INTRODUCTION TO ICD-10-CM CODES: PART 3 CHAPTER-SPECIFIC GUIDELINES

Transcription

INTRODUCTION TO ICD-10-CM CODES:
PART 3
CHAPTER-SPECIFIC GUIDELINES
CHAPTERS 16-21
2012 Official Guidelines for Coding and Reporting
COURSE DESCRIPTION
This CE course is the third of three courses that introduces basic
information on ICD-10-CM codes. This course identifies diseases
and injuries in Chapters 16-21of the ICD-10-CM Tabular List,
including examples of codes found in each chapter. Also included
are chapter-specific coding guidelines and attachments of the
Tabular List, Alphabetic Index, and Table of Drugs.
Rev 4.0
©May 2014
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COURSE TITLE: Introduction to ICD-10-CM: Part 3
Author: Steve M. Verno, CMBSI, CMSCS, CEMCS, CPM-MCS
Billing and Coding Consultant
Heal Your Practice
Lucia Johnson, M.A. Ed, MT(ASCP)SBB
Vice President, Recertification
NCCT
Number of Clock Hours Credit: 6.0
Course # 1221412
P.A.C.E. ® Approved: __ Yes
X_ No
OBJECTIVES
Upon completion of this continuing education course, the professional
should be able to:
1. Identify diseases and injuries located in Chapters 16-21 of the ICD10-CM Tabular List.
2. List examples of codes found in Chapters 16-21 of the ICD-10-CM
Tabular List.
3. Identify chapter-specific coding guidelines in Chapters 16-21 based
on the 2012 ICD-10-CM Official Guidelines for Coding and Reporting.
4. Using the examples of the Tabular List, Alphabetic Index, and Table
of Drugs provided, locate codes for specific diseases and injuries.
Disclaimer
The writers for NCCT continuing education courses attempt to provide factual information based
on literature review and current professional practice. However, NCCT does not guarantee that
the information contained in the continuing education courses is free from all errors and
omissions.
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INTRODUCTION
Chapters 16-21 of the ICD-10-CM codes (2012 version) will be reviewed in this last of
three introductory courses which discusses the new diagnosis codes that will be
implemented on October 1, 2014*.
*NOTE: On 3/27/2014, Congress voted to delay implementation of ICD-10 code
sets until October 1, 2015.
The NCCT CE courses Introduction to ICD-10-CM Codes: Part 1 and Introduction to
ICD-10-CM Codes: Part 2 should be completed before this course. The Part 1
introduction course reviews the structure and conventions of ICD-10-CM codes which
assists with the understanding of the content presented in this course. The Part 2
introduction course provides information on Chapters 1-15 of the ICD-10-CM Tabular
List.
CHAPTER REVIEW
The following table identifies diseases and injuries found in Chapters 16-21 of the ICD10-CM Tabular List. Associated codes and examples of codes are included. The
examples of codes should be reviewed with attention placed on code structure and
increased specificity. As discussed in CE course Introduction to ICD-10-CM: Part 1,
ICD-10-CM codes are structured as follows.
Combination of letters and numbers that can go to as many as 7 characters
 Characters 1-3: Category
o First character is alpha
o Characters 2 and 3 are numeric
 Characters 4-6: Etiology, anatomic site, severity, or other clinical detail such as
laterality
o Can be alpha or numeric
 Character 7: Extension (initial encounter, subsequent encounter, sequela, etc.)
o Can be alpha or numeric
ICD-10-CM
CHAPTER
NUMBER
16
CHAPTER TITLE/ASSOCIATED CODES
Certain Conditions Originating in the Newborn (perinatal period)
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Newborn affected by maternal factors and by complications of pregnancy, labor, and delivery: P00 – P04
Disorders related to length of gestation and fetal growth: P05 – P08
Abnormal findings on neonatal screening: P09
Birth trauma: P10 – P15
Respiratory and cardiovascular disorders specific to the perinatal period: P10 – P29
Hemorrhagic and hematological disorders of newborn: P50 – P61
Transitory endocrine and metabolic disorders specific to newborn: P70 – P74
Digestive system disorders of newborn: P76 – P78
Conditions involving the integument and temperature regulation of newborn: P80 – P83
Other problems with newborn: P84
Other disorders originating in the perinatal period: P90 – P96
Examples from the Tabular List
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P00.4
Newborn (suspected to be) affected by maternal nutritional disorders
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P01.01
P02.4
P03.2
P04.2
P05.18
P07.33
P08.2
P09
P10.4
P12.3
P24.00
P28.3
P35.1
P39.3
P51.9
P52.6
P55.1
P58.41
P61.3
P70.2
P74.1
P92.6
Newborn (suspected to be) affected by premature rupture of membranes
Newborn (suspected to be) affected by prolapsed cord
Newborn (suspected to be) affected by forceps delivery
Newborn (suspected to be) affected by maternal use of tobacco
Newborn small for gestational age, 2000-2499 grams
Preterm newborn, gestational age 30 completed weeks
Post-term newborn
Abnormal findings on neonatal screening
Tentorial tear due to birth injury
Bruising of scalp due to birth injury
Meconium aspiration without respiratory symptoms
Primary sleep apnea of newborn
Congenital cytomegalovirus infection
Neonatal urinary tract infection
Umbilical hemorrhage of newborn
Cerebellar (nontraumatic) and posterior fossa hemorrhage of newborn
ABO isoimmunization of newborn
Neonatal jaundice due to drugs or toxins transmitted from mother
Congenital anemia from fetal blood loss
Neonatal diabetes mellitus
Dehydration of newborn
Failure to thrive in newborn
Congenital Malformations, Deformations, and Chromosomal Abnormalities
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Congenital malformations of the nervous system: Q00 – Q07
Congenital malformations of the eye, ear, face, and neck: Q10 – Q18
Congenital malformations of the circulatory system: Q20 – Q28
Congenital malformations of the respiratory system: Q30 – Q34
Cleft lip and cleft palate: Q35 – Q37
Other congenital malformations of the digestive system: Q38 – Q45
Congenital malformations of the genital organs: Q50 – Q56
Congenital malformations of the urinary system: Q60 – Q64
Congenital malformations and deformations of the musculoskeletal system: Q65 – Q79
Other congenital malformations: Q80 – Q89
Chromosomal abnormalities, not elsewhere classified: Q90 – Q99
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Q00.0
Anencephaly
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Q01.2
Occipital encephalocele
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Q04.5
Megalencephaly
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Q05.0
Cervical spina bifida with hydrocephalus
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Q07.03 Arnold-Chiari syndrome with spina bifida and hydrocephalus
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Q10.2
Congenital entropion
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Q13.3
Congenital corneal opacity
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Q16.0
Congenital absence of (ear) auricle
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Q18.3
Webbing of neck
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Q21.3
Tetralogy of Fallot
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Q22.4
Congenital tricuspid stenosis
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Q25.0
Patent ductus arteriosus
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Q27.32 Arteriovenous malformation of renal vessel
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Q30.3
Congenital perforated nasal septum
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Q35.1
Cleft hard palate
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Q37.2
Cleft soft palate with bilateral cleft lip
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Q39.6
Congenital diverticulum of esophagus
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Q43.1
Hirschsprung’s disease
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Q44.6
Cystic disease of liver
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Q50.01 Congenital absence of ovary, unilateral
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Q52.11 Transverse vaginal septum
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Q53.02 Ectopic testis, unilateral
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Q55.5
Congenital absence and aplasia of penis
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Q61.01 Congenital single renal cyst
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Q64.5
Congenital absence of bladder and urethra
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Q66.2
Q70.02
Q72.31
Q74.1
Q76.427
Q77.4
Q79.6
Q85.1
Q09.2
Q96.0
Q98.0
Congenital metatarsus (primus) varus
Fused fingers, left hand
Congenital absence of right foot and toe(s)
Congenital malformation of knee
Congenital lordosis, lumbosacral region
Acondroplasia
Ehlers-Danlos syndrome
Tuberous sclerosis
Trisomy 21, translocation
Karyotype 45, X
Klinefelter syndrome karyotype 47, XXY
Symptoms, Signs, and Abnormal Clinical and Laboratory Findings
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Symptoms and signs involving the circulatory and respiratory systems: R00 – R09
Symptoms and signs involving the digestive system and abdomen: R10 – R19
Symptoms and signs involving the skin and subcutaneous tissue: R20 – R23
Symptoms and signs involving the nervous and musculoskeletal systems: R25 – R29
Symptoms and signs involving the genitourinary system: R30 – R39
Symptoms and signs involving cognition, perception, emotional state, and behavior: R40 – R46
Symptoms and signs involving speech and voice: R47 – R49
General symptoms and signs: R50 – R69
Abnormal findings on examination of blood, without diagnosis: R70 – R79
Abnormal findings on examination of urine, without diagnosis: R80 – R82
Abnormal findings on examination of other body fluids, substances, and tissues, without diagnosis: R83 –
R89
Abnormal findings on diagnostic imaging and in function studies, without diagnosis: R90 – R94
Abnormal tumor markers: R97
Ill-defined and unknown cause of mortality: R99
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R00.0
Tachycardia, unspecified
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R00.2
Palpitations
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R03.0
Elevated blood-pressure reading, without diagnosis of hypertension
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R04.0
Epistaxis
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R04.4
Hemoptysis
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R06.02 Shortness of breath
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R07.1
Chest pain on breathing
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R09.1
Pleurisy
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R09.81 Nasal congestion
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R10.11 Right upper quadrant pain
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R11.1
Vomiting
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R14.3
Flatulence
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R19.06 Epigastric swelling, mass or lump
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R20.3
Hyperesthesia
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R23.3
Spontaneous ecchymosis
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R29.4
Clicking hip
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R35.1
Nocturia
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R36.0
Urethral discharge without blood
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R40.0
Somnolence
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R41.81 Age-related cognitive decline
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R45.1
Restlessness and agitation
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R45.86 Emotional lability
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R47.81 Slurred speech
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R50.83 Postvaccination fever
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R56.00 Simple febrile convulsions
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R60.0
Localized edema
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R63.1
Polydipsia
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R68.11 Excessive crying of infant (baby)
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R70.0
Elevated erythrocyte sedimentation rate
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R73.01 Impaired fasting glucose
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R78.79 Finding of abnormal level of heavy metals in blood
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R82.3
Hemoglobinuria
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R87.5
R92.2
R94.31
R97.2
Abnormal microbiological findings in specimens from female genital organs
Inconclusive mammogram
Abnormal electrocardiogram [ECG] [EKG]
Elevated prostate specific antigen [PSA]
Injury, Poisoning, and Certain Other External Consequences of External Causes
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Injuries to the head: S00 – S09
Injuries to the neck: S10 – S19
Injuries to the thorax: S20 – S29
Injuries to the abdomen, lower back, lumbar spine, pelvis, and external genitals: S30 – S39
Injuries to the shoulder and upper arm: S40 – S49
Injuries to the elbow and forearm: S50 – S59
Injuries to the wrist, hand, and fingers: S60 – S69
Injuries to the hip and thigh: S70 – S79
Injuries to the knee and lower leg: S80 – S89
Injuries to the ankle and foot: S90 – S99
Unspecified multiple injuries: T07
Injury of unspecified body region: T14
Effects of foreign body entering through natural orifice: T15 – T19
Burns and corrosions of external body surface, specified by site: T20 – T25
Burns and corrosions confined to eye and internal organs: T26 – T28
Burns and corrosions of multiple and unspecified body regions: T30 – T32
Frostbite: T33 – T34
Poisoning by, adverse effects of, and underdosing of drugs, medicaments, and biological substances: T36 –
T50
Toxic effects of substances chiefly nonmedical as to source: T51 – T65
Other and unspecified effects of external causes: T66 – T78
Certain early complications of trauma: T79
Complications of surgical and medical care, not elsewhere classified: T80 – T88
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S00.03 Contusion of scalp
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S00.12 Contusion of left eyelid and periocular area
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S00.451 Superficial foreign body of right ear
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S00.561 Insect bite (nonvenomous) of lip
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S01.24 Puncture wound with foreign body of nose
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S01.451 Laceration of lip and oral cavity without foreign body
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S02.2
Fracture of nasal bones
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S03.2
Dislocation of tooth
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S04.51 Injury of facial nerve, right side
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S05.72 Avulsion of left eye
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S06.2X4 Diffuse traumatic brain injury with loss of consciousness of 6 hours to 24 hours
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S06.320 Contusion and laceration of left cerebrum without loss of consciousness
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S06.825 Injury of left internal carotid artery, intracranial portion, not elsewhere classified with loss of
consciousness greater than 24 hours with return to pre-existing conscious level
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S08.122 Partial traumatic amputation of left ear
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S13.130 Subluxation of C2/C3 cervical vertebrae
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S15.011 Minor laceration of right carotid artery
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S21.052 Open bite of left breast
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S22.070 Wedge compression fracture of T9/T10 vertebra
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S25.511 Laceration of intercostal blood vessels, right side
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S31.824 Puncture wound with foreign body of left buttock
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S32.2
Fracture of coccyx
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S32.482 Displaced dome fracture of left acetabulum
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S33.6
Sprain of sacroiliac joint
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S36.031 Moderate laceration of spleen
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S37.522 Contusion of fallopian tube, bilateral
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S42.242 4-part fracture of surgical neck of left humerus
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S44.22 Injury of radial nerve a upper arm level, left arm
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S46.392 Other injury of muscle, fascia, and tendon of triceps, left arm
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S48.021 Partial traumatic amputation at right shoulder joint
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S52.122 Displaced fracture of head of left radius
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20
S53.401 Unspecified sprain of right elbow
S57.82 Crushing injury of left forearm
S60.111 Contusion of right thumb with damage to nail
S60.322 Blister (nonthermal) of left thumb
S61.324 Laceration with foreign body of right ring finger with damage to nail
S62.211 Bennett’s fracture, right hand
S62.645 Nondisplaced fracture of proximal phalanx of left ring finger
S63.410 Traumatic rupture of collateral ligament of right index finger at metacarpophalangeal and
interphalangeal joint
S65.412 Laceration of blood vessel of left thumb
S66.319 Strain of extensor muscle, fascia and tendon of unspecified finger at wrist and hand level
S70.01 Contusion of right hip
S72.432 Displaced fracture of medial condyle of left femur
S76.321 Laceration of muscle, fascia and tendon of the posterior muscle group at thigh level, right thigh
S82.045 Nondisplaced comminuted fracture of left patella
S83.512 Sprain of anterior cruciate ligament of left knee
S90.111 Contusion of right great toe without damage to nail
S91.351 Open bite, right foot
S96.022 Laceration of muscle and tendon of long flexor muscle of toe at ankle and foot level, left foot
T15.11 Foreign body in conjunctival sac, right eye
T20.26 Burn of second degree of forehead and cheek
T21.75 Corrosion of third degree of buttock
T23.251 Burn of second degree of right palm
T26.02 Burn of left eyelid and periocular area
T32.98 Corrosions involving 90% or more of body surface with 80-89% third degree corrosion
T33.532 Superficial frostbite of left finger(s)
T36.4X2 Poisoning by tetracyclines, intentional self-harm
T37.5X5 Adverse effect of antiviral drugs
T41.1X5 Adverse effect of intravenous anesthetics
T42.4X6 Underdosing of benzodiazepines
T43.621 Poisoning by amphetamines, accidental (unintentional)
T45.515 Adverse effect of anticoagulants
T47.2X5 Adverse effect of stimulant laxatives
T50.5X3 Poisoning by appetite depressants, assault
T52.8X1 Toxic effect of other organic solvents, accidental (unintentional)
T58.02 Toxic effect of carbon monoxide from motor vehicle exhaust, intentional self-harm
T62.0X1 Toxic effect of ingested mushrooms, accidental (unintentional)
T63.331 Toxic effect of venom of brown recluse spider, accidental (unintentional)
T67.3
Heat exhaustion, anhidrotic
T71.113 Asphyxiation due to smothering under pillow, assault
T74.12 Child physical abuse, confirmed
T75.01 Shock due to being struck by lightning
T75.3
Motion sickness
T76.21 Adult sexual abuse, suspected
T78.01 Anaphylactic reaction due to peanuts
T79.4
Traumatic shock
T80.212 Local infection due to central venous catheter
T80.310 ABO incompatibility with acute hemolytic transfusion reaction
T81.500 Unspecified complication of foreign body accidentally left in body following surgical operation
T82.03 Leakage of heart valve prosthesis
T83.32 Displacement of intrauterine contraceptive device
T84.033 Mechanical loosening of internal left knee prosthetic joint
T86.841 Corneal transplant failure
T88.0
Infection following immunization
External Causes of Morbidity
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Pedestrian injured in transport accident: V00 – V09
Pedal cycle rider injured in transport accident: V10 – V19
Motorcycle rider injured in transport accident: V20 – V29
Occupant of 3-wheeled motor vehicle injured in transport accident: V30 – V39
Car occupant injured in transport accident: V40 – V49
Occupant of pick-up truck or van injured in transport accident: V50 – V59
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Occupant of heavy transport vehicle injured in transport accident: V60 – V69
Bus occupant injured in transport accident: V70 – V79
Other land transport accidents: V80 – V89
Water transport accidents: V90 – V94
Air and space transport accidents: V95-V97
Other and unspecified transport accidents: V98 – V99
Slipping, tripping, stumbling, and falls: W00 – W19
Exposure to inanimate mechanical forces: W20 – W49
Exposure to animate mechanical forces: W50 – W64
Accidental non-transport drowning and submersion: W65 – W74
Exposure to electric current, radiation, and extreme ambient air temperature and pressure: W85 – W99
Exposure to smoke, fire, and flames: X00 – X08
Contact with heat and hot substances: X10 – X19
Exposure to forces of nature: X30 – X39
Accidental exposure to other specified factors: X52 – X58
Intentional self-harm: X71 – X83
Assault: X92 – Y09
Event of undetermined intent: Y21 – Y33
Legal intervention, operations of war, military operations, and terrorism: Y35 – Y38
Misadventures to patients during surgical and medical care: Y62 – Y69
Medical devices associated with adverse incidents in diagnostic and therapeutic use: Y70 – Y82
Surgical and other medical procedures as the cause of abnormal reaction of the patient, or of later
complication, without mention of misadventure at the time of the procedure: Y83 – Y84
Supplementary factors related to causes of morbidity classified elsewhere: Y90 – Y99
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V00.01 Pedestrian on foot injured in collision with roller-skater
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V00.132 Skateboarder colliding with stationary object
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V00.811 Fall from moving wheelchair (powered)
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V09.21 Pedestrian injured in traffic accident involving military vehicle
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V26.4
Motorcycle driver injured in collision with other nonmotor vehicle in traffic accident
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V37.1
Passenger in three-wheeled motor vehicle injured in collision with fixed or stationary object in
nontraffic accident
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V45.6
Car passenger injured in collision with railway train or railway vehicle in traffic accident
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V64.4
Person boarding or alighting a heavy transport vehicle injured in noncollision transport accident
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V80.010 Animal-rider injured by fall from or being thrown from horse in noncollision accident
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V86.11 Passenger of ambulance or fire engine injured in traffic accident
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V90.15 Drowning and submersion due to canoe or kayak sinking
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V91.04 Burn due to sailboat on fire
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V93.62 Machinery accident on board fishing boat
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V95.41 Spacecraft crash injuring occupant
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W10.1 Fall (on) (from) sidewalk curb
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W16.012 Fall into swimming pool striking water surface causing other injury
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W18.42 Slipping, tripping and stumbling without falling due to stepping into hole or opening
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W21.02 Struck by soccer ball
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W22.11 Striking against or struck by driver side automobile airbag
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W21.0 Contact with powered kitchen appliance
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W33.12 Accidental malfunction of hunting rifle
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W46.1
Contact with contaminated hypodermic needle
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W54.0
Bitten by dog
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W56.41 Bitten by shark
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W61.11 Bitten by macaw
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W88.1
Exposure to radioactive isotopes
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W93.2
Prolonged exposure in deep freeze unit or refrigerator
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X00.3
Fall from burning building or structure in uncontrolled fire
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X11.0
Contact with hot water in bath or tub
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X17
Contact with hot engines, machinery and tools
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X34
Earthquake
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X73.0
Intentional self-harm by shotgun discharge
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Y02.0
Assault by pushing or placing victim in front of motor vehicle
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V07.420 Foster father, perpetrator of maltreatment and neglect
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Y35.001 Legal intervention involving unspecified firearm discharge, law enforcement official injured
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Y36.270 War operations involving fragments from weapons, military personnel
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21
Y36.6X1
Y37.92
Y38.3X2
Y38.811
Y62.0
Y63.3
Y65.53
Y76.0
Y84.1
War operation involving biological weapons, civilian
Military operations involving friendly fire
Terrorism involving fires, conflagration and hot substances, civilian injured
Terrorism involving suicide bomber, public safety official injured
Failure of sterile precautions during surgical operation
Inadvertent exposure of patient to radiation during medical care
Performance of correct procedure (operation) on wrong side or body part
Diagnostic and monitoring obstetric and gynecological devices associated with adverse incidents
Kidney dialysis as the cause of abnormal reaction of the patient, or of later complication, without
mention of misadventure at the time of the procedure
Y90.5
Blood alcohol level of 100-119 mg/100 mL
Y92.017 Garden or yard in single-family (private) house as the place of occurrence of the external cause
Y92.221 Middle school as the place of occurrence of the external cause
Y93.75 Activity, martial arts
Y93.K1 Activity, walking an animal
Factors Influencing Health Status and Contact with Health Services
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Persons encountering health services for examination: Z00 – Z13
Genetic carrier and genetic susceptibility to disease: Z14 – Z15
Infection and drug-resistant microorganisms: Z16
Estrogen receptor status: Z17
Retained foreign body fragments: Z18
Persons with potential health hazards related to communicable diseases: Z20 – Z28
Persons encountering health services in circumstances related to reproduction: Z30 – Z39
Persons encountering health services for specific procedures and health care: Z40 – Z53
Persons with potential health hazards related to socioeconomic and psychosocial circumstances: Z55 – Z65
Do not resuscitate (DNR) status: Z66
Blood type: Z67
Body mass index (BMI): Z68
Persons encountering health services in other circumstances: Z69 – Z76
Persons with potential health hazards related to family and personal history and certain conditions influencing
health status: Z77 – Z99
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Z00.111 Health examination for newborn 8 to 28 days old
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Z00.3
Encounter for examination for adolescent development state
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Z01.110 Encounter for hearing examination following failed hearing screening
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Z01.83 Encounter for blood typing
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Z02.1
Encounter for pre-employment examination
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Z02.83 Encounter for blood-alcohol and blood-drug test

Z12.31 Encounter for screening mammogram for malignant neoplasm of breast

Z15.02 Genetic susceptibility to malignant neoplasm of ovary

Z16.21 Resistance to vancomycin

Z22.51 Carrier of viral hepatitis B

Z28.01 Immunization not carried out because of acute illness of patient

Z31.41 Encounter for fertility testing

Z34.02 Encounter for supervision of normal first pregnancy, second trimester

Z43.2
Encounter for attention to ileostomy

Z45.010 Encounter for checking and testing of cardiac pacemaker pulse generator [battery]

Z48.811 Encounter for surgical aftercare following surgery on the nervous system

Z52.4
Kidney donor

Z55.3
Underachievement in school

Z56.82 Military employment status

Z59.0
Homelessness

Z62.22 Institutional upbringing

Z63.0
Problems in relationship with spouse or partner

Z65.2
Problems related to release from prison

Z65.4
Victim of crime and terrorism

Z67.21 Type B blood, Rh negative

Z68.37 Body mass index (BMI) 37.0 – 37.9, adult

Z69.010 Encounter for mental health services for victim of parental child abuse

Z71.6
Tobacco abuse counseling
9

















Z76.82
Z77.21
Z79.52
Z80.42
Z82.41
Z84.81
Z85.6
Z86.14
Z87.312
Z88.2
Z89.212
Z91.010
Z91.11
Z94.7
Z95.810
Z97.2
Z99.81
Awaiting organ transplant status
Contact with and (suspected) exposure to potentially hazardous body fluids
Long term (current) use of systemic steroids
Family history of malignant neoplasm of prostate
Family history of sudden cardiac death
Family history of carrier of genetic disease
Personal history of leukemia
Personal history of Methicillin resistant Staphylococcus aureus infection
Personal history of (healed) stress fracture
Allergy status to sulfonamides status
Acquired absence of left upper limb below elbow
Allergy to peanuts
Patient’s noncompliance with dietary regimen
Corneal transplant status
Presence of automatic (implantable) cardiac defibrillator
Presence of dental prosthetic device (complete) (partial)
Dependence on supplemental oxygen
CODING GUIDELINES: CHAPTERS 16-21
The following are coding guidelines for ICD-10-CM that come from the Centers for
Medicare and Medicaid Services (CMS). This information is from the CMS website
(www.cms.gov) and it is in the public domain, available for downloading and use without
copyright infringement.
10
ICD-10-CM Official Guidelines for Coding and Reporting
2012
Narrative changes appear in bold text
Items underlined have been moved within the guidelines since the 2011 version
Italics are used to indicate revisions to heading changes
The Centers for Medicare and Medicaid Services (CMS) and the National Center for Health
Statistics (NCHS), two departments within the U.S. Federal Government’s Department of Health
and Human Services (DHHS) provide the following guidelines for coding and reporting using
the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM).
These guidelines should be used as a companion document to the official version of the ICD-10CM as published on the NCHS website. The ICD-10-CM is a morbidity classification published
by the United States for classifying diagnoses and reason for visits in all health care settings.
The ICD-10-CM is based on the ICD-10, the statistical classification of disease published by the
World Health Organization (WHO).
These guidelines have been approved by the four organizations that make up t he Cooperating
Parties for the ICD-10-CM: the American Hospital Association (AHA), the American Health
Information Management Association (AHIMA), CMS, and NCHS.
These guidelines are a set of rules that have been developed to accompany and complement the
official conventions and instructions provided within the ICD-10-CM itself. The instructions
and conventions of the classification take precedence over guidelines. These guidelines are
based on t he coding and sequencing instructions in the Tabular List and Alphabetic Index of
ICD-10-CM, but provide additional instruction. Adherence to these guidelines when assigning
ICD-10-CM diagnosis codes is required under the Health Insurance Portability and
Accountability Act (HIPAA). The diagnosis codes (Tabular List and Alphabetic Index) have
been adopted under HIPAA for all healthcare settings. A joint effort between the healthcare
provider and the coder is essential to achieve complete and accurate documentation, code
assignment, and reporting of diagnoses and procedures. These guidelines have been developed
to assist both the healthcare provider and the coder in identifying those diagnoses and procedures
that are to be reported. The importance of consistent, complete documentation in the medical
record cannot be overemphasized. W ithout such documentation accurate coding cannot be
achieved. The entire record should be reviewed to determine the specific reason for the
encounter and the conditions treated.
The term encounter is used for all settings, including hospital admissions. In the context of these
guidelines, the term provider is used throughout the guidelines to mean physician or any
qualified health care practitioner who is legally accountable for establishing the patient’s
diagnosis. Only this set of guidelines, approved by the Cooperating Parties, is official.
The guidelines are organized into sections. Section I includes the structure and conventions of
the classification and general guidelines that apply to the entire classification, and chapterspecific guidelines that correspond to the chapters as they are arranged in the classification.
Section II includes guidelines for selection of principal diagnosis for non-outpatient settings.
Section III includes guidelines for reporting additional diagnoses in non-outpatient settings.
Section IV is for outpatient coding and reporting. It is necessary to review all sections of the
guidelines to fully understand all of the rules and instructions needed to code properly.
16.
Chapter 16: Certain Conditions Originating in the Perinatal
Period (P00-P96)
For coding and reporting purposes the perinatal period is defined as before
birth through the 28th day following birth. The following guidelines are
provided for reporting purposes
a.
General Perinatal Rules
1)
Use of Chapter 16 Codes
Codes in this chapter are never for use on the maternal record.
Codes from Chapter 15, the obstetric chapter, are never
permitted on the newborn record. Chapter 16 codes may be
used throughout the life of the patient if the condition is still
present.
2)
Principal Diagnosis for Birth Record
When coding the birth episode in a newborn record, assign a
code from category Z38, Liveborn infants according to place of
birth and type of delivery, as the principal diagnosis. A code
from category Z38 is assigned only once, to a newborn at the
time of birth. If a newborn is transferred to another institution,
a code from category Z38 should not be used at the receiving
hospital.
A code from category Z38 is used only on the newborn record,
not on the mother’s record.
3)
Use of Codes from other Chapters with Codes from
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Chapter 16
Codes from other chapters may be used with codes from
chapter 16 if the codes from the other chapters provide more
specific detail. Codes for signs and symptoms may be assigned
when a definitive diagnosis has not been established. If the
reason for the encounter is a perinatal condition, the code from
chapter 16 should be sequenced first.
4)
Use of Chapter 16 Codes after the Perinatal Period
Should a condition originate in the perinatal period, and
continue throughout the life of the patient, the perinatal code
should continue to be used regardless of the patient’s age.
5)
Birth process or community acquired conditions
If a newborn has a condition that may be either due to the birth
process or community acquired and the documentation does
not indicate which it is, the default is due to the birth process
and the code from Chapter 16 should be used. If the condition
is community-acquired, a code from Chapter 16 should not be
assigned.
6)
Code all clinically significant conditions
All clinically significant conditions noted on routine newborn
examination should be coded. A condition is clinically
significant if it requires:
 clinical evaluation; or
 therapeutic treatment; or
 diagnostic procedures; or
 extended length of hospital stay; or
 increased nursing care and/or monitoring; or
 has implications for future health care needs
Note: The perinatal guidelines listed above are the same as the
general coding guidelines for “additional diagnoses”, except
for the final point regarding implications for future health care
needs. Codes should be assigned for conditions that have been
specified by the provider as having implications for future
health care needs.
b.
Observation and Evaluation of Newborns for Suspected
Conditions not Found
Assign a code from categories P00-P04 to identify those instances
when a healthy newborn is evaluated for a suspected condition that
is determined after study not to be present. Do not use a code from
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categories P00-P04 when the patient has identified signs or
symptoms of a suspected problem; in such cases, code the sign or
symptom.
c.
Coding Additional Perinatal Diagnoses
1)
Assigning codes for conditions that require treatment
Assign codes for conditions that require treatment or further
investigation, prolong the length of stay, or require resource
utilization.
2)
Codes for conditions specified as having implications
for future health care needs
Assign codes for conditions that have been specified by the
provider as having implications for future health care needs.
Note: This guideline should not be used for adult patients.
d.
Prematurity and Fetal Growth Retardation
Providers utilize different criteria in determining prematurity. A code
for prematurity should not be assigned unless it is documented.
Assignment of codes in categories P05, Disorders of newborn related
to slow fetal growth and fetal malnutrition, and P07, Disorders of
newborn related to short gestation and low birth weight, not elsewhere
classified, should be based on the recorded birth weight and estimated
gestational age. Codes from category P05 should not be assigned with
codes from category P07.
When both birth weight and gestational age are available, two codes
from category P07 should be assigned, with the code for birth weight
sequenced before the code for gestational age.
A code from P05 and codes from P07.2 and P07.3 may be used to
specify weeks of gestation as documented by the provider in the
record.
e.
Low birth weight and immaturity status
Codes from category P07, Disorders of newborn related to short
gestation and low birth weight, not elsewhere classified, are for use for
a child or adult who was premature or had a low birth weight as a
newborn and this is affecting the patient’s current health status.
See Section I.C.21. Factors influencing health status and contact with
health services, Status.
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f.
Bacterial Sepsis of Newborn
Category P36, Bacterial sepsis of newborn, includes congenital sepsis.
If a perinate is documented as having sepsis without documentation of
congenital or community acquired, the default is congenital and a code
from category P36 should be assigned. If the P36 code includes the
causal organism, an additional code from category B95, Streptococcus,
Staphylococcus, and Enterococcus as the cause of diseases classified
elsewhere, or B96, Other bacterial agents as the cause of diseases
classified elsewhere, should not be assigned. If the P36 code does not
include the causal organism, assign an additional code from category
B96. If applicable, use additional codes to identify severe sepsis
(R65.2-) and any associated acute organ dysfunction.
g.
Stillbirth
Code P95, Stillbirth, is only for use in institutions that maintain
separate records for stillbirths. No other code should be used with P95.
Code P95 should not be used on the mother’s record.
17.
Chapter 17: Congenital malformations, deformations, and
chromosomal abnormalities (Q00-Q99)
Assign an appropriate code(s) from categories Q00-Q99, Congenital
malformations, deformations, and chromosomal abnormalities when a
malformation/deformation or chromosomal abnormality is documented. A
malformation/deformation/or chromosomal abnormality may be the
principal/first-listed diagnosis on a record or a secondary diagnosis.
When a malformation/deformation/or chromosomal abnormality does not
have a unique code assignment, assign additional code(s) for any
manifestations that may be present.
When the code assignment specifically identifies the
malformation/deformation/or chromosomal abnormality, manifestations that
are an inherent component of the anomaly should not be coded separately.
Additional codes should be assigned for manifestations that are not an
inherent component.
Codes from Chapter 17 may be used throughout the life of the patient. If a
congenital malformation or deformity has been corrected, a personal history
code should be used to identify the history of the malformation or deformity.
Although present at birth, malformation/deformation/or chromosomal
abnormality may not be identified until later in life. Whenever the condition
is diagnosed by the physician, it is appropriate to assign a code from codes
Q00-Q99.For the birth admission, the appropriate code from category Z38,
Liveborn infants, according to place of birth and type of delivery, should be
sequenced as the principal diagnosis, followed by any congenital anomaly
codes, Q00- Q99.
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18.
Chapter 18: Symptoms, signs, and abnormal clinical and
laboratory findings, not elsewhere classified (R00-R99)
Chapter 18 includes symptoms, signs, abnormal results of clinical or other
investigative procedures, and ill-defined conditions regarding which no
diagnosis classifiable elsewhere is recorded. Signs and symptoms that point to
a specific diagnosis have been assigned to a category in other chapters of the
classification.
a.
Use of symptom codes
Codes that describe symptoms and signs are acceptable for reporting
purposes when a related definitive diagnosis has not been established
(confirmed) by the provider.
b.
Use of a symptom code with a definitive diagnosis code
Codes for signs and symptoms may be reported in addition to a related
definitive diagnosis when the sign or symptom is not routinely
associated with that diagnosis, such as the various signs and symptoms
associated with complex syndromes. The definitive diagnosis code
should be sequenced before the symptom code.
Signs or symptoms that are associated routinely with a disease process
should not be assigned as additional codes, unless otherwise instructed
by the classification.
c.
Combination codes that include symptoms
ICD-10-CM contains a number of combination codes that identify
both the definitive diagnosis and common symptoms of that diagnosis.
When using one of these combination codes, an additional code should
not be assigned for the symptom.
d.
Repeated falls
Code R29.6, Repeated falls, is for use for encounters when a patient
has recently fallen and the reason for the fall is being investigated.
Code Z91.81, History of falling, is for use when a patient has fallen in
the past and is at risk for future falls. When appropriate, both codes
R29.6 and Z91.81 may be assigned together.
e.
Coma scale
The coma scale codes (R40.2-) can be used in conjunction with
traumatic brain injury codes, acute cerebrovascular disease or sequelae
of cerebrovascular disease codes. These codes are primarily for use by
trauma registries, but they may be used in any setting where this
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information is collected. The coma scale codes should be sequenced
after the diagnosis code(s).
These codes, one from each subcategory, are needed to complete the
scale. The 7th character indicates when the scale was recorded. The 7th
character should match for all three codes.
At a minimum, report the initial score documented on presentation at
your facility. This may be a score from the emergency medicine
technician (EMT) or in the emergency department. If desired, a
facility may choose to capture multiple coma scale scores.
Assign code R40.24, Glasgow coma scale, total score, when only
the total score is documented in the medical record and not the
individual score(s).
f.
Functional quadriplegia
Functional quadriplegia (code R53.2) is the lack of ability to use one’s
limbs or to ambulate due to extreme debility. It is not associated with
neurologic deficit or injury, and code R53.2 should not be used for
cases of neurologic quadriplegia. It should only be assigned if
functional quadriplegia is specifically documented in the medical
record.
g.
SIRS due to Non-Infectious Process
The systemic inflammatory response syndrome (SIRS) can develop as
a result of certain non-infectious disease processes, such as trauma,
malignant neoplasm, or pancreatitis. When SIRS is documented with
a noninfectious condition, and no subsequent infection is documented,
the code for the underlying condition, such as an injury, should be
assigned, followed by code R65.10, Systemic inflammatory response
syndrome (SIRS) of non-infectious origin without acute organ
dysfunction, or code R65.11, Systemic inflammatory response
syndrome (SIRS) of non-infectious origin with acute organ
dysfunction. If an associated acute organ dysfunction is documented,
the appropriate code(s) for the specific type of organ dysfunction(s)
should be assigned in addition to code R65.11. If acute organ
dysfunction is documented, but it cannot be determined if the acute
organ dysfunction is associated with SIRS or due to another condition
(e.g., directly due to the trauma), the provider should be queried.
h.
Death NOS
Code R99, Ill-defined and unknown cause of mortality, is only for use
in the very limited circumstance when a patient who has already died
is brought into an emergency department or other healthcare facility
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and is pronounced dead upon arrival. It does not represent the
discharge disposition of death.
19.
Chapter 19: Injury, poisoning, and certain other consequences of
external causes (S00-T88)
a.
Application of 7th Characters in Chapter 19
Most categories in chapter 19 have a 7th character requirement for each
applicable code. Most categories in this chapter have three 7th
character values (with the exception of fractures): A, initial
encounter, D, subsequent encounter and S, sequela. Categories for
traumatic fractures have additional 7th character values.
7th character “A”, initial encounter is used while the patient is
receiving active treatment for the condition. Examples of active
treatment are: surgical treatment, emergency department encounter,
and evaluation and treatment by a new physician.
7th character “D” subsequent encounter is used for encounters after
the patient has received active treatment of the condition and is
receiving routine care for the condition during the healing or recovery
phase. Examples of subsequent care are: cast change or removal,
removal of external or internal fixation device, medication adjustment,
other aftercare and follow up visits following treatment of the injury
or condition.
The aftercare Z codes should not be used for aftercare for conditions
such as injuries or poisonings, where 7th characters are provided to
identify subsequent care. For example, for aftercare of an injury,
assign the acute injury code with the 7th character “D” (subsequent
encounter).
7th character “S”, sequela, is for use for complications or conditions
that arise as a direct result of a condition, such as scar formation after
a burn. The scars are sequelae of the burn. When using 7th character
“S”, it is necessary to use both the injury code that precipitated the
sequela and the code for the sequela itself. The “S” is added only to
the injury code, not the sequela code. The 7th character “S”
identifies the injury responsible for the sequela. The specific type of
sequela (e.g. scar) is sequenced first, followed by the injury code.
b.
Coding of Injuries
When coding injuries, assign separate codes for each injury unless a
combination code is provided, in which case the combination code is
assigned. Code T07, Unspecified multiple injuries should not be
assigned in the inpatient setting unless information for a more
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specific code is not available. Traumatic injury codes (S00-T14.9) are
not to be used for normal, healing surgical wounds or to identify
complications of surgical wounds.
The code for the most serious injury, as determined by the provider
and the focus of treatment, is sequenced first.
1)
Superficial injuries
Superficial injuries such as abrasions or contusions are not
coded when associated with more severe injuries of the same
site.
2)
Primary injury with damage to nerves/blood vessels
When a primary injury results in minor damage to peripheral
nerves or blood vessels, the primary injury is sequenced first
with additional code(s) for injuries to nerves and spinal cord
(such as category S04), and/or injury to blood vessels (such as
category S15). When the primary injury is to the blood vessels
or nerves, that injury should be sequenced first.
c.
Coding of Traumatic Fractures
The principles of multiple coding of injuries should be followed in
coding fractures. Fractures of specified sites are coded individually by
site in accordance with both the provisions within categories S02, S12,
S22, S32, S42, S49, S52, S59, S62, S72, S79, S82, S89, S92 and the
level of detail furnished by medical record content.
A fracture not indicated as open or closed should be coded to closed.
A fracture not indicated whether displaced or not displaced should be
coded to displaced.
More specific guidelines are as follows:
1)
Initial vs. Subsequent Encounter for Fractures
Traumatic fractures are coded using the appropriate 7th
character for initial encounter (A, B, C) while the patient is
receiving active treatment for the fracture. Examples of active
treatment are: surgical treatment, emergency department
encounter, and evaluation and treatment by a new physician.
The appropriate 7th character for initial encounter should also
be assigned for a patient who delayed seeking treatment for the
fracture or nonunion.
Fractures are coded using the appropriate 7th character for
subsequent care for encounters after the patient has completed
active treatment of the fracture and is receiving routine care for
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the fracture during the healing or recovery phase. Examples of
fracture aftercare are: cast change or removal, removal of
external or internal fixation device, medication adjustment, and
follow-up visits following fracture treatment.
Care for complications of surgical treatment for fracture repairs
during the healing or recovery phase should be coded with the
appropriate complication codes.
Care of complications of fractures, such as malunion and
nonunion, should be reported with the appropriate 7th character
for subsequent care with nonunion (K, M, N,) or subsequent
care with malunion (P, Q, R).
A code from category M80, not a traumatic fracture code,
should be used for any patient with known osteoporosis who
suffers a fracture, even if the patient had a minor fall or trauma,
if that fall or trauma would not usually break a normal, healthy
bone.
See Section I.C.13. Osteoporosis.
The aftercare Z codes should not be used for aftercare for
traumatic fractures. For aftercare of a traumatic fracture, assign
the acute fracture code with the appropriate 7th character.
2)
Multiple fractures sequencing
Multiple fractures are sequenced in accordance with the
severity of the fracture.
d.
Coding of Burns and Corrosions
The ICD-10-CM makes a distinction between burns and corrosions.
The burn codes are for thermal burns, except sunburns, that come from
a heat source, such as a fire or hot appliance. The burn codes are also
for burns resulting from electricity and radiation. Corrosions are burns
due to chemicals. The guidelines are the same for burns and
corrosions.
Current burns (T20-T25) are classified by depth, extent and by agent
(X code). Burns are classified by depth as first degree (erythema),
second degree (blistering), and third degree (full-thickness
involvement). Burns of the eye and internal organs (T26-T28) are
classified by site, but not by degree.
1)
Sequencing of burn and related condition codes
Sequence first the code that reflects the highest degree of burn
when more than one burn is present.
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a. When the reason for the admission or encounter is for
treatment of external multiple burns, sequence first the
code that reflects the burn of the highest degree.
b. When a patient has both internal and external burns, the
circumstances of admission govern the selection of the
principal diagnosis or first-listed diagnosis.
c. When a patient is admitted for burn injuries and other
related conditions such as smoke inhalation and/or
respiratory failure, the circumstances of admission govern
the selection of the principal or first-listed diagnosis.
2)
Burns of the same local site
Classify burns of the same local site (three-character category
level, T20-T28) but of different degrees to the subcategory
identifying the highest degree recorded in the diagnosis.
3)
Non-healing burns
Non-healing burns are coded as acute burns.
Necrosis of burned skin should be coded as a non-healed burn.
4)
Infected Burn
For any documented infected burn site, use an additional code
for the infection.
5)
Assign separate codes for each burn site
When coding burns, assign separate codes for each burn site.
Category T30, Burn and corrosion, body region unspecified is
extremely vague and should rarely be used.
6)
Burns and Corrosions Classified According to Extent
of Body Surface Involved
Assign codes from category T31, Burns classified according to
extent of body surface involved, or T32, Corrosions classified
according to extent of body surface involved, when the site of
the burn is not specified or when there is a need for additional
data. It is advisable to use category T31 as additional coding
when needed to provide data for evaluating burn mortality,
such as that needed by burn units. It is also advisable to use
category T31 as an additional code for reporting purposes
when there is mention of a third-degree burn involving 20
percent or more of the body surface.
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Categories T31 and T32 are based on the classic “rule of nines”
in estimating body surface involved: head and neck are
assigned nine percent, each arm nine percent, each leg 18
percent, the anterior trunk 18 percent, posterior trunk 18
percent, and genitalia one percent. Providers may change these
percentage assignments where necessary to accommodate
infants and children who have proportionately larger heads
than adults, and patients who have large buttocks, thighs, or
abdomen that involve burns.
7)
Encounters for treatment of sequela of burns
Encounters for the treatment of the late effects of burns or
corrosions (i.e., scars or joint contractures) should be coded
with a burn or corrosion code with the 7th character “S” for
sequela.
8)
Sequelae with a late effect code and current burn
When appropriate, both a code for a current burn or corrosion
with 7th character “A” or “D” and a burn or corrosion code
with 7th character “S” may be assigned on the same record
(when both a current burn and sequelae of an old burn exist).
Burns and corrosions do not heal at the same rate and a current
healing wound may still exist with sequela of a healed burn or
corrosion.
9)
Use of an external cause code with burns and
corrosions
An external cause code should be used with burns and
corrosions to identify the source and intent of the burn, as well
as the place where it occurred.
e.
Adverse Effects, Poisoning, Underdosing and Toxic
Effects
Codes in categories T36-T65 are combination codes that include the
substance that was taken as well as the intent. No additional external
cause code is required for poisonings, toxic effects, adverse effects and
underdosing codes.
1)
Do not code directly from the Table of Drugs
Do not code directly from the Table of Drugs and Chemicals.
Always refer back to the Tabular List.
2)
Use as many codes as necessary to describe
Use as many codes as necessary to describe completely all
drugs, medicinal or biological substances.
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3)
If the same code would describe the causative agent
If the same code would describe the causative agent for more
than one adverse reaction, poisoning, toxic effect or
underdosing, assign the code only once.
4)
If two or more drugs, medicinal or biological
substances
If two or more drugs, medicinal or biological substances are
reported, code each individually unless a combination code is
listed in the Table of Drugs and Chemicals.
5)
The occurrence of drug toxicity is classified in ICD-10CM as follows:
(a)
Adverse Effect
When coding an adverse effect of a drug that has
been correctly prescribed and properly
administered, assign the appropriate code for the
nature of the adverse effect followed by the
appropriate code for the adverse effect of the drug
(T36-T50). The code for the drug should have a 5th
or 6th character “5” (for example T36.0X5-)
Examples of the nature of an adverse effect are
tachycardia, delirium, gastrointestinal hemorrhaging,
vomiting, hypokalemia, hepatitis, renal failure, or
respiratory failure.
(b)
Poisoning
When coding a poisoning or reaction to the improper
use of a medication (e.g., overdose, wrong substance
given or taken in error, wrong route of administration),
first assign the appropriate code from categories T36T50. The poisoning codes have an associated intent as
their 5th or 6th character (accidental, intentional selfharm, assault and undetermined. Use additional code(s)
for all manifestations of poisonings.
If there is also a diagnosis of abuse or dependence of
the substance, the abuse or dependence is assigned as
an additional code.
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Examples of poisoning include:
(i)
Error was made in drug prescription
Errors made in drug prescription or in the
administration of the drug by provider, nurse,
patient, or other person.
(ii)
Overdose of a drug intentionally taken
If an overdose of a drug was intentionally taken
or administered and resulted in drug toxicity, it
would be coded as a poisoning.
(iii)
Nonprescribed drug taken with correctly
prescribed and properly administered drug
If a nonprescribed drug or medicinal agent was
taken in combination with a correctly prescribed
and properly administered drug, any drug
toxicity or other reaction resulting from the
interaction of the two drugs would be classified
as a poisoning.
(iv)
Interaction of drug(s) and alcohol
When a reaction results from the interaction of a
drug(s) and alcohol, this would be classified as
poisoning.
See Section I.C.4. if poisoning is the result of
insulin pump malfunctions.
(c)
Underdosing
Underdosing refers to taking less of a medication than
is prescribed by a provider or a manufacturer’s
instruction. For underdosing, assign the code from
categories T36-T50 (fifth or sixth character “6”).
Codes for underdosing should never be assigned as
principal or first-listed codes. If a patient has a relapse
or exacerbation of the medical condition for which the
drug is prescribed because of the reduction in dose, then
the medical condition itself should be coded.
Noncompliance (Z91.12-, Z91.13-) or complication of
care (Y63.8-Y63.9) codes are to be used with an
underdosing code to indicate intent, if known.
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(d)
Toxic Effects
When a harmful substance is ingested or comes in
contact with a person, this is classified as a toxic effect.
The toxic effect codes are in categories T51-T65.
Toxic effect codes have an associated intent:
accidental, intentional self-harm, assault and
undetermined.
f.
Adult and child abuse, neglect and other maltreatment
Sequence first the appropriate code from categories T74.- (Adult and
child abuse, neglect and other maltreatment, confirmed) or T76.(Adult and child abuse, neglect and other maltreatment, suspected)
for abuse, neglect and other maltreatment, followed by any
accompanying mental health or injury code(s).
If the documentation in the medical record states abuse or neglect it
is coded as confirmed (T74.-). It is coded as suspected if it is
documented as suspected (T76.-).
For cases of confirmed abuse or neglect an external cause code from
the assault section (X92-Y08) should be added to identify the cause
of any physical injuries. A perpetrator code (Y07) should be added
when the perpetrator of the abuse is known. For suspected cases of
abuse or neglect, do not report external cause or perpetrator code.
If a suspected case of abuse, neglect or mistreatment is ruled out
during an encounter code Z04.71, Encounter for examination and
observation following alleged physical adult abuse, ruled out, or
code Z04.72, Encounter for examination and observation
following alleged child physical abuse, ruled out, should be used,
not a code from T76.
If a suspected case of alleged rape or sexual abuse is ruled out
during an encounter code Z04.41, Encounter for examination
and observation following alleged physical adult abuse, ruled
out, or code Z04.42, Encounter for examination and observation
following alleged rape or sexual abuse, ruled out, should be used,
not a code from T76.
See Section I.C.15. Abuse in a pregnant patient.
g.
Complications of care
1)
General guidelines for complications of care
(a)
Documentation of complications of care
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See Section I.B.16. for information on documentation
of complications of care.
2)
Pain due to medical devices
Pain associated with devices, implants or grafts left in a
surgical site (for example painful hip prosthesis) is assigned to
the appropriate code(s) found in Chapter 19, Injury, poisoning,
and certain other consequences of external causes. Specific
codes for pain due to medical devices are found in the T code
section of the ICD-10-CM. Use additional code(s) from
category G89 to identify acute or chronic pain due to presence
of the device, implant or graft (G89.18 or G89.28).
3)
Transplant complications
(a)
Transplant complications other than kidney
Codes under category T86, Complications of
transplanted organs and tissues, are for use for both
complications and rejection of transplanted organs. A
transplant complication code is only assigned if the
complication affects the function of the transplanted
organ. Two codes are required to fully describe a
transplant complication: the appropriate code from
category T86 and a secondary code that identifies the
complication.
Pre-existing conditions or conditions that develop after
the transplant are not coded as complications unless
they affect the function of the transplanted organs.
See I.C.21. for transplant organ removal status
See I.C.2. for malignant neoplasm associated with
transplanted organ.
(b)
Kidney transplant complications
Patients who have undergone kidney transplant may
still have some form of chronic kidney disease (CKD)
because the kidney transplant may not fully restore
kidney function. Code T86.1- should be assigned for
documented complications of a kidney transplant, such
as transplant failure or rejection or other transplant
complication. Code T86.1- should not be assigned for
post kidney transplant patients who have chronic
kidney (CKD) unless a transplant complication such as
transplant failure or rejection is documented. If the
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documentation is unclear as to whether the patient has a
complication of the transplant, query the provider.
Conditions that affect the function of the transplanted
kidney, other than CKD, should be assigned a code
from subcategory T86.1, Complications of
transplanted organ, Kidney, and a secondary code that
identifies the complication.
For patients with CKD following a kidney transplant,
but who do not have a complication such as failure or
rejection, see section I.C.14. Chronic kidney disease
and kidney transplant status.
4)
Complication codes that include the external cause
As with certain other T codes, some of the complications of
care codes have the external cause included in the code. The
code includes the nature of the complication as well as the type
of procedure that caused the complication. No external cause
code indicating the type of procedure is necessary for these
codes.
5)
Complications of care codes within the body system
chapters
Intraoperative and postprocedural complication codes are
found within the body system chapters with codes specific to
the organs and structures of that body system. These codes
should be sequenced first, followed by a code(s) for the
specific complication, if applicable.
20.
Chapter 20: External Causes of Morbidity (V01-Y99)
Introduction: These guidelines are provided for the reporting of external
causes of morbidity codes in order that there will be standardization in the
process. These codes are secondary codes for use in any health care setting.
External cause codes are intended to provide data for injury research and
evaluation of injury prevention strategies. These codes capture how the injury
or health condition happened (cause), the intent (unintentional or accidental;
or intentional, such as suicide or assault), the place where the event occurred
the activity of the patient at the time of the event, and the person’s status (e.g.,
civilian, military).
a.
General External Cause Coding Guidelines
1)
Used with any code in the range of A00.0-T88.9,
Z00-Z99
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An external cause code may be used with any code in the range
of A00.0-T88.9, Z00-Z99, classification that is a health
condition due to an external cause. Though they are most
applicable to injuries, they are also valid for use with such
things as infections or diseases due to an external source, and
other health conditions, such as a heart attack that occurs
during strenuous physical activity.
2)
External cause code used for length of treatment
Assign the external cause code, with the appropriate 7th
character (initial encounter, subsequent encounter or sequela)
for each encounter for which the injury or condition is being
treated.
3)
Use the full range of external cause codes
Use the full range of external cause codes to completely
describe the cause, the intent, the place of occurrence, and if
applicable, the activity of the patient at the time of the event,
and the patient’s status, for all injuries, and other health
conditions due to an external cause.
4)
Assign as many external cause codes as necessary
Assign as many external cause codes as necessary to fully
explain each cause. If only one external code can be recorded,
assign the code most related to the principal diagnosis.
5)
The selection of the appropriate external cause code
The selection of the appropriate external cause code is guided
by the Alphabetic Index of External Causes and by Inclusion
and Exclusion notes in the Tabular List.
6)
External cause code can never be a principal diagnosis
An external cause code can never be a principal (first-listed)
diagnosis.
7)
Combination external cause codes
Certain of the external cause codes are combination codes that
identify sequential events that result in an injury, such as a fall
which results in striking against an object. The injury may be
due to either event or both. The combination external cause
code used should correspond to the sequence of events
regardless of which caused the most serious injury.
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8)
No external cause code needed in certain
circumstances
No external cause code from Chapter 20 is needed if the
external cause and intent are included in a code from another
chapter (e.g. T36.0X1- Poisoning by penicillins, accidental
(unintentional)).
b.
Place of Occurrence Guideline
Codes from category Y92, Place of occurrence of the external cause,
are secondary codes for use after other external cause codes to identify
the location of the patient at the time of injury or other condition.
A place of occurrence code is used only once, at the initial encounter
for treatment. No 7th characters are used for Y92. Only one code from
Y92 should be recorded on a medical record. A place of occurrence
code should be used in conjunction with an activity code, Y93.
Do not use place of occurrence code Y92.9 if the place is not stated or
is not applicable.
c.
Activity Code
Assign a code from category Y93, Activity code, to describe the
activity of the patient at the time the injury or other health condition
occurred.
An activity code is used only once, at the initial encounter for
treatment. Only one code from Y93 should be recorded on a medical
record. An activity code should be used in conjunction with a place of
occurrence code, Y92.
The activity codes are not applicable to poisonings, adverse effects,
misadventures or sequela .
Do not assign Y93.9, Unspecified activity, if the activity is not stated.
A code from category Y93 is appropriate for use with external cause
and intent codes if identifying the activity provides additional
information about the event.
d.
Place of Occurrence, Activity, and Status Codes Used
with other External Cause Code
When applicable, place of occurrence, activity, and external cause
status codes are sequenced after the main external cause code(s).
Regardless of the number of external cause codes assigned, there
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should be only one place of occurrence code, one activity code, and
one external cause status code assigned to an encounter.
e.
If the Reporting Format Limits the Number of External
Cause Codes
If the reporting format limits the number of external cause codes that
can be used in reporting clinical data, report the code for the
cause/intent most related to the principal diagnosis. If the format
permits capture of additional external cause codes, the cause/intent,
including medical misadventures, of the additional events should be
reported rather than the codes for place, activity, or external status.
f.
Multiple External Cause Coding Guidelines
More than one external cause code is required to fully describe the
external cause of an illness or injury. The assignment of external cause
codes should be sequenced in the following priority:
If two or more events cause separate injuries, an external cause code
should be assigned for each cause. The first-listed external cause code
will be selected in the following order:
External codes for child and adult abuse take priority over all other
external cause codes.
See Section I.C.19., Child and Adult abuse guidelines.
External cause codes for terrorism events take priority over all other
external cause codes except child and adult abuse.
External cause codes for cataclysmic events take priority over all other
external cause codes except child and adult abuse and terrorism.
External cause codes for transport accidents take priority over all other
external cause codes except cataclysmic events, child and adult abuse
and terrorism.
Activity and external cause status codes are assigned following all
causal (intent) external cause codes.
The first-listed external cause code should correspond to the cause of
the most serious diagnosis due to an assault, accident, or self-harm,
following the order of hierarchy listed above.
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g.
Child and Adult Abuse Guideline
Adult and child abuse, neglect and maltreatment are classified as
assault. Any of the assault codes may be used to indicate the external
cause of any injury resulting from the confirmed abuse.
For confirmed cases of abuse, neglect and maltreatment, when the
perpetrator is known, a code from Y07, Perpetrator of maltreatment
and neglect, should accompany any other assault codes.
See Section I.C.19. Adult and child abuse, neglect and other
maltreatment
h.
Unknown or Undetermined Intent Guideline
If the intent (accident, self-harm, assault) of the cause of an injury or
other condition is unknown or unspecified, code the intent as
accidental intent. All transport accident categories assume accidental
intent.
1)
Use of undetermined intent
External cause codes for events of undetermined intent are only
for use if the documentation in the record specifies that the
intent cannot be determined.
i.
Sequelae (Late Effects) of External Cause Guidelines
1)
Sequelae external cause codes
Sequela are reported using the external cause code with the 7th
character “S” for sequela. These codes should be used with
any report of a late effect or sequela resulting from a previous
injury.
2)
Sequela external cause code with a related current
injury
A sequela external cause code should never be used with a
related current nature of injury code.
3)
Use of sequela external cause codes for subsequent
visits
Use a late effect external cause code for subsequent visits when
a late effect of the initial injury is being treated. Do not use a
late effect external cause code for subsequent visits for followup care (e.g., to assess healing, to receive rehabilitative
therapy) of the injury when no late effect of the injury has been
documented.
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j.
Terrorism Guidelines
1)
Cause of injury identified by the Federal Government
(FBI) as terrorism
When the cause of an injury is identified by the Federal
Government (FBI) as terrorism, the first-listed external cause
code should be a code from category Y38, Terrorism. The
definition of terrorism employed by the FBI is found at the
inclusion note at the beginning of category Y38. Use
additional code for place of occurrence (Y92.-). More than
one Y38 code may be assigned if the injury is the result of
more than one mechanism of terrorism.
2)
Cause of an injury is suspected to be the result of
terrorism
When the cause of an injury is suspected to be the result of
terrorism a code from category Y38 should not be assigned.
Suspected cases should be classified as assault.
3)
Code Y38.9, Terrorism, secondary effects
Assign code Y38.9, Terrorism, secondary effects, for
conditions occurring subsequent to the terrorist event. This
code should not be assigned for conditions that are due to the
initial terrorist act.
It is acceptable to assign code Y38.9 with another code from
Y38 if there is an injury due to the initial terrorist event and an
injury that is a subsequent result of the terrorist event.
k.
External cause status
A code from category Y99, External cause status, should be assigned
whenever any other external cause code is assigned for an encounter,
including an Activity code, except for the events noted below. Assign
a code from category Y99, External cause status, to indicate the work
status of the person at the time the event occurred. The status code
indicates whether the event occurred during military activity, whether
a non-military person was at work, whether an individual including a
student or volunteer was involved in a non-work activity at the time of
the causal event.
A code from Y99, External cause status, should be assigned, when
applicable, with other external cause codes, such as transport accidents
and falls. The external cause status codes are not applicable to
poisonings, adverse effects, misadventures or late effects.
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Do not assign a code from category Y99 if no other external cause
codes (cause, activity) are applicable for the encounter.
An external cause status code is used only once, at the initial encounter
for treatment. Only one code from Y99 should be recorded on a
medical record.
Do not assign code Y99.9, Unspecified external cause status, if the
status is not stated.
21.
Chapter 21: Factors influencing health status and contact with
health services (Z00-Z99)
Note: The chapter specific guidelines provide additional information about
the use of Z codes for specified encounters.
a.
Use of Z codes in any healthcare setting
Z codes are for use in any healthcare setting. Z codes may be used as
either a first-listed (principal diagnosis code in the inpatient setting) or
secondary code, depending on the circumstances of the encounter.
Certain Z codes may only be used as first-listed or principal diagnosis.
b.
Z Codes indicate a reason for an encounter
Z codes are not procedure codes. A corresponding procedure code
must accompany a Z code to describe any procedure performed.
c.
Categories of Z Codes
1)
Contact/Exposure
Category Z20 indicates contact with, and suspected exposure
to, communicable diseases. These codes are for patients who
do not show any sign or symptom of a disease but are
suspected to have been exposed to it by close personal contact
with an infected individual or are in an area where a disease is
epidemic.
Category Z77, indicates contact with and suspected exposures
hazardous to health.
Contact/exposure codes may be used as a first-listed code to
explain an encounter for testing, or, more commonly, as a
secondary code to identify a potential risk.
2)
Inoculations and vaccinations
Code Z23 is for encounters for inoculations and vaccinations.
It indicates that a patient is being seen to receive a prophylactic
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inoculation against a disease. Procedure codes are required to
identify the actual administration of the injection and the
type(s) of immunizations given. Code Z23 may be used as a
secondary code if the inoculation is given as a routine part of
preventive health care, such as a well-baby visit.
3)
Status
Status codes indicate that a patient is either a carrier of a
disease or has the sequelae or residual of a past disease or
condition. This includes such things as the presence of
prosthetic or mechanical devices resulting from past treatment.
A status code is informative, because the status may affect the
course of treatment and its outcome. A status code is distinct
from a history code. The history code indicates that the patient
no longer has the condition.
A status code should not be used with a diagnosis code from
one of the body system chapters, if the diagnosis code includes
the information provided by the status code. For example,
code Z94.1, Heart transplant status, should not be used with a
code from subcategory T86.2, Complications of heart
transplant. The status code does not provide additional
information. The complication code indicates that the patient
is a heart transplant patient.
For encounters for weaning from a mechanical ventilator,
assign a code from subcategory J96.1, Chronic respiratory
failure, followed by code Z99.11, Dependence on respirator
[ventilator] status.
The status Z codes/categories are:
Z14
Genetic carrier
Genetic carrier status indicates that a person carries
a gene, associated with a particular disease, which
may be passed to offspring who may develop that
disease. The person does not have the disease and
is not at risk of developing the disease.
Z15
Genetic susceptibility to disease
Genetic susceptibility indicates that a person has a
gene that increases the risk of that person
developing the disease.
Codes from category Z15 should not be used as
principal or first-listed codes. If the patient has the
condition to which he/she is susceptible, and that
condition is the reason for the encounter, the code
for the current condition should be sequenced first.
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Z16
Z17
Z18
Z21
Z22
Z28.3
Z33.1
Z66
Z67
Z68
Z74.01
Z76.82
Z78
If the patient is being seen for follow-up after
completed treatment for this condition, and the
condition no longer exists, a follow-up code should
be sequenced first, followed by the appropriate
personal history and genetic susceptibility codes. If
the purpose of the encounter is genetic counseling
associated with procreative management, code
Z31.5, Encounter for genetic counseling, should be
assigned as the first-listed code, followed by a code
from category Z15. Additional codes should be
assigned for any applicable family or personal
history.
Resistance to antimicrobial drugs
This code indicates that a patient has a condition
that is resistant to antimicrobial drug treatment.
Sequence the infection code first.
Estrogen receptor status
Retained foreign body fragments
Asymptomatic HIV infection status
This code indicates that a patient has tested positive
for HIV but has manifested no signs or symptoms
of the disease.
Carrier of infectious disease
Carrier status indicates that a person harbors the
specific organisms of a disease without manifest
symptoms and is capable of transmitting the
infection.
Underimmunization status
Pregnant state, incidental
This code is a secondary code only for use when the
pregnancy is in no way complicating the reason for
visit. Otherwise, a code from the obstetric chapter
is required.
Do not resuscitate
This code may be used when it is documented by
the provider that a patient is on do not resuscitate
status at any time during the stay.
Blood type
Body mass index (BMI)
Bed confinement status
Awaiting organ transplant status
Other specified health status
Code Z78.1, Physical restraint status, may be used
when it is documented by the provider that a patient
has been put in restraints during the current
encounter. Please note that this code should not be
reported when it is documented by the provider that
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Z79
Z88
Z89
Z90
Z91.0Z92.82
a patient is temporarily restrained during a
procedure.
Long-term (current) drug therapy
Codes from this category indicate a patient’s
continuous use of a prescribed drug (including such
things as aspirin therapy) for the long-term
treatment of a condition or for prophylactic use. It
is not for use for patients who have addictions to
drugs. This subcategory is not for use of
medications for detoxification or maintenance
programs to prevent withdrawal symptoms in
patients with drug dependence (e.g., methadone
maintenance for opiate dependence). Assign the
appropriate code for the drug dependence instead.
Assign a code from Z79 if the patient is receiving a
medication for an extended period as a prophylactic
measure (such as for the prevention of deep vein
thrombosis) or as treatment of a chronic condition
(such as arthritis) or a disease requiring a lengthy
course of treatment (such as cancer). Do not assign
a code from category Z79 for medication being
administered for a brief period of time to treat an
acute illness or injury (such as a course of
antibiotics to treat acute bronchitis).
Allergy status to drugs, medicaments and biological
substances
Except: Z88.9, Allergy status to unspecified drugs,
medicaments and biological substances status
Acquired absence of limb
Acquired absence of organs, not elsewhere
classified
Allergy status, other than to drugs and biological
substances
Status post administration of tPA (rtPA) in a
different facility within the last 24 hours prior to
admission to a current facility
Assign code Z92.82, Status post administration of
tPA (rtPA) in a different facility within the last 24
hours prior to admission to current facility, as a
secondary diagnosis when a patient is received by
transfer into a facility and documentation indicates
they were administered tissue plasminogen activator
(tPA) within the last 24 hours prior to admission to
the current facility.
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This guideline applies even if the patient is still
receiving the tPA at the time they are received into
the current facility.
The appropriate code for the condition for which the
tPA was administered (such as cerebrovascular
disease or myocardial infarction) should be assigned
first.
Z93
Z94
Z95
Z96
Z97
Z98
Code Z92.82 is only applicable to the receiving
facility record and not to the transferring facility
record.
Artificial opening status
Transplanted organ and tissue status
Presence of cardiac and vascular implants and grafts
Presence of other functional implants
Presence of other devices
Other postprocedural states
Assign code Z98.85, Transplanted organ removal
status, to indicate that a transplanted organ has been
previously removed. This code should not be
assigned for the encounter in which the transplanted
organ is removed. The complication necessitating
removal of the transplant organ should be assigned
for that encounter.
See section I.C19. for information on the coding of
organ transplant complications.
Z99
4)
Dependence on enabling machines and devices, not
elsewhere classified
Note: Categories Z89-Z90 and Z93-Z99 are for use
only if there are no complications or malfunctions
of the organ or tissue replaced, the amputation site
or the equipment on which the patient is dependent.
History (of)
There are two types of history Z codes, personal and family.
Personal history codes explain a patient’s past medical
condition that no longer exists and is not receiving any
treatment, but that has the potential for recurrence, and
therefore may require continued monitoring.
Family history codes are for use when a patient has a family
member(s) who has had a particular disease that causes the
patient to be at higher risk of also contracting the disease.
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Personal history codes may be used in conjunction with followup codes and family history codes may be used in conjunction
with screening codes to explain the need for a test or
procedure. History codes are also acceptable on any medical
record regardless of the reason for visit. A history of an illness,
even if no longer present, is important information that may
alter the type of treatment ordered.
The history Z code categories are:
Z80
Family history of primary malignant neoplasm
Z81
Family history of mental and behavioral disorders
Z82
Family history of certain disabilities and chronic
diseases (leading to disablement)
Z83
Family history of other specific disorders
Z84
Family history of other conditions
Z85
Personal history of malignant neoplasm
Z86
Personal history of certain other diseases
Z87
Personal history of other diseases and conditions
Z91.4Personal history of psychological trauma, not
Z91.5
Personal history of self-harm
Z91.8Other specified personal risk factors, not elsewhere
classified
Exception:
Z91.83, Wandering in diseases classified
elsewhere
Z92
Personal history of medical treatment
Except: Z92.0, Personal history of contraception
Except: Z92.82, Status post administration of tPA
(rtPA) in a different facility within the last 24 hours
prior to admission to a current facility
5)
Screening
Screening is the testing for disease or disease precursors in
seemingly well individuals so that early detection and
treatment can be provided for those who test positive for the
disease (e.g., screening mammogram).
The testing of a person to rule out or confirm a suspected
diagnosis because the patient has some sign or symptom is a
diagnostic examination, not a screening. In these cases, the
sign or symptom is used to explain the reason for the test.
A screening code may be a first-listed code if the reason for the
visit is specifically the screening exam. It may also be used as
an additional code if the screening is done during an office visit
for other health problems. A screening code is not necessary if
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the screening is inherent to a routine examination, such as a
pap smear done during a routine pelvic examination.
Should a condition be discovered during the screening then the
code for the condition may be assigned as an additional
diagnosis.
The Z code indicates that a screening exam is planned. A
procedure code is required to confirm that the screening was
performed.
The screening Z codes/categories:
Z11
Encounter for screening for infectious and parasitic
diseases
Z12
Encounter for screening for malignant neoplasms
Z13
Encounter for screening for other diseases and
disorders
Except: Z13.9, Encounter for screening, unspecified
Z36
Encounter for antenatal screening for mother
6)
Observation
There are two observation Z code categories. They are for use
in very limited circumstances when a person is being observed
for a suspected condition that is ruled out. The observation
codes are not for use if an injury or illness or any signs or
symptoms related to the suspected condition are present. In
such cases the diagnosis/symptom code is used with the
corresponding external cause code.
The observation codes are to be used as principal diagnosis
only. Additional codes may be used in addition to the
observation code but only if they are unrelated to the suspected
condition being observed.
Codes from subcategory Z03.7, Encounter for suspected
maternal and fetal conditions ruled out, may either be used as a
first-listed or as an additional code assignment depending on
the case. They are for use in very limited circumstances on a
maternal record when an encounter is for a suspected maternal
or fetal condition that is ruled out during that encounter (for
example, a maternal or fetal condition may be suspected due to
an abnormal test result). These codes should not be used when
the condition is confirmed. In those cases, the confirmed
condition should be coded. In addition, these codes are not for
use if an illness or any signs or symptoms related to the
suspected condition or problem are present. In such cases the
diagnosis/symptom code is used.
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Additional codes may be used in addition to the code from
subcategory Z03.7, but only if they are unrelated to the
suspected condition being evaluated.
Codes from subcategory Z03.7 may not be used for encounters
for antenatal screening of mother. See Section I.C.21.
Screening.
For encounters for suspected fetal condition that are
inconclusive following testing and evaluation, assign the
appropriate code from category O35, O36, O40 or O41.
The observation Z code categories:
Z03
Encounter for medical observation for suspected
diseases and conditions ruled out
Z04
Encounter for examination and observation for
other reasons
Except: Z04.9, Encounter for examination and
observation for unspecified reason
7)
Aftercare
Aftercare visit codes cover situations when the initial treatment
of a disease has been performed and the patient requires
continued care during the healing or recovery phase, or for the
long-term consequences of the disease. The aftercare Z code
should not be used if treatment is directed at a current, acute
disease. The diagnosis code is to be used in these cases.
Exceptions to this rule are codes Z51.0, Encounter for
antineoplastic radiation therapy, and codes from subcategory
Z51.1, Encounter for antineoplastic chemotherapy and
immunotherapy. These codes are to be first-listed, followed by
the diagnosis code when a patient’s encounter is solely to
receive radiation therapy, chemotherapy, or immunotherapy for
the treatment of a neoplasm. If the reason for the encounter is
more than one type of antineoplastic therapy, code Z51.0 and a
code from subcategory Z51.1 may be assigned together, in
which case one of these codes would be reported as a
secondary diagnosis.
The aftercare Z codes should also not be used for aftercare for
injuries. For aftercare of an injury, assign the acute injury code
with the appropriate 7th character (for subsequent encounter).
The aftercare codes are generally first-listed to explain the
specific reason for the encounter. An aftercare code may be
used as an additional code when some type of aftercare is
provided in addition to the reason for admission and no
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diagnosis code is applicable. An example of this would be the
closure of a colostomy during an encounter for treatment of
another condition.
Aftercare codes should be used in conjunction with other
aftercare codes or diagnosis codes to provide better detail on
the specifics of an aftercare encounter visit, unless otherwise
directed by the classification. Should a patient receive multiple
types of antineoplastic therapy during the same encounter, code
Z51.0, Encounter for antineoplastic radiation therapy, and
codes from subcategory Z51.1, Encounter for antineoplastic
chemotherapy and immunotherapy, may be used together on a
record. The sequencing of multiple aftercare codes depends on
the circumstances of the encounter.
Certain aftercare Z code categories need a secondary diagnosis
code to describe the resolving condition or sequelae. For
others, the condition is included in the code title.
Additional Z code aftercare category terms include fitting and
adjustment, and attention to artificial openings.
Status Z codes may be used with aftercare Z codes to indicate
the nature of the aftercare. For example code Z95.1, Presence
of aortocoronary bypass graft, may be used with code Z48.812,
Encounter for surgical aftercare following surgery on the
circulatory system, to indicate the surgery for which the
aftercare is being performed. A status code should not be used
when the aftercare code indicates the type of status, such as
using Z43.0, Encounter for attention to tracheostomy, with
Z93.0, Tracheostomy status.
The aftercare Z category/codes:
Z42
Encounter for plastic and reconstructive surgery
following medical procedure or healed injury
Z43
Encounter for attention to artificial openings
Z44
Encounter for fitting and adjustment of external
prosthetic device
Z45
Encounter for adjustment and management of
implanted device
Z46
Encounter for fitting and adjustment of other
devices
Z47
Orthopedic aftercare
Z48
Encounter for other postprocedural aftercare
Z49
Encounter for care involving renal dialysis
Z51
Encounter for other aftercare
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8)
Follow-up
The follow-up codes are used to explain continuing
surveillance following completed treatment of a disease,
condition, or injury. They imply that the condition has been
fully treated and no longer exists. They should not be confused
with aftercare codes, or injury codes with a 7th character for
subsequent encounter, that explain ongoing care of a healing
condition or its sequelae. Follow-up codes may be used in
conjunction with history codes to provide the full picture of the
healed condition and its treatment. The follow-up code is
sequenced first, followed by the history code.
A follow-up code may be used to explain multiple visits.
Should a condition be found to have recurred on the follow-up
visit, then the diagnosis code for the condition should be
assigned in place of the follow-up code.
The follow-up Z code categories:
Z08
Encounter for follow-up examination after
completed treatment for malignant neoplasm
Z09
Encounter for follow-up examination after
completed treatment for conditions other than
malignant neoplasm
Z39
Encounter for maternal postpartum care and
examination
9)
Donor
Codes in category Z52, Donors of organs and tissues, are used
for living individuals who are donating blood or other body
tissue. These codes are only for individuals donating for
others, not for self-donations. They are not used to identify
cadaveric donations.
10)
Counseling
Counseling Z codes are used when a patient or family member
receives assistance in the aftermath of an illness or injury, or
when support is required in coping with family or social
problems. They are not used in conjunction with a diagnosis
code when the counseling component of care is considered
integral to standard treatment.
The counseling Z codes/categories:
Z30.0Encounter for general counseling and advice on
contraception
Z31.5
Encounter for genetic counseling
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Z31.6Z32.2
Z32.3
Z69
Z70
Z71
Z76.81
11)
Encounter for general counseling and advice on
procreation
Encounter for childbirth instruction
Encounter for childcare instruction
Encounter for mental health services for victim and
perpetrator of abuse
Counseling related to sexual attitude, behavior and
orientation
Persons encountering health services for other
counseling and medical advice, not elsewhere
classified
Expectant mother prebirth pediatrician visit
Encounters for Obstetrical and Reproductive Services
See Section I.C.15. Pregnancy, Childbirth, and the
Puerperium, for further instruction on the use of these codes.
Z codes for pregnancy are for use in those circumstances when
none of the problems or complications included in the codes
from the Obstetrics chapter exist (a routine prenatal visit or
postpartum care). Codes in category Z34, Encounter for
supervision of normal pregnancy, are always first-listed and are
not to be used with any other code from the OB chapter.
Codes in category Z3A, Weeks of gestation, may be
assigned to provide additional information about the
pregnancy.
The outcome of delivery, category Z37, should be included on
all maternal delivery records. It is always a secondary code.
Codes in category Z37 should not be used on the newborn
record.
Z codes for family planning (contraceptive) or procreative
management and counseling should be included on an obstetric
record either during the pregnancy or the postpartum stage, if
applicable.
Z codes/categories for obstetrical and reproductive services:
Z30
Encounter for contraceptive management
Z31
Encounter for procreative management
Z32.2
Z32.3
Z33
Pregnant state
Z34
Encounter for supervision of normal pregnancy
Z36
Encounter for antenatal screening of mother
Z3A
Weeks of gestation
Z37
Outcome of delivery
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Z39
Z76.81
12)
examination
Expectant mother prebirth pediatrician visit
Newborns and Infants
See Section I.C.16. Newborn (Perinatal) Guidelines, for further
instruction on the use of these codes.
Newborn Z codes/categories:
Z76.1
Encounter for health supervision and care of
foundling
Z00.1Encounter for routine child health examination
Z38
Liveborn infants according to place of birth and
type of delivery
13)
Routine and administrative examinations
The Z codes allow for the description of encounters for routine
examinations, such as, a general check-up, or, examinations for
administrative purposes, such as, a pre-employment physical.
The codes are not to be used if the examination is for diagnosis
of a suspected condition or for treatment purposes. In such
cases the diagnosis code is used. During a routine exam,
should a diagnosis or condition be discovered, it should be
coded as an additional code. Pre-existing and chronic
conditions and history codes may also be included as additional
codes as long as the examination is for administrative purposes
and not focused on any particular condition.
Some of the codes for routine health examinations distinguish
between “with” and “without” abnormal findings. Code
assignment depends on the information that is known at the
time the encounter is being coded. For example, if no abnormal
findings were found during the examination, but the encounter
is being coded before test results are back, it is acceptable to
assign the code for “without abnormal findings.” When
assigning a code for “with abnormal findings,” additional
code(s) should be assigned to identify the specific abnormal
finding(s).
Pre-operative examination and pre-procedural laboratory
examination Z codes are for use only in those situations when a
patient is being cleared for a procedure or surgery and no
treatment is given.
The Z codes/categories for routine and administrative
examinations:
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Z00
Z01
Z02
Z32.0-
14)
Encounter for general examination without
complaint, suspected or reported diagnosis
Encounter for other special examination without
Encounter for administrative examination
Except: Z02.9, Encounter for administrative
examinations, unspecified
Encounter for pregnancy test
Miscellaneous Z codes
The miscellaneous Z codes capture a number of other health
care encounters that do not fall into one of the other categories.
Certain of these codes identify the reason for the encounter;
others are for use as additional codes that provide useful
information on circumstances that may affect a patient’s care
and treatment.
Prophylactic Organ Removal
For encounters specifically for prophylactic removal of an
organ (such as prophylactic removal of breasts due to a genetic
susceptibility to cancer or a family history of cancer), the
principal or first-listed code should be a code from category
Z40, Encounter for prophylactic surgery, followed by the
appropriate codes to identify the associated risk factor (such as
genetic susceptibility or family history).
If the patient has a malignancy of one site and is having
prophylactic removal at another site to prevent either a new
primary malignancy or metastatic disease, a code for the
malignancy should also be assigned in addition to a code from
subcategory Z40.0, Encounter for prophylactic surgery for risk
factors related to malignant neoplasms. A Z40.0 code should
not be assigned if the patient is having organ removal for
treatment of a malignancy, such as the removal of the testes for
the treatment of prostate cancer.
Miscellaneous Z codes/categories:
Z28
Immunization not carried out
Except: Z28.3, Underimmunization status
Z40
Encounter for prophylactic surgery
Z41
Encounter for procedures for purposes other than
remedying health state
Except: Z41.9, Encounter for procedure for
purposes other than remedying health state,
unspecified
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Z53
Z55
Z56
Z57
Z58
Z59
Z60
Z62
Z63
Z64
Z65
Z72
Z73
Z74
Z75
Z76.0
Z76.3
Z76.4
Z76.5
Z91.1Z91.83
Z91.89
15)
Persons encountering health services for specific
procedures and treatment, not carried out
Problems related to education and literacy
Problems related to employment and unemployment
Occupational exposure to risk factors
Problems related to physical environment
Problems related to housing and economic
circumstances
Problems related to social environment
Problems related to upbringing
Other problems related to primary support group,
including family circumstances
Problems related to certain psychosocial
circumstances
Problems related to other psychosocial
circumstances
Problems related to lifestyle
Problems related to life management difficulty
Problems related to care provider dependency
Except: Z74.01, Bed confinement status
Problems related to medical facilities and other
health care
Encounter for issue of repeat prescription
Healthy person accompanying sick person
Other boarder to healthcare facility
Malingerer [conscious simulation]
Patient’s noncompliance with medical treatment
and regimen
Wandering in diseases classified elsewhere
Other specified personal risk factors, not elsewhere
classified
Nonspecific Z codes
Certain Z codes are so non-specific, or potentially redundant
with other codes in the classification, that there can be little
justification for their use in the inpatient setting. Their use in
the outpatient setting should be limited to those instances when
there is no further documentation to permit more precise
coding. Otherwise, any sign or symptom or any other reason
for visit that is captured in another code should be used.
Nonspecific Z codes/categories:
Z02.9
Encounter for administrative examinations,
unspecified
Z04.9
unspecified reason
Z13.9
Encounter for screening, unspecified
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Z41.9
Z52.9
Z86.59
Z92.0
16)
Encounter for procedure for purposes other than
remedying health state, unspecified
Donor of unspecified organ or tissue
Personal history of other mental and behavioral
disordersZ88.9
Allergy status to
unspecified drugs, medicaments and biological
substances status
Personal history of contraception
Z Codes That May Only be Principal/First-Listed
Diagnosis
The following Z codes/categories may only be reported as the
principal/first-listed diagnosis, except when there are multiple
encounters on the same day and the medical records for the
encounters are combined:
Z00
Encounter for general examination without
Z01
Encounter for other special examination without
Z02
Encounter for administrative examination
Z03
Encounter for medical observation for suspected
diseases and conditions ruled out
Z04
other reasons
Z33.2
Encounter for elective termination of pregnancy
Z31.81
Encounter for male factor infertility in female
patient
Z31.82
Encounter for Rh incompatibility status
Z31.83
Encounter for assisted reproductive fertility
procedure cycle
Z31.84
Encounter for fertility preservation procedure
Z34
Encounter for supervision of normal pregnancy
Z39
examination
Z38
Liveborn infants according to place of birth and
type of delivery
Z42
Encounter for plastic and reconstructive surgery
following medical procedure or healed injury
Z51.0
Encounter for antineoplastic radiation therapy
Z51.1Encounter for antineoplastic chemotherapy and
immunotherapy
Z52
Donors of organs and tissues
Except: Z52.9, Donor of unspecified organ or tissue
Z76.1
Encounter for health supervision and care of
foundling
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Z76.2
Z99.12
Encounter for health supervision and care of other
healthy infant and child
Encounter for respirator [ventilator] dependence
during power failure
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workup and/or therapy provided, and the Alphabetic Index, Tabular List, or another
coding guidelines does not provide sequencing direction, any one of the diagnoses
may be sequenced first.
D. Two or more comparative or contrasting conditions.
In those rare instances when two or more contrasting or comparative diagnoses are
documented as “either/or” (or similar terminology), they are coded as if the diagnoses
were confirmed and the diagnoses are sequenced according to the circumstances of
the admission. If no further determination can be made as to which diagnosis should
be principal, either diagnosis may be sequenced first.
E. A symptom(s) followed by contrasting/comparative diagnoses
When a symptom(s) is followed by contrasting/comparative diagnoses, the symptom
code is sequenced first. All the contrasting/comparative diagnoses should be coded
as additional diagnoses.
F. Original treatment plan not carried out
Sequence as the principal diagnosis the condition, which after study occasioned the
admission to the hospital, even though treatment may not have been carried out due to
unforeseen circumstances.
G. Complications of surgery and other medical care
When the admission is for treatment of a complication resulting from surgery or other
medical care, the complication code is sequenced as the principal diagnosis. If the
complication is classified to the T80-T88 series and the code lacks the necessary
specificity in describing the complication, an additional code for the specific
complication should be assigned.
H. Uncertain Diagnosis
If the diagnosis documented at the time of discharge is qualified as “probable”,
“suspected”, “likely”, “questionable”, “possible”, or “still to be ruled out”, or other
similar terms indicating uncertainty, code the condition as if it existed or was
established. The bases for these guidelines are the diagnostic workup, arrangements
for further workup or observation, and initial therapeutic approach that correspond
most closely with the established diagnosis.
Note: This guideline is applicable only to inpatient admissions to short-term, acute,
long-term care and psychiatric hospitals.
I. Admission from Observation Unit
1.
Admission Following Medical Observation
When a patient is admitted to an observation unit for a medical condition,
which either worsens or does not improve, and is subsequently admitted as an
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inpatient of the same hospital for this same medical condition, the principal
diagnosis would be the medical condition which led to the hospital admission.
2.
Admission Following Post-Operative Observation
When a patient is admitted to an observation unit to monitor a condition (or
complication) that develops following outpatient surgery, and then is
subsequently admitted as an inpatient of the same hospital, hospitals should
apply the Uniform Hospital Discharge Data Set (UHDDS) definition of
principal diagnosis as "that condition established after study to be chiefly
responsible for occasioning the admission of the patient to the hospital for
care."
J. Admission from Outpatient Surgery
When a patient receives surgery in the hospital's outpatient surgery department and is
subsequently admitted for continuing inpatient care at the same hospital, the
following guidelines should be followed in selecting the principal diagnosis for the
inpatient admission:
•
•
•
If the reason for the inpatient admission is a complication, assign the
complication as the principal diagnosis.
If no complication, or other condition, is documented as the reason for the
inpatient admission, assign the reason for the outpatient surgery as the
principal diagnosis.
If the reason for the inpatient admission is another condition unrelated to
the surgery, assign the unrelated condition as the principal diagnosis.
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CONCLUSION
This CE course has reviewed Chapters 16-21 of the ICD-10-CM coding guidelines.
Included in the review are diseases and injuries classified by chapter, examples of
codes found in each chapter, and examples of codes from the Tabular List, Alphabetic
Index, and Table of Drugs. At the completion of this course, the professional should be
familiar with ICD-10-CM code structure, detail, and location of codes for diseases and
injuries found in Chapters 16-21.
REFERENCES
Grider, Deborah J. Principles of ICD-10-CM Coding. The American Medical
Association. 2012.
The Centers for Medicare and Medicaid Services (CMS) and the National Center for
Health Statistics (NCHS). ICD-10-CM Official Guidelines for Coding and Reporting
2012. www.cms.gov. Accessed 1 May 2012.
ABOUT THE AUTHOR
Steve Verno is a Certified Medical Billing Specialist Instructor, a Certified Emergency
Medical Coding Specialist, a Certified Multispecialty Coding Specialist, and a Certified
Practice Manager-Medical Coding Specialist. He is a retired American Red Cross
Health and Safety Instructor Trainer, a retired American Red Cross Disaster Action
Team Captain, a graduate of the American Red Cross College. He is a coding and
billing consultant and instructor for Heal Your Practice, The Coding Institute, Lake
Sumter Medical Society, Physician Office Managers Association of America, the
Professional Association of Healthcare Coding Specialists and he is a member of the
Medical Economics Committee with the Florida College of Emergency Physicians and a
coding/billing consultant to the Federal Trade Commission. He is an Editorial Board
Member of the Medical Association of Billers, Billing-Coding Advantage, Physician
Office Managers Association of America and the Professional Association of Healthcare
Coding Specialists. Steve’s specialties are Emergency Medicine, Family Practice,
Urgent care, Internal Medicine, Pediatrics, ERISA, ICD-10, Appeals, AR Recovery,
Fraud and Abuse, Health Insurance Contracts, and Compliance. Steve with Don Self is
a co-author of the Layperson’s Guide to the Employment Retirement Income Security
Act (ERISA). For the last ten years, Steve has been a moderator of the Medical
Association of Billers On-Line Medical Billing forum, providing almost 10,000 responses
to visitor questions on coding, medical billing, fraud and abuse and compliance. He has
had more than 40 articles on coding and billing published in the Billing-Coding
Advantage magazine, the Medical Association of Billers, Codetrends Newsletter, and
the Professional Association of Healthcare Coding Specialists coding newsletter. He
was a contributing editor for the Insurance Handbook for the Medical Office, written by
Marilyn Fordney and published by Elsevier Science. He has also developed guidebooks
on ERISA, Appeals, and specialty ICD-10-CM training for emergency medicine, family
practice, cardiology, general surgery, radiation oncology, sports medicine, and
preparing for ICD-10-CM. Steve is also an Adjunct Professor of the Health and Safety
Department at Everest University and is presently on medical leave.
11
ATTACHMENT A: ICD-10-CM 2012 TABULAR LIST- Examples
Note: This handout is to be used for the ICD-10-CM CE test only. This handout is NOT to be used
for actual coding.
PO5 Disorders of newborn related to slow fetal growth and fetal malnutrition
P05.1 Newborn small for gestational age
Newborn small-and-light-for-dates
Newborn small-for-dates
P05.10
P05.11
P05.12
P05.13
P05.14
P05.15
P05.16
P05.17
P05.18
P35
Newborn small for gestational age, unspecified weight
Newborn small for gestational age, less than 500 grams
Congenital viral diseases
Includes: infections acquired in utero or during birth
P35.0
P35.1
P35.2
P35.3
P35.8
P35.9
Congenital rubella syndrome
Congenital rubella pneumonitis
Congenital cytomegalovirus infection
Congenital herpesviral [herpes simplex] infection
Congenital viral hepatitis
Other congenital viral diseases
Congenital varicella [chickenpox]
Congenital viral disease, unspecified
P55
Hemolytic disease of newborn
P55.0 Rh isoimmunization of newborn
P55.1 ABO isoimmunization of newborn
P55.8 Other hemolytic diseases of newborn
P55.9 Hemolytic disease of newborn, unspecified
P56
Hydrops fetalis due to hemolytic disease
Excludes1: hydrops fetalis NOS (P83.2)
P56.0 Hydrops fetalis due to isoimmunization
P56.9 Hydrops fetalis due to other and unspecified hemolytic disease
P56.90 Hydrops fetalis due to unspecified hemolytic disease
P56.99 Hydrops fetalis due to other hemolytic disease
P57
Kernicterus
P57.0 Kernicterus due to isoimmunization
P57.8 Other specified kernicterus
Excludes1: Crigler-Najjar syndrome (E80.5)
P57.9 Kernicterus, unspecified
P58
Neonatal jaundice due to other excessive hemolysis
Excludes1: jaundice due to isoimmunization (P55-P57)
P58.0 Neonatal jaundice due to bruising
12
P58.1
P58.2
P58.3
P58.4
Neonatal jaundice due to bleeding
Neonatal jaundice due to infection
Neonatal jaundice due to polycythemia
Neonatal jaundice due to drugs or toxins transmitted from mother or given to newborn
Code first poisoning due to drug or toxin, if applicable (T36-T65 with fifth or sixth
character 1-4 or 6)
Use additional code for adverse effect, if applicable, to identify drug (T36-T50 with fifth
or sixth character 5)
P58.41 Neonatal jaundice due to drugs or toxins transmitted from mother
P58.42 Neonatal jaundice due to drugs or toxins given to newborn
P58.5 Neonatal jaundice due to swallowed maternal blood
P58.8 Neonatal jaundice due to other specified excessive hemolysis
P58.9 Neonatal jaundice due to excessive hemolysis, unspecified
P59
Neonatal jaundice from other and unspecified causes
Excludes1: jaundice due to inborn errors of metabolism (E70-E88)
kernicterus (P57.-)
P59.0 Neonatal jaundice associated with preterm delivery
Hyperbilirubinemia of prematurity
Jaundice due to delayed conjugation associated with preterm delivery
P59.1 Inspissated bile syndrome
P59.2 Neonatal jaundice from other and unspecified hepatocellular damage
Excludes1: congenital viral hepatitis (P35.3)
P59.20 Neonatal jaundice from unspecified hepatocellular damage
P59.29 Neonatal jaundice from other hepatocellular damage
Neonatal giant cell hepatitis
Neonatal (idiopathic) hepatitis
P59.3 Neonatal jaundice from breast milk inhibitor
P59.8 Neonatal jaundice from other specified causes
P59.9 Neonatal jaundice, unspecified
Neonatal physiological jaundice (intense)(prolonged) NOS
P92
Feeding problems of newborn
Excludes1: feeding problems in child over 28 days old (R63.3)
P92.0 Vomiting of newborn
Excludes1: vomiting of child over 28 days old (R11.-)
P92.01 Bilious vomiting of newborn
Excludes1: bilious vomiting in child over 28 days old (R11.4)
P92.09 Other vomiting of newborn
Excludes1: regurgitation of food in newborn (P92.1)
P92.1 Regurgitation and rumination of newborn
P92.2 Slow feeding of newborn
P92.3 Underfeeding of newborn
P92.4 Overfeeding of newborn
P92.5 Neonatal difficulty in feeding at breast
P92.6 Failure to thrive in newborn
Excludes1: failure to thrive in child over 28 days old (R62.51)
P92.8 Other feeding problems of newborn
P92.9 Feeding problem of newborn, unspecified
Q05
Spina bifida
Includes: hydromeningocele (spinal)
meningocele (spinal)
meningomyelocele
myelocele
myelomeningocele
rachischisis
13
spina bifida (aperta)(cystica)
syringomyelocele
Use additional code for any associated paraplegia (paraparesis) (G82.2-)
Excludes1: Arnold-Chiari syndrome, type II (Q07.0-)
spina bifida occulta (Q76.0)
Q05.0 Cervical spina bifida with hydrocephalus
Q05.1 Thoracic spina bifida with hydrocephalus
Dorsal spina bifida with hydrocephalus
Thoracolumbar spina bifida with hydrocephalus
Q05.2 Lumbar spina bifida with hydrocephalus
Lumbosacral spina bifida with hydrocephalus
Q05.3 Sacral spina bifida with hydrocephalus
Q05.4 Unspecified spina bifida with hydrocephalus
Q05.5 Cervical spina bifida without hydrocephalus
Q05.6 Thoracic spina bifida without hydrocephalus
Dorsal spina bifida NOS
Thoracolumbar spina bifida NOS
Q05.7 Lumbar spina bifida without hydrocephalus
Lumbosacral spina bifida NOS
Q05.8 Sacral spina bifida without hydrocephalus
Q05.9 Spina bifida, unspecified
Q35
Cleft palate
Includes: fissure of palate
palatoschisis
Excludes1: cleft palate with cleft lip (Q37.-)
Q35.1
Q35.3
Q35.5
Q35.7
Q35.9
Q36
Cleft hard palate
Cleft soft palate
Cleft hard palate with cleft soft palate
Cleft uvula
Cleft palate, unspecified
Cleft palate NOS
Cleft lip
Includes: cheiloschisis
congenital fissure of lip
harelip
labium leporinum
Excludes1: cleft lip with cleft palate (Q37.-)
Q36.0 Cleft lip, bilateral
Q36.1 Cleft lip, median
Q36.9 Cleft lip, unilateral
Cleft lip NOS
Q37
Cleft palate with cleft lip
Includes: cheilopalatoschisis
Q37.0 Cleft hard palate with bilateral cleft lip
Q37.1 Cleft hard palate with unilateral cleft lip
Cleft hard palate with cleft lip NOS
Q37.2 Cleft soft palate with bilateral cleft lip
Q37.3 Cleft soft palate with unilateral cleft lip
Cleft soft palate with cleft lip NOS
Q37.4 Cleft hard and soft palate with bilateral cleft lip
Q37.5 Cleft hard and soft palate with unilateral cleft lip
Cleft hard and soft palate with cleft lip NOS
14
Q37.8 Unspecified cleft palate with bilateral cleft lip
Q37.9 Unspecified cleft palate with unilateral cleft lip
Cleft palate with cleft lip NOS
Q90
Down syndrome
Use additional code(s) to identify any associated physical conditions and degree of intellectual
disabilities (F70-F79)
Q90.0
Q90.1
Q90.2
Q90.9
Q91
Trisomy 18 and Trisomy 13
Q91.0
Q91.1
Q91.2
Q91.3
Q91.4
Q91.5
Q91.6
Q91.7
Q92
Trisomy 21, nonmosaicism (meiotic nondisjunction)
Trisomy 21, mosaicism (mitotic nondisjunction)
Down syndrome, unspecified
Trisomy 21 NOS
Trisomy 18, unspecified
Trisomy 13, unspecified
Other trisomies and partial trisomies of the autosomes, not elsewhere classified
Includes: unbalanced translocations and insertions
Excludes1: trisomies of chromosomes 13, 18, 21 (Q90-Q91)
Q92.0 Whole chromosome trisomy, nonmosaicism (meiotic nondisjunction)
Q92.1 Whole chromosome trisomy, mosaicism (mitotic nondisjunction)
Q92.2 Partial trisomy
Less than whole arm duplicated
Whole arm or more duplicated
Excludes1: partial trisomy due to unbalanced translocation (Q92.5)
Q92.5 Duplications with other complex rearrangements
Partial trisomy due to unbalanced translocations
Code also any associated deletions due to unbalanced translocations, inversions and
insertions (Q93.7)
Q92.6 Marker chromosomes
Trisomies due to dicentrics
Trisomies due to extra rings
Trisomies due to isochromosomes
Individual with marker heterochromatin
Q92.61 Marker chromosomes in normal individual
Q92.62 Marker chromosomes in abnormal individual
Q92.7 Triploidy and polyploidy
Q92.8 Other specified trisomies and partial trisomies of autosomes
Duplications identified by fluorescence in situ hybridization (FISH)
Duplications identified by in situ hybridization (ISH)
Duplications seen only at prometaphase
Q92.9 Trisomy and partial trisomy of autosomes, unspecified
R00
Abnormalities of heart beat
Excludes1: abnormalities originating in the perinatal period (P29.1-)
specified arrhythmias (I47-I49)
R00.0 Tachycardia, unspecified
Rapid heart beat
Sinoauricular tachycardia NOS
15
R00.1
R00.2
R00.8
R00.9
R01
Sinus [sinusal] tachycardia NOS
Excludes1: neonatal tachycardia (P29.11)
paroxysmal tachycardia (I47.-)
Bradycardia, unspecified
Sinoatrial bradycardia
Sinus bradycardia
Slow heart beat
Vagal bradycardia
Excludes1: neonatal bradycardia (P29.12)
Palpitations
Awareness of heart beat
Other abnormalities of heart beat
Unspecified abnormalities of heart beat
Cardiac murmurs and other cardiac sounds
Excludes1: cardiac murmurs and sounds originating in the perinatal period (P29.8)
R01.0 Benign and innocent cardiac murmurs
Functional cardiac murmur
R01.1 Cardiac murmur, unspecified
Cardiac bruit NOS
Heart murmur NOS
R01.2 Other cardiac sounds
Cardiac dullness, increased or decreased
Precordial friction
R03
Abnormal blood-pressure reading, without diagnosis
R03.0 Elevated blood-pressure reading, without diagnosis of hypertension
Note: This category is to be used to record an episode of elevated blood pressure in a
patient in whom no formal diagnosis of hypertension has been made, or as an isolated
incidental finding.
R03.1 Nonspecific low blood-pressure reading
Excludes1: hypotension (I95.-)
maternal hypotension syndrome (O26.5-)
neurogenic orthostatic hypotension (G90.3)
R05
Cough
Excludes1: cough with hemorrhage (R04.2)
smoker's cough (J41.0)
R06
Abnormalities of breathing
Excludes1: acute respiratory distress syndrome (J80)
respiratory arrest (R09.2)
respiratory arrest of newborn (P28.81)
respiratory distress syndrome of newborn (P22.-)
respiratory failure (J96.-)
respiratory failure of newborn (P28.5)
R06.0 Dyspnea
Excludes1: tachypnea NOS (R06.82)
transient tachypnea of newborn (P22.1)
R06.00 Dyspnea, unspecified
R06.01 Orthopnea
R06.02 Shortness of breath
R06.09 Other forms of dyspnea
16
R06.1 Stridor
Excludes1: congenital laryngeal stridor (P28.89)
laryngismus (stridulus) (J38.5)
R06.2 Wheezing
Excludes1: Asthma (J45.-)
R06.3 Periodic breathing
Cheyne-Stokes breathing
R06.4 Hyperventilation
Excludes1: psychogenic hyperventilation (F45.8)
R06.5 Mouth breathing
Excludes2: dry mouth NOS (R68.2)
R06.6 Hiccough
Excludes1: psychogenic hiccough (F45.8)
R06.7 Sneezing
R06.8 Other abnormalities of breathing
R06.81 Apnea, not elsewhere classified
Apnea NOS
Excludes1: apnea (of) newborn (P28.4)
sleep apnea (G47.3-)
sleep apnea of newborn (primary) (P28.3)
R06.82 Tachypnea, not elsewhere classified
Tachypnea NOS
Excludes1: transitory tachypnea of newborn (P22.1)
R06.83 Snoring
R06.89 Other abnormalities of breathing
Breath-holding (spells)
Sighing
R06.9 Unspecified abnormalities of breathing
R11
Nausea and vomiting
Excludes1: cyclical vomiting associated with migraine (G43.A-)
excessive vomiting in pregnancy (O21.-)
hematemesis (K92.0)
neonatal hematemesis (P54.0)
newborn vomiting (P92.0-)
psychogenic vomiting (F50.8)
vomiting associated with bulimia nervosa (F50.2)
vomiting following gastrointestinal surgery (K91.0)
R11.0 Nausea
Nausea NOS
Nausea without vomiting
R11.1 Vomiting
R11.10 Vomiting, unspecified
Vomiting NOS
R11.11 Vomiting without nausea
R11.12 Projectile vomiting
R11.13 Vomiting of fecal matter
R11.14 Bilious vomiting
Bilious emesis
R11.2 Nausea with vomiting, unspecified
Persistent nausea with vomiting NOS
R12
Heartburn
Excludes1: dyspepsia NOS (R10.13)
functional dyspepsia (K30)
R30
Pain associated with micturition
Excludes1: psychogenic pain associated with micturition (F45.8)
17
R30.0 Dysuria
Strangury
R30.1 Vesical tenesmus
R30.9 Micturition, unspecified
Painful urination NOS
R31
Hematuria
Excludes1: hematuria included with underlying conditions, such as:
acute cystitis with hematuria (N30.01)
acute prostatitis with hematuria (N41.01)
recurrent and persistent hematuria in glomerular diseases (N02.-)
R31.0
R31.1
R31.2
R31.9
Gross hematuria
Benign essential microscopic hematuria
Other microscopic hematuria
Hematuria, unspecified
R32
Unspecified urinary incontinence
Enuresis NOS
Excludes1: functional urinary incontinence (R39.81)
nonorganic enuresis (F98.0)
stress incontinence and other specified urinary incontinence (N39.3-N39.4-)
urinary incontinence associated with cognitive impairment (R39.81)
R33
Retention of urine
Excludes1: psychogenic retention of urine (F45.8)
R33.0 Drug induced retention of urine
R33.8 Other retention of urine
Code first, if applicable, any causal condition, such as: enlarged prostate (N40.1)
R33.9 Retention of urine, unspecified
R34
Anuria and oliguria
Excludes1: anuria and oliguria complicating abortion or ectopic or molar pregnancy (O00-O07,
O08.4)
anuria and oliguria complicating pregnancy (O26.83-)
anuria and oliguria complicating the puerperium (O90.4)
R35
Polyuria
Code first, if applicable, any causal condition, such as: enlarged prostate (N40.1)
Excludes1: psychogenic polyuria (F45.8)
R35.0 Frequency of micturition
R35.1 Nocturia
R35.8 Other polyuria
Polyuria NOS
R45
Symptoms and signs involving emotional state
R45.0 Nervousness
Nervous tension
R45.1 Restlessness and agitation
R45.2 Unhappiness
R45.3 Demoralization and apathy
Excludes1: anhedonia (R45.84)
R45.4 Irritability and anger
R45.5 Hostility
R45.6 Violent behavior
18
R45.7 State of emotional shock and stress, unspecified
R45.8 Other symptoms and signs involving emotional state
R45.81 Low self-esteem
R45.82 Worries
R45.83 Excessive crying of child, adolescent or adult
Excludes1: excessive crying of infant (baby) R68.11
R45.84 Anhedonia
R45.85 Homicidal and suicidal ideations
Excludes1: suicide attempt (T14.91)
R45.850 Homicidal ideations
R45.851 Suicidal ideations
R45.86 Emotional lability
R45.87 Impulsiveness
R45.89 Other symptoms and signs involving emotional state
R46
Symptoms and signs involving appearance and behavior
Excludes1: appearance and behavior in schizophrenia, schizotypal and delusional disorders
(F20-F29)
mental and behavioral disorders (F01-F99)
R46.0
R46.1
R46.2
R46.3
R46.4
R46.5
R46.6
R46.7
R46.8
R59
Very low level of personal hygiene
Bizarre personal appearance
Strange and inexplicable behavior
Overactivity
Slowness and poor responsiveness
Excludes1: stupor (R40.1)
Suspiciousness and marked evasiveness
Undue concern and preoccupation with stressful events
Verbosity and circumstantial detail obscuring reason for contact
Other symptoms and signs involving appearance and behavior
R46.81 Obsessive-compulsive behavior
Excludes1: obsessive-compulsive disorder (F42)
R46.89 Other symptoms and signs involving appearance and behavior
Enlarged lymph nodes
Includes: swollen glands
Excludes1: lymphadenitis NOS (I88.9)
acute lymphadenitis (L04.-)
chronic lymphadenitis (I88.1)
mesenteric (acute) (chronic) lymphadenitis (I88.0)
R59.0 Localized enlarged lymph nodes
R59.1 Generalized enlarged lymph nodes
Lymphadenopathy NOS
R59.9 Enlarged lymph nodes, unspecified
R60
Edema, not elsewhere classified
Excludes1: angioneurotic edema (T78.3)
ascites (R18.-)
cerebral edema (G93.6)
cerebral edema due to birth injury (P11.0)
edema of larynx (J38.4)
edema of nasopharynx (J39.2)
edema of pharynx (J39.2)
gestational edema (O12.0-)
hereditary edema (Q82.0)
hydrops fetalis NOS (P83.2)
hydrothorax (J94.8)
nutritional edema (E40-E46)
hydrops fetalis NOS (P83.2)
19
newborn edema (P83.3)
pulmonary edema (J81.-)
R60.0 Localized edema
R60.1 Generalized edema
R60.9 Edema, unspecified
Abnormal findings on examination of urine, without diagnosis (R80-R82)
Excludes1: abnormal findings on antenatal screening of mother (O28.-)
diagnostic abnormal findings classified elsewhere - see Alphabetical Index
specific findings indicating disorder of:
amino-acid metabolism (E70-E72)
carbohydrate metabolism (E73-E74)
R80
Proteinuria
Excludes1: gestational proteinuria (O12.1-)
R80.0 Isolated proteinuria
Idiopathic proteinuria
Excludes1: isolated proteinuria with specific morphological lesion (N06.-)
R80.1 Persistent proteinuria, unspecified
R80.2 Orthostatic proteinuria, unspecified
Postural proteinuria
R80.3 Bence Jones proteinuria
R80.8 Other proteinuria
R80.9 Proteinuria, unspecified
Albuminuria NOS
R81
Glycosuria
Excludes1: renal glycosuria (E74.8)
R82
Other and unspecified abnormal findings in urine
Includes: chromoabnormalities in urine
Use additional code to identify any retained foreign body, if applicable (Z18.-)
Excludes2: hematuria (R31.-)
R82.0 Chyluria
Excludes1: filarial chyluria (B74.-)
R82.1 Myoglobinuria
R82.2 Biliuria
R82.3 Hemoglobinuria
Excludes1: hemoglobinuria due to hemolysis from external causes NEC
(D59.6)
hemoglobinuria due to paroxysmal nocturnal [Marchiafava-Micheli]
(D59.5)
R82.4 Acetonuria
Ketonuria
R82.5 Elevated urine levels of drugs, medicaments and biological substances
Elevated urine levels of catecholamines
Elevated urine levels of indoleacetic acid
Elevated urine levels of 17-ketosteroids
Elevated urine levels of steroids
R82.6 Abnormal urine levels of substances chiefly nonmedicinal as to source
Abnormal urine level of heavy metals
R82.7 Abnormal findings on microbiological examination of urine
Positive culture findings of urine
20
Excludes1: colonization status (Z22.-)
R82.8 Abnormal findings on cytological and histological examination of urine
R82.9 Other and unspecified abnormal findings in urine
R82.90 Unspecified abnormal findings in urine
R82.91 Other chromoabnormalities of urine
Chromoconversion (dipstick)
Idiopathic dipstick converts positive for blood with no cellular forms in
sediment
Excludes1: hemoglobinuria (R82.3)
myoglobinuria (R82.1)
R82.99 Other abnormal findings in urine
Cells and casts in urine
Crystalluria
Melanuria
R94
Abnormal results of function studies
Includes: abnormal results of radionuclide [radioisotope] uptake studies
abnormal results of scintigraphy
R94.0 Abnormal results of function studies of central nervous system
R94.01 Abnormal electroencephalogram [EEG]
R94.02 Abnormal brain scan
R94.09 Abnormal results of other function studies of central nervous system
R94.1 Abnormal results of function studies of peripheral nervous system and special senses
R94.11 Abnormal results of function studies of eye
R94.110 Abnormal electro-oculogram [EOG]
R94.111 Abnormal electroretinogram [ERG]
Abnormal retinal function study
R94.112 Abnormal visually evoked potential [VEP]
R94.113 Abnormal oculomotor study
R94.118 Abnormal results of other function studies of eye
R94.12 Abnormal results of function studies of ear and other special senses
R94.120 Abnormal auditory function study
R94.121 Abnormal vestibular function study
R94.128 Abnormal results of other function studies of ear and other special
senses
R94.13 Abnormal results of function studies of peripheral nervous system
R94.130 Abnormal response to nerve stimulation, unspecified
R94.131 Abnormal electromyogram [EMG]
Excludes1: electromyogram of eye (R94.113)
R94.138 Abnormal results of other function studies of peripheral nervous system
R94.2 Abnormal results of pulmonary function studies
Reduced ventilatory capacity
Reduced vital capacity
R94.3 Abnormal results of cardiovascular function studies
R94.30 Abnormal result of cardiovascular function study, unspecified
R94.31 Abnormal electrocardiogram [ECG] [EKG]
Excludes1: long QT syndrome (I45.81)
R94.39 Abnormal result of other cardiovascular function study
Abnormal electrophysiological intracardiac studies
Abnormal phonocardiogram
Abnormal vectorcardiogram
S00
Superficial injury of head
Excludes1: diffuse cerebral contusion (S06.2-)
focal cerebral contusion (S06.3-)
injury of eye and orbit (S05.-)
open wound of head (S01.-)
21
The appropriate 7th character is to be added to each code from category S00
A - initial encounter
D - subsequent encounter
S - sequela
S00.0 Superficial injury of scalp
S00.00 Unspecified superficial injury of scalp
S00.01 Abrasion of scalp
S00.02 Blister (nonthermal) of scalp
S00.03 Contusion of scalp
Bruise of scalp
Hematoma of scalp
S00.04 External constriction of part of scalp
S00.05 Superficial foreign body of scalp
Splinter in the scalp
S00.06 Insect bite (nonvenomous) of scalp
S00.07 Other superficial bite of scalp
Excludes1: open bite of scalp (S01.05)
S00.1 Contusion of eyelid and periocular area
Black eye
Excludes2: contusion of eyeball and orbital tissues (S05.1)
S00.10 Contusion of unspecified eyelid and periocular area
S00.11 Contusion of right eyelid and periocular area
S00.12 Contusion of left eyelid and periocular area
S00.2 Other and unspecified superficial injuries of eyelid and periocular area
Excludes2: superficial injury of conjunctiva and cornea (S05.0-)
S00.20 Unspecified superficial injury of eyelid and periocular area
S00.201 Unspecified superficial injury of right eyelid and periocular area
S00.202 Unspecified superficial injury of left eyelid and periocular area
S00.209 Unspecified superficial injury of unspecified eyelid and periocular area
S00.21 Abrasion of eyelid and periocular area
S00.211 Abrasion of right eyelid and periocular area
S00.212 Abrasion of left eyelid and periocular area
S00.219 Abrasion of unspecified eyelid and periocular area
S00.22 Blister (nonthermal) of eyelid and periocular area
S00.221 Blister (nonthermal) of right eyelid and periocular area
S00.222 Blister (nonthermal) of left eyelid and periocular area
S00.229 Blister (nonthermal) of unspecified eyelid and periocular area
S00.24 External constriction of eyelid and periocular area
S00.241 External constriction of right eyelid and periocular area
S00.242 External constriction of left eyelid and periocular area
S00.249 External constriction of unspecified eyelid and periocular area
S00.25 Superficial foreign body of eyelid and periocular area
Splinter of eyelid and periocular area
Excludes2: retained foreign body in eyelid (H02.81-)
S00.251 Superficial foreign body of right eyelid and periocular area
S00.252 Superficial foreign body of left eyelid and periocular area
S00.259 Superficial foreign body of unspecified eyelid and periocular area
S00.26 Insect bite (nonvenomous) of eyelid and periocular area
S00.261 Insect bite (nonvenomous) of right eyelid and periocular area
S00.262 Insect bite (nonvenomous) of left eyelid and periocular area
S00.269 Insect bite (nonvenomous) of unspecified eyelid and periocular area
S00.27 Other superficial bite of eyelid and periocular area
Excludes1: open bite of eyelid and periocular area (S01.15)
S00.271 Other superficial bite of right eyelid and periocular area
S00.272 Other superficial bite of left eyelid and periocular area
S00.279 Other superficial bite of unspecified eyelid and periocular area
S00.3 Superficial injury of nose
S00.30 Unspecified superficial injury of nose
S00.31 Abrasion of nose
22
S00.32 Blister (nonthermal) of nose
S00.33 Contusion of nose
Bruise of nose
Hematoma of nose
S00.34 External constriction of nose
S00.35 Superficial foreign body of nose
Splinter in the nose
S00.36 Insect bite (nonvenomous) of nose
S00.37 Other superficial bite of nose
Excludes1: open bite of nose (S01.25)
S52
Fracture of forearm
Note:
A fracture not indicated as displaced or nondisplaced should be coded to displaced
A fracture not indicated as open or closed should be coded to closed
The open fracture designations are based on the Gustilo open fracture classification
Excludes1: traumatic amputation of forearm (S58.-)
Excludes2: fracture at wrist and hand level (S62.-)
The appropriate 7th character is to be added to all codes from category S52
A - initial encounter for closed fracture
B - initial encounter for open fracture type I or II
initial encounter for open fracture NOS
C - initial encounter for open fracture type IIIA, IIIB, or IIIC
D - subsequent encounter for closed fracture with routine healing
E - subsequent encounter for open fracture type I or II with routine healing
F - subsequent encounter for open fracture type IIIA, IIIB, or IIIC with routine healing
G - subsequent encounter for closed fracture with delayed healing
H - subsequent encounter for open fracture type I or II with delayed healing
J - subsequent encounter for open fracture type IIIA, IIIB, or IIIC with delayed healing
K - subsequent encounter for closed fracture with nonunion
M - subsequent encounter for open fracture type I or II with nonunion
N - subsequent encounter for open fracture type IIIA, IIIB, or IIIC with nonunion
P - subsequent encounter for closed fracture with malunion
Q - subsequent encounter for open fracture type I or II with malunion
R - subsequent encounter for open fracture type IIIA, IIIB, or IIIC with malunion
S - sequela
S52.0 Fracture of upper end of ulna
Fracture of proximal end of ulna
Excludes2: fracture of elbow NOS (S42.40-)
fractures of shaft of ulna (S52.2-)
S52.00 Unspecified fracture of upper end of ulna
S52.001 Unspecified fracture of upper end of right ulna
S52.002 Unspecified fracture of upper end of left ulna
S52.009 Unspecified fracture of upper end of unspecified ulna
S52.01 Torus fracture of upper end of ulna
The appropriate 7th character is to be added to all codes in subcategory
A - initial encounter for closed fracture
D - subsequent encounter for fracture with routine healing
G - subsequent encounter for fracture with delayed healing
K - subsequent encounter for fracture with nonunion
P - subsequent encounter for fracture with malunion
S - sequela
S52.011 Torus fracture of upper end of right ulna
S52.012 Torus fracture of upper end of left ulna
S52.019 Torus fracture of upper end of unspecified ulna
23
S52.02 Fracture of olecranon process without intraarticular extension of ulna
S52.021 Displaced fracture of olecranon process without intraarticular extension
of right ulna
of left ulna
of unspecified ulna
S52.024 Nondisplaced fracture of olecranon process without intraarticular
extension of right ulna
extension of left ulna
extension of unspecified ulna
S52.03 Fracture of olecranon process with intraarticular extension of ulna
S52.031 Displaced fracture of olecranon process with intraarticular extension of
right ulna
left ulna
unspecified ulna
S52.034 Nondisplaced fracture of olecranon process with intraarticular extension
of right ulna
of left ulna
of unspecified ulna
S52.04 Fracture of coronoid process of ulna
S52.041 Displaced fracture of coronoid process of right ulna
S52.042 Displaced fracture of coronoid process of left ulna
S52.043 Displaced fracture of coronoid process of unspecified ulna
S52.044 Nondisplaced fracture of coronoid process of right ulna
S52.045 Nondisplaced fracture of coronoid process of left ulna
S52.046 Nondisplaced fracture of coronoid process of unspecified ulna
S52.09 Other fracture of upper end of ulna
S52.091 Other fracture of upper end of right ulna
S52.092 Other fracture of upper end of left ulna
S52.099 Other fracture of upper end of unspecified ulna
S60
Superficial injury of wrist, hand and fingers
The appropriate 7th character is to be added to each code from category S60
S - sequela
S60.0 Contusion of finger without damage to nail
Excludes1: contusion involving nail (matrix) (S60.1)
S60.00 Contusion of unspecified finger without damage to nail
Contusion of finger(s) NOS
S60.01 Contusion of thumb without damage to nail
S60.011 Contusion of right thumb without damage to nail
S60.012 Contusion of left thumb without damage to nail
S60.019 Contusion of unspecified thumb without damage to nail
S60.02 Contusion of index finger without damage to nail
S60.021 Contusion of right index finger without damage to nail
S60.022 Contusion of left index finger without damage to nail
S60.029 Contusion of unspecified index finger without damage to nail
S60.03 Contusion of middle finger without damage to nail
S60.031 Contusion of right middle finger without damage to nail
S60.032 Contusion of left middle finger without damage to nail
24
S60.039 Contusion of unspecified middle finger without damage to nail
S60.04 Contusion of ring finger without damage to nail
S60.041 Contusion of right ring finger without damage to nail
S60.042 Contusion of left ring finger without damage to nail
S60.049 Contusion of unspecified ring finger without damage to nail
S60.05 Contusion of little finger without damage to nail
S60.051 Contusion of right little finger without damage to nail
S60.052 Contusion of left little finger without damage to nail
S60.059 Contusion of unspecified little finger without damage to nail
S60.1 Contusion of finger with damage to nail
S60.10 Contusion of unspecified finger with damage to nail
S60.11 Contusion of thumb with damage to nail
S60.111 Contusion of right thumb with damage to nail
S60.112 Contusion of left thumb with damage to nail
S60.119 Contusion of unspecified thumb with damage to nail
S60.12 Contusion of index finger with damage to nail
S60.121 Contusion of right index finger with damage to nail
S60.122 Contusion of left index finger with damage to nail
S60.129 Contusion of unspecified index finger with damage to nail
S60.13 Contusion of middle finger with damage to nail
S60.131 Contusion of right middle finger with damage to nail
S60.132 Contusion of left middle finger with damage to nail
S60.139 Contusion of unspecified middle finger with damage to nail
S60.14 Contusion of ring finger with damage to nail
S60.141 Contusion of right ring finger with damage to nail
S60.142 Contusion of left ring finger with damage to nail
S60.149 Contusion of unspecified ring finger with damage to nail
S60.15 Contusion of little finger with damage to nail
S60.151 Contusion of right little finger with damage to nail
S60.152 Contusion of left little finger with damage to nail
S60.159 Contusion of unspecified little finger with damage to nail
T16
Foreign body in ear
Includes: foreign body in auditory canal
The appropriate 7th character is to be added to each code from category T16
S - sequela
T16.1
T16.2
T16.9
T17
Foreign body in right ear
Foreign body in left ear
Foreign body in ear, unspecified ear
Foreign body in respiratory tract
S - sequela
T17.0
T17.1
T17.2
Foreign body in nasal sinus
Foreign body in nostril
Foreign body in nose NOS
Foreign body in pharynx
Foreign body in nasopharynx
Foreign body in throat NOS
T17.20 Unspecified foreign body in pharynx
T17.200 Unspecified foreign body in pharynx causing asphyxiation
T17.208 Unspecified foreign body in pharynx causing other injury
25
T17.21 Gastric contents in pharynx
Aspiration of gastric contents into pharynx
Vomitus in pharynx
T17.210 Gastric contents in pharynx causing asphyxiation
T17.218 Gastric contents in pharynx causing other injury
T17.22 Food in pharynx
Bones in pharynx
Seeds in pharynx
T17.220 Food in pharynx causing asphyxiation
T17.228 Food in pharynx causing other injury
T17.29 Other foreign object in pharynx
T17.290 Other foreign object in pharynx causing asphyxiation
T58
Toxic effect of carbon monoxide
Includes: asphyxiation from carbon monoxide
toxic effect of carbon monoxide from all sources
S - sequela
T58.0
T58.1
T58.2
Toxic effect of carbon monoxide from motor vehicle exhaust
Toxic effect of exhaust gas from gas engine
Toxic effect of exhaust gas from motor pump
T58.01 Toxic effect of carbon monoxide from motor vehicle exhaust, accidental
(unintentional)
T58.02 Toxic effect of carbon monoxide from motor vehicle exhaust, intentional selfharm
T58.03 Toxic effect of carbon monoxide from motor vehicle exhaust, assault
T58.04 Toxic effect of carbon monoxide from motor vehicle exhaust, undetermined
Toxic effect of carbon monoxide from utility gas
Toxic effect of acetylene
Toxic effect of gas NOS used for lighting, heating, cooking
Toxic effect of water gas
T58.11 Toxic effect of carbon monoxide from utility gas, accidental (unintentional)
T58.12 Toxic effect of carbon monoxide from utility gas, intentional self-harm
T58.13 Toxic effect of carbon monoxide from utility gas, assault
T58.14 Toxic effect of carbon monoxide from utility gas, undetermined
Toxic effect of carbon monoxide from incomplete combustion of other domestic fuels
Toxic effect of carbon monoxide from incomplete combustion of coal, coke, kerosene,
wood
T58.2X Toxic effect of carbon monoxide from incomplete combustion of other domestic
fuels
T58.2X1 Toxic effect of carbon monoxide from incomplete combustion of other
domestic fuels, accidental (unintentional)
domestic fuels, intentional self-harm
domestic fuels, assault
domestic fuels, undetermined
T58.8 Toxic effect of carbon monoxide from other source
Toxic effect of carbon monoxide from blast furnace gas
Toxic effect of carbon monoxide from fuels in industrial use
Toxic effect of carbon monoxide from kiln vapor
T58.8X Toxic effect of carbon monoxide from other source
T58.8X1 Toxic effect of carbon monoxide from other source, accidental
(unintentional)
26
T58.9
T67
T58.8X2 Toxic effect of carbon monoxide from other source, intentional
self-harm
T58.8X3 Toxic effect of carbon monoxide from other source, assault
T58.8X4 Toxic effect of carbon monoxide from other source, undetermined
Toxic effect of carbon monoxide from unspecified source
T58.91 Toxic effect of carbon monoxide from unspecified source, accidental
(unintentional)
T58.92 Toxic effect of carbon monoxide from unspecified source, intentional selfharm
T58.93 Toxic effect of carbon monoxide from unspecified source, assault
T58.94 Toxic effect of carbon monoxide from unspecified source, undetermined
Effects of heat and light
Excludes1: erythema [dermatitis] ab igne (L59.0)
malignant hyperpyrexia due to anesthesia (T88.3)
radiation-related disorders of the skin and subcutaneous tissue (L55-L59)
Excludes2: burns (T20-T31)
sunburn (L55.-)
sweat disorder due to heat (L74-L75)
S - sequela
T67.0
T67.1
T67.2
T67.3
T67.4
T67.5
T67.6
T67.7
T67.8
T67.9
T76
Heatstroke and sunstroke
Heat apoplexy
Heat pyrexia
Siriasis
Thermoplegia
Use additional code(s) to identify any associated complications of heatstroke, such as:
coma and stupor (R40.-)
systemic inflammatory response syndrome (R65.1-)
Heat syncope
Heat collapse
Heat cramp
Heat exhaustion, anhydrotic
Heat prostration due to water depletion
Excludes1: heat exhaustion due to salt depletion (T67.4)
Heat exhaustion due to salt depletion
Heat prostration due to salt (and water) depletion
Heat exhaustion, unspecified
Heat prostration NOS
Heat fatigue, transient
Heat edema
Other effects of heat and light
Effect of heat and light, unspecified
Adult and child abuse, neglect and other maltreatment, suspected
Use additional code, if applicable, to identify any associated current injury
Excludes1: adult and child maltreatment, confirmed (T74.-)
suspected abuse and maltreatment in pregnancy (O9A.3-, O9A.4-, O9A.5-)
suspected adult physical and sexual abuse, ruled out (Z04.71)
suspected child physical and sexual abuse, ruled out (Z04.72)
S - sequela
27
T76.0
T76.1
T76.2
T76.3
T76.9
T84
Neglect or abandonment, suspected
T76.01 Adult neglect or abandonment, suspected
T76.02 Child neglect or abandonment, suspected
Physical abuse, suspected
T76.11 Adult physical abuse, suspected
T76.12 Child physical abuse, suspected
Sexual abuse, suspected
Rape, suspected
Sexual abuse, suspected
Excludes1: alleged abuse, ruled out (Z04.7)
T76.21 Adult sexual abuse, suspected
T76.22 Child sexual abuse, suspected
Psychological abuse, suspected
T76.31 Adult psychological abuse, suspected
T76.32 Child psychological abuse, suspected
Unspecified maltreatment, suspected
T76.91 Unspecified adult maltreatment, suspected
T76.92 Unspecified child maltreatment, suspected
Complications of internal orthopedic prosthetic devices, implants and grafts
Excludes2: failure and rejection of transplanted organs and tissues (T86.-)
fracture of bone following insertion of orthopedic implant, joint prosthesis or bone
plate (M96.6)
S - sequela
T84.0
Mechanical complication of internal joint prosthesis
T84.01 Broken internal joint prosthesis
Breakage (fracture) of prosthetic joint
Broken prosthetic joint implant
Excludes1: periprosthetic joint implant fracture (T84.04)
T84.010 Broken internal right hip prosthesis
T84.011 Broken internal left hip prosthesis
T84.012 Broken internal right knee prosthesis
T84.013 Broken internal left knee prosthesis
T84.018 Broken internal joint prosthesis, other site
Use additional code to identify the joint (Z96.6-)
T84.019 Broken internal joint prosthesis, unspecified site
T84.02 Dislocation of internal joint prosthesis
Instability of internal joint prosthesis
Subluxation of internal joint prosthesis
T84.020 Dislocation of internal right hip prosthesis
T84.021 Dislocation of internal left hip prosthesis
T84.022 Instability of internal right knee prosthesis
T84.023 Instability of internal left knee prosthesis
T84.028 Dislocation of other internal joint prosthesis
T84.029 Dislocation of unspecified internal joint prosthesis
T84.03 Mechanical loosening of internal prosthetic joint
Aseptic loosening of prosthetic joint
T84.030 Mechanical loosening of internal right hip prosthetic joint
T84.031 Mechanical loosening of internal left hip prosthetic joint
T84.032 Mechanical loosening of internal right knee prosthetic joint
T84.033 Mechanical loosening of internal left knee prosthetic joint
T84.038 Mechanical loosening of other internal prosthetic joint
28
T84.039 Mechanical loosening of unspecified internal prosthetic joint
T84.04 Periprosthetic fracture around internal prosthetic joint
Excludes2: breakage (fracture) of prosthetic joint (T84.01)
T84.040 Periprosthetic fracture around internal prosthetic right hip joint
T84.041 Periprosthetic fracture around internal prosthetic left hip joint
T84.042 Periprosthetic fracture around internal prosthetic right knee joint
T84.043 Periprosthetic fracture around internal prosthetic left knee joint
T84.048 Periprosthetic fracture around other internal prosthetic joint
Accidents (V00-X58)
Transport accidents (V00-V99)
Note:
This section is structured in 12 groups. Those relating to land transport accidents (V01- V89) reflect the
victim's mode of transport and are subdivided to identify the victim's 'counterpart' or the type of event. The
vehicle of which the injured person is an occupant is identified in the first two characters since it is seen
as the most important factor to identify for prevention purposes. A transport accident is one in which the
vehicle involved must be moving or running or in use for transport purposes at the time of the accident.
Use additional code to identify: Airbag injury (W22.1)
Type of street or road (Y92.4-)
Use of cellular telephone and other electronic equipment at the time of
the transport accident (Y93.C-)
Excludes1: agricultural vehicles in stationary use or maintenance (W31.-)
assault by crashing of motor vehicle (Y03.-)
automobile or motor cycle in stationary use or maintenance- code to type of accident
crashing of motor vehicle, undetermined intent (Y32)
intentional self-harm by crashing of motor vehicle (X82)
Excludes2: transport accidents due to cataclysm (X34-X38)
Note:
Definitions of transport vehicles:
(a) A transport accident is any accident involving a device designed primarily for, or used at the
time primarily for, conveying persons or good from one place to another.
(b) A public highway [traffic way] or street is the entire width between property lines (or other
boundary lines) of land open to the public as a matter of right or custom for purposes of
moving persons or property from one place to another. A roadway is that part of the public
highway designed, improved and customarily used for vehicular traffic.
(c) A traffic accident is any vehicle accident occurring on the public highway [i.e. originating on,
terminating on, or involving a vehicle partially on the highway]. A vehicle accident is assumed
to have occurred on the public highway unless another place is specified, except in the case
of accidents involving only off-road motor vehicles, which are classified as nontraffic accidents
unless the contrary is stated.
(d) A nontraffic accident is any vehicle accident that occurs entirely in any place other than a
public highway.
(e) A pedestrian is any person involved in an accident who was not at the time of the accident
riding in or on a motor vehicle, railway train, streetcar or animal-drawn or other vehicle, or on a
pedal cycle or animal. This includes, a person changing a tire or working on a parked car. It
also includes the use of a pedestrian conveyance such as a baby carriage, ice-skates, roller
skates, a skateboard, nonmotorized or motorized wheelchair, motorized mobility scooter, or
nonmotorized scooter.
(f) A driver is an occupant of a transport vehicle who is operating or intending to operate it.
(g) A passenger is any occupant of a transport vehicle other than the driver, except a person
traveling on the outside of the vehicle.
(h) A person on the outside of a vehicle is any person being transported by a vehicle but not
occupying the space normally reserved for the driver or passengers, or the space intended for
29
the transport of property. This includes the body, bumper, fender, roof, running board or step
of a vehicle.
(i) A pedal cycle is any land transport vehicle operated solely by nonmotorized pedals including a
bicycle or tricycle.
(j) A pedal cyclist is any person riding a pedal cycle or in a sidecar or trailer attached to a pedal cycle.
(k) A motorcycle is a two-wheeled motor vehicle with one or two riding saddles and sometimes with a third
wheel for the support of a sidecar. The sidecar is considered part of the motorcycle.
(l) A motorcycle rider is any person riding a motorcycle or in a sidecar or trailer attached to the
motorcycle.
(m) A three-wheeled motor vehicle is a motorized tricycle designed primarily for on-road use. This
includes a motor-driven tricycle, a motorized rickshaw, or a three-wheeled motor car.
(n) A car [automobile] is a four-wheeled motor vehicle designed primarily for carrying up to 7
persons. A trailer being towed by the car is considered part of the car.
(o) A pick-up truck or van is a four or six-wheeled motor vehicle designed for carrying passengers
as well as property or cargo weighing less than the local limit for classification as a heavy
goods vehicle, and not requiring a special driver's license. This includes a minivan and a
sport-utility vehicle (SUV).
(p) A heavy transport vehicle is a motor vehicle designed primarily for carrying property, meeting
local criteria for classification as a heavy goods vehicle in terms of weight and requiring a
special driver's license.
(q) A bus (coach) is a motor vehicle designed or adapted primarily for carrying more than 10
passengers, and requiring a special driver's license.
(r) A railway train or railway vehicle is any device, with or without freight or passenger cars couple
to it, designed for traffic on a railway track. This includes subterranean (subways) or elevated
trains.
(s) A streetcar is a device designed and used primarily for transporting passengers within a
municipality, running on rails, usually subject to normal traffic control signals, and operated
principally on a right-of-way that forms part of the roadway. This includes a tram or trolley that
runs on rails. A trailer being towed by a streetcar is considered part of the streetcar.
(t) A special vehicle mainly used on industrial premises is a motor vehicle designed primarily for
use within the buildings and premises of industrial or commercial establishments. This includes
battery-powered trucks, forklifts, coal-cars in a coal mine, logging cars and trucks used in
mines or quarries.
(u) A special vehicle mainly used in agriculture is a motor vehicle designed specifically for use in
farming and agriculture (horticulture), to work the land, tend and harvest crops and transport
materials on the farm. This includes harvesters, farm machinery and tractor and trailers.
(v) A special construction vehicle is a motor vehicle designed specifically for use on construction
and demolition sites. This includes bulldozers, diggers, earth levellers, dump trucks. backhoes,
front-end loaders, pavers, and mechanical shovels.
(w) A special all-terrain vehicle is a motor vehicle of special design to enable it to negotiate over
rough or soft terrain, snow or sand. This includes snow mobiles, All-terrain vehicles (ATV), and
dune buggies. It does not include passenger vehicle designated as Sport Utility Vehicles
(SUV).
(w) A watercraft is any device designed for transporting passengers or goods on water. This
includes motor or sailboats, ships, and hovercraft.
(x) An aircraft is any device for transporting passengers or goods in the air. This includes hot-air
balloons, gliders, helicopters and airplanes.
(y) A military vehicle is any motorized vehicle operating on a public roadway owned by the military
and being operated by a member of the military.
Pedestrian injured in transport accident (V00-V09)
Includes: person changing tire on transport vehicle
person examining engine of vehicle broken down in (on side of) road
Excludes1: fall due to non-transport collision with other person (W03)
pedestrian on foot falling (slipping) on ice and snow (W00.-)
struck or bumped by another person (W51)
30
V00
Pedestrian conveyance accident
Use additional place of occurrence and activity external cause codes, if known (Y92.-, Y93.)
Excludes1: collision with another person without fall (W51)
fall due to person on foot colliding with another person on foot (W03)
fall from non-moving wheelchair, nonmotorized scooter and motorized mobility
scooter without collision(W05.-)
pedestrian (conveyance) collision with other land transport vehicle (V01-V09)
pedestrian on foot falling (slipping) on ice and snow (W00.-)
The appropriate 7th character is to be added to each code from category V00
S - sequela
V00.0 Pedestrian on foot injured in collision with pedestrian conveyance
V00.01 Pedestrian on foot injured in collision with roller-skater
V00.02 Pedestrian on foot injured in collision with skateboarder
V00.09 Pedestrian on foot injured in collision with other pedestrian conveyance
V00.1 Rolling-type pedestrian conveyance accident
Excludes1: accident with babystroller (V00.82-)
accident with wheelchair (powered) (V00.81-)
accident with motorized mobility scooter (V00.83-)
V00.11 In-line roller-skate accident
V00.111 Fall from in-line roller-skates
V00.112 In-line roller-skater colliding with stationary object
V00.118 Other in-line roller-skate accident
Excludes1: roller-skater collision with other land transport vehicle (V01V09 with 5thcharacter 1)
V00.12 Non-in- line roller-skate accident
V00.121 Fall from non-in-line roller-skates
V00.122 Non-in-line roller-skater colliding with stationary object
V00.128 Other non-in-line roller-skating accident
Excludes1: roller-skater collision with other land transport vehicle (V01th
V09 with 5 character 1)
V00.13 Skateboard accident
V00.131 Fall from skateboard
V00.132 Skateboarder colliding with stationary object
V00.138 Other skateboard accident
Excludes1: skateboarder collision with other land transport vehicle
th
(V01-V09 with 5 character 2)
V00.14 Scooter (nonmotorized) accident
Excludes1: Motor scooter accident (V20-V29)
V00.141 Fall from scooter (nonmotorized)
V00.142 Scooter (nonmotorized) colliding with stationary object
V00.148 Other scooter (nonmotorized) accident
Excludes1: scooter (nonmotorized) collision with other land transport
th
vehicle (V01-V09 with 5 character 9)
V00.15 Heelies accident
Rolling shoe
Wheeled shoe
Wheelies accident
V00.151 Fall from heelies
V00.152 Heelies colliding with stationary object
V00.158 Other heelies accident
V00.18 Accident on other rolling-type pedestrian conveyance
V00.181 Fall from other rolling-type pedestrian conveyance
V00.182 Pedestrian on other rolling-type pedestrian conveyance colliding with
stationary object
V00.188 Other accident on other rolling-type pedestrian conveyance
31
V00.2 Gliding-type pedestrian conveyance accident
V00.21 Ice-skates accident
V00.211 Fall from ice-skates
V00.212 Ice-skater colliding with stationary object
V00.218 Other ice-skates accident
Excludes1: ice-skater collision with other land transport vehicle (V01th
V09 with 5 digit 9)
V00.22 Sled accident
V00.221 Fall from sled
V00.222 Sledder colliding with stationary object
V00.228 Other sled accident
Excludes1: sled collision with other land transport vehicle (V01-V09
th
with 5 digit 9)
V00.28 Other gliding-type pedestrian conveyance accident
V00.281 Fall from other gliding-type pedestrian conveyance
V00.282 Pedestrian on other gliding-type pedestrian conveyance colliding with
stationary object
V00.288 Other accident on other gliding-type pedestrian conveyance
Excludes1: gliding-type pedestrian conveyance collision with other
th
land transport vehicle (V01-V09 with 5 digit 9)
W00
Fall due to ice and snow
Includes: pedestrian on foot falling (slipping) on ice and snow
Excludes1: fall on (from) ice and snow involving pedestrian conveyance (V00.-)
fall from stairs and steps not due to ice and snow (W10.-)
The appropriate 7th character is to be added to each code from category W00
S - sequela
W00.0
W00.1
W00.2
W00.9
W01
Fall on same level due to ice and snow
Fall from stairs and steps due to ice and snow
Other fall from one level to another due to ice and snow
Unspecified fall due to ice and snow
Fall on same level from slipping, tripping and stumbling
Includes: fall on moving sidewalk
Excludes1: fall due to bumping (striking) against object (W18.0-)
fall in shower or bathtub (W18.2-)
fall on same level NOS (W18.30)
fall on same level from slipping, tripping and stumbling due to ice or snow (W00.0)
fall off or from toilet (W18.1-)
slipping, tripping and stumbling NOS (W18.40)
slipping, tripping and stumbling without falling (W18.4-)
The appropriate 7th character is to be added to each code from category W01
S - sequela
W01.0 Fall on same level from slipping, tripping and stumbling without subsequent striking
against object
Falling over animal
32
W01.1 Fall on same level from slipping, tripping and stumbling with subsequent striking against
object
W01.10 Fall on same level from slipping, tripping and stumbling with subsequent striking
against unspecified object
against sharp object
W01.110 Fall on same level from slipping, tripping and stumbling with
subsequent striking against sharp glass
subsequent striking against power tool or machine
subsequent striking against other sharp object
subsequent striking against unspecified sharp object
against other object
subsequent striking against furniture
subsequent striking against other object
X11
Contact with hot tap-water
Includes: contact with boiling tap-water
contact with boiling water NOS
Excludes1: contact with water heated on stove (X12)
The appropriate 7th character is to be added to each code from category X11
S - sequela
X11.0 Contact with hot water in bath or tub
Excludes1: contact with running hot water in bath or tub (X11.1)
X11.1 Contact with running hot water
Contact with hot water running out of hose
Contact with hot water running out of tap
X11.8 Contact with other hot tap-water
Contact with hot water in bucket
Contact with hot tap-water NOS
X37
Cataclysmic storm
S - sequela
X37.0 Hurricane
Storm surge
Typhoon
X37.1 Tornado
Cyclone
Twister
X37.2 Blizzard (snow)(ice)
X37.3 Dust storm
X37.4 Tidalwave
X37.41 Tidal wave due to earthquake or volcanic eruption
Tidal wave NOS
Tsunami
33
X37.42 Tidal wave due to storm
X37.43 Tidal wave due to landslide
X37.8 Other cataclysmic storms
Cloudburst
Torrential rain
Excludes2: flood (X38)
X37.9 Unspecified cataclysmic storm
Storm NOS
Excludes1: collapse of dam or man-made structure causing earth movement (X39.0)
X38
Flood
Flood arising from remote storm
Flood of cataclysmic nature arising from melting snow
Flood resulting directly from storm
Excludes1: collapse of dam or man-made structure causing earth movement (X39.0)
tidal wave NOS (X37.41)
tidal wave caused by storm (X37.2)
The appropriate 7th character is to be added to code X38
S – sequela
X78
Intentional self-harm by sharp object
S - sequela
X78.0
X78.1
X78.2
X78.8
X78.9
Y04
Intentional self-harm by sharp glass
Intentional self-harm by knife
Intentional self-harm by sword or dagger
Intentional self-harm by other sharp object
Intentional self-harm by unspecified sharp object
Assault by bodily force
Excludes1: assault by:
submersion (X92.-)
use of weapon (X93-X95, X99, Y00)
The appropriate 7th character is to be added to each code from category Y04
S - sequela
Y04.0
Y04.1
Y04.2
Y04.8
Y36
Assault by unarmed brawl or fight
Assault by human bite
Assault by strike against or bumped into by another person
Assault by other bodily force
Assault by bodily force NOS
Operations of war
Includes: injuries to military personnel and civilians caused by war, civil insurrection, and
peacekeeping missions
Excludes1: injury to military personnel occurring during peacetime military operations (Y37.-)
military vehicles involved in transport accidents with non-military vehicle during
peacetime (V09.01,V09.21, V19.81, V29.81, V39.81, V49.81, V59.81, V69.81,
V79.81)
34
S - sequela
Y36.3 War operations involving fires, conflagrations and hot substances
War operations involving smoke, fumes, and heat from fires, conflagrations and hot
substances
Excludes1: war operations involving fires and conflagrations aboard military aircraft
(Y36.1-)
war operations involving fires and conflagrations aboard military watercraft
(Y36.0-)
war operations involving fires and conflagrations caused indirectly by
conventional weapons(Y36.2-)
war operations involving fires and thermal effects of nuclear weapons
(Y36.53-)
Y36.30 War operations involving unspecified fire, conflagration and hot substance
Y36.300 War operations involving unspecified fire, conflagration and hot
substance, military personnel
Y36.301 War operations involving unspecified fire, conflagration and hot
substance, civilian
Y36.31 War operations involving gasoline bomb
War operations involving incendiary bomb
War operations involving petrol bomb
Y36.310 War operations involving gasoline bomb, military personnel
Y36.311 War operations involving gasoline bomb, civilian
Y36.32 War operations involving incendiary bullet
Y36.320 War operations involving incendiary bullet, military personnel
Y36.321 War operations involving incendiary bullet, civilian
Y36.33 War operations involving flamethrower
Y36.330 War operations involving flamethrower, military personnel
Y36.331 War operations involving flamethrower, civilian
Y36.39 War operations involving other fires, conflagrations and hot substances
Y36.390 War operations involving other fires, conflagrations and hot substances,
military personnel
Y36.391 War operations involving other fires, conflagrations and hot substances,
civilian
Y38
Terrorism
These codes are for use to identify injuries resulting from the unlawful use of force or violence
against persons or property to intimidate or coerce a Government, the civilian population, or any
segment thereof, in furtherance of political or social objective
Use additional code for place of occurrence (Y92.-)
S - sequela
Y38.6 Terrorism involving biological weapons
Terrorism involving anthrax
Terrorism involving cholera
Terrorism involving smallpox
Y38.6X Terrorism involving biological weapons
Y38.6X1 Terrorism involving biological weapons, public safety official injured
Y38.6X2 Terrorism involving biological weapons, civilian injured
Y38.6X3 Terrorism involving biological weapons, terrorist injured
35
Complications of medical and surgical care (Y62-Y84)
Includes: complications of medical devices
surgical and medical procedures as the cause of abnormal reaction of the patient, or of later
complication, without mention of misadventure at the time of the procedure
Misadventures to patients during surgical and medical care (Y62-Y69)
Excludes2: breakdown or malfunctioning of medical device (during procedure) (after implantation)
(ongoing use) (Y70-Y82)
surgical and medical procedures as the cause of abnormal reaction of the patient, without
mention of misadventure at the time of the procedure (Y83-Y84)
Y62
Failure of sterile precautions during surgical and medical care
Y62.0
Y62.1
Y62.2
Y62.3
Y62.4
Y62.5
Y62.6
Y62.8
Y62.9
Y76
Failure of sterile precautions during surgical operation
Failure of sterile precautions during infusion or transfusion
Failure of sterile precautions during kidney dialysis and other perfusion
Failure of sterile precautions during injection or immunization
Failure of sterile precautions during endoscopic examination
Failure of sterile precautions during heart catheterization
Failure of sterile precautions during aspiration, puncture and other catheterization
Failure of sterile precautions during other surgical and medical care
Failure of sterile precautions during unspecified surgical and medical care
Obstetric and gynecological devices associated with adverse incidents
Y76.0 Diagnostic and monitoring obstetric and gynecological devices associated with adverse
incidents
Y76.1 Therapeutic (nonsurgical) and rehabilitative obstetric and gynecological devices
associated with adverse incidents
Y76.2 Prosthetic and other implants, materials and accessory obstetric and gynecological
devices associated with adverse incidents
Y76.3 Surgical instruments, materials and obstetric and gynecological devices (including
sutures) associated with adverse incidents
Y76.8 Miscellaneous obstetric and gynecological devices associated with adverse incidents, not
Supplementary factors related to causes of morbidity classified elsewhere (Y90-Y99)
Note:
These categories may be used to provide supplementary information concerning causes of
morbidity. They are not to be used for single-condition coding.
Y92
Place of occurrence of the external cause
The following category is for use, when relevant, to identify the place of occurrence of the
external cause. Use in conjunction with an activity code.
Place of occurrence should be recorded only at the initial encounter for treatment
Y92.1 Institutional (nonprivate) residence as the place of occurrence of the external cause
Y92.12 Nursing home as the place of occurrence of the external cause
Home for the sick as the place of occurrence of the external cause
Hospice as the place of occurrence of the external cause
Y92.120 Kitchen in nursing home as the place of occurrence of the external
cause
Y92.121 Bathroom in nursing home as the place of occurrence of the external
cause
36
Y92.122 Bedroom in nursing home as the place of occurrence of the external
cause
Y92.123 Driveway of nursing home as the place of occurrence of the external
cause
Y92.124 Garage of nursing home as the place of occurrence of the external
cause
Y92.125 Swimming-pool of nursing home as the place of occurrence of the
external cause
Y92.126 Garden or yard of nursing home as the place of occurrence of the
external cause
Y92.128 Other place in nursing home as the place of occurrence of the external
cause
Y92.129 Unspecified place in nursing home as the place of occurrence of the
external cause
Y92.3 Sports and athletics area as the place of occurrence of the external cause
Y92.31 Athletic court as the place of occurrence of the external cause
Excludes1: tennis court in private home or garden (Y92.09)
Y92.310 Basketball court as the place of occurrence of the external cause
Y92.311 Squash court as the place of occurrence of the external cause
Y92.312 Tennis court as the place of occurrence of the external cause
Y92.318 Other athletic court as the place of occurrence of the external cause
Y92.32 Athletic field as the place of occurrence of the external cause
Y92.320 Baseball field as the place of occurrence of the external cause
Y92.321 Football field as the place of occurrence of the external cause
Y92.322 Soccer field as the place of occurrence of the external cause
Y92.328 Other athletic field as the place of occurrence of the external cause
Cricket field as the place of occurrence of the external cause
Hockey field as the place of occurrence of the external cause
Y92.33 Skating rink as the place of occurrence of the external cause
Y92.330 Ice skating rink (indoor) (outdoor) as the place of occurrence of the
external cause
Y92.331 Roller skating rink as the place of occurrence of the external cause
Y92.34 Swimming pool (public) as the place of occurrence of the external cause
Excludes1: swimming pool in private home or garden (Y92.016)
Y92.39 Other specified sports and athletic area as the place of occurrence of the
external cause
Golf-course as the place of occurrence of the external cause
Gymnasium as the place of occurrence of the external cause
Riding-school as the place of occurrence of the external cause
Stadium as the place of occurrence of the external cause
Y93
Activity codes
Note: Category Y93 is provided for use to indicate the activity of the person seeking healthcare
for an injury or health condition, such as a heart attack while shoveling snow, which resulted from,
or was contributed to, by the activity. These codes are appropriate for use for both acute injuries,
such as those from chapter 19, and conditions that are due to the long-term, cumulative effects of
an activity, such as those from chapter 13. They are also appropriate for use with external cause
codes for cause and intent if identifying the activity provides additional information on the event.
These codes should be used in conjunction with codes for external cause status (Y99) and place
of occurrence (Y92).
Y93.0 Activities involving walking and running
Excludes1: activity, walking an animal (Y93.K1)
activity, walking or running on a treadmill (Y93.A1)
Y93.01 Activity, walking, marching and hiking
Activity, walking, marching and hiking on level or elevated terrain
Excludes1: activity, mountain climbing (Y93.31)
Y93.02 Activity, running
37
Y93.H Activities involving exterior property and land maintenance, building and construction
Y93.H1 Activity, digging, shoveling and raking
Activity, dirt digging
Activity, raking leaves
Activity, snow shoveling
Y93.H2 Activity, gardening and landscaping
Activity, pruning, trimming shrubs, weeding
Y93.H3 Activity, building and construction
Y93.H9 Activity, other involving exterior property and land maintenance, building and
construction
Z00
Encounter for general examination without complaint, suspected or reported diagnosis
Excludes1: encounter for examination for administrative purposes (Z02.-)
Excludes2: encounter for pre-procedural examinations (Z01.81-)
special screening examinations (Z11-Z13)
Z00.0
Encounter for general adult medical examination
Encounter for adult periodic examination (annual) (physical) and any associated
laboratory and radiologic examinations
Excludes1: encounter for examination of sign or symptom- code to sign or symptom
general health check-up of infant or child (Z00.12.-)
Z00.1
Z00.00 Encounter for general adult medical examination without abnormal findings
Encounter for adult health check-up NOS
Z00.01 Encounter for general adult medical examination with abnormal findings
Use additional code to identify abnormal findings
Encounter for newborn, infant and child health examinations
Z00.11 Newborn health examination
Health check for child under 29 days old
Use additional code to identify any abnormal findings
Excludes1: health check for child over 28 days old (Z00.12-)
Z00.110 Health examination for newborn under 8 days old
Health check for newborn under 8 days old
Z00.111 Health examination for newborn 8 to 28 days old
Health check for newborn 8 to 28 days old
Newborn weight check
Z00.12 Encounter for routine child health examination
Encounter for development testing of infant or child
Health check (routine) for child over 28 days old
Excludes1: health check for child under 29 days old (Z0.11-)
health supervision of foundling or other healthy infant or child
(Z76.1-Z76.2)
newborn health examination (Z00.11-)
Z00.121 Encounter for routine child health examination with abnormal findings
Use additional code to identify abnormal findings
Z00.129 Encounter for routine child health examination without abnormal findings
Encounter for routine child health examination NOS
Estrogen receptor status (Z17)
Z17
Estrogen receptor status
Code first malignant neoplasm of breast (C50.-)
Z17.0
Z17.1
Estrogen receptor positive status [ER+]
Estrogen receptor negative status [ER-]
38
Persons with potential health hazards related to communicable diseases (Z20-Z28)
Z20
Contact with and (suspected) exposure to communicable diseases
Excludes1: carrier of infectious disease (Z22.-)
diagnosed current infectious or parasitic disease -see Alphabetic Index
Excludes2: personal history of infectious and parasitic diseases (Z86.1-)
Z20.0
Z20.1
Z20.2
Z20.3
Z20.4
Z20.5
Z20.6
Z32
Encounter for pregnancy test and childbirth and childcare instruction
Z32.0
Z32.2
Z32.3
Z43
Contact with and (suspected) exposure to intestinal infectious diseases
Z20.01 Contact with and (suspected) exposure to intestinal infectious diseases due to
Escherichia coli (E. coli)
Z20.09 Contact with and (suspected) exposure to other intestinal infectious diseases
Contact with and (suspected) exposure to tuberculosis
Contact with and (suspected) exposure to infections with a predominantly sexual mode of
transmission
Contact with and (suspected) exposure to rabies
Contact with and (suspected) exposure to rubella
Contact with and (suspected) exposure to viral hepatitis
Contact with and (suspected) exposure to human immunodeficiency virus [HIV]
Excludes1: asymptomatic human immunodeficiency virus [HIV]
HIV infection status (Z21)
Encounter for pregnancy test
Z32.00 Encounter for pregnancy test, result unknown
Encounter for pregnancy test NOS
Z32.01 Encounter for pregnancy test, result positive
Z32.02 Encounter for pregnancy test, result negative
Encounter for prenatal or postpartum childcare instruction
Encounter for attention to artificial openings
Includes: closure of artificial openings
passage of sounds or bougies through artificial openings
reforming artificial openings
removal of catheter from artificial openings
toilet or cleansing of artificial openings
Excludes1: artificial opening status only, without need for care (Z93.-)
complications of external stoma (J95.0-, K94.-, N99.5-)
Excludes2: fitting and adjustment of prosthetic and other devices (Z44-Z46)
Z43.0
Z43.1
Z43.2
Z43.3
Z43.4
Z43.5
Z43.6
Z43.7
Z43.8
Z43.9
Encounter for attention to tracheostomy
Encounter for attention to gastrostomy
Encounter for attention to ileostomy
Encounter for attention to colostomy
Encounter for attention to other artificial openings of digestive tract
Encounter for attention to cystostomy
Encounter for attention to other artificial openings of urinary tract
Encounter for attention to nephrostomy
Encounter for attention to ureterostomy
Encounter for attention to urethrostomy
Encounter for attention to artificial vagina
Encounter for attention to other artificial openings
Encounter for attention to unspecified artificial opening
39
Z48
Encounter for other postprocedural aftercare
Excludes1: encounter for follow-up examination after completed treatment (Z08-Z09)
Excludes2: encounter for attention to artificial openings (Z43.-)
encounter for fitting and adjustment of prosthetic and other devices (Z44-Z46)
Z48.0
Z72
Encounter for attention to dressings, sutures and drains
Excludes1: encounter for planned postprocedural wound closure (Z48.1)
Z48.00 Encounter for change or removal of nonsurgical wound dressing
Encounter for change or removal of wound dressing NOS
Z48.01 Encounter for change or removal of surgical wound dressing
Z48.02 Encounter for removal of sutures
Encounter for removal of staples
Z48.03 Encounter for change or removal of drains
Problems related to lifestyle
Excludes2: problems related to life-management difficulty (Z73.-)
problems related to socioeconomic and psychosocial circumstances (Z55-Z65)
Z72.0
Z72.3
Z72.4
Z72.5
Z72.6
Z72.8
Tobacco use
Tobacco use NOS
Excludes1: history of tobacco dependence (Z87.891)
nicotine dependence (F17.2-)
tobacco dependence (F17.2-)
tobacco use during pregnancy (O99.33-)
Lack of physical exercise
Inappropriate diet and eating habits
Excludes1: behavioral eating disorders of infancy or childhood (F98.2.- F98.3)
eating disorders (F50.-)
lack of adequate food (Z59.4)
malnutrition and other nutritional deficiencies (E40-E64)
High risk sexual behavior
Promiscuity
Excludes1: paraphilias (F65)
Z72.51 High risk heterosexual behavior
Z72.52 High risk homosexual behavior
Z72.53 High risk bisexual behavior
Gambling and betting
Excludes1: compulsive or pathological gambling (F63.0)
Other problems related to lifestyle
Z72.81 Antisocial behavior
Excludes1: conduct disorders (F91.-)
Z72.810 Child and adolescent antisocial behavior
Antisocial behavior (child) (adolescent) without manifest psychiatric
disorder
Delinquency NOS
Group delinquency
Offenses in the context of gang membership
Stealing in company with others
Truancy from school
Z72.811 Adult antisocial behavior
Adult antisocial behavior without manifest psychiatric disorder
Z72.82 Problems related to sleep
Z72.820 Sleep deprivation
Lack of adequate sleep
Excludes1: insomnia (G47.0-)
Z72.821 Inadequate sleep hygiene
Bad sleep habits
Irregular sleep habits
40
Z72.9
Z88
Unhealthy sleep wake schedule
Excludes1: insomnia (F51.0-, G47.0-)
Z72.89 Other problems related to lifestyle
Self-damaging behavior
Problem related to lifestyle, unspecified
Allergy status to drugs, medicaments and biological substances
Excludes2: Allergy status, other than to drugs and biological substances (Z91.0-)
Z88.0
Z88.1
Z88.2
Z88.3
Z88.4
Z88.5
Z88.6
Z88.7
Z88.8
Z88.9
Z98
Allergy status to penicillin
Allergy status to other antibiotic agents status
Allergy status to sulfonamides status
Allergy status to other anti-infective agents status
Allergy status to anesthetic agent status
Allergy status to narcotic agent status
Allergy status to analgesic agent status
Allergy status to serum and vaccine status
Allergy status to other drugs, medicaments and biological substances status
Allergy status to unspecified drugs, medicaments and biological substances status
Other postprocedural states
Excludes2: aftercare (Z43-Z49, Z51)
follow-up medical care (Z08-Z09)
postprocedural complication - see Alphabetical Index
Z98.5
Sterilization status
Excludes1: female infertility (N97.-)
male infertility (N46.-)
Z98.51 Tubal ligation status
Z98.52 Vasectomy status
41
ATTACHMENT B: ICD-10-CM ALPHABETIC INDEX TO DISEASES and INJURIESExamples
for actual coding.
Abuse
adult - see Maltreatment, adult
as reason for
couple seeking advice(including offender) Z63.0
Aftercare - see also Care Z51.89
involving
removal of
drains Z48.03
dressings(nonsurgical) Z48.00
staples Z48.02
surgical dressings Z48.01
sutures Z48.02
Allergy, allergic (reaction) (to) T78.40
air-borne substance NEC(rhinitis) J30.89
anaphylactic reaction or shock T78.2
angioneurotic edema T78.3
animal(dander) (epidermal) (hair) (rhinitis) J30.81
bee sting(anaphylactic shock) - see Toxicity, venom, arthropod, bee
biological - see Allergy, drug
dander(animal) (rhinitis) J30.81
dandruff(rhinitis) J30.81
dental restorative material(existing) K08.55
dermatitis - see Dermatitis, contact, allergic
diathesis - see History, allergy
drug, medicament & biological(any) (external) (internal) T78.40
correct substance properly administered - see Table of drugs and chemicals, by drug, adverse effect
wrong substance given or taken NEC(by accident) - see Table of drugs and chemicals, by drug, poisoning
due to pollen J30.1
dust(house) (stock) (rhinitis) J30.89
with asthma - see Asthma, allergic extrinsic
eczema - see Dermatitis, contact, allergic
epidermal(animal) (rhinitis) J30.81
feathers(rhinitis) J30.89
food(any) (ingested) NEC T78.1
anaphylactic shock - see Shock, anaphylactic, due to food
dermatitis - see Dermatitis, due to, food
dietary counseling and surveillance Z71.3
in contact with skin L23.6
rhinitis J30.5
status(without reaction) Z91.018
eggs Z91.012
milk products Z91.011
peanuts Z91.010
42
seafood Z91.013
specified NEC Z91.018
grain J30.1
grass(hay fever) (pollen) J30.1
asthma - see Asthma, allergic extrinsic
hair(animal) (rhinitis) J30.81
history(of) - see History, allergy
horse serum - see Allergy, serum
inhalant(rhinitis) J30.89
pollen J30.1
kapok(rhinitis) J30.89
medicine - see Allergy, drug
milk protein K52.2
nasal, seasonal due to pollen J30.1
pollen(any) (hay fever) J30.1
primrose J30.1
primula J30.1
purpura D69.0
ragweed(hay fever) (pollen) J30.1
rose(pollen) J30.1
seasonal NEC J30.2
tree(any) (hay fever) (pollen) J30.1
upper respiratory J30.9
urticaria L50.0
vaccine - see Allergy, serum
Cleft (congenital) - see also Imperfect, closure
alveolar process M26.79
branchial (cyst) (persistent) Q18.2
cricoid cartilage, posterior Q31.8
lip (unilateral) Q36.9
with cleft palate Q37.9
hard Q37.1
with soft Q37.5
soft Q37.3
with hard Q37.5
bilateral Q36.0
with cleft palate Q37.8
hard Q37.0
with soft Q37.4
soft Q37.2
with hard Q37.4
median Q36.1
nose Q30.2
palate Q35.9
with cleft lip(unilateral) Q37.9
43
bilateral Q37.8
hard Q35.1
with
cleft lip (unilateral) Q37.1
bilateral Q37.0
soft Q35.5
with cleft lip (unilateral) Q37.5
bilateral Q37.4
medial Q35.5
soft Q35.3
with
cleft lip(unilateral) Q37.3
bilateral Q37.2
hard Q35.5
with cleft lip(unilateral) Q37.5
bilateral Q37.4
penis Q55.69
scrotum Q55.29
thyroid cartilage Q31.8
uvula Q35.7
Complication(s) (from) (of)
orthopedic - see also Disorder, soft tissue
device or implant T84.9
bone
device or implant - see Complication, bone, device NEC
graft - see Complication, graft, bone
breakdown T84.418
displacement T84.428
electronic bone stimulator - see Complications, electronic stimulator device, bone
embolism T84.81
fibrosis T84.82
fixation device - see Complication, fixation device, internal
hemorrhage T84.83
infection or inflammation T84.7
joint prosthesis - see Complication, joint prosthesis, internal
malfunction T84.418
malposition T84.428
mechanical NEC T84.498
muscle graft - see Complications, graft, muscle
obstruction T84.498
pain T84.84
perforation T84.498
protrusion T84.498
specified complication NEC T84.89
stenosis T84.85
tendon graft - see Complications, graft, tendon
thrombosis T84.86
44
Contusion (skin surface intact) T14.8
finger(s) S60.00
with damage to nail(matrix) S60.10
index S60.02with damage to nail S60.12little S60.05with damage to nail S60.15middle S60.03with damage to nail S60.13ring S60.04with damage to nail S60.14thumb - see Contusion, thumb
Cough (affected) (chronic) (epidemic) (nervous) R05
with hemorrhage - see Hemoptysis
bronchial R05
with grippe or influenza - see Influenza, with, respiratory manifestations NEC
functional F45.8
hysterical F45.8
laryngeal, spasmodic R05
psychogenic F45.8
smokers' J41.0
tea taster's B49
Dyspnea (nocturnal) (paroxysmal) R06.00
asthmatic(bronchial) J45.909
with
exacerbation(acute) J45.901
bronchitis J45.909
with
exacerbation(acute) J45.901
status asthmaticus J45.902
chronic J44.9
status asthmaticus J45.902
cardiac - see Failure, ventricular, left
cardiac - see Failure, ventricular, left
functional F45.8
hyperventilation R06.4
hysterical F45.8
newborn P28.89
orthopnea R06.01
psychogenic F45.8
shortness of breath R06.02
specified type NEC R06.09
Down syndrome Q90.9
meiotic nondisjunction Q90.0
mitotic nondisjunction Q90.1
mosaicism Q90.1
translocation Q90.2
45
Dysuria R30.0
psychogenic F45.8
Edema, edematous(infectious) (pitting) (toxic) R60.9
with nephritis - see Nephrosis
allergic T78.3
amputation stump(surgical) (sequelae (late effect)) T87.89
angioneurotic(allergic) (any site) (with urticaria) T78.3
hereditary D84.1
angiospastic I73.9
Berlin's(traumatic) S05.8Xbrain(cytotoxic) (vasogenic) G93.6
due to birth injury P11.0
newborn(anoxia or hypoxia) P52.4
birth injury P11.0
traumatic - see Injury, intracranial, cerebral edema
cardiac - see Failure, heart, congestive
cardiovascular - see Failure, heart, congestive
cerebral - see Edema, brain
cerebrospinal - see Edema, brain
cervix(uteri) (acute) N88.8
puerperal, postpartum O90.89
chronic hereditary Q82.0
circumscribed, acute T78.3
hereditary D84.1
conjunctiva H11.42cornea H18.2idiopathic H18.22secondary H18.23due to contact lens H18.21due to
lymphatic obstruction I89.0
salt retention E87.0
epiglottis - see Edema, glottis
essential, acute T78.3
hereditary D84.1
extremities, lower - see Edema, legs
eyelid NEC H02.849
left H02.846
lower H02.845
upper H02.844
right H02.843
lower H02.842
upper H02.841
Examination (for) (following) (general) (of) (routine) Z00.00with abnormal findings Z00.01
abuse, physical(alleged), ruled out
adult Z04.71
child Z04.72
46
adolescent(development state) Z00.3
alleged rape or sexual assault(victim), ruled out
adult Z04.41
child Z04.42
allergy Z01.82
annual(adult) (periodic) (physical) Z00.00
with abnormal findings Z00.01
gynecological Z01.419
antibody response Z01.84
blood - see Examination, laboratory
blood pressure Z01.30
cancer staging - see Neoplasm, malignant, by site
cervical Papanicolaou smear Z12.4
as part of routine gynecological examination Z01.419
child(over 28 days old) Z00.129
under 28 days old - see Newborn, examination
clinical research control or normal comparison(control) (participant) Z00.6
contraceptive(drug) maintenance (routine) Z30.8
device(intrauterine) Z30.431
dental Z01.20
developmental - see Examination, child
donor(potential) Z00.5
ear Z01.10
with abnormal findings NEC Z01.118
eye Z01.00
following
accident NEC Z04.3
transport Z04.1
work Z04.2
assault, alleged, ruled out
adult Z04.71
child Z04.72
motor vehicle accident Z04.1
treatment(for) Z09
combined NEC Z09
fracture Z09
malignant neoplasm Z08
mental disorder Z09
specified condition NEC Z09
follow-up(routine) (following) Z09
chemotherapy NEC Z09
47
fracture Z09
postpartum Z39.2
psychotherapy Z09
radiotherapy NEC Z09
surgery NEC Z09
gynecological Z01.419
for contraceptive maintenance Z30.8
health - see Examination, medical
hearing Z01.10
with abnormal findings NEC Z01.118
following failed hearing screening Z01.110
immunity status testing Z01.84
laboratory(as part of a general medical examination) Z00.00
preprocedural Z01.812
lactating mother Z39.1
medical(adult) (for) (of) Z00.00
administrative purpose only Z02.9
admission to
armed forces Z02.3
old age home Z02.2
prison Z02.89
residential institution Z02.2
school Z02.0
following illness or medical treatment Z02.0
summer camp Z02.89
adoption Z02.82
blood alcohol or drug level Z02.83
camp(summer) Z02.89
clinical research, normal subject(control) (participant) Z00.6
control subject in clinical research(normal comparison) (participant) Z00.6
donor(potential) Z00.5
driving license Z02.4
general(adult) Z00.00
immigration Z02.89
insurance purposes Z02.6
marriage Z02.89
medicolegal reasons NEC Z04.8
naturalization Z02.89
participation in sport Z02.5
paternity testing Z02.81
population survey Z00.8
48
pre-employment Z02.1
pre-operative - see Examination, pre-procedural
pre-procedural
cardiovascular Z01.810
respiratory Z01.811
preschool children
for admission to school Z02.0
prisoners
for entrance into prison Z02.89
recruitment for armed forces Z02.3
specified NEC Z00.8
sport competition Z02.5
medicolegal reason NEC Z04.8
newborn - see Newborn, examination
pelvic(annual) (periodic) Z01.419
period of rapid growth in childhood Z00.2
periodic(adult) (annual) (routine) Z00.00
physical(adult) - see also Examination, medical Z00.00
sports Z02.5
postpartum
immediately after delivery Z39.0
routine follow-up Z39.2
prenatal(normal pregnancy) - see also Pregnancy, normal Z34.9pre-chemotherapy(antineoplastic) Z01.818
pre-procedural(pre-operative)
cardiovascular Z01.810
laboratory Z01.812
respiratory Z01.811
prior to chemotherapy(antineoplastic) Z01.818
psychiatric NEC Z00.8
follow-up not needing further care Z09
requested by authority Z04.6
radiological(as part of a general medical examination) Z00.00
repeat cervical smear to confirm findings of recent normal smear following initial abnormal smear Z01.42
skin(hypersensitivity) Z01.82
special - see also Examination, by type Z01.89
specified type NEC Z01.89
specified type or reason NEC Z04.8
teeth Z01.20
urine - see Examination, laboratory
vision Z01.00
49
Foreign body
esophagus T18.108
causing
injury NEC T18.108
food(bone) (seed) T18.128
gastric contents(vomitus) T18.118
specified type NEC T18.198
tracheal compression T18.100
pharynx T17.208
causing
asphyxiation T17.200
injury NEC T17.208
Fracture, traumatic (abduction) (adduction) (separation) - see also Fracture, pathological T14.8
ulna(shaft) S52.20bent bone S52.28coronoid process - see Fracture, ulna, upper end, coronoid process
distal end - see Fracture, ulna, lower end
following insertion of implant, prosthesis or plate M96.63head S52.00lower end S52.60physeal S59.00Salter-Harris
Type I S59.01Type II S59.02Type III S59.03Type IV S59.04specified NEC S59.09specified NEC S52.69styloid process(displaced) S52.61nondisplaced S52.61torus S52.62proximal end - see Fracture, ulna, upper end
shaft S52.20comminuted(displaced) S52.25nondisplaced S52.25greenstick S52.21Monteggia's - see Monteggia's fracture
oblique(displaced) S52.23-
50
nondisplaced S52.23segmental(displaced) S52.26nondisplaced S52.26specified NEC S52.29spiral(displaced) S52.24nondisplaced S52.24transverse(displaced) S52.22nondisplaced S52.22upper end S52.00coronoid process(displaced) S52.04nondisplaced S52.04olecranon process(displaced) S52.02with intraarticular extension S52.03with intraarticular extension S52.03nondisplaced S52.02with intraarticular extension S52.03with intraarticular extension S52.03with intraarticular extension S52.03with intraarticular extension S52.03specified NEC S52.09torus S52.01Heart beat
abnormality R00.9
specified NEC R00.8
awareness R00.2
rapid R00.0
slow R00.1
Heat(effects) T67.9
apoplexy T67.0
burn - see also Burn L55.9
collapse T67.1
cramps T67.2
dermatitis or eczema L59.0
edema T67.7
erythema - code by site under Burn, first degree
excessive T67.9
specified effect NEC T67.8
exhaustion T67.5
anhydrotic T67.3
due to
salt(and water) depletion T67.4
water depletion T67.3
with salt depletion T67.4
fatigue(transient) T67.6
fever T67.0
hyperpyrexia T67.0
prickly L74.0
prostration - see Heat, exhaustion
51
pyrexia T67.0
rash L74.0
specified effect NEC T67.8
stroke T67.0
sunburn - see Sunburn
syncope T67.1
Hematuria R31.9
due to sulphonamide, sulfonamide - see Table of drugs and chemicals, by drug
benign(familial) (of childhood) - see also Hematuria, idiopathic
essential microscopic R31.1
endemic - see also Schistosomiasis B65.0
gross R31.0
idiopathic N02.9
with glomerular lesion
crescentic(diffuse) glomerulonephritis N02.7
dense deposit disease N02.6
endocapillary proliferative glomerulonephritis N02.4
focal and segmental hyalinosis or sclerosis N02.1
membranoproliferative(diffuse) N02.5
membranous(diffuse) N02.2
mesangial proliferative(diffuse) N02.3
mesangiocapillary(diffuse) N02.5
minor abnormality N02.0
proliferative NEC N02.8
specified pathology NEC N02.8
intermittent - see Hematuria, idiopathic
malarial B50.8
microscopic NEC R31.2
benign essential R31.1
paroxysmal - see also Hematuria, idiopathic
nocturnal D59.5
persistent - see Hematuria, idiopathic
recurrent - see Hematuria, idiopathic
tropical - see also Schistosomiasis B65.0
tuberculous A18.13
Hydrops R60.9
abdominis R18.8
articulorum intermittens - see Hydrarthrosis, intermittent
cardiac - see Failure, heart, congecausing obstructed labor(mother) O66.3
endolymphatic H81.0fetal - see Pregnancy, complicated by, hydrops, fetalis
fetalis P83.2
due to
ABO isoimmunization P56.0
alpha thalassemia D56.0
hemolytic disease P56.90
specified NEC P56.99
isoimmunization(ABO) (Rh) P56.0
52
other specified nonhemolytic disease NEC P83.2
Rh incompatibility P56.0
during pregnancy - see Pregnancy, complicated by, hydrops, fetalis
Hypertension, hypertensive (accelerated) (benign) (essential) (idiopathic) (malignant) (systemic) I10
with
heart involvement(conditions in I51.4 - I51.9 due to hypertension) - see Hypertension, heart
kidney involvement - see Hypertension, kidney
benign, intracranial G93.2
borderline R03.0
cardiorenal(disease) I13.10
with heart failure I13.0
with stage 1 through stage 4 chronic kidney disease I13.0
with stage 5 or end stage renal disease I13.2
without heart failure I13.10
with stage 1 through stage 4 chronic kidney disease I13.10
with stage 5 or end stage renal disease I13.11
cardiovascular
disease(arteriosclerotic) (sclerotic) - see Hypertension, heart
renal(disease) - see Hypertension, cardiorenal
chronic venous - see Hypertension, venous (chronic)
complicating
childbirth(labor) O10.92
with
heart disease O10.12
with renal disease O10.32
renal disease O10.22
with heart disease O10.32
essential O10.02
secondary O10.42
pregnancy O16.with edema - see also Pre-eclampsia O14.9gestational(pregnancy induced) (transient) (without proteinuria) O13.with proteinuria O14.9mild pre-eclampsia O14.0moderate pre-eclampsia O14.0severe pre-eclampsia O14.1with hemolysis, elevated liver enzymes and low platelet count(HELLP) O14.2pre-existing O10.91with
heart disease O10.11with renal disease O10.31pre-eclampsia O11.renal disease O10.21with heart disease O10.31essential O10.01secondary O10.41puerperium O10.93
with
53
heart disease O10.13
with renal disease O10.33
renal disease O10.23
with heart disease O10.33
essential O10.03
secondary O10.43
due to
endocrine disorders I15.2
pheochromocytoma I15.2
renal disorders NEC I15.1
arterial I15.0
renovascular disorders I15.0
specified disease NEC I15.8
encephalopathy I67.4
gestational(without significant proteinuria) (pregnancy-induced) (transient) O13.with significant proteinuria - see Pre-eclampsia
Goldblatt's I70.1
heart(disease) (conditions in I51.4-I51.9 due to hypertension) I11.9
with
heart failure(congestive) I11.0
kidney disease(chronic) - see Hypertension, cardiorenal
intracranial(benign) G93.2
kidney I12.9
with
heart disease - see Hypertension, cardiorenal
stage 5 chronic kidney disease(CKD) or end stage renal disease (ESRD) I12.0
stage 1 through stage 4 chronic kidney disease I12.9
lesser circulation I27.0
newborn P29.2
pulmonary(persistent) P29.3
ocular H40.05pancreatic duct - code to underlying condition
with chronic pancreatitis K86.1
portal(due to chronic liver disease) (idiopathic) K76.6
gastropathy K31.89
in(due to) schistosomiasis (bilharziasis) B65.9
postoperative I97.3
psychogenic F45.8
pulmonary(artery) (secondary) NEC I27.2
with
cor pulmonale(chronic) I27.2
acute I26.09
right heart ventricular strain/failure I27.2
acute I26.09
of newborn(persistent) P29.3
primary(idiopathic) I27.0
renal - see Hypertension, kidney
renovascular I15.0
secondary NEC I15.9
54
due to
endocrine disorders I15.2
pheochromocytoma I15.2
renal disorders NEC I15.1
arterial I15.0
renovascular disorders I15.0
specified NEC I15.8
venous(chronic)
due to
deep vein thrombosis - see Syndrome, postthrombotic
idiopathic I87.309
with
inflammation I87.32with ulcer I87.33specified complication NEC I87.39ulcer I87.31with inflammation I87.33asymptomatic I87.30Injury - see also specified injury type T14.90
eye S05.9avulsion S05.7ball - see Injury, eyeball
conjunctiva S05.0cornea
abrasion S05.0laceration S05.3with prolapse S05.2lacrimal apparatus S05.8Xorbit penetration S05.4specified site NEC S05.8Xhead S09.90
with loss of consciousness S06.9specified NEC S09.8
Injury - see also specified injury type T14.90
Jaundice (yellow) R17
newborn P59.9
due to or associated with
ABO
antibodies P55.1
incompatibility, maternal/fetal P55.1
isoimmunization P55.1
absence or deficiency of enzyme system for bilirubin conjugation(congenital) P59.8
bleeding P58.1
breast milk inhibitors to conjugation P59.3
associated with preterm delivery P59.0
bruising P58.0
55
Crigler-Najjar syndrome E80.5
delayed conjugation P59.8
associated with preterm delivery P59.0
drugs or toxins
given to newborn P58.42
transmitted from mother P58.41
excessive hemolysis P58.9
due to
bleeding P58.1
bruising P58.0
drugs or toxins
given to newborn P58.42
transmitted from mother P58.41
infection P58.2
polycythemia P58.3
swallowed maternal blood P58.5
specified type NEC P58.8
galactosemia E74.21
Gilbert syndrome E80.4
hemolytic disease P55.9
ABO isoimmunization P55.1
Rh isoimmunization P55.0
specified NEC P55.8
hepatocellular damage P59.20
hereditary hemolytic anemia P58.8
hypothyroidism, congenital E03.1
incompatibility, maternal/fetal NOS P55.9
infection P58.2
inspissated bile syndrome P59.1
isoimmunization NOS P55.9
mucoviscidosis E84.9
polycythemia P58.3
preterm delivery P59.0
Rh
antibodies P55.0
incompatibility, maternal/fetal P55.0
isoimmunization P55.0
specified cause NEC P59.8
swallowed maternal blood P58.5
spherocytosis(congenital) D58.0
neonatal - see Jaundice, newborn
nonhemolytic congenital familial(Gilbert) E80.4
nuclear, newborn - see also Kernicterus of newborn P57.9
obstructive - see also Obstruction, bile duct K83.1
post-immunization - see Hepatitis, viral, type, B
post-transfusion - see Hepatitis, viral, type, B
regurgitation - see also Obstruction, bile duct K83.1
serum(homologous) (prophylactic) (therapeutic) - see Hepatitis, viral, type, B
56
spirochetal(hemorrhagic) A27.0
symptomatic R17
newborn P59.9
Maltreatment
adult
abandonment
confirmed T74.01
suspected T76.01
confirmed T74.91
history of Z91.419
neglect
confirmed T74.01
suspected T76.01
physical abuse
confirmed T74.11
suspected T76.11
psychological abuse
confirmed T74.31
suspected T76.31
history of Z91.411
sexual abuse
confirmed T74.21
suspected T76.21
suspected T76.91
child
abandonment
confirmed T74.02
suspected T76.02
confirmed T74.92
history of - see History, personal (of), abuse
neglect
confirmed T74.02
suspected T76.02
physical abuse
confirmed T74.12
suspected T76.12
psychological abuse
confirmed T74.32
suspected T76.32
sexual abuse
confirmed T74.22
suspected T76.22
suspected T76.92
personal history of Z91.89
57
Murmur (cardiac) (heart) (organic) R01.1
abdominal R19.15
aortic(valve) - see Endocarditis, aortic
benign R01.0
diastolic - see Endocarditis
Flint I35.1
functional R01.0
Graham Steell I37.1
innocent R01.0
mitral(valve) - see Insufficiency, mitral
nonorganic R01.0
presystolic, mitral - see Insufficiency, mitral
pulmonic(valve) I37.8
systolic(valvular) - see Endocarditis
tricuspid(valve) I07.9
valvular - see Endocarditis
Nausea (without vomiting) R11.0
with vomiting R11.2
gravidarum - see Hyperemesis, gravidarum
marina T75.3
navalis T75.3
Newborn(infant) (liveborn) (singleton) Z38.2
acne L70.4
abstinence syndrome P96.1
affected by(suspected to be)
abnormalities of membranes P02.9
specified NEC P02.8
abruptio placenta P02.1
amino-acid metabolic disorder, transitory P74.8
amniocentesis(while in utero) P00.6
amnionitis P02.7
apparent life threatening event(ALTE) R68.13
bleeding(into)
cerebral cortex P52.22
germinal matrix P52.0
ventricles P52.1
breech delivery P03.0
cardiac arrest P29.81
cardiomyopathy I42.8
congenital I42.4
cerebral ischemia P91.0
Cesarean delivery P03.4
chemotherapy agents P04.1
chorioamnionitis P02.7
cocaine(crack) P04.41
complications of labor and delivery P03.9
58
compression of umbilical cord NEC P02.5
contracted pelvis P03.1
delivery P03.9
Cesarean P03.4
forceps P03.2
vacuum extractor P03.3
environmental chemicals P04.6
entanglement(knot) in umbilical cord P02.5
fetal(intrauterine)
growth retardation P05.9
malnutrition not light or small for gestational age P05.2
forceps delivery P03.2
heart rate abnormalities
bradycardia P29.12
intrauterine P03.819
before onset of labor P03.810
during labor P03.811
tachycardia P29.11
hemorrhage(antepartum) P02.1
cerebellar(nontraumatic) P52.6
intracerebral(nontraumatic) P52.4
intracranial(nontraumatic) P52.9
specified NEC P52.8
intraventricular(nontraumatic) P52.3
grade 1 P52.0
grade 2 P52.1
grade 3 P52.21
grade 4 P52.22
posterior fossa(nontraumatic) P52.6
subarachnoid(nontraumatic) P52.5
subependymal P52.0
with intracerebral extension P52.22
with intraventricular extension P52.1
with enlargment of ventricles P52.21
without intraventricular extension P52.0
hypoxic ischemic encephalopathy [HIE] P91.60
mild P91.61
moderate P91.62
severe P91.63
induction of labor P03.89
intestinal perforation P78.0
intrauterine(fetal) blood loss P50.9
due to(from)
cut end of co-twin cord P50.5
hemorrhage into
co-twin P50.3
maternal circulation P50.4
placenta P50.2
ruptured cord blood P50.1
59
vasa previa P50.0
specified NEC P50.8
intrauterine(fetal) hemorrhage P50.9
intrauterine(in utero) procedure P96.5
malpresentation(malposition) NEC P03.1
maternal(complication of) (use of)
alcohol P04.3
analgesia(maternal) P04.0
anesthesia(maternal) P04.0
blood loss P02.1
circulatory disease P00.3
condition P00.9
delivery P03.9
Cesarean P03.4
forceps P03.2
vacuum extractor P03.3
diabetes mellitus(pre-existing) P70.1
disorder P00.9
drugs(addictive) (illegal) NEC P04.49
ectopic pregnancy P01.4
gestational diabetes P70.0
hemorrhage P02.1
hypertensive disorder P00.0
incompetent cervix P01.0
infectious disease P00.2
injury P00.5
labor and delivery P03.9
malpresentation before labor P01.7
maternal death P01.6
medical procedure P00.7
medication P04.1
multiple pregnancy P01.5
nutritional disorder P00.4
oligohydramnios P01.2
parasitic disease P00.2
periodontal disease P00.81
placenta previa P02.0
polyhydramnios P01.3
precipitate delivery P03.5
pregnancy P01.9
specified P01.8
premature rupture of membranes P01.1
renal disease P00.1
respiratory disease P00.3
surgical procedure P00.6
urinary tract disease P00.1
uterine contraction(abnormal) P03.6
60
meconium peritonitis P78.0
medication(legal) (maternal use) (prescribed) P04.1
membrane abnormalities P02.9
specified NEC P02.8
membranitis P02.7
methamphetamine(s) P04.49
mixed metabolic and respiratory acidosis P84
neonatal abstinence syndrome P96.1
noxious substances transmitted via placenta or breast milk P04.9
specified NEC P04.8
nutritional supplements P04.5
placenta previa P02.0
placental
abnormality(functional) (morphological) P02.20
dysfunction P02.29
infarction P02.29
insufficiency P02.29
separation NEC P02.1
transfusion syndromes P02.3
placentitis P02.7
precipitate delivery P03.5
prolapsed cord P02.4
respiratory arrest P28.81
slow intrauterine growth P05.9
tobacco P04.2
twin to twin transplacental transfusion P02.3
umbilical cord(tightly) around neck P02.5
umbilical cord condition P02.60
short cord P02.69
uterine contractions(abnormal) P03.6
vasa previa P02.69
from intrauterine blood loss P50.0
apnea P28.3
primary P28.3
obstructive P28.4
specified P28.4
born in hospital Z38.00
by cesarean Z38.01
born outside hospital Z38.1
breast buds P96.89
breast engorgement P83.4
check-up - see Newborn, examination
convulsion P90
dehydration P74.1
examination
8 to 28 days old Z00.111
under 8 days old Z00.110
61
fever P81.9
environmentally-induced P81.0
hyperbilirubinemia P59.9
of prematurity P59.0
hypernatremia P74.2
hyponatremia P74.2
infection P39.9
candidal P37.5
specified NEC P39.8
urinary tract P39.3
jaundice P59.8
due to
breast milk inhibitor P59.3
hepatocellular damage P59.20
preterm delivery P59.0
of prematurity P59.0
specified NEC P59.8
late metabolic acidosis P74.0
mastitis P39.0
infective P39.0
noninfective P83.4
multiple born NEC Z38.8
by cesarean Z38.69
omphalitis P38.9
with mild hemorrhage P38.1
without hemorrhage P38.9
post-term P08.21
prolonged gestation(over 42 completed weeks) P08.22
quadruplet Z38.8
by cesarean Z38.64
quintuplet Z38.8
by cesarean Z38.66
seizure P90
sepsis(congenital) P36.9
due to
anaerobes NEC P36.5
Escherichia coli P36.4
Staphylococcus P36.30
aureus P36.2
Streptococcus P36.10
group B P36.0
62
specified NEC P36.8
triplet Z38.8
by cesarean Z38.62
twin Z38.5
by cesarean Z38.31
vomiting P92.09
bilious P92.01
weight check Z00.111
Proteinuria R80.9
Bence Jones R80.3
complicating pregnancy - see Proteinuria, gestational
gestational O12.1with edema O12.2idiopathic R80.0
isolated R80.0
with glomerular lesion N06.9
dense deposit disease N06.6
diffuse
crescentic glomerulonephritis N06.7
endocapillary proliferative glomerulonephritis N06.4
mesangiocapillary glomerulonephritis N06.5
focal and segmental hyalinosis or sclerosis N06.1
membranous(diffuse) N06.2
mesangial proliferative(diffuse) N06.3
minimal change N06.0
specified pathology NEC N06.8
orthostatic R80.2
with glomerular lesion - see Proteinuria, isolated, with glomerular lesion
persistent R80.1
postural R80.2
pre-eclamptic - see Pre-eclampsia
specified type NEC R80.8
Spina bifida (aperta) Q05.9
with hydrocephalus NEC Q05.4
cervical Q05.5
with hydrocephalus Q05.0
dorsal Q05.6
lumbar Q05.7
lumbosacral Q05.7
63
occulta Q76.0
sacral Q05.8
thoracic Q05.6
thoracolumbar Q05.6
Trisomy (syndrome) Q92.9
autosomes Q92.9
chromosome specified NEC Q92.8
partial Q92.2
due to unbalanced translocation Q92.5
whole(nonsex chromosome)
mosaicism Q92.1
specified NEC Q92.8
due to
dicentrics - see Extra, marker chromosomes
extra rings - see Extra, marker chromosomes
isochromosomes - see Extra, marker chromosomes
specified NEC Q92.8
whole chromosome Q92.9
mosaicism Q92.1
partial Q92.9
specified NEC Q92.8
13(partial) Q91.7
mosaicism Q91.5
translocation Q91.6
18(partial) Q91.3
mosaicism Q91.1
translocation Q91.2
20 Q92.8
21(partial) Q90.9
mosaicism Q90.1
translocation Q90.2
Vomiting R11.10
with nausea R11.2
asphyxia - see Foreign body, by site, causing asphyxia, gastric contents
64
bilious(cause unknown) R11.14
in newborn P92.01
following gastro-intestinal surgery K91.0
blood - see Hematemesis
causing asphyxia, choking, or suffocation - see Foreign body, by site
cyclical G43.A0
with refractory migraine G43.A1
intractable G43.A1
not intractable G43.A0
psychogenic F50.8
without refractory migraine G43.A0
fecal matter R11.13
following gastrointestinal surgery K91.0
psychogenic F50.8
functional K31.89
hysterical F50.8
nervous F50.8
neurotic F50.8
newborn NEC P92.09
bilious P92.01
periodic R11.10
psychogenic F50.8
projectile R11.12
psychogenic F50.8
uremic - see Uremia
without nausea R11.11
Suicide, suicidal (attempted) T14.91
by poisoning - see Table of drugs and chemicals
history of(personal) Z91.5
in family Z81.8
ideation - see Ideation, suicidal
risk
meaning personal history of attempted suicide Z91.5
meaning suicidal ideation - see Ideation, suicidal
tendencies
meaning personal history of attempted suicide Z91.5
meaning suicidal ideation - see Ideation, suicidal
trauma - see nature of injury by sit
Tachycardia R00.0
atrial(paroxysmal) I47.1
auricular I47.1
AV nodal re-entry(re-entrant) I47.1
Junctional (paroxysmal) I47.1
newborn P29.11
nodal(paroxysmal) I47.1
non-paroxysmal AV nodal I45.89
paroxysmal(sustained) (nonsustained) I47.9
with sinus bradycardia I49.5
65
atrial(PAT) I47.1
atrioventricular(AV) (re-entrant) I47.1
psychogenic F54
junctional I47.1
ectopic I47.1
nodal I47.1
psychogenic(atrial) (supraventricular) (ventricular) F54
supraventricular(sustained) I47.1
psychogenic F54
ventricular I47.2
psychogenic F54
psychogenic F45.8
sick sinus I49.5
sinoauricular NOS R00.0
paroxysmal I47.1
sinus [sinusal] NOS R00.0
paroxysmal I47.1
supraventricular I47.1
ventricular(paroxysmal) (sustained) I47.2
psychogenic F54
66
ATTACHMENT C: 2012 ICD-10-CM EXTERNAL CAUSE INDEX – Examples
for actual coding.
Burn, burned, burning(accidental) (by) (from) (on)
acid NEC - see Table of drugs and chemicals
bed linen - see Exposure, fire, uncontrolled, in building, bed
blowtorch X08.8
with ignition of clothing NEC X06.2
nightwear X05
bonfire, campfire(controlled) - see also Exposure, fire, controlled, not in building
uncontrolled - see Exposure, fire, uncontrolled, not in building
candle X08.8
nightwear X05
caustic liquid, substance(external) (internal) NEC - see Table of drugs and chemicals
chemical(external) (internal) - see also Table of drugs and chemicals
in war operations - see War operations. fire
cigar(s) or cigarette(s) X08.8
nightwear X05
clothes, clothing NEC(from controlled fire) X06.2
with conflagration - see Exposure, fire, uncontrolled, building
not in building or structure - see Exposure, fire, uncontrolled, not in building
cooker(hot) X15.8
stated as undetermined whether accidental or intentional Y27.3
suicide(attempt) X77.3
electric blanket X16
engine(hot) X17
fire, flames - see Exposure, fire
flare, Very pistol - see Discharge, firearm NEC
heat
from appliance(electrical) (household) X15.8
cooker X15.8
hotplate X15.2
kettle X15.8
light bulb X15.8
saucepan X15.3
skillet X15.3
stove X15.0
toaster X15.1
in local application or packing during medical or surgical procedure Y63.5
heating
appliance, radiator or pipe X16
homicide(attempt) - see Assault, burning
hot
67
air X14.1
cooker X15.8
drink X10.0
engine X17
fat X10.2
fluid NEC X12
food X10.1
gases X14.1
heating appliance X16
household appliance NEC X15.8
kettle X15.8
liquid NEC X12
machinery X17
metal(molten) (liquid) NEC X18
object(not producing fire or flames) NEC X19
oil(cooking) X10.2
pipe(s) X16
radiator X16
saucepan(glass) (metal) X15.3
stove(kitchen) X15.0
substance NEC X19
caustic or corrosive NEC - see Table of drugs and chemicals
toaster X15.1
tool X17
vapor X13.1
water(tap) - see Contact, with, hot, tap water
hotplate X15.2
ignition - see Ignition
in war operations - see War operations, fire
inflicted by other person X97
by hot objects, hot vapor, and steam - see Assault, burning, hot object
internal, from swallowed caustic, corrosive liquid, substance - see Table of drugs and chemicals
iron(hot) X15.8
kettle(hot) X15.8
lamp(flame) X08.8
nightwear X05
lighter(cigar) (cigarette) X08.8
nightwear X05
lightning
causing fire - see Exposure, fire
liquid(boiling) (hot) NEC X12
68
local application of externally applied substance in medical or surgical care Y63.5
on board watercraft
due to
accident to watercraft V91.09
powered craft V91.03
ferry boat V91.01
fishing boat V91.02
jet skis V91.03
liner V91.01
merchant ship V91.00
passenger ship V91.01
unpowered craft V91.08
canoe V91.05
inflatable V91.06
kayak V91.05
sailboat V91.04
surf-board V91.08
water skis V91.07
windsurfer V91.08
fire on board V93.09
ferry boat V93.01
fishing boat V93.02
jet skis V93.03
liner V93.01
powered craft NEC V93.03
sailboat V93.04
specified heat source NEC on board V93.19
ferry boat V93.11
fishing boat V93.12
jet skis V93.13
liner V93.11
powered craft NEC V93.13
sailboat V93.14
machinery(hot) X17
matches X08.8
nightwear X05
mattress - see Exposure, fire, uncontrolled, building, bed
medicament, externally applied Y63.5
metal(hot) (liquid) (molten) NEC X18
nightwear(nightclothes, nightdress, gown, pajamas, robe) X05
object(hot) NEC X19
69
pipe(hot) X16
smoking X08.8
nightwear X05
powder - see Powder burn
radiator(hot) X16
saucepan(hot) (glass) (metal) X15.3
self-inflicted X76
stated as undetermined whether accidental or intentional Y26
steam X13.1
pipe X16
stove(hot) (kitchen) X15.0
substance(hot) NEC X19
boiling X12
molten(metal) X18
suicide(attempt) NEC X76
hot
household appliance X77.3
object X77.9
therapeutic misadventure
heat in local application or packing during medical or surgical procedure Y63.5
overdose of radiation Y63.2
toaster(hot) X15.1
tool(hot) X17
Complication(delayed) of or following (medical or surgical procedure) Y84.9
with misadventure - see Misadventure
amputation of limb(s) Y83.5
anastomosis(arteriovenous) (blood vessel) (gastrojejunal) (tendon) (natural or artificial material) Y83.2
aspiration(of fluid) Y84.4
tissue Y84.8
biopsy Y84.8
blood
sampling Y84.7
transfusion
procedure Y84.8
70
bypass Y83.2
catheterization(urinary) Y84.6
cardiac Y84.0
colostomy Y83.3
cystostomy Y83.3
dialysis(kidney) Y84.1
drug - see Table of drugs and chemicals
due to misadventure - see Misadventure
duodenostomy Y83.3
electroshock therapy Y84.3
external stoma, creation of Y83.3
formation of external stoma Y83.3
gastrostomy Y83.3
graft Y83.2
hypothermia(medically-induced) Y84.8
implant, implantation(of)
artificial
internal device(cardiac pacemaker) (electrodes in brain) (heart valve prosthesis) (orthopedic)
Y83.1
material or tissue(for anastomosis or bypass) Y83.2
with creation of external stoma Y83.3
natural tissues(for anastomosis or bypass) Y83.2
with creation of external stoma Y83.3
infusion
procedure Y84.8
injection - see Table of drugs and chemicals
procedure Y84.8
insertion of gastric or duodenal sound Y84.5
insulin-shock therapy Y84.3
paracentesis(abdominal) (thoracic) (aspirative) Y84.4
procedures other than surgical operation - see Complication of or following, by type of procedure
radiological procedure or therapy Y84.2
removal of organ(partial) (total) NEC Y83.6
sampling
blood Y84.7
fluid NEC Y84.4
tissue Y84.8
shock therapy Y84.3
surgical operation NEC - see also Complication of or following, by type of operation Y83.9
reconstructive NEC Y83.4
with
anastomosis, bypass or graft Y83.2
formation of external stoma Y83.3
specified NEC Y83.8
transfusion - see also Table of drugs and chemicals
procedure Y84.8
transplant, transplantation(heart) (kidney) (liver) (whole organ, any) Y83.0
partial organ Y83.4
71
ureterostomy Y83.3
vaccination - see also Table of drugs and chemicals
procedure Y84.8
Fall, falling(accidental) W19
building W20.1
burning(uncontrolled fire) X00.3
down
embankment W17.81
escalator W10.0
hill W17.81
ladder W11
ramp W10.2
stairs, steps W10.9
due to
bumping against
object W18.00
sharp glass W18.02
specified NEC W18.09
sports equipment W18.01
person W03
due to ice or snow W00.0
on pedestrian conveyance - see Accident, transport, pedestrian, conveyance
collision with another person W03
involving pedestrian conveyance - see Accident, transport, pedestrian, conveyance
grocery cart tipping over W17.82
ice or snow W00.9
from one level to another W00.2
on stairs or steps W00.1
involving pedestrian conveyance - see Accident, transport, pedestrian, conveyance
on same level W00.0
slipping(on moving sidewalk) W01.0
with subsequent striking against object W01.10
furniture W01.190
sharp object W01.119
glass W01.110
power tool or machine W01.111
striking against
object W18.00
sharp glass W18.02
sports equipment W18.01
person W03
on pedestrian conveyance - see Accident, transport, pedestrian, conveyance
earth(with asphyxia or suffocation (by pressure)) - see Earth, falling
72
from, off, out of
aircraft NEC(with accident to aircraft NEC) V97.0
while boarding or alighting V97.1
balcony W13.0
bed W06
boat, ship, watercraft NEC(with drowning or submersion) - see Drowning, due to, fall
overboard
with hitting bottom or object V94.0
bridge W13.1
building W13.9
cavity W17.2
chair W07
cherry picker W17.89
cliff W15
dock W17.4
embankment W17.81
escalator W10.0
flagpole W13.8
furniture NEC W08
grocery cart W17.82
haystack W17.89
high place NEC W17.89
hole W17.2
incline W10.2
ladder W11
lifting device W17.89
machine, machinery - see also Contact, with, by type of machine
not in operation W17.89
manhole W17.1
mobile elevated work platform [MEWP] W17.89
motorized mobility scooter W05.2
one level to another NEC W17.89
intentional, purposeful, suicide(attempt) X80
pit W17.2
playground equipment W09.8
jungle gym W09.2
slide W09.0
swing W09.1
quarry W17.89
railing W13.9
ramp W10.2
roof W13.2
scaffolding W12
scooter(nonmotorized) W05.1
motorized mobility W05.2
73
sky lift W17.89
stairs, steps W10.9
curb W10.1
escalator W10.0
incline W10.2
ramp W10.2
sidewalk curb W10.1
specified NEC W10.8
stepladder W11
storm drain W17.1
streetcar NEC V82.6
with antecedent collision - see Accident, transport, streetcar occupant
structure NEC W13.8
table W08
toilet W18.11
with subsequent striking against object W18.12
train NEC V81.6
during derailment(without antecedent collision) V81.7
with antecedent collision - see Accident, transport, railway vehicle occupant
transport vehicle after collision - see Accident, transport, by type of vehicle, collision
tree W14
vehicle(in motion) NEC - see also Accident, transport V89.9
motor NEC - see also Accident, transport, occupant, by type of vehicle V87.8
stationary W17.89
while boarding or alighting B - see Accident, transport, by type of vehicle, while
boarding or alighting
viaduct W13.8
wall W13.8
watercraft - see also Drowning, due to, fall overboard
with hitting bottom or object V94.0
well W17.0
wheelchair, non-moving W05.0
powered - see Accident, transport, pedestrian, conveyance occupant, specified type
NEC
window W13.4
in, on
aircraft NEC V97.0
with accident to aircraft V97.0
bathtub(empty) W18.2
filled W16.212
causing drowning W16.211
escalator W10.0
incline W10.2
74
ladder W11
machine, machinery - see Contact, with, by type of machine
object, edged, pointed or sharp(with cut) - see Fall, by type
playground equipment W09.8
jungle gym W09.2
slide W09.0
swing W09.1
ramp W10.2
scaffolding W12
shower W18.2
causing drowning W16.211
staircase, stairs, steps W10.9
curb W10.1
escalator W10.0
incline W10.2
specified NEC W10.8
streetcar(without antecedent collision) V82.5
with antecedent collision - see Accident, transport, streetcar occupant
train(without antecedent collision) V81.5
during derailment(without antecedent collision) V81.7
transport vehicle after collision - see Accident, transport, by type of vehicle, collision
watercraft V93.39
due to
accident to craft V91.29
ferry boat V91.21
fishing boat V91.22
jet skis V91.23
liner V91.21
unpowered craft
canoe V91.25
inflatable V91.26
kayak V91.25
sailboat V91.24
ferry boat V93.31
fishing boat V93.32
jet skis V93.33
liner V93.31
75
unpowered craft V93.38
canoe V93.35
inflatable V93.36
kayak V93.35
sailboat V93.34
surf-board V93.38
windsurfer V93.38
Foreign body entering through skin W45.8
can lid W45.2
nail W45.0
paper W45.1
specified NEC W45.8
splinter W45.8
Forces of nature X39.8
avalanche X36.1
causing transport accident - see Accident, transport, by type of vehicle
blizzard X37.2
cataclysmic storm X37.9
with flood X38
blizzard X37.2
cloudburst X37.8
cyclone X37.1
dust storm X37.3
hurricane X37.0
specified storm NEC X37.8
storm surge X37.0
tornado X37.1
twister X37.1
typhoon X37.0
cloudburst X37.8
cold(natural) X31
cyclone X37.1
dam collapse causing earth movement X36.0
dust storm X37.3
earth movement X36.1
earthquake X34
caused by dam or structure collapse X36.0
earthquake X34
flood(caused by) X38
dam collapse X36.0
tidal wave B - see Forces of nature, tidal wave
heat(natural) X30
hurricane X37.0
landslide X36.1
lightning
causing fire - see Exposure, fire
76
mudslide X36.1
radiation(natural) X39.08
radon X39.01
radon X39.01
specified force NEC X39.8
storm surge X37.0
structure collapse causing earth movement X36.0
sunlight X32
tidal wave X37.41
due to
earthquake X37.41
landslide X37.43
storm X37.42
volcanic eruption X37.41
tornado X37.1
tsunami X37.41
twister X37.1
typhoon X37.0
volcanic eruption X35
Incident, adverse
device
anesthesiology Y70.8
accessory Y70.2
diagnostic Y70.0
miscellaneous Y70.8
monitoring Y70.0
prosthetic Y70.2
rehabilitative Y70.1
surgical Y70.3
therapeutic Y70.1
cardiovascular Y71.8
accessory Y71.2
diagnostic Y71.0
miscellaneous Y71.8
monitoring Y71.0
prosthetic Y71.2
surgical Y71.3
therapeutic Y71.1
gastroenterology Y73.8
accessory Y73.2
diagnostic Y73.0
miscellaneous Y73.8
monitoring Y73.0
prosthetic Y73.2
77
surgical Y73.3
therapeutic Y73.1
general
hospital Y74.8
accessory Y74.2
diagnostic Y74.0
miscellaneous Y74.8
monitoring Y74.0
prosthetic Y74.2
surgical Y74.3
therapeutic Y74.1
surgical Y81.8
accessory Y81.2
diagnostic Y81.0
miscellaneous Y81.8
monitoring Y81.0
prosthetic Y81.2
surgical Y81.3
therapeutic Y81.1
gynecological Y76.8
accessory Y76.2
diagnostic Y76.0
miscellaneous Y76.8
monitoring Y76.0
prosthetic Y76.2
surgical Y76.3
therapeutic Y76.1
Injury, injured(accidental(ly)) NOS X58
by, caused by, from
assault - see Assault
law-enforcing agent, police, in course of legal intervention - see Legal intervention
due to, in
civil insurrection - see War operations
fight - see also Assault, fight Y04.0
war operations - see War operations
homicide - see also Assault Y09
inflicted(by)
in course of arrest(attempted), suppression of disturbance, maintenance of order, by law-enforcing
agents - see Legal intervention
other person
stated as
accidental X58
intentional, homicide(attempt) - see Assault
undetermined whether accidental or intentional Y33
78
purposely(inflicted) by other person(s) - see Assault
self-inflicted X83.8
stated as accidental X58
specified cause NEC X58
undetermined whether accidental or intentional Y33
Run over(accidentally) (by)
animal(not being ridden) NEC W55.89
machinery - see Contact, with, by specified type of machine
transport vehicle NEC - see also Accident, transport V09.9
intentional homicide(attempt) Y03.0
motor NEC V09.20
intentional homicide(attempt) Y03.0
Status of external cause Y99.9
child assisting in compensated work for family Y99.8
civilian activity done for financial or other compensation Y99.0
civilian activity done for income or pay Y99.0
family member assisting in compensated work for other family member Y99.8
hobby not done for income Y99.8
leisure activity Y99.8
military activity Y99.1
off-duty activity of military personnel Y99.8
recreation or sport not for income or while a student Y99.8
specified NEC Y99.8
student activity Y99.8
volunteer activity Y99.2
Terrorism(involving) Y38.80
biological weapons Y38.6Xchemical weapons Y38.7Xconflagration Y38.3Xexplosion Y38.2Xdestruction of aircraft Y38.1Xmarine weapons Y38.0Xfire Y38.3Xfirearms Y38.4Xhot substances Y38.5Xnuclear weapons Y38.5Xspecified method NEC Y38.8XWalked into stationary object(any) W22.09
furniture W22.03
lamppost W22.02
wall W22.01
79
ATTACHMENT D: ICD-10-CM ALPHABETIC INDEX TO DISEASES and INJURIESExamples
for actual coding.
Drug
Poisoning
Accidental
Poisoning
Intentional
Poisoning
Assault
Poisoning
Undetermined
Adverse
Effect
Underdosing
Dacarbazine
T45.1X1
T45.1X2
T45.1X3
T45.1X4
T45.1X5
T45.1X6
Dactinomycin
T45.1X1
T45.1X2
T45.1X3
T45.1X4
T45.1X5
T45.1X6
DADPS
T37.1X1
T37.1X2
T37.1X3
T37.1X4
T37.1X5
T37.1X6
Dakin's solution
T49.0X1
T49.0X2
T49.0X3
T49.0X4
T49.0X5
T49.0X6
Dalapon(sodium)
T60.3X1
T60.3X2
T60.3X3
T60.3X4
Dalmane
T42.4X1
T42.4X2
T42.4X3
T42.4X4
T42.4X5
T42.4X6
Danazol
T38.6X1
T38.6X2
T38.6X3
T38.6X4
T38.6X5
T38.6X6
Danilone
T45.511
T45.512
T45.513
T45.514
T45.515
T45.516
Danthron
T47.2X1
T47.2X2
T47.2X3
T47.2X4
T47.2X5
T47.2X6
Dantrolene
T42.8X1
T42.8X2
T42.8X3
T42.8X4
T42.8X5
T42.8X6
Dantron
T47.2X1
T47.2X2
T47.2X3
T47.2X4
T47.2X5
T47.2X6
Daphne(gnidium) (mezereum)
T62.2X1
T62.2X2
T62.2X3
T62.2X4
berry
T62.1X1
T62.1X2
T62.1X3
T62.1X4
Dapsone
T37.1X1
T37.1X2
T37.1X3
T37.1X4
T37.1X5
T37.1X6
Daraprim
T37.2X1
T37.2X2
T37.2X3
T37.2X4
T37.2X5
T37.2X6
Darnel
T62.2X1
T62.2X2
T62.2X3
T62.2X4
Darvon
T39.8X1
T39.8X2
T39.8X3
T39.8X4
T39.8X5
T39.8X6
Daunomycin
T45.1X1
T45.1X2
T45.1X3
T45.1X4
T45.1X5
T45.1X6
Daunorubicin
T45.1X1
T45.1X2
T45.1X3
T45.1X4
T45.1X5
T45.1X6
DBI
T38.3X1
T38.3X2
T38.3X3
T38.3X4
T38.3X5
T38.3X6
D-Con
T60.91
T60.92
T60.93
T60.94
insecticide
T60.2X1
T60.2X2
T60.2X3
T60.2X4
rodenticide
T60.4X1
T60.4X2
T60.4X3
T60.4X4
T38.895
T38.896
T37.1X5
T37.1X6
DDAVP
T38.891
T38.892
T38.893
T38.894
DDE(bis(chlorophenyl)-dichloroethylene) T60.2X1
T60.2X2
T60.2X3
T60.2X4
DDS
T37.1X1
T37.1X2
T37.1X3
T37.1X4
DDT(dust)
T60.1X1
T60.1X2
T60.1X3
T60.1X4
Deadly nightshade
T62.2X1
T62.2X2
T62.2X3
T62.2X4
T62.1X1
T62.1X2
T62.1X3
T62.1X4
Deamino-D-arginine vasopressin
T38.891
T38.892
T38.893
T38.894
T38.895
T38.896
Deanol(aceglumate)
T50.991
T50.992
T50.993
T50.994
T50.995
T50.996
Debrisoquine
T46.5X1
T46.5X2
T46.5X3
T46.5X4
T46.5X5
T46.5X6
Decaborane
T57.8X1
T57.8X2
T57.8X3
T57.8X4
fumes
T59.891
T59.892
T59.893
T59.894
Decadron
T38.0X1
T38.0X2
T38.0X3
T38.0X4
T38.0X5
T38.0X6
ENT agent
T49.6X1
T49.6X2
T49.6X3
T49.6X4
T49.6X5
T49.6X6
ophthalmic preparation
T49.5X1
T49.5X2
T49.5X3
T49.5X4
T49.5X5
T49.5X6
topical NEC
T49.0X1
T49.0X2
T49.0X3
T49.0X4
T49.0X5
T49.0X6
Decahydronaphthalene
T52.8X1
T52.8X2
T52.8X3
T52.8X4
Decalin
T52.8X1
T52.8X2
T52.8X3
T52.8X4
Decamethonium(bromide)
T48.1X1
T48.1X2
T48.1X3
T48.1X4
T48.1X5
T48.1X6
berry
80
Poisoning
Accidental
Drug
Poisoning
Intentional
Poisoning
Assault
Poisoning
Undetermined
Adverse
Effect
Underdosing
Decholin
T47.5X1
T47.5X2
T47.5X3
T47.5X4
T47.5X5
T47.5X6
Declomycin
T36.4X1
T36.4X2
T36.4X3
T36.4X4
T36.4X5
T36.4X6
Decongestant, nasal(mucosa)
T48.5X1
T48.5X2
T48.5X3
T48.5X4
T48.5X5
T48.5X6
T48.5X1
T48.5X2
T48.5X3
T48.5X4
T48.5X5
T48.5X6
Deet
T60.8X1
T60.8X2
T60.8X3
T60.8X4
Deferoxamine
T45.8X1
T45.8X2
T45.8X3
T45.8X4
T45.8X5
T45.8X6
Deflazacort
T38.0X1
T38.0X2
T38.0X3
T38.0X4
T38.0X5
T38.0X6
Deglycyrrhizinized extract of licorice
T48.4X1
T48.4X2
T48.4X3
T48.4X4
T48.4X5
T48.4X6
Dehydrocholic acid
T47.5X1
T47.5X2
T47.5X3
T47.5X4
T47.5X5
T47.5X6
Dehydroemetine
T37.3X1
T37.3X2
T37.3X3
T37.3X4
T37.3X5
T37.3X6
Dekalin
T52.8X1
T52.8X2
T52.8X3
T52.8X4
Delalutin
T38.5X1
T38.5X2
T38.5X3
T38.5X4
T38.5X5
T38.5X6
Delorazepam
T42.4X1
T42.4X2
T42.4X3
T42.4X4
T42.4X5
T42.4X6
Delphinium
T62.2X1
T62.2X2
T62.2X3
T62.2X4
Deltamethrin
T60.1X1
T60.1X2
T60.1X3
T60.1X4
Deltasone
T38.0X1
T38.0X2
T38.0X3
T38.0X4
T38.0X5
T38.0X6
Deltra
T38.0X1
T38.0X2
T38.0X3
T38.0X4
T38.0X5
T38.0X6
Delvinal
T42.3X1
T42.3X2
T42.3X3
T42.3X4
T42.3X5
T42.3X6
Demecarium(bromide)
T49.5X1
T49.5X2
T49.5X3
T49.5X4
T49.5X5
T49.5X6
Demeclocycline
T36.4X1
T36.4X2
T36.4X3
T36.4X4
T36.4X5
T36.4X6
Demecolcine
T45.1X1
T45.1X2
T45.1X3
T45.1X4
T45.1X5
T45.1X6
Demegestone
T38.5X1
T38.5X2
T38.5X3
T38.5X4
T38.5X5
T38.5X6
Demelanizing agents
T49.8X1
T49.8X2
T49.8X3
T49.8X4
T49.8X5
T49.8X6
Demephion -O and -S
T60.0X1
T60.0X2
T60.0X3
T60.0X4
Demerol
T40.2X1
T40.2X2
T40.2X3
T40.2X4
T40.2X5
T40.2X6
Demethylchlortetracycline
T36.4X1
T36.4X2
T36.4X3
T36.4X4
T36.4X5
T36.4X6
Demethyltetracycline
T36.4X1
T36.4X2
T36.4X3
T36.4X4
T36.4X5
T36.4X6
Demeton -O and -S
T60.0X1
T60.0X2
T60.0X3
T60.0X4
Demulcent(external)
T49.3X1
T49.3X2
T49.3X3
T49.3X4
T49.3X5
T49.3X6
T49.3X1
T49.3X2
T49.3X3
T49.3X4
T49.3X5
T49.3X6
Demulen
T38.4X1
T38.4X2
T38.4X3
T38.4X4
T38.4X5
T38.4X6
Denatured alcohol
T51.0X1
T51.0X2
T51.0X3
T51.0X4
Dendrid
T49.5X1
T49.5X2
T49.5X3
T49.5X4
T49.5X5
T49.5X6
Dental drug, topical application NEC
T49.7X1
T49.7X2
T49.7X3
T49.7X4
T49.7X5
T49.7X6
Dentifrice
T49.7X1
T49.7X2
T49.7X3
T49.7X4
T49.7X5
T49.7X6
Deodorant spray(feminine hygiene)
T49.8X1
T49.8X2
T49.8X3
T49.8X4
T49.8X5
T49.8X6
Deoxycortone
T50.0X1
T50.0X2
T50.0X3
T50.0X4
T50.0X5
T50.0X6
Deoxyribonuclease(pancreatic)
T45.3X1
T45.3X2
T45.3X3
T45.3X4
T45.3X5
T45.3X6
Depilatory
T49.4X1
T49.4X2
T49.4X3
T49.4X4
T49.4X5
T49.4X6
Deprenalin
T42.8X1
T42.8X2
T42.8X3
T42.8X4
T42.8X5
T42.8X6
Deprenyl
T42.8X1
T42.8X2
T42.8X3
T42.8X4
T42.8X5
T42.8X6
Depressant, appetite
T50.5X1
T50.5X2
T50.5X3
T50.5X4
T50.5X5
T50.5X6
appetite(central)
T50.5X1
T50.5X2
T50.5X3
T50.5X4
T50.5X5
T50.5X6
cardiac
T46.2X1
T46.2X2
T46.2X3
T46.2X4
T46.2X5
T46.2X6
central nervous system(anesthetic)
T42.71
T42.72
T42.73
T42.74
T42.75
T42.76
general anesthetic
T41.201
T41.202
T41.203
T41.204
T41.205
T41.206
muscle tone
T42.8X1
T42.8X2
T42.8X3
T42.8X4
T42.8X5
T42.8X6
combination
specified NEC
Depressant
81
Drug
Poisoning
Accidental
Poisoning
Intentional
Poisoning
Assault
Poisoning
Undetermined
Adverse
Effect
Underdosing
muscle tone, central
T42.8X1
T42.8X2
T42.8X3
T42.8X4
T42.8X5
T42.8X6
psychotherapeutic
T43.501
T43.502
T43.503
T43.504
T43.505
T43.506
Deptropine
T45.0X1
T45.0X2
T45.0X3
T45.0X4
T45.0X5
T45.0X6
Dequalinium(chloride)
T49.0X1
T49.0X2
T49.0X3
T49.0X4
T49.0X5
T49.0X6
Derris root
T60.2X1
T60.2X2
T60.2X3
T60.2X4
Deserpidine
T46.5X1
T46.5X2
T46.5X3
T46.5X4
T46.5X5
T46.5X6
Desferrioxamine
T45.8X1
T45.8X2
T45.8X3
T45.8X4
T45.8X5
T45.8X6
Desipramine
T43.011
T43.012
T43.013
T43.014
T43.015
T43.016
Deslanoside
T46.0X1
T46.0X2
T46.0X3
T46.0X4
T46.0X5
T46.0X6
Desloughing agent
T49.4X1
T49.4X2
T49.4X3
T49.4X4
T49.4X5
T49.4X6
Desmethylimipramine
T43.011
T43.012
T43.013
T43.014
T43.015
T43.016
Desmopressin
T38.891
T38.892
T38.893
T38.894
T38.895
T38.896
Desocodeine
T40.2X1
T40.2X2
T40.2X3
T40.2X4
T40.2X5
T40.2X6
Desogestrel
T38.5X1
T38.5X2
T38.5X3
T38.5X4
T38.5X5
T38.5X6
Desomorphine
T40.2X1
T40.2X2
T40.2X3
T40.2X4
Desonide
T49.0X1
T49.0X2
T49.0X3
T49.0X4
T49.0X5
T49.0X6
Desoximetasone
T49.0X1
T49.0X2
T49.0X3
T49.0X4
T49.0X5
T49.0X6
Desoxycorticosteroid
T50.0X1
T50.0X2
T50.0X3
T50.0X4
T50.0X5
T50.0X6
Desoxycortone
T50.0X1
T50.0X2
T50.0X3
T50.0X4
T50.0X5
T50.0X6
Desoxyephedrine
T43.621
T43.622
T43.623
T43.624
T43.625
T43.626
Detaxtran
T46.6X1
T46.6X2
T46.6X3
T46.6X4
T46.6X5
T46.6X6
Detergent
T49.2X1
T49.2X2
T49.2X3
T49.2X4
T49.2X5
T49.2X6
external medication
T49.2X1
T49.2X2
T49.2X3
T49.2X4
T49.2X5
T49.2X6
local
T49.2X1
T49.2X2
T49.2X3
T49.2X4
T49.2X5
T49.2X6
medicinal
T49.2X1
T49.2X2
T49.2X3
T49.2X4
T49.2X5
T49.2X6
nonmedicinal
T55.1X1
T55.1X2
T55.1X3
T55.1X4
specified NEC
T55.1X1
T55.1X2
T55.1X3
T55.1X4
Deterrent, alcohol
T50.6X1
T50.6X2
T50.6X3
T50.6X4
T50.6X5
T50.6X6
Detoxifying agent
T50.6X1
T50.6X2
T50.6X3
T50.6X4
T50.6X5
T50.6X6
Detrothyronine
T38.1X1
T38.1X2
T38.1X3
T38.1X4
T38.1X5
T38.1X6
Dettol(external medication)
T49.0X1
T49.0X2
T49.0X3
T49.0X4
T49.0X5
T49.0X6
Dexamethasone
T38.0X1
T38.0X2
T38.0X3
T38.0X4
T38.0X5
T38.0X6
ENT agent
T49.6X1
T49.6X2
T49.6X3
T49.6X4
T49.6X5
T49.6X6
ophthalmic preparation
T49.5X1
T49.5X2
T49.5X3
T49.5X4
T49.5X5
T49.5X6
topical NEC
T49.0X1
T49.0X2
T49.0X3
T49.0X4
T49.0X5
T49.0X6
Dexamfetamine
T43.621
T43.622
T43.623
T43.624
T43.625
T43.626
Dexamphetamine
T43.621
T43.622
T43.623
T43.624
T43.625
T43.626
Dexbrompheniramine
T45.0X1
T45.0X2
T45.0X3
T45.0X4
T45.0X5
T45.0X6
Dexchlorpheniramine
T45.0X1
T45.0X2
T45.0X3
T45.0X4
T45.0X5
T45.0X6
Dexedrine
T43.621
T43.622
T43.623
T43.624
T43.625
T43.626
Dexetimide
T44.3X1
T44.3X2
T44.3X3
T44.3X4
T44.3X5
T44.3X6
Dexfenfluramine
T50.5X1
T50.5X2
T50.5X3
T50.5X4
T50.5X5
T50.5X6
Dexpanthenol
T45.2X1
T45.2X2
T45.2X3
T45.2X4
T45.2X5
T45.2X6
Dextran(40) (70) (150)
T45.8X1
T45.8X2
T45.8X3
T45.8X4
T45.8X5
T45.8X6
Dextriferron
T45.4X1
T45.4X2
T45.4X3
T45.4X4
T45.4X5
T45.4X6
Dextro calcium pantothenate
T45.2X1
T45.2X2
T45.2X3
T45.2X4
T45.2X5
T45.2X6
Dextro pantothenyl alcohol
T45.2X1
T45.2X2
T45.2X3
T45.2X4
T45.2X5
T45.2X6
82
Drug
Poisoning
Accidental
Poisoning
Intentional
Poisoning
Assault
Poisoning
Undetermined
Adverse
Effect
Underdosing
Dextroamphetamine
T43.621
T43.622
T43.623
T43.624
T43.625
T43.626
Dextromethorphan
T48.3X1
T48.3X2
T48.3X3
T48.3X4
T48.3X5
T48.3X6
Dextromoramide
T40.4X1
T40.4X2
T40.4X3
T40.4X4
T49.8X1
T49.8X2
T49.8X3
T49.8X4
T49.8X5
T49.8X6
Dextropropoxyphene
T40.4X1
T40.4X2
T40.4X3
T40.4X4
T40.4X5
T40.4X6
Dextrorphan
T40.2X1
T40.2X2
T40.2X3
T40.2X4
T40.2X5
T40.2X6
Dextrose
T50.3X1
T50.3X2
T50.3X3
T50.3X4
T50.3X5
T50.3X6
T46.8X1
T46.8X2
T46.8X3
T46.8X4
T46.8X5
T46.8X6
Dextrothyroxin
T38.1X1
T38.1X2
T38.1X3
T38.1X4
T38.1X5
T38.1X6
Dextrothyroxine sodium
T38.1X1
T38.1X2
T38.1X3
T38.1X4
T38.1X5
T38.1X6
DFP
T44.0X1
T44.0X2
T44.0X3
T44.0X4
T44.0X5
T44.0X6
DHE
T37.3X1
T37.3X2
T37.3X3
T37.3X4
T37.3X5
T37.3X6
45
T46.5X1
T46.5X2
T46.5X3
T46.5X4
T46.5X5
T46.5X6
Diabinese
T38.3X1
T38.3X2
T38.3X3
T38.3X4
T38.3X5
T38.3X6
Diacetone alcohol
T52.4X1
T52.4X2
T52.4X3
T52.4X4
Diacetyl monoxime
T50.991
T50.992
T50.993
T50.994
Diacetylmorphine
T40.1X1
T40.1X2
T40.1X3
T40.1X4
T40.1X5
Diachylon plaster
T49.4X1
T49.4X2
T49.4X3
T49.4X4
T49.4X5
T49.4X6
Diaethylstilboestrolum
T38.5X1
T38.5X2
T38.5X3
T38.5X4
T38.5X5
T38.5X6
Diagnostic agent NEC
T50.8X1
T50.8X2
T50.8X3
T50.8X4
T50.8X5
T50.8X6
Dial(soap)
T49.2X1
T49.2X2
T49.2X3
T49.2X4
T49.2X5
T49.2X6
T42.3X1
T42.3X2
T42.3X3
T42.3X4
T42.3X5
T42.3X6
Dialkyl carbonate
T52.91
T52.92
T52.93
T52.94
Diallylbarbituric acid
T42.3X1
T42.3X2
T42.3X3
T42.3X4
T42.3X5
T42.3X6
Diallymal
T42.3X1
T42.3X2
T42.3X3
T42.3X4
T42.3X5
T42.3X6
Dialysis solution(intraperitoneal)
T50.3X1
T50.3X2
T50.3X3
T50.3X4
T50.3X5
T50.3X6
Diaminodiphenylsulfone
T37.1X1
T37.1X2
T37.1X3
T37.1X4
T37.1X5
T37.1X6
Diamorphine
T40.1X1
T40.1X2
T40.1X3
T40.1X4
T40.1X5
Diamox
T50.2X1
T50.2X2
T50.2X3
T50.2X4
T50.2X5
T50.2X6
Diamthazole
T49.0X1
T49.0X2
T49.0X3
T49.0X4
T49.0X5
T49.0X6
Dianthone
T47.2X1
T47.2X2
T47.2X3
T47.2X4
T47.2X5
T47.2X6
Diaphenylsulfone
T37.0X1
T37.0X2
T37.0X3
T37.0X4
T37.0X5
T37.0X6
Diasone(sodium)
T37.1X1
T37.1X2
T37.1X3
T37.1X4
T37.1X5
T37.1X6
Diastase
T47.5X1
T47.5X2
T47.5X3
T47.5X4
T47.5X5
T47.5X6
Diatrizoate
T50.8X1
T50.8X2
T50.8X3
T50.8X4
T50.8X5
T50.8X6
Diazepam
T42.4X1
T42.4X2
T42.4X3
T42.4X4
T42.4X5
T42.4X6
Diazinon
T60.0X1
T60.0X2
T60.0X3
T60.0X4
Diazomethane(gas)
T59.891
T59.892
T59.893
T59.894
Diazoxide
T46.5X1
T46.5X2
T46.5X3
T46.5X4
T46.5X5
T46.5X6
Dibekacin
T36.5X1
T36.5X2
T36.5X3
T36.5X4
T36.5X5
T36.5X6
Dibenamine
T44.6X1
T44.6X2
T44.6X3
T44.6X4
T44.6X5
T44.6X6
Dibenzepin
T43.011
T43.012
T43.013
T43.014
T43.015
T43.016
Dibenzheptropine
T45.0X1
T45.0X2
T45.0X3
T45.0X4
T45.0X5
T45.0X6
Dibenzyline
T44.6X1
T44.6X2
T44.6X3
T44.6X4
T44.6X5
T44.6X6
Diborane(gas)
T59.891
T59.892
T59.893
T59.894
Dibromochloropropane
T60.8X1
T60.8X2
T60.8X3
T60.8X4
Dibromodulcitol
T45.1X1
T45.1X2
T45.1X3
T45.1X4
T45.1X5
T45.1X6
Dibromoethane
T53.6X1
T53.6X2
T53.6X3
T53.6X4
Dibromomannitol
T45.1X1
T45.1X2
T45.1X3
T45.1X4
T45.1X5
T45.1X6
topical
concentrated solution, intravenous
sedative
83
Drug
Poisoning
Accidental
Poisoning
Intentional
Poisoning
Assault
Poisoning
Undetermined
Adverse
Effect
Underdosing
Dibromopropamidine isethionate
T49.0X1
T49.0X2
T49.0X3
T49.0X4
T49.0X5
T49.0X6
Dibrompropamidine
T49.0X1
T49.0X2
T49.0X3
T49.0X4
T49.0X5
T49.0X6
Dibucaine
T41.3X1
T41.3X2
T41.3X3
T41.3X4
T41.3X5
T41.3X6
T41.3X1
T41.3X2
T41.3X3
T41.3X4
T41.3X5
T41.3X6
Dibunate sodium
T48.3X1
T48.3X2
T48.3X3
T48.3X4
T48.3X5
T48.3X6
Dibutoline sulfate
T44.3X1
T44.3X2
T44.3X3
T44.3X4
T44.3X5
T44.3X6
Dicamba
T60.3X1
T60.3X2
T60.3X3
T60.3X4
Dicapthon
T60.0X1
T60.0X2
T60.0X3
T60.0X4
Dichlobenil
T60.3X1
T60.3X2
T60.3X3
T60.3X4
Dichlone
T60.3X1
T60.3X2
T60.3X3
T60.3X4
Dichloralphenozone
T42.6X1
T42.6X2
T42.6X3
T42.6X4
T42.6X5
T42.6X6
Dichlorbenzidine
T65.3X1
T65.3X2
T65.3X3
T65.3X4
Dichlorhydrin
T52.8X1
T52.8X2
T52.8X3
T52.8X4
Dichlorhydroxyquinoline
T37.8X1
T37.8X2
T37.8X3
T37.8X4
T37.8X5
T37.8X6
Dichlorobenzene
T53.7X1
T53.7X2
T53.7X3
T53.7X4
Dichlorobenzyl alcohol
T49.6X1
T49.6X2
T49.6X3
T49.6X4
T49.6X5
T49.6X6
Dichlorodifluoromethane
T53.5X1
T53.5X2
T53.5X3
T53.5X4
Dichloroethane
T52.8X1
T52.8X2
T52.8X3
T52.8X4
Dichloroethyl sulfide, not in war
T59.891
T59.892
T59.893
T59.894
Dichloroethylene
T53.6X1
T53.6X2
T53.6X3
T53.6X4
Dichloroformoxine, not in war
T59.891
T59.892
T59.893
T59.894
Dichlorohydrin, alpha-dichlorohydrin
T52.8X1
T52.8X2
T52.8X3
T52.8X4
Dichloromethane(solvent)
T53.4X1
T53.4X2
T53.4X3
T53.4X4
T53.4X1
T53.4X2
T53.4X3
T53.4X4
Dichloronaphthoquinone
T60.3X1
T60.3X2
T60.3X3
T60.3X4
Dichlorophen
T37.4X1
T37.4X2
T37.4X3
T37.4X4
T37.4X5
T37.4X6
Dichloropropene
T60.3X1
T60.3X2
T60.3X3
T60.3X4
Dichloropropionic acid
T60.3X1
T60.3X2
T60.3X3
T60.3X4
Dichlorphenamide
T50.2X1
T50.2X2
T50.2X3
T50.2X4
T50.2X5
T50.2X6
Dichlorvos
T60.0X1
T60.0X2
T60.0X3
T60.0X4
Diclofenac
T39.391
T39.392
T39.393
T39.394
T39.395
T39.396
Diclofenamide
T50.2X1
T50.2X2
T50.2X3
T50.2X4
T50.2X5
T50.2X6
Diclofensine
T43.291
T43.292
T43.293
T43.294
T43.295
T43.296
Diclonixine
T39.8X1
T39.8X2
T39.8X3
T39.8X4
T39.8X5
T39.8X6
Dicloxacillin
T36.0X1
T36.0X2
T36.0X3
T36.0X4
T36.0X5
T36.0X6
Dicophane
T49.0X1
T49.0X2
T49.0X3
T49.0X4
T49.0X5
T49.0X6
Dicoumarol, dicoumarin, dicumarol
T45.511
T45.512
T45.513
T45.514
T45.515
T45.516
Dicrotophos
T60.0X1
T60.0X2
T60.0X3
T60.0X4
Dicyanogen(gas)
T65.0X1
T65.0X2
T65.0X3
T65.0X4
Dicyclomine
T44.3X1
T44.3X2
T44.3X3
T44.3X4
T44.3X5
T44.3X6
Dicycloverine
T44.3X1
T44.3X2
T44.3X3
T44.3X4
T44.3X5
T44.3X6
Dideoxycytidine
T37.5X1
T37.5X2
T37.5X3
T37.5X4
T37.5X5
T37.5X6
Dideoxyinosine
T37.5X1
T37.5X2
T37.5X3
T37.5X4
T37.5X5
T37.5X6
Dieldrin(vapor)
T60.1X1
T60.1X2
T60.1X3
T60.1X4
Diemal
T42.3X1
T42.3X2
T42.3X3
T42.3X4
T42.3X5
T42.3X6
Dienestrol
T38.5X1
T38.5X2
T38.5X3
T38.5X4
T38.5X5
T38.5X6
Dienoestrol
T38.5X1
T38.5X2
T38.5X3
T38.5X4
T38.5X5
T38.5X6
Dietetic drug NEC
T50.901
T50.902
T50.903
T50.904
T50.905
T50.906
Diethazine
T42.8X1
T42.8X2
T42.8X3
T42.8X4
T42.8X5
T42.8X6
topical(surface)
vapor
84
Poisoning
Accidental
Drug
Poisoning
Intentional
Poisoning
Assault
Poisoning
Undetermined
Adverse
Effect
Underdosing
Diethyl
barbituric acid
T42.3X1
T42.3X2
T42.3X3
T42.3X4
T42.3X5
T42.3X6
carbamazine
T37.4X1
T37.4X2
T37.4X3
T37.4X4
T37.4X5
T37.4X6
carbinol
T51.3X1
T51.3X2
T51.3X3
T51.3X4
carbonate
T52.8X1
T52.8X2
T52.8X3
T52.8X4
ether(vapor)
T41.0X1
T41.0X2
T41.0X3
T41.0X4
T41.0X5
T41.0X6
oxide
T52.8X1
T52.8X2
T52.8X3
T52.8X4
propion
T50.5X1
T50.5X2
T50.5X3
T50.5X4
T50.5X5
T50.5X6
stilbestrol
T38.5X1
T38.5X2
T38.5X3
T38.5X4
T38.5X5
T38.5X6
toluamide(nonmedicinal)
T60.8X1
T60.8X2
T60.8X3
T60.8X4
T49.3X1
T49.3X2
T49.3X3
T49.3X4
T49.3X5
T49.3X6
T37.4X1
T37.4X2
T37.4X3
T37.4X4
T37.4X5
T37.4X6
T52.8X1
T52.8X2
T52.8X3
T52.8X4
glycol(monoacetate) (monobutyl
ether) (monoethyl ether)
T52.3X1
T52.3X2
T52.3X3
T52.3X4
Diethylhexylphthalate
T65.891
T65.892
T65.893
T65.894
Diethylpropion
T50.5X1
T50.5X2
T50.5X3
T50.5X4
T50.5X5
T50.5X6
Diethylstilbestrol
T38.5X1
T38.5X2
T38.5X3
T38.5X4
T38.5X5
T38.5X6
Diethylstilboestrol
T38.5X1
T38.5X2
T38.5X3
T38.5X4
T38.5X5
T38.5X6
Diethylsulfone-diethylmethane
T42.6X1
T42.6X2
T42.6X3
T42.6X4
T42.6X5
T42.6X6
Diethyltoluamide
T49.0X1
T49.0X2
T49.0X3
T49.0X4
T49.0X5
T49.0X6
Diethyltryptamine(DET)
T40.991
T40.992
T40.993
T40.994
Difebarbamate
T42.3X1
T42.3X2
T42.3X3
T42.3X4
T42.3X5
T42.3X6
Difencloxazine
T40.2X1
T40.2X2
T40.2X3
T40.2X4
T40.2X5
T40.2X6
Difenidol
T45.0X1
T45.0X2
T45.0X3
T45.0X4
T45.0X5
T45.0X6
Difenoxin
T47.6X1
T47.6X2
T47.6X3
T47.6X4
T47.6X5
T47.6X6
Difetarsone
T37.3X1
T37.3X2
T37.3X3
T37.3X4
T37.3X5
T37.3X6
Diffusin
T45.3X1
T45.3X2
T45.3X3
T45.3X4
T45.3X5
T45.3X6
Diflorasone
T49.0X1
T49.0X2
T49.0X3
T49.0X4
T49.0X5
T49.0X6
Diflos
T44.0X1
T44.0X2
T44.0X3
T44.0X4
T44.0X5
T44.0X6
Diflubenzuron
T60.1X1
T60.1X2
T60.1X3
T60.1X4
Diflucortolone
T49.0X1
T49.0X2
T49.0X3
T49.0X4
T49.0X5
T49.0X6
Diflunisal
T39.091
T39.092
T39.093
T39.094
T39.095
T39.096
Difluoromethyldopa
T42.8X1
T42.8X2
T42.8X3
T42.8X4
T42.8X5
T42.8X6
Difluorophate
T44.0X1
T44.0X2
T44.0X3
T44.0X4
T44.0X5
T44.0X6
Digestant NEC
T47.5X1
T47.5X2
T47.5X3
T47.5X4
T47.5X5
T47.5X6
Digitalin(e)
T46.0X1
T46.0X2
T46.0X3
T46.0X4
T46.0X5
T46.0X6
Digitalis(leaf)(glycoside)
T46.0X1
T46.0X2
T46.0X3
T46.0X4
T46.0X5
T46.0X6
lanata
T46.0X1
T46.0X2
T46.0X3
T46.0X4
T46.0X5
T46.0X6
purpurea
T46.0X1
T46.0X2
T46.0X3
T46.0X4
T46.0X5
T46.0X6
Digitoxin
T46.0X1
T46.0X2
T46.0X3
T46.0X4
T46.0X5
T46.0X6
Digitoxose
T46.0X1
T46.0X2
T46.0X3
T46.0X4
T46.0X5
T46.0X6
Digoxin
T46.0X1
T46.0X2
T46.0X3
T46.0X4
T46.0X5
T46.0X6
Digoxine
T46.0X1
T46.0X2
T46.0X3
T46.0X4
T46.0X5
T46.0X6
Dihydralazine
T46.5X1
T46.5X2
T46.5X3
T46.5X4
T46.5X5
T46.5X6
medicinal
Diethylcarbamazine
Diethylene
dioxide
85
Drug
Poisoning
Accidental
Poisoning
Intentional
Poisoning
Assault
Poisoning
Undetermined
Adverse
Effect
Underdosing
Dihydrazine
T46.5X1
T46.5X2
T46.5X3
T46.5X4
T46.5X5
T46.5X6
Dihydrocodeine
T40.2X1
T40.2X2
T40.2X3
T40.2X4
T40.2X5
T40.2X6
Dihydrocodeinone
T40.2X1
T40.2X2
T40.2X3
T40.2X4
T40.2X5
T40.2X6
Dihydroergocornine
T46.7X1
T46.7X2
T46.7X3
T46.7X4
T46.7X5
T46.7X6
Dihydroergocristine(mesilate)
T46.7X1
T46.7X2
T46.7X3
T46.7X4
T46.7X5
T46.7X6
Dihydroergokryptine
T46.7X1
T46.7X2
T46.7X3
T46.7X4
T46.7X5
T46.7X6
Dihydroergotamine
T46.5X1
T46.5X2
T46.5X3
T46.5X4
T46.5X5
T46.5X6
Dihydroergotoxine
T46.7X1
T46.7X2
T46.7X3
T46.7X4
T46.7X5
T46.7X6
T46.7X1
T46.7X2
T46.7X3
T46.7X4
T46.7X5
T46.7X6
Dihydrohydroxycodeinone
T40.2X1
T40.2X2
T40.2X3
T40.2X4
T40.2X5
T40.2X6
Dihydrohydroxymorphinone
T40.2X1
T40.2X2
T40.2X3
T40.2X4
T40.2X5
T40.2X6
Dihydroisocodeine
T40.2X1
T40.2X2
T40.2X3
T40.2X4
T40.2X5
T40.2X6
Dihydromorphine
T40.2X1
T40.2X2
T40.2X3
T40.2X4
Dihydromorphinone
T40.2X1
T40.2X2
T40.2X3
T40.2X4
T40.2X5
T40.2X6
Dihydrostreptomycin
T36.5X1
T36.5X2
T36.5X3
T36.5X4
T36.5X5
T36.5X6
Dihydrotachysterol
T45.2X1
T45.2X2
T45.2X3
T45.2X4
T45.2X5
T45.2X6
Dihydroxyaluminum aminoacetate
T47.1X1
T47.1X2
T47.1X3
T47.1X4
T47.1X5
T47.1X6
Dihydroxyaluminum sodium carbonate
T47.1X1
T47.1X2
T47.1X3
T47.1X4
T47.1X5
T47.1X6
Dihydroxyanthraquinone
T47.2X1
T47.2X2
T47.2X3
T47.2X4
T47.2X5
T47.2X6
Dihydroxycodeinone
T40.2X1
T40.2X2
T40.2X3
T40.2X4
T40.2X5
T40.2X6
Dihydroxypropyl theophylline
T50.2X1
T50.2X2
T50.2X3
T50.2X4
T50.2X5
T50.2X6
Diiodohydroxyquin
T37.8X1
T37.8X2
T37.8X3
T37.8X4
T37.8X5
T37.8X6
T49.0X1
T49.0X2
T49.0X3
T49.0X4
T49.0X5
T49.0X6
Diiodohydroxyquinoline
T37.8X1
T37.8X2
T37.8X3
T37.8X4
T37.8X5
T37.8X6
Diiodotyrosine
T38.2X1
T38.2X2
T38.2X3
T38.2X4
T38.2X5
T38.2X6
Diisopromine
T44.3X1
T44.3X2
T44.3X3
T44.3X4
T44.3X5
T44.3X6
Diisopropylamine
T46.3X1
T46.3X2
T46.3X3
T46.3X4
T46.3X5
T46.3X6
Diisopropylfluorophos-phonate
T44.0X1
T44.0X2
T44.0X3
T44.0X4
T44.0X5
T44.0X6
Dilantin
T42.0X1
T42.0X2
T42.0X3
T42.0X4
T42.0X5
T42.0X6
Dilaudid
T40.2X1
T40.2X2
T40.2X3
T40.2X4
T40.2X5
T40.2X6
Dilazep
T46.3X1
T46.3X2
T46.3X3
T46.3X4
T46.3X5
T46.3X6
Dill
T47.5X1
T47.5X2
T47.5X3
T47.5X4
T47.5X5
T47.5X6
Diloxanide
T37.3X1
T37.3X2
T37.3X3
T37.3X4
T37.3X5
T37.3X6
Diltiazem
T46.1X1
T46.1X2
T46.1X3
T46.1X4
T46.1X5
T46.1X6
Dimazole
T49.0X1
T49.0X2
T49.0X3
T49.0X4
T49.0X5
T49.0X6
Dimefline
T50.7X1
T50.7X2
T50.7X3
T50.7X4
T50.7X5
T50.7X6
Dimefox
T60.0X1
T60.0X2
T60.0X3
T60.0X4
Dimemorfan
T48.3X1
T48.3X2
T48.3X3
T48.3X4
T48.3X5
T48.3X6
Dimenhydrinate
T45.0X1
T45.0X2
T45.0X3
T45.0X4
T45.0X5
T45.0X6
Dimercaprol(British anti-lewisite)
T45.8X1
T45.8X2
T45.8X3
T45.8X4
T45.8X5
T45.8X6
Dimercaptopropanol
T45.8X1
T45.8X2
T45.8X3
T45.8X4
T45.8X5
T45.8X6
Dimestrol
T38.5X1
T38.5X2
T38.5X3
T38.5X4
T38.5X5
T38.5X6
Dimetane
T45.0X1
T45.0X2
T45.0X3
T45.0X4
T45.0X5
T45.0X6
Dimethicone
T47.1X1
T47.1X2
T47.1X3
T47.1X4
T47.1X5
T47.1X6
Dimethindene
T45.0X1
T45.0X2
T45.0X3
T45.0X4
T45.0X5
T45.0X6
Dimethisoquin
T49.1X1
T49.1X2
T49.1X3
T49.1X4
T49.1X5
T49.1X6
Dimethisterone
T38.5X1
T38.5X2
T38.5X3
T38.5X4
T38.5X5
T38.5X6
mesilate
topical
86
TEST QUESTIONS
Introduction to ICD-10-CM: Part 3 #1221412
Directions:
 Before taking this test, read the instructions on how to complete the answer sheets
correctly. If taking the test online, log in to your User Account on the NCCT website
www.ncctinc.com.
 Select the response that best completes each sentence or answers each question
from the information presented in the module.
 If you are having difficulty answering a question, go to www.ncctinc.com and select
Forms/Documents. Then select CE Updates and Revisions to see if course content
and/or a test questions have been revised. If you do not have access to the internet,
call Customer Service at 800-875-4404.
1. Which chapter of the ICD-10-CM Tabular List contains codes for cleft palate?
a.
b.
c.
d.
Chapter 16
Chapter 17
Chapter 18
Chapter 19
2. Which of the following code sets include codes for digestive system disorders of
the newborn?
a.
b.
c.
d.
P90 - P96
P80 - P83
P76 - P78
P70 - P74
3. Which chapter of the ICD-10-CM Tabular List contains codes for failure to thrive
in the newborn?
a.
b.
c.
d.
Chapter 16
Chapter 17
Chapter 18
Chapter 19
4. Codes for congenital chromosomal abnormalities such as Trisomy 21 are found
in which of the following chapters of the ICD-10-CM Tabular List?
a.
b.
c.
d.
Chapter 16
Chapter 17
Chapter 18
Chapter 19
87
5. Which of the following code sets includes codes for congenital malformations of
the eye, ear, face, and neck?
a.
b.
c.
d.
Q60 – Q64
Q50 – Q56
Q35 – Q37
Q10 – Q18
6. A patient has abnormal laboratory tests results on blood but no diagnosis. Which
of the following code sets includes codes for these findings?
a.
b.
c.
d.
R70 – R79
R40 – R46
R83 – R89
R25 – R29
7. Codes for a patient experiencing recurrent nose bleeds would be found in
symptoms and signs involving the __________.
a.
b.
c.
d.
circulatory and respiratory systems
digestive system and abdomen
nervous and musculoskeletal systems
skin and subcutaneous tissue
8. Codes for a patient experiencing hemoglobinuria with no diagnosis would be
found in abnormal findings on examination of __________.
a.
b.
c.
d.
blood
body fluids
tissues
urine
9. An adolescent boy receives an injury to his shoulder while playing softball.
Which of the following chapters contains codes for this injury?
a.
b.
c.
d.
Chapter 18
Chapter 17
Chapter 20
Chapter 19
10. Which of the following code sets includes codes for a broken nose?
a.
b.
c.
d.
S00 – S09
S20 – S29
S40 – S49
S60 – S69
88
11. Which of the following code sets includes codes for a fracture of the coccyx?
a.
b.
c.
d.
S20 – S29
S30 – S39
S60 – S69
S90 – S99
12. Which of the following code sets includes codes for sunburn to the shoulders?
a.
b.
c.
d.
T14
T15 – T19
T26 – T28
T20 – T25
13. A patient with epilepsy has unknowingly taken less than the recommended dose
of anti-seizure drugs. Which of the following code sets includes codes for this
type of event?
a.
b.
c.
d.
T36 – T50
T52 – T65
T66 – T78
T80 – T88
14. Codes used for injuries resulting from slipping, tripping, stumbling, and falls are
found in which of the following chapters of the Tabular List?
a.
b.
c.
d.
Chapter 18
Chapter 19
Chapter 20
Chapter 21
15. Codes used for assault are found in the chapter entitled __________.
a. External Causes of Morbidity
b. Factors Influencing Health Status and Contact with Health Services
c. Injury, Poisoning, and Certain Other External Consequences of External
Causes
d. Symptoms, Signs, and Abnormal Clinical and Laboratory Findings
16. Which of the following code sets are used for operations of war, military
operations, and terrorism?
a.
b.
c.
d.
Y90 – Y99
Y70 – Y82
Y35 – Y38
X52 – X58
89
17. Codes used for examination encounters are found in which of the following
chapters?
a.
b.
c.
d.
21
20
19
18
18. Which of the following are the codes used for estrogen receptor status?
a.
b.
c.
d.
Z68
Z66
Z17
Z16
19. Which of the following codes are used for body mass index?
a.
b.
c.
d.
Z68
Z66
Z17
Z18
Refer to the Chapter-Specific Coding Guidelines to answer questions 20 - 40
20. Codes from Chapter 16 are used in which of the following instances?
a.
b.
c.
d.
For documentation of conditions on the maternal record
For documentation of conditions only at the time of birth
For documentation of conditions due to prematurity only
For documentation of conditions present at birth and throughout life
21. How many times can a code from category Z38 be used?
a.
b.
c.
d.
As many times as needed
One
Two
Three
22. What is the default when a newborn has a condition that may be due either to the
birth process or community acquired and the documentation does not state one
or the other?
a. Birth process
b. Community acquired
90
23. Which of the following is TRUE regarding criteria used to identify a condition as
clinically significant?
a.
b.
c.
d.
The condition requires no diagnostic procedures
The condition has no implications for future health care needs
The condition needs increased nursing care and/or monitoring
The condition requires short-term hospital length of stay
24. If a newborn has bacterial sepsis but there is no documentation of the condition
being congenital or community acquired, which is the default?
a. Community acquired
b. Congenital
25. Which of the following is a TRUE statement regarding codes in Chapter 17?
a.
b.
c.
d.
Codes from this chapter may be used throughout the life of the patient.
Codes Q00 – Q99 are used only as the principal/first-listed diagnosis.
Documentation is not necessary to use codes Q00 – Q99.
For liveborn infants, the congenital anomaly is coded before the place of
birth and type of delivery.
26. When is it acceptable to report codes that describe symptoms and signs?
a. When a diagnosis has been confirmed by the provider
b. When a diagnosis has not been confirmed by the provider
27. Which of the following is TRUE regarding the use of codes for repeated falls?
a. Both R29.6 and Z91.81 may be assigned together when appropriate.
b. Code R29.6 is used when a patient has fallen in the past and is at risk for
future falls.
c. Code R29.6 is used when a patient has fallen and the reason for the fall
has been investigated in full.
d. Code Z91.81 is used when a patient has no history of falls but is at risk for
future falls.
28. When should code R53.2 be used?
a. When an individual has quadriplegia due to extreme debility
b. When an individual has quadriplegia due to an injury
c. When an individual has quadriplegia due to a neurologic deficit
91
29. When is the 7th character A used with codes in Chapter 19?
a. When the patient is receiving routine care during the healing or recovery
process for the condition
b. When the patient is receiving care for complications or conditions that
arise as a direct result of the condition
c. When the patient is receiving active treatment for the condition
d. When the patient has a traumatic fracture
30. When is the 7th character D used with codes in Chapter 19?
31. When is the 7th character S used with codes in Chapter 19?
32. What is the default for coding a fracture that is not indicated as open or closed?
a. Closed
b. Open
33. What is the default for coding a fracture that is not indicated as displaced or not
displaced?
a. Displaced
b. Not displaced
34. What is the distinction between burns and corrosions made by ICD-10-CM?
a.
b.
c.
d.
Burn codes are used for chemical burns
Burn codes are used for thermal burns
Corrosion codes are used for electrical burns
Corrosion codes are used for thermal burns
92
35. Which of the following is TRUE regarding the use of codes for adverse effects,
poisoning, underdosing and toxic effects?
a.
b.
c.
d.
Code directly from the Table of Drugs
Use as many codes as necessary
Use underdosing codes as the principal or first-listed codes
When a harmful substance is ingested or comes in contact with a person,
this is classified as a poisoning effect
36. Which of the following is not captured in codes used for external causes of
morbidity?
a.
b.
c.
d.
How the injury/condition happened
Location/activity at the time of the event
Patient status (civilian/military)
Time of day the event occurred
37. Which of the following is a TRUE statement regarding the general use of
external causes of morbidity codes?
a. An external cause code can be the principal (first-listed) diagnosis.
b. As many codes as needed may be used to fully explain each cause.
c. External cause codes are used only for the initial injury or condition
encounter.
d. They may be used only with codes in the range of Z00 – Z99.
38. If multiple external cause codes are needed, which codes take priority overall all
other external cause codes?
a.
b.
c.
d.
Cataclysmic events
Child and adult abuse
Terrorism
Transport accidents
39. Which of the following is a TRUE statement regarding the use of Z codes?
a.
b.
c.
d.
Z codes are procedure codes used for specific encounters.
The use of Z codes is limited to inpatient facilities such as hospitals.
Z codes may only be used as first-listed or principal diagnosis.
A corresponding procedure code must accompany a Z code to describe
any procedure performed.
40. Which of the following is NOT a category of Z codes?
a.
b.
c.
d.
Counseling
Inoculations/vaccinations
Cadaveric organ donations
Contact/suspected exposure to communicable disease
93
Refer to Attachments A - D to answer questions 41 - 58
41. Which of the following codes is used for a newborn small for gestational age
weighing 1623 grams?
a.
b.
c.
d.
P05.11
P05.14
P05.16
P05.18
42. Which of the following is the code used for an infant with sacral spina bifida
without hydrocephalus?
a.
b.
c.
d.
Q05.5
Q05.6
Q05.7
Q05.8
43. Which of the following codes is used for a patient seeing the doctor because he
has an awareness of his heart beat?
a.
b.
c.
d.
R00.0
R00.1
R00.2
R00.8
44. The code used for gross hematuria is __________.
a.
b.
c.
d.
R31.0
R31.1
R31.2
R31.9
45. What is the code used when Bence Jones proteins are identified in a urine
specimen and the patient has no diagnosis?
a.
b.
c.
d.
R80.8
R80.3
R80.2
R80.1
46. What is the code used when a patient has abnormal electromyogram test
results?
a.
b.
c.
d.
R94.01
R94.112
R94.131
R94.31
94
47. What code is used when a patient is returning for a follow up evaluation of a
nonthermal blister of the right eyelid?
a.
b.
c.
d.
S00.221A
S00.221D
S00.221S
S00.221
48. A patient has long-term problems from scar tissue that developed following the
removal of fish bones from her pharynx. What code is used for this encounter?
a.
b.
c.
d.
T17.22
T17.22XA
T17.22XD
T17.22XS
49. During an initial encounter, a healthcare professional suspects an elderly adult
has been physically abused. What code is used to document this diagnosis?
a.
b.
c.
d.
T76.01
T76.11
T76.11XA
T76.01XA
50. A patient sees his orthopedic surgeon for post-operative total knee problems.
Following X-rays, the physician diagnoses the patient with a broken internal left
knee prosthesis. What code is used to document this diagnosis?
a.
b.
c.
d.
T84.013A
T84.013D
T84.013S
T84.013
51. A young boy runs into a tree while sledding. His mother takes him to his
pediatrician to look at a contusion on his arm. What code is used to document
the accident?
a.
b.
c.
d.
V00.221
V00.222A
V00.221A
V00.222
52. A television news reporter is injured when an incendiary bomb explodes when he
was working in a war zone. After initial treatment at the site, he returns to the
United States and has a follow up visit with his private physician. What code is
used to document this encounter?
a.
b.
c.
d.
Y36.310
Y36.310D
Y36.3111
Y36.311D
95
53. During the routine administration of a vaccine to a child, the healthcare
professional fails to follow sterile precautions. What code is used to document
this incident?
a.
b.
c.
d.
Y62.3
Y62.6
Y62.8
Y62.1
54. A young girl receives an injury while on a public tennis court. Which of the
following codes is used to document the place of this occurrence?
a.
b.
c.
d.
Y92.09
Y92.31
Y92.311
Y92.312
55. What is the code used for a routine health examination of a child where there are
no abnormal findings?
a.
b.
c.
d.
Z00.129
Z00.121
Z00.00
Z00.01
56. What is the code used to document a patient’s encounter for reforming the
artificial opening of an ileostomy?
a.
b.
c.
d.
Z43.0
Z43.1
Z43.2
Z43.3
57. What code is used to document a patient has an allergy to penicillin?
a.
b.
c.
d.
Z88.1
Z88.0
Z88.2
Z88.3
58. A child has accidentally ingested a bottle of cough syrup containing
dextromethorphan. What code from the Table of Drugs is used to document this
occurrence?
a.
b.
c.
d.
T48.3X1
T48.3X2
T48.3X3
T48.3X4
*End of Test*
96

INTRODUCTION TO ICD-10-CM CODES: PART 3 CHAPTER-SPECIFIC GUIDELINES

Transcription

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