2 - Chronic atrial fibrillation
I48.
0 - Idiopathic 1 - Orthostatic 2 - Due to drugs
HYPOTENSION I95.
ABNORMALITIES OF HEART BEAT
0 - Tachycardia, unspecified 1 - Bradycardia, unspecified 2 - Palpitations
R00.
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NONFAMILIAL HYPOGAMMAGLOBULINEMIA
D80.1
EPISTAXIS R04.0
GRAFT-VERSUS-HOST DISEASE
0 - Acute 1 - Chronic 2 - Acute on chronic 3 - Unspecified
D89.81
1 - Right lacrimal gland 2– Left lacrimal gland 3 - Bilateral lacrimal glands 9 - Unspecified lacrimal gland
DRY EYE SYNDROME H04.12
NICOTINE DEPENDENCE - CIGARETTES
0 - Uncomplicated 1 - In Remission 3 - With withdrawal 8 - With other nicotine-induced disorders 9 - Unspecified nicotine-induced disorders
F17.21
SICCA SYNDROME 0 -Unspecified 1 - With keratoconjunctivitis 2 - With lung involvement 3 - With myopathy 4 - With tubulo-interstitial nephropathy 9 - With other organ involvement
M35.0
ORAL MUCOSITIS, ULCERATIVE
0 -Unspecified 1 - Due to antineoplastic therapy 2 - Due to other drugs 3 - Due to radiation 9 - Other
K12.3
ENLARGED LYMPH NODES
0 - Localized 1 - Generalized
R59.
SHINE DIAGNOSIS CODES
LYMPHEDEMA, NOT ELSEWHERE CLASSIFIED
I89.0
0 - Ataxic gait 1 - Paralytic gait 2 - Difficulty in walking
ABNORMALITIES OF GAIT & MOBILITY
1 - Unsteadiness on feet
8 - Other abnormalities of gait & mobility
STOP
R26.
MISCELLANEOUS
L54 ERYTHEMA IN DISEASES CLASSIFIED ELSEWHERE
HEPATIC VENO- OCCLUSIVE DISEASE (SINUSOIDAL OBSTRUCTION SYNDROME –SOS)
K76.5
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