A Reason for Visit Classification for Ambulatory Care

DATA EVALUATION AND METHODS RESEARCH Series 2 Number 78

A Reasonfor Visit Classification for AmbulatoryCare

This report presents a classification system developed to code reasons for seeking ambulatory medical care. .

DHEW Publication No. (PHS) 79-1352

U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE Public Health Service Office of the Assistant Secretary for Health National Center for Health Statistics Hyattsville, Md. February 1979 Library of Congress Cataloging in Publication Data

Schneider, Don. A reason for visit classification for ambulatory care.

(Vital and health statistics: Series 2, Data evaluation and methods research; no. 78) (DHEW publication; no. (PHS) 79-1352) Includes bibliographical references and index. 1. Nosology. 2. Ambulatory medical care. I. Appleton, Linda, joint author. II. McLemore, Thomas, ,joint author. III. Title. IV. Series: United States. National Center for Health Sta- tistics. Vital and health statistics: Series 2, Data evaluation and methods research; no. 78. V. Series: United States. Dept. of Health, Education and Welfare. DHEW publication; no. (PHS) 79-1352. [DNLM: 1. Ambulatory care. 2. Classification. W2 A N148vb no. 78] RA409.U45 no. 78 [RB115] 312’.07’23s [616’.001’2] 78-11549 NATIONAL CENTER FOR HEALTH STATISTICS

DOROTHY P. RICE, Director

ROBERT A. ISRAEL, Deputy Director JACOB J. FELDMAN, Ph.D., Associate Director for Analysis GAIL F. FISHER, Ph.D., Associate Director for the Cooperative Health Statistics System ELIJAH L. WHITE, Associate Director for Data Systems JAMES T. BAIRD, JR., Ph.D., Associate .Directorfor International Statistics ROBERT C, HUBER, Associate Director for Management MONROE G. SIRKEN, Ph. D., Associate Director for Mathematiccd Statistics PETER L. HURLEY, Associate Director for Operations JAMES M. ROBEY, Ph.D., Associate Director for Program Development PAUL E. LEAVERTON, Ph. D., Associate Director for Research ALICE HAYWOOD, Information Officer

DIVISION OF HEALTH RESOURCES UTILIZATION STATISTICS

SIEGFRIED A. HOERMANN, Director JOAN F. VAN NOSTRAND, Chiefi Long-Term Care Statistics Branch SIEGFRIED A. HOERMANN, Acting C)ziej Hospital Care Statistics Branch STEWART C. RICE, Chief Family Pknning Statistics Branch JAMES E. DeLOZIER, Chief Ambukztory Care Statistics Branch MANOOCHEHR K. NOZARY, Chief Technical Services Branch

Vital and Health Statistics-Series 2-No. 78

DHEW Publication No. (PHS) 79-1352 Library of Congress Catalog Card No. 78-11549 PREFACE

This report presents a Reason for Visit Classification for Ambulatory Care. The Reason for Visit Classification (RVC), developed by The American Medical Records Association under the auspices of the National Center for Health Sta- tistics (NCHS) for use in the National Ambulatory Medical Care Survey and by others, is primarily a classification of patient or lay terminology encountered in the ambulatory care setting. The emphasis of the RVC is on the patient’s motivation for seeking medical care and his perspective of the probIem or reason for visit. This is an important conceptual difference distinguishing the RVC from the Ninth Revision of the International Classification of Diseases (ICD-9) and its U.S. adaptation, International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). The ICD-9 is an official World Health Organization (WHO) publication and will be used in the United States for mortality coding beginning in 1979. The ICD-9-CM has been prepared jointly by the Government and private sector and has resulted in an expanded, but compatible, version of the ICD-9 which is used in the United States to classify diseases and conditions in clinical settings. The WHO Center for Classification of Diseases for North America at the NCHS is responsible for the ICD in the United States and for the official U.S. and Canadian input into future revisions of the ICD. The WHO reco~izes that the ICD-9 does not entirely meet the needs of an ambulatory care classification. It is hoped that the experience gained through the use of the RVC will provide an important contribution to future revisions of the ICD. It is the policy of NCHS that methodological reports are to be given peer review for technicaI merit and readabilityy by one or more persons familiax with the subject matter of the report, but not invoIved in producing the report. Ms. Alice Hetzel of the Division of Vital Statistics performed the peer review for this report.

... Ill ACKNOWLEDGMENT

The classification presented in this report is based primarily on the work of the American Medical Records Association (AMRA) under contract number HRA 230-75-0197 with the National Center for Health Statistics. The contribution of the AMRA and its staff is ,gratefully acknowledged. CONTENTS

... Preface ...... 111

Acknowledgment ...... iv

Summary ...... 1

Introduction ...... 1

Development of the Reason for Vkit Classification ...... 3

Reason for Visit Classification ...... 4 Basic Design Features ...... 4 Tabular List ...... 4 Alphabetical Index ...... 6

Applications ...... 6

Revision ...... 7

References ...... 8

Appendixes L Reason for Visit Classification Tabular Lkt ...... 10 IL Reason for Visit Classification Alphabetical Index ...... 35 111. Coding Rules and Instructions ...... 62

FIGURE

1. National Ambulatory Medical Care Survey Patient Record form ...... 2

v Comments, suggestions, and criticisms of the Reason for Visit Classi- fication are solicited and should be addressed to the Ambulatory Care Statistics Branch, Division of Health Resources Utilization Statistics, National Center for Health Statistics, Room 2-12,3700 East-West Highway, HyattsvilIe, Maryland 20782. A REASON FOR VISIT CLASSIFICATION FOR AMBULATORY CARE

Don Schneider, Ph. D., Linda Appleton, R. R.A., and Thomas McLemore, M.S .P.H.=

SUMMARY RVC. The tabukw list of the RVC is presented in appendix I; the alphabetical index is found in In May 1974, the National Ambulatory Med- appendix II; and general coding rules and in- ical Care Survey Symptom Classification was structions appear in appendix III. published as “the first attempt of the National Center for Health Statistics to develop a meth- odolo~y for classifying patients’ symptoms, com- INTRODUCTION plaints, problems, and reasons for seeking ambulatory medical care.”1 The Symptom In an effort to provide national baseline data Classification has been used since that time in concerning the Nation’s utilization of ambula- the National Ambulatory Medical Care Survey tory medical care resources, the National Center and by others. In 1975, an evaluation of the for Health Statistics (NCHS) of the Department National Ambulatory Medical Care Survey of Health, Education, and Welfare launched the Symptom Classification and other existing classi- National, Ambulatory Medical Care Survey fications that might be used to classify reasons (NAMCS) in May 1973. In its current scope, fur ambulatory medical care visits was under- this continuous survey is designed to provide tdwm by the American Medical Record Associa- natiomd statistics on the volume and character- tion under contract to the National Center for istics of office visits to non-Federal, office-based Hm.lth Statistics. As a finaJ product of the con- physicians. When appropriate methodologies are tract, a model system for classifying reason for developed, the NAMCS target population will visit data was developed. This report, abstracting be expanded to include other settings and pro- mtiterial from the contractor’s final report and fessionals, for example, outpatient departments, related sources, presents the Reason for Visit emergency rooms, and non-office-based physi- Classification for Ambulatory Care (RVC) along cians. A more detailed description of the back- with a summary of events leading to its develop- ground and methodological development of the ment. The philosophy and structure of the RVC NAMCS is available in an earlier report.z are presented, along with comments on possible The actual data collection for the NAMCS is applications and on updating or revision of the carried out by participating physicians who complete Patient Record forms for a sample of the 3Mr. Schneider is Director, Health Systems Manage- patients that they see during a randomly assigned ment Engineering, Rensselaer Polytechnic Institute, week of practice. One of the unique aspects of Troy, N.Y. Ms. Appleton is Manager, Medical Records, this survey is its attempt to incorporate the Ellis Hospital, Schenectady, N.Y. Both worked for the dimension of perceived need for seeking medical American Medical Records Association during the development of the RVC. Mr. McLemore is Survey Stat- care as expressed by the patient; that is, the rea- istician, Ambulatory Care Statistics Branch, National son for visit in the patient’s own words. This Center for Health Statistics. information is one of the data elements in the uniform minimum basic data set for ambulatory NAMCS pilot studies and on schemes ex- care approved by the U.S. National Committee pounded by Bain and Spaulding,4 and Renner on Vital and Health Statistics.3 During the and Piernot.s The NAMCS Symptom Classifi- 1973-74 NAMCS, reason for visit data were col- cation, as this earlier scheme was called, was lected in item 5 of the Patient Record in which designed to be simple and flexible; and consisted the physician was requested to record, of some 200 rubrics or codes grouped into 13 “PATIENT’S PRINCIPAL PROBLEM(S), COM- classes, primarily around a body system axis. PLAINT(S), OR SYMPTOM(S) THIS VISIT (h It was developed to code the patient’s symp- patient’s own words).” (See fi~re 1.) toms, complaints, and other reasons for visit, in During 1970-72 when the NAMCS was field the patient’s own words, and, thus, is primarily tested, it was apparent that an adequate classifi- a classification of lay terminology. Although cation scheme was not available to code these the Symptom Classification was originally de- reason for visit data. Consequently, a new classi- signed as a processing instrument for the fication was developed by Meads and Mc- NAMCS, and was used in that capacity from Lemore,l based largely on data from the 1973 through 1976, it has been adopted, usually

ASSURANCE OF CONFIDENTIALITY-AII mformz.tton which would permtt identtftcatton of .“ mdw,d. al, a prmwce. m an estabhshmmt WIII be held conf,denttal, wdl be used only by persom engaged m and for the purposes of the survey and WIII not be d,sclosed or released lo other persons or used for any other purwse. 1A

1. DATE OF VISIT PATl ENT RECORD NATIONAL AMBULATORY MEDICAL CARE SURVEY .~

2. DATE OF BIRTH 4. COLOR OR 5. PATIENT’S PRINCIPAL PROBLEM(S) 6. SERIOUSNESS OF 7. HAVE YOU EVER SEEN RACE COMPLAINT(S), OR SYMPTOM(S) ~ VISIT PROBLEM IN ITEM 50 THIS PATIENT BEFORE? [In patient’s own words) (Check one) f a Y;s , ➤ NO * ;: ;:’., — , ❑ VERY SERIOUS a MOST 3. SEX BLACK IMPORTANT D SERIOUS If YES. for the problem mdmated m ITEM 5a 7 , ❑ FEMALE J❑ OTHER ,uSLIGHTLY SERIOUS , ~ MALE I,- . i_ UNKNOWN b OTHER I . ~ NOT SERIOUS I 1

PHYSICIAN’S PRINCIPAL OIAGNOSIS ~ VISIT 8. MAJOR REASON(S) FOR THIS VISIT— [Check*//major reasmd 9. a OIAGNOSIS ASSOCIATE WITH ITEM Sa ENTRY

I ❑ ACUTE PROBLEM . D WELL AOULT/CHILO EXAM ? ❑ ACUTE PROBLEM. FOLLOW-UP . ❑ FAMILY PLANNING ,, ❑ CHRONIC PROBLEM, ROUTINE ~ ❑ COUNSELING/ADVICE ,4 ❑ CHRONIC PROBLEM, FLARE. UP ,, 0 IMMUNIZATION 5 ❑ PRENATAL CARE . IJ REFERREO BY OTHER PHYS/AGENCY b OTHER SIGNIFICANT CURRENT OIAGNOSES (In order of importance) 6 ❑ POSTNATAL CARE I ❑ ADMINISTRATIVE PURPOSE I ❑ POSTOPERATIVE CARE . IJ OTHER (SW’CIIY) 7

(Operatwe procedure)

10. DIAGNOSTICflHERAPEUTIC SERVICES ORDEREO/PROVIOEO THIS VISIT (Checks//that apply, 11. DISPOSITION TM VISIT 12. OURATION OF US VISIT (T/nM (Checkall [hat apply] 01 ❑ NONE 11 ❑ DRUG PRESCRIBED ●mrallf spent w{lh 02 ❑ LIMITED HISTORYIEXAM 12 ❑ X-RAY ph)’wcm) NO FOLLOW. UP PLANNEO 03 ❑ GENERAL HISTORY/EXAM 13 ❑ INJECTION RETURN AT SPECIFIEO TIME 04 ❑ CLINICAL LAB. TEST 14 ❑ lMMUNIZATION/OESENSITIZATION RETURN IF NEEDED, P R N 05 ❑ BLOOO PRESSURE CHECK 15 ❑ PHYSIOTHERAPY TELEPHONE FOLLOW. UP PLANNED 06 ❑ EKG 16 ❑ MEDICAL COUNSELING REFERRED TO OTHER MINUTES ❑ ❑ 07 HEARING TEST 17 PSYCHOTHERAPY~HE RAPEUTIC PHYSICIAN, AGENCY ❑ 08 VISION TEST LISTENING RETURNEO TO REFERRING 09 U ENOOSCOPY 18 tl OTHER [Spec,fy) PHYSICIAN 10 1=1 OFFICE SURGERY AOMIT TO HOSPITAL OTHER (Spec@)

4RA-34-2 DEPARTMENT OF HEALTH, EDUCATIC I ANO WELFARE O.M.B Y6S-S72106 REV. 8-74 PUBLIC HEALTH SERV q EXPIRATION DATE 12/31fT5 HEALTH RESOURCES ADMINI! RATION NATIONAL CENTER FOR HEALTt TATISTICS

Figure 1. National Ambulatory Medical Care Survey Patient Record form

2 after some modification, in a number of other The specific goals of the conference included settings, for example, in the Rand Corporation’s establishing criteria for evaluation of reason for Health Insurance Study.G visit classifications and concepts leading to the Through analysis of NAMCS data and data development of a methodology for the design of requests, and feedback from users of the Symp- health care classification systems. Information tom Classification, some problems or deficien- was gathered from a variety of users of the cies in this scheme were identified. The most NAMCS Symptom Classification, and problems important of these concerned the lack of speci- associated with the Symptom Classification were ficity or detail in some areas, especially in the identified. nonsymptomatic reason for visit section and in A methodology for the evaluation and de- the residual or “other” categories. These consid- sign of medical classification systems was sub- erations indicated the need for a more compre- sequently developed. The principles set forth in hensive classification and were, in part, responsi- this methodology provided the conceptual ble for the decision to initiate the evaluation framework from which the model reason for contract discussed in the next section of the visit classification was deveIoped and tested. A report. complete description of the background for the evaluation and design methodology has been presented by Schneider and Parziale.T DEVELOPMENT OF THE REASON Six existing classification systems were FOR VISIT CLASSIFICATION selected, tested, and evaluated for their applicability in coding reason for visit data; (1) NAMCS In July 1975, the American Medical Record Symptom Classification,l (2) Patient Request Association (AMRA) was awarded a contract to Code,s (3) CR Alpha Code,g (4) Columbia evaluate, the NAMCS Symptom Classification Medical Plan Classification,l O (5) International and other existing medical taxonomies that Classification of Health Problems in Primary might be used to classify patients’ reasons for Care,l 1 and (6) International Classification of seeking ambulatory medical care, and to develop Diseases (ICD-9).1 z The last two classifications and test a model system for classifying this type are primarily diagnostic codes and are not spe- of information. One of the many requirements cifically designed to classify reason for visit data, of this model system was that it meet not only particularly in lay terminology. They were in- the needs of the NAMCS, but also the needs of cluded in the evaluation because of their wide- a wide variety of other users. spread use, and because they may be considered An initial research phase included an exten- by many users for coding reason for visit data. sive review of the literature pertaining to medi- Reason for visit data from the 1974 NAMCS cal and health care classifications and the com- and from the State of Wisconsin emergency pilation of an annotated bibliography relating room study]s were used to test each of the to the design, development, description, use, above system’s applicability to code these data. evaluation, and analysis of medical classification Each system was evaluated according to the fol- systems. Consultations with over 100 individ- lowing criteria: ease of understanding, clarity, uals involved in fields relating to the classifica- accuracy, specificity, efficiency, conciseness, tion of health care data provided the necessary comprehensiveness, flexibility of revision, and input to determine the needs and purposes for a computer applicability. These evaluations helped classification of reason for visit data. to pinpoint the strengths and weaknesses of the This preliminary research paved the way for existing systems, and the findings from these the Conference on Symptom Classifications for evaluations were used as a basis for the develop- Ambulatory Care held in November 1975. This ment of the RVC. ‘conference provided a forum for national ex- The RVC underwent several revisions before perts in the field of ambulatory medical care reaching the version presented in this report. classifications and users of the NAMCS Symp- The modular structure, which is discussed later tom Classification for input into the project. in the report, was introduced in the first version.

3 This version was tested using reason for visit randomly selected patient visit coded into a pax- data from the NAMCS and from emergency titular module is expected to be more highly room and outpatient clinic studies. The results correlated with other patient visits in the same of the coding tests were incorporated into a sec- module than it is with patient visits coded int{~ ond version which was evaluated by representa- other modules. tives of 10 professional associations and by an This hypothesis was tested by comparing the evaluation workshop of classification experts in modules with respect to their correlation with May 1976. Recommendations from these several attributes or characteristics of a patient sources were considered and included whenever visit, for example, visit initiator and patient possible in the final RVC. Minor modifications status, and with other items on the NAMCS prompted by further coding tests and evalua- Patient Record form: seriousness of the problem tions at NCHS resulted in the RVC as presented (item 6), visit status (item 7), reason(s) fur visit in this report. categories (item 8), treatments/services ordered or provided (item 10), and disposition (item 11). Generally, the results, which are discussed in de- REASON FOR VISIT CLASSIFICATION tail in the contractor’s final report, show that the modules represent distinctly different SToup- Basic Design Features ings of patient visits.14 Strengths of the modular structure include: The structural philosophy of the RVC is best explained by describing its modular design. The 1. Aggregated at the modular level, the data RVC utilizes a modular structure with the fol- provide a description of the basic types lowing modules representing basic categoriza- of reasons for visit, tions of the patient’s reason for visit: 2. The RVC is flexible in that the modules 1. Symptom can be expanded or contracted according 2. Disease to the particular needs of the user. For example, if a hospital outpatient depart- 3. Diagnostic, screening, and preventive ment desires greater specificity in coding 4. Treatment therapeutic procedures, that module could be expanded, as required, without 5. Injuries and adverse effects disturbing the remaining modules. 6. Test results 3. Categories for some of the modules may 7. Administrative be abstracted from other classification systems that are specific to that particular module, for example, sections of the When the modules were designed, the pri- International Classification Oj- Diseases, mary emphasis on the selection of the modules Adapted (ICDA)15 or the International and the categories within the modules was that Classification of Health Problems in Pri- they discriminate well with respect to mary Care (ICHPPC),l 1 may be inserted into the Disease Module. 1. The patient’s motivation or reason for seeking medical care, and 4. Coding decisions are simplified because 2. The physician’s response to that reason the modules represent logical ~groupings for visit. for reasons for visit.

This does not imply that all or nearly all of Tabular List tlie patient visits falling into a particular module are uniform with respect to the two character- The RVC consists of two parts: a tabular list istics just listed. Instead, it is implied that a of categories and an alphabetical index of terms.

4 The tabular list is divided into the seven previ- a diagnosis as the reason for visit. This could be ously listed modules. The listing of inclusive either a diagnosis previously supplied by the terms for each category in the tabular list is not physician or a condition that the patient has ex- exhaustive, but is meant to be illustrative of the perienced before and/or has self-diagnosed. Most reasons for visit contained within each category. folIowup visits for chronic diseases will be coded A brief description of the types of patient visits into this module. Physician’s response is prob- falling into each module and the categorical con- ably a checkup or observation of the condition. tent of each module follow. The reader may The Disease Module, also arranged by body sys- find it useful to refer to the appendixes while tem, is based on a condensation of the Interna- reading the following sections. tional Classification of Health Problems In Pri- Symptom Module. –The reasons for visit mary Care. *1 classified in this module represent visits in which Diagnostic, Screening, and Preventive hlod- the patient expresses his or her reason for visit ule. —The reasons for visit coded into this mod- as a complaint, symptom, or problem. Often ule usually represent nonillness visits, for these are initial visits for the problem, and the example, visits for routine physicals and preven- physician generally responds by collecting infor- tive care, visits by patients in high-risk groups, or mation through examination, history, and/or visits for family planning services or pregnancy- tests. A tentative diagnosis is the probable out- related examinations. The physician’s response come. is to directly carry out the patient’s request and In the Symptom Module, symptoms are generally involves the provision of some type of grouped by body system. Each symptom has test or diagnostic procedure. been assigned to the body system in which it is Treatment Module. –These visits are, gener- primarily manifested. For example, cough is as- ally, for the purpose of providing specific thera- signed to the respiratory system and nausea to peutic care, treatment, or counseling; the physi- the digestive system. In cases where the symp- cian’s response is to carry out the request and tom manifests itself in several systems or in the usually includes the provision of a therapeutic entire body, the symptom has been assigned to a procedure. category in the General Symptoms section. The Injuries and Adverse Efji?cts Module. –This General Symptoms section also includes symp- module includes reasons for visit that are clearly toms in which the problem descriptor is listed the result of an injury or adverse effect. These without reference to a body part or system, for visits are often emergency visits that require im- example, bleeding, or where no body system is mediate care, and the physician’s response is to applicable, as fatigue. aIleviate the patient’s immediate problem. It may appear that some of the codes in the Test Results Module. –Reasons coded into Symptom Module represent diseases, for examp- this module represent return visits to receive test le, the term “infection” to indicate an unspeci- results. The patient may have been toId that fied infection of a body part. Distinguishing be- results from previously administered tests were tween what is a symptom and what is a disease abnormal or may be returning to receive test is, at best, a very tenuous and difficult problem. results. The dia~osis may or may not yet be The tendency in the RVC is to treat the reason established. The physician’s response is usually for visit as a symptom, rather than a disease. to carry out further diagnostic tests or to Thus in the example, when a patient states that initiate a therapeutic regimen. hc or she has an infection, the patient is really Administrative Module. –Reasons for visit expressing a symptom complex, rather than an coded into this module are unique in that they established diagnosis. Unspecified allergies, are initiated by an outside party rather than by warts, and moles are likewise coded into the the patient or the physician. The visits usually Symptom Module. However, specified infec- involve completion of a form or other paper- tions, as “staphylococcal infection” are coded work to verify that the physician has seen the into the Disease Module. patient and fulfilled the request. For example, Disease Module. –Reasons coded into this insurance physicals, return-to-work certificates, section represent visits at which the patient gives and court-ordered examinations fall into this

5 module. Physician’s response is to carry out the APPLICATIONS administrative request. The list is designed to provide the option of The RVC has been developed to classify the coding and aggregating at two levels. Code num- patients’ stated reasons for seeking ambulatory bers with decimal point zero (.0) represent the medical care. It should be recognized that the upper hierarchy or broad codes, and c, de num- quality of the output of the RVC is affected by bers ending in .1-.9, the lower hierarchy or more both the code and the data. Data collection specific codes. For example, considerations, such as who records the reason for visit and when it is recorded, are important (Upper level) – S3 10.0 Discharge from eye factors affecting the distribution of the reasons for visit. Utilization of the RVC will generally (Lower level) – S31O.1 Bleeding from eye be enhanced if instructions in the following – S3 10.2 Excessive tearing areas are provided and adhered to by the re- corder of the reason for visit: – S31O.3 Pus in eye 1. List the diagnosis as the reason for visit Thus, depending on the reliability of the data only if so stated by the patient. and the needs of the user, two levels of specificity are provided. 2. Specify administrative examinations as such, and not simply state “general ex- Alphabetical Index amination, ” for example. 3. State if the reason for visit is related to The second part of the RVC is the alphabeti- an injury, and specify the injury. cal index of terms, an extensive list of words and terms with their appropriate code numbers. The 4. Specify what followup visits are for. alphabetical index includes many synonyms and 5. Avoid recording “none” or “no com- patients’ expressions to facilitate the coding of plaint” as the re&on for visit. the reason for visit data. As discussed in the section “Revision,” the alphabetical index will be The RVC has been adopted for use in continuously expanding as new terms are added. the NAMCS beginning with the 1977 survey, The Entries are alphabetically indexed according RVC has been purposely designed to allow appli- to the following general rules: cation in a variety of ambulatory settings, including clinics, outpatient departments, and 1. When the reason for visit is given as a emergency rooms. Use of the RVC outside the problem descriptor along with a body NAMCS, and feedback regarding its use, are part, for example, “skin itching” or “eye encouraged. pain,” the entry is indexed by the de- Potential uses of data classified using the scriptor, not by the body part. Thus, RVC are many and varied. Selected examples “eye pain” is located under “pain, eye. ” are to provide descriptive information indicating 2. When a problem of a body function is why patients are seeking ambulatory medical given as the reason for visit, for example, care; to indicate which visits might be delegated “blurred vision,” the reason for visit is to particular members of the health care team indexed by the body function. Thus, (immunizations and well baby care might be “blurred vision” is located under “vision, seen by a nurse practitioner or physician assist- blurred.” ant); and to aid in resource allocation and patient scheduling decisions. Specific applications Users of the RVC should refer to appendix of the RVC to quality assurance and other areas III for guidelines for using the alphabetical of patient and clinic management have been dis- index. cussed by Schneider and Appleton.] 6 REVISION mentioned before, comments and criticisms regarding the use of the RVC are solicited, as this Because basic reasons for seeking ambula- feedback will be valuable in determining future tory medical care change little from year to alterations in the RVC. year, it is unlikely that the tabular list of the Every attempt has been made to make the RVC will become quickly outdated and in need alphabetical index as compIete as possible; how- of large-scale revision. Therefore, no specific ever, it is still far from exhaustive. Periodic up- timetable has been set to revise this part of the dates of the index are, therefore, anticipated. RVC. The time and extent of revision will be NAMCS coding procedures call for each medical dictated by several factors, including analysis of coder to maintain a list of nonindexed and un- NAMCS data and feedback from other users of classifiable terms as they are encountered. These the RVC. Reason for visit data from the 1977 lists are periodically compiled and reviewed and NAMCS will be analyzed when it becomes avail- necessary additions will be made to the index. able and should provide several measures of the Users of the RVC are also urged to maintain need for revision: low frequency codes and such lists and to forward copies of these lists to residual or “catchall” codes that occur with high the address given on page vi so that new terms frequencies wilI be analyzed to determine if may be added to the index to make it as com- modifications of the RVC are necessary. And, as prehensive as possible.

000 REFERENCES

1National Center for Health statistics: National system for coding the presenting problems of ambula- Ambulatory Medical Care Survey: Symptom classifi- tory patients. Group Health Cooperative of Puget cation, United States, by Sue Meads and Thomas Mc- Sound, Seattle, Wash. Unpublished paper. Lemore. Vital and Health Statistics. Series 2-No. 63. ‘Martin, L. R., and Werblun, M. N.: The CR alpha DHEW Pub. No. (HRA) 74-1337. Health Resources Ad- diagnostic coding system for ambulatory care. ]. Fare. ministration. Washington. U.S. Government Printing Pratt. 4(3):563-566, 1977. Office, May 1974. 10Steinwachs, D. M., and MushEn, A. I: The Johns 2Nation~ Center for He~th Statistics: National Hopkins ambulatory-care coding scheme. Health Serv. Ambulatory h4edical Care Survey: Background and Res. 13(1):36-49, 1978. methodology, United States, by James B. Tenney, M. D., 11 World Orgmizationof National Colleges, Acad- Kerr L. White, M.D., and John W. Williamson, M.D. emies, and Academic Associations of General Practition- Vital and Health Statistics. Series 2-No. 61. DHEW ers/Family Physicians: International Classification of Pub. No. (HRA) 74-1335. Health Resources Adminis- Health Problems in Primary Care. Chicago. American tration. Washington. U.S. Government Printing Office, Hospital Association, 1975. Mar. 1974. 12World Health Organization: Manual of the Interna- 3Nation~ Center for He~th Statistics: Ambulatory tional Statistical Classification of Diseases, Injuries, and medical care records: Uniform minimum basic data set, Causes of Death, Based on the Recommendations of the United States. Vital and Health Statistics. Series 4- Ninth Revision Conference, 1975. Geneva. World Health No. 16. DHEW Pub. No. (HRA) 75-1453. Health Re- Organization, 1977. Preliminary draft. sources Administration. Washington. U.S. Government 13Bureau of He&h Statistics: History and Develop- Printing Office, Aug. 1974 ment of the Emergency Department Encounter Form, 4Bain, S. T., and Spaulding, W. B.: The importance an unpublished paper by T. Engstrom. Wisconsin De- of coding presenting symptoms. Can. Med. Assoc. J. partment of Health and Social Services, Division of 97(16):953-959, 1967. Health, Madison, Wis., May 1978. 5 Renner, J. H., and Piernot, R. W.: A revised symp- 14Americm Medic~ Record Association: Evaluation tom code list for ambulatory medical record data. Paper of the National Ambulatory Medical Care Survey Symp- prepared for Family Practice Program, University of Wis- tom Classification contractor’s final report. Contract consin, hladison, 1972. No. HRA 230-75-0197. Chicago. Oct. 1976. 6Newhouse, J. p.: A summary of the experimental 15 Nation~ Center for HeAth Statistics: Eighth Revi- portion of the Rand health insurance study. Santa sion International Classification of Diseases, Adapted Monica, Calif. The Rand Corporation, 1975. for Use in the United States. PHS Pub. No. 1693. Public 7Schneider, D., ~d parziale, A.: Development of Health Service. Washington. U.S. Government Printing medical classification systems for productivity analysis. Office, 1967. Proceedings. Seventh Conference of the Hospital and 16Schneider, D., ~d Appleton, L.: Reason for visit Health Services Division of the American Institute of classification system for patient records in an ambu- Industrial Engineers, Colorado Springs, Feb. 1976. latory care system. dual. Rev. Bull. 3(1): 20-26, Jan. 8Weinstein, P., Gordon, M. J., and Gilson, J. S.: A 1977. APPENDIXES

CONTENTS

L Reason for Vkit Classification Tabular List ...... 10 Symptom Module ...... Disease Module ...... ;: Diagnostic, Screening, and Preventive Module ...... 26 Treatment Module ...... 29 Injuries and Adverse Effects Module ...... 31 Test Results Module ...... 33 Administrative Module ...... 34 Uncodable Entries ...... 34

IL Reason for Visit Clmsification Nphabeticd Index ...... 35

III. Coding Rules and Instmctions ...... 62

9 APPENDIX I

REASON FOR VISIT CLASSIFICATION TABULAR LIST

Code Code Module Module number number

SYMPTOM MODULE DISEASE MODULE–Con.

General Symptoms ...... SOOI-S099 Diseases of the Musculoskeletal System Symptoms Referable to Psychological and and Connective Tissue ...... D900-D949 Mental Disorders ...... SIOO-S199 Congenital Anomalies ...... D950-D989 Symptoms Referable to the Nervous Sys- Perinatal Morbidity and Mortality Condi- tem (excluding sense organs) ...... S200-S259 tions ...... D990-D999 Symptoms Raferable to the Cardiovascular and Lymphatic Systems ...... S260-S299 DIAGNOSTIC, SCREEN ING, AND PREVEN- Symptoms Referable to the Eyes end TIVE MODULE Ears ...... S300-S399 Symptoms Referable to the Respiratory General Examinations ...... xlOo-x199 System ...... S400-S499 Special Examinations ...... X200-X299 Symptoms Referable to the Digestive Diagnostic Tests ...... X300-X399 System ...... S500*639 Other Screening and Preventive Pro- Symptoms Referable to the Genitouri- cedures ...... X400-X499 nary System ...... S6405829 Family Planning ...... X500-X599 Symptoms Referable to the Skin, Nails, and Hair ...... S830-SB99 TREATMENT MODULE Symptoms Referable to the Musculoskele- tal System ...... S900-S999 Medications ...... T100-T1 99 Preoperative and Postoperative Care ...... T200-T299 DISEASE MODULE Specific Types of Therapy ...... T400-T499 Specific Therapeutic Procedures ...... T500-T599 Infective and Parasitic Diseases ...... DOOI-D099 Medical Counseling ...... T600-T699 Neoplasms ...... DIOO-D199 Social Problem Counseling ...... T700-T799 Endocrine, Nutritional, and Metabolic Progress Visit, NEC ...... T800-T899 Diseases...... D200-D249 Diseases of the Blood and Blood-Forming INJURIES AND ADVERSE EFFECTS Organs ...... D250-D299 MODULE Mental Disorders ...... D300-D349 Diseases of the Nervous System ...... D350-D399 Injury by Type and/or Location ...... JOO1-J799 Diseases of the Eye ...... D400-D449 Injury, NOS ...... J800-J899 Diseases of the Ear ...... D450-D499 Poisoning and Adverse Effects ...... J900-J999 Diseases of the Circulatory System ...... D500-D599 Diseasesof the Respiratory System ...... D600-D649 TEST RESULTS MODULE ...... R 1OO-R7OO Diseases of the Digestive System ...... D650-D699 Diseases of the Genitourinary System ...... D700-D799 ADMINISTRATIVE MODULE ...... A1OO-AI4O Disaases of the Skin and Subcutaneous Tissue ...... D800-D899 UNCODABLE ENTRIES ...... U990-U999

NOTE: NEC = not elsewhere classifiable; NOS = not otherwise specified,

10 SYMPTOM MODULE S04500 Weight loss S045.1 Recent weight loss General Symptoms (S001-S099) S045.2 Underweight S050.O Chest pain and related symptoms (not S005.0 Chills referable to body system) SO1O.O Fever S050.1 Chest pain Includes: Excludes: High temperature Heart pain (S265.0) SO15.0 Tiredness, exhaustion S050.2 Chest discomfort, pressure, Includes: tightness Fatigue S050.3 Burning sensation in the chest No energy S055.O Pain, site not referable to a specific Run down body system Worn out Excludes: S020.0 General weakness Chest pain (S050.1) S025.0 General ill feeling Abdominal pain (see S550.0) Includes: S055.1 Rib pain Not feeling well S055.2 Side pain, flank pain Multiple complaints S055.3 Groin pain Malaise S055.4 Facial pain Illness, NOS S060.0 Pain and related symptoms, general- S030.0 Fainting (syncope) ized, site unspecified Includes: S060.1 Pain, site unspecified Blacking out Includes: Passing out Ache all over Fainting spells S060.2 Cramps, spasms, site unspeci- Excludes: fied Unconsciousness (J840.0) Excludes: S035.0 Symptoms of fluid abnormalities Menstrual cramps S035.1 Edema (S745.2) Includes: S060.3 Stiffness, site unspecified Bloated S065.0 Tumor or mass, site unspecified Swollen with water S070.O Bleeding, site unspecified Dropsy S075.O Symptoms of growth and develop- Ankles swelling (both) mental disorders Excludes: S075.1 Lack of growth Swelling of one ankle Includes: (s930.3) Failure to thrive S035.2 Excessive sweating, perspira- Slowness, physical tion Too short S035.3 Excessive thirst Immaturity, physical S040.0 Weight gain Poor weight gain Includes: S075.2 Excessive growth Obesity Includes: Overweight Too tall Excludes: Too big for age Counseling for weight problem Development, early (T600.0) (physical) S080.0 General symptoms of infants, NEC NOTE: NEC = not elsewhere classifiable; NOS = not S080.1 Crying too much, fussy, otherwise specified. fidgetv, irritable

11 S080.0 General symptoms of infants, NEC–Con. S120.0 Problems with identity and self-esteem Includes: SO80.2 Regurgitation, spitting up No confidence Excludes: Loss of identity Vomiting (S530.0) Identity crisis S080.3 Feeding problem Don’t like myself S085.0 General or unspecified infection Guilt S085. 1 General viral infection S125.0 Restlessness S090.0 Allergy, NOS Includes: Includes: Hyperactivity Allergic reaction, NOS Overactivity Excludes: S130.0 Behavioral disturbances Allergic skin reaction (D825.0) S 130.1 Antisocial behavior Allergy to medications (J905.0) Includes: Nasal allergy (D635.0) Avoiding people S095.0 Disorders of motor functions Excessive shyness Includes: Social isolation Difficulty in walking Withdrawal Clumsiness S130.2 Hostile behavior Limping Includes: Staggering Aggressiveness Stumbling Criminality Uncoordinated Cruelty Destructiveness Symptoms Referable to Psychological Negativism and Mental Disorders (S100-S199) Quarrelsome S 130.3 Hysterical behavior S 100.0 Anxiety and nervousness S1 30.4 Temper problems Includes: Includes: Apprehension Blowing up Bad nerves Losing temper Panicky feeling Temper tantrums Tension S130.5 Obsessions and compulsions Upset S 135.0 Disturbances of sleep Worried S135.1 Insomnia S105.O Fears and phobias Includes: S1 10.0 Depression Sleeplessness Includes: Can’t sleep Crying excessively Trouble falling asleep Dejected S135.2 Sleepiness (hypersomnia) Feeling low Includes: Hopelessness Drowsiness Sadness Can’t stay awake Unhappy S135.3 Nightmares S1 15.0 Anger S1 35.4 Sleepwalking Includes: Bitterness S140.0 Smoking problems Hostile feelings Includes: Excludes: Smoking too much Temper problems (S130.4) Can’t quit smoking

12 S140.0 Smoking probIems–Con. Symptoms Referable to the Nervous System (excluding sense organs) Excludes: (S200-S259) Smoker’s cough (S440.0) Physical symptoms of smoking S2 00.0 Abnormal involuntary movements Includes: (see particular symptom) Shaking S145.0 Alcohol-related problems Jerking Includes: , Tics Drinking problem Tremors Excludes: Twitch Adverse effects of alcohol Excludes: (J915.0) Eye movements (S320.0) Alcoholism (D320.0) Eyelid twitch (S335.4) S150.0 Abnormal drug usage “ S205.0 Convulsions Includes: Includes: Drug abuse Fits Frequent or excessive use of Febrile convulsions 8 stimulants, hallucinogens, depres- Seizures sants, etc. Spells Excludes: Excludes: Drug addiction (D320.0) Fainting (S030.0) Overdose, unintention~ (J910.()) S2 10.0 Headache, pain in head Intoxication with drugs (J9 10.0) Excludes: Sinus headache (S410.1) S 155.0 Delusions or hallucinations Migraine (D365.0) Includes: S21 5.0 Memory, disturbances of Seeing things Includes: Hearing voices Amnesia Medicine is poisoned Forgetfulness S1 60.0 Psychosexual disorders Lack or loss of memory S160.1 Frigidity, loss of sex drive, Temporary loss of memory lack of response S220.0 Disturbances of sensation S 160.2 Homosexuality, concerns with S220.1 Loss of feeling (anesthesia) S1 60.3 Impotence Includes: S 160.4 Premature ejaculation Numbness ., S1 60.5 h4asturbation excessive, con- No response to pain cerns about S220.2 Increased sensation (hyper- S160.6 Orgasm, problem with esthesia) S 165.0 Other symptoms or problems relating S220.3 Abnormal sensation (pares- to psychological and mental disorders, thesia) NEC Includes: Includes: Prickly feeling Can’t cope Burning, tingling sensa- Going cr;zy tion Losing my mind Needles and pins Excludes: S220.4 Other disturbances of sense, Character disorder (D315.0) including smell and taste Personality disorder (D3 15.0) S225.0 Vertigo–dizziness S 165.1 Nailbiting Includes: S1 65.2 Thumb sucking Falling sensation

13 S225.0 Vertigo–dizziness–Con. S275.0 Symptoms of lymph glands (or nodes) Giddiness (dizziness) S2 75.1 Swollen or enlarged glands Lightheadedness S275.2 Sore glands Loss of sense of equilibrium or S280.0 Other symptoms referable to cardio- balance vascul;r/iymphatic system, NEC Room spinning S2 80.1 Poor circulation S230.0 Weakness (necrologic) S280,2 Pallor, paleness Includes: S280.3 Flushed, blushing Right- or left-sided weakness Drooping, facial or NOS Symptoms Referable to the Eyes and Excludes: Ears (S300-S399) General weakness (S020.0) S235.0 Disorders of speech, speech disturbance S305.0 Vision dysfunctions S2 35.1 Stuttering, stammering Excludes: S235.2 Slurring Refractive errors (D405.0) S240.0 Other symptoms referable to the nerv- S305. 1 Blindness and half vision ous system S305.2 Diminished vision Includes: Includes: Pinched nerve “ Blurred vision Confusion Difficulty reading Poor vision Symptoms Referable to the Cardiovascular Trouble seeing and Lymphatic Systems (S260-S299) Can’t see distances S2 60.0 Abnormal pulsations and palpitations Weak eyes S260.1 Increased heartbeat S305.3 Extraneous vision Includes: Includes: Pulse too fast Cloudy vision Rapid heartbeat Hazy vision S260.2 Decreased heartbeat Spots in front of eyes Includes: (floaters) Pulse too slow S305.4 Double vision (diplopia) Slow heart S31O.O Discharge from eye S260.3 Irregular heartbeat S3 10.1 Bleeding Includes: S3 10.2 Tearing, watering (Iacrimation) Fluttering S3 10.3 Pus, matter, white discharge Skipped beat S315.O Eye infection and inflammation S26.5.0 Heart pain S3 15.1 Pinkeye Includes: S320.0 Abnormal sensations of the eye Heart distress S320.1 Pain Pain over heart S320.2 Itching Excludes: S320.3 Burning Angina pectoris (D515.0) S320.4 Strain Chest pain (S050.1) S325.0 Abnormal eye movements S270.0 Other symptoms of the heart S325.1 Abnormal retraction Includes: S325.2 Cross-eyed Bad heart S325.3 Pupils unequal Poor heart S325.4 Deviation Weak heart S330.O Abnormal appearance of eyes Heart condition S330.1 Abnormal color

14 S330.0 Abnormal appearance of eyes–Con. S360.0 Plugged feeling in ear–Con. Includes: Blocked Bloodshot Cracking Red Popping Excludes: Ears need cleaning Yellow (S610.2) S365.0 Other symptoms referable to the ears, S330.2 Protrusion (exophthalmos) NEC S330.3 Cloudy, dull, hazy appearance S3 65.1 Itching S335.0 Other symptoms referable to eye, NEC S365.2 Growths or mass S335.1 Contact lens problems S365.3 Pulling at ears, picking at ears S335.2 Allergy S365.4 Abnormal size or shape, “ears S335.3 Swelling stick out” Excludes: Excludes: Foreign body (J600.0) Foreign body in ear Injury (J51 0.0) (J620.0) Abrasion (J41O.O) S340,0 Symptoms of eyelids Symptoms Referable to the Respiratory S340.1 Infection, inflammation, swell- System (S400-S499) ing S400.0 Nasal congestion S340.2 Itching Includes: S340.3 Mass or growth Drippy nose, runny nose, post- S340,4 Abnormal movement nasal drip, sniffles, stuffy nose Includes: Nasal obstruction Twitching S405.0 Other symptoms of nose Blinking Excludes: Squinting Allergy (D635.0) Drooping S405.1 Nosebleed (epistaxis) S345.0 Hearing dysfunctions S405.2 Sore in nose S345.1 Diminished hearing S405.3 Inflammation and swelling Includes: Includes: Deafness Sore nose Trouble hearing Infection Hearing loss Red nose S345.2 Heightened or acute hearing S405.4 Problem with appearance of S345.3 Extraneous hearing nose Includes: Includes: Ringing (tinnitus) Too large Excludes: Bump(s) Hearing things (S155.0) Undesirable appearance S350.0 Discharge from ear S4 10.0 Sinus problems S350.1 Bleeding S41 0.1 Pain and pressure S350.2 Pus (purulent drainage) Includes: S350.3 Swimmer’s ear Sinus headache S355.0 Earache, or ear infection S41 0.2 Sinus inflammation, infection S355.1 Earache, pain’ S41 0.3 Sinus congestion S355.2 Ear infection S415.0 Shortness of breath S360.0 Plugged feeling in ear Includes: Includes: Breathlessness Ear wax Sensation of suffocation

15 S420.0 Labored or difficult breathing S460.0 Symptoms referable to tonsils (dyspnea) Includes: S425.0 Wheezing Infection Includes: Inflammation Sighing respiration S470.0 Abnormalities of sputum or phlegm S430.0 Breathing problems, NEC S470.1 Coughing up blood S430.1 Disorders of respiratory S470.2 Pus in sputum sound, NEC S470.3 Excessive sputum Includes: S475.0 Congestion in chest Abnormal breathing Includes: sounds Lung congestion Snoring Chest cold Rattles S480.0 Disorders of voice Strider S480.1 Hoarseness, loss of voice S430.2 Rapid breathing (hyperventi- S480.2 Hypernasality lation) S485.0 Other symptoms referable to the respi- S435.0 Sneezing ratory system, NEC S440.O Cough Includes: Symptoms Referable to the Digestive Croupy cough System (S500-S639) Smoker’s cough S4’45.O Head cold, upper respiratory infection S500.O Symptoms of teeth and gums (coryza) S500.1 Toothache Includes: S500.2 Gum pain Cold, NOS S500.3 Bleeding gums Excludes: S505.O Symptoms referable to lips Chest cold (S475.0) S505.1 Cracked, bleeding, dry S450.0 Flu S5 05.2 Abnormal color Includes: S505.3 Cold sore Grip S51O.O Symptoms referable to mouth Influenza S5 10.1 Pain, burning, soreness Excludes: S5 10.2 Bleeding Croup (D600.0) S5 10.3 Dryness S455.0 Symptoms referable to throat S51 0.4 Ulcer, sore S455.1 Soreness S515.O Symptoms referable to tongue S455.2 Pain S515.1 Pain S455.3 Infection S5 15.2 Bleeding Includes: S5 15.3 Inflammation, infection, swell- Throat virus ing Excludes: S5 15.4 Abnormal color, ridges, coated Strep throat (DO1O.O) S520.0 Difficulty in swallowing (dysphagia) S455.4 Irritation, scratch, tickle Includes: S455.5 Swelling Choking S455.6 Lump or mass Inability to swallow Includes: S525.0 Nausea Sensation of something Includes: in throat Upset stomach Excludes: Sick to stomach Foreign body in throat Nervous stomach (J615.0) Feel like throwing up

16 S530.0 Vomiting S570.O Appetite abnormaI-Con. Includes: S5 70.2 Decreased appetite Can’t keep food down Not hungry Throwing up Loss of appetite Retching S580.0 Gastrointestinal bleeding Excludes: S580.1 Blood in stool (melena) Regurgitation, infants (S080.2) S580.2 Vomiting blood (hemateme- Vomiting blood (S580.2) sis) S535.0 Heartburn and indigestion (dyspepsia) S585.0 Flatulence Includes: Includes: Excessive belching Bloated, gas S540.0 Gastrointestinal infection Excessive gas Includes: Distention due to gas Stomach flu Excludes: Stomach virus Gas pains (S550.0) Intestinal virus S590.O Constipation S545.0 Stomach pain, cramps and spasms S595.O Diarrhea S545.1 Pain Includes: Includes: Loose stools Stomachache, inflamma- The runs tion Other symptoms or changes in bowel S545.2 Cramps, spasms S600.0 function S550.0 Abdominal pain, cramps, spasms S600.1 Discharge in stools Includes: Includes: Intestinal colic Mucus Gas pains Pus Excludes: S600.2 Worms Groin pain (S055.3) S600.3 Changes in size, color, shape, S550.1 Lower abdominal pain or odor Includes: Includes: Right lower quadrant Bulky stools (RLQ) pain Too narrow Left lower quadrant Unusual odor or color (LLQ) pain S600.4 Incontinence of stool S550.2 Upper abdominal pain Includes: Includes: Dirty pants (encopresis) Epigastric pain Leaking stools Left upper quadrant Symptoms referable to anus-rectum (LUQ) pain S605.0 S605.1 Pain Pain in umbilical region S605.2 Bleeding Right upper quadrant S605.3 Swelling or mass (RUQ) pain S605.4 Itching S565.0 Change in abdominal size S565.1 Distention, fullness, NOS S61O.O Symptoms of liver, gallbladder, and S565.2 Mass or tumor biliary tract S565.3 Abdominal swelling, NOS S61O.1 Pain S5 70.0 Appetite, abnormal S61O.2 Jaundice S5 70.1 Excessive appetite Includes: Eats too much Yellow eyes Always hungry Yellow skin

l-i S61 5.0 Other symptoms referable to digestive Sb6U.U“” ““ “ Other symptoms referable to urinary system tract—Coti. Includes: Excludes: Bad breath (halitosis) Kidney stones or bladder stones Stomach problem (D705.0) Hiccoughs S700.O Symptoms of penis Gastrointestinal distress S700. 1 Pain, aching, soreness, tenderness, painful erection S700.2 Infection, inflammation, swell- Symptoms Referable to the Genitourinary ing System (S640-S829) S700.3 Lumps, bumps, growths, warts S640.0 Abnormalities of urine S705.O Penile discharge Excludes: S71O.O Symptoms of prostate Abnormal findings of urine tests Includes: (R200.0) Prostate trouble S640.1 Blood in urine (hematuria) S7 10.1 Swelling S640.2 Pus in urine S7 10.2 Infection S640.3 Unusual color or odor S715.O Symptoms of scrotum and testes S645.0 Frequency and urgency of urination S7 15.1 Pain, aching, tenderness S645.1 Excessive urination, night S7 15.2 Swelling, inflammation (nocturia) S7 15.3 Growths, warts, lumps, bumps S650.0 Painful urination S7 15.4 Itching, jock itch Includes: S720.0 Other symptoms of male reproductive Burning, discomfort system S655.0 Incontinence of urine (enuresis) Excludes: S655.1 Involuntary urination, can’t Psychosexual problems (S160.0) hold urine, dribbling S730.O Absence of menstruation (amenorrhea) S655.2 Bedwetting Excludes: S660.0 Other urinary dysfunctions Suspected pre~ancy (X200.0) S660.1 Retention of urine Missed a period (X200.0) Can’t urinate Period late (X200.0) S660.2 Hesitancy S735.O Irregularity of menstrual interval Difficulty in starting stream S735.1 Frequent S660.3 Large volume S735.2 Infrequent S665.0 Symptoms of the bladder S735.3 Unpredictable Includes: S740.O Irrewlarity of menstrual flow Bladder trouble S740.1 Excessively heavy (menorr- S665.1 Pain hagia) S665.2 Infection S740.2 Scanty flow (oligomenorrhca) S670.0 Symptoms of the kidneys S740.3 Abnormal material, including Includes: clots Kidney trouble S745.O Menstrual symptoms, other and un- S670.1 Pain specified S6 70.2 Infection S745. 1 Premenstrual symptoms S675.0 Urinary tract infection, NOS Includes: Includes: Premenstrual tension or Genitourinary infection irritability Urine infection Bloating before periods S680.0 Other symptoms referable to urinary S745.2 Painful menstruation (dysmen- tract orrhea) Includes: Includes: Passed stones Menstrual cramps

18 S745.O Menstrual symptoms, other and un- S790.0 Problems of pregnancy and the post- specified—Con. partum period-Con. Pain in legs and back dur- Ruptured membranes ing menstruation Labor pain, contractions S750.O Menopausal symptoms S790.4 Postpartum problems I;cludes: - S750.-1 Early o; late onset of meno- Bleeding pause Pain S750.2 Vasomotor symptoms–hot the flashes S795.0 Other symptoms referable to female reproductive system S750.3 Emotional symptoms, change S800.0 Pain or soreness of breast of life problems Includes: Uterine and vaginal bleeding S755.O Tenderness Excludes: S805.0 Lump or mass of breast Bleeding during pregnancy Includes: (S790.2) Bump, knot, nodule, cyst S755.1 Intermenstrual bleeding S8 10.0 Other symptoms referable to breast (metrorrhagia) S8 10.1 Bleedlng or dkcharge from Includes: nipple Breakthrough bleeding S8 10.2 Postpartum problems Bleeding between periods Includes: S755.2 Postmenopausal bleeding Engorgement S755.3 Postcoital bleeding Postpartum infection S760.0 Vaginal discharge Nursing difficulties Includes: S8 10.3 Problems with shape or size Bloody, brown, white (leukor- Includes: rhea), excessive Too large S765.0 Other vaginal symptoms Too small S765.1 Pain Sagging S765.2 Infection Uneven development S765.3 Itching, burning S81 5.0 Symptoms of infertility S770.O Vulvar disorders Includes: S7 70.1 Itching and irritation, swelling Can’t get pregnant S770.2 Mass, lump Inability to conceive S7 70.3 Growth, wart, cyst, ulcer, sore Sterility S775.O Pelvic symptoms S820.0 Hormone deficiency or problem S775.1 Pain S825.0 Symptoms of sexual dysfunction S7 75.2 Pressure or dropping sensation Includes: Includes: Dyspareunia Feeling of uterus falling Painful intercourse Out Excludes: S775.3 Infection, inflammation Psychological disorders (S160.0) S790.O Problems of pregnancy and the postpartum period Symptoms Referable to the Skin, Nails, Excludes: and Hair (S830-S899) Routine prenatal visits (X205.0) S790.1 Pain during pre~ancy S830.0 Acne or pimples S790.2 Spotting, bleedingduring preg- Includes: nancy Bad complexion S790.3 Symptoms of onset of labor Blackheads Includes: Blemishes Water broke Breaking out

19 S830.0 Acne or pimples–Con. S875.0 Swelling of skin Complexion, NOS Includes: Whiteheads Bumps, lumps S835.0 Discoloration or pigmentation Nodules Includes: Welts, except hives (D825.0) Freckles Tumor, skin Blotches S880.0 Other symptoms referable t.o skin Redness S880.1 Oiliness spots S880.2 Dryness, peeling, scaliness Circles under eyes S880.3 Wrinkles Excludes: S885.0 Symptoms referable to nails Jaundice (S610.2) S885.1 Infected Bruise (J405.0-J430.0) S885.2 Ingrown Flushing (S280.3) S885.3 Brittle, breaking, splitting, Blushing (S280.3) cracked, ridged S840.0 Infections of skin, NOS S890.0 Symptoms referable to hair and scalp Excludes: S890.1 Too little hair Athlete’s foot (D025.0) Baldness (alopecia) S840.1 Infection of skin of head or Falling out neck area Losing hair S840.2 Infection of skin of arm, hand, S890.2 Unwanted hair or finger Superfluous hair S840.3 Infection of skin of leg, foot, Abnormal hairiness (hirsutism) or toe S890.3 Dryness, flaky scalp S845.0 Symptoms of skin moles S890.4 Itching Includes: S895.0 Other symptoms of skin, nails, and hair Skin mole, NOS Includes: S845.1 Change in size or color Navel problems S845.2 Bleeding mole Umbilicus not healing S850.0 Warts, NOS Excludes: Symptoms Referable to the Musculoskeletal Plantar’s warts (DO 15.0) System (S900-S999) S855.0 Other growths of skin These codes exclude all injuries. (See Injuries Includes: and Adverse Effects Module.) Skin growth, NOS Cysts, NOS The following fourth di~ts should be used with callus categories S900-S9 70. Corns .1 pain, ache, soreness S860.0 Skin rash .2 cramps, contractures, spasms Excludes: .3 limitation of movement, stiffness Poison ivy (D825.0) .4 weakness Poison oak (D825.0) .5 swelling S860.1 Diaper rash .6 lump, mass, tumor S865.0 Skin lesion S900.0 Neck symptoms Includes: S905.0 Back symptoms Ulcer, sore, blister S91O.O Low back symptoms S870.0 Skin irritations, NEC S9 15.0 Hip symptoms S870.1 Pain S920.0 Leg symptoms S870.2 Itching S925.0 Knee symptoms

20 S930.O Ankle symptoms D020.O Venereal diseases S935.O Foot and toe symptoms Includes: S94’O.OShoulder symptoms Syphilis S945.O Arm symptoms Gonorrhea S950.O Elbow symptoms Venereal diseases, NOS S955.O Wrist symptoms D025.O Fungus infections (mycoses) S960.0 Hand and finger symptoms Includes: S965.0 Symptoms of unspecified muscles Candidiasis S970.O Symptoms of unspecified joints Yeast infection S975.O Musculoskeletal deformities Moniliasis Excludes: Dermatophytoses Clubfoot (D960.0) Athlete’s foot Curvature of spine (D91O.O) Ringworm S9 75.1 Bowlegged, knock-kneed Thrush S9 75.2 Posture problems D03 0.0 Parasitic diseases S9 75.3 Pigeon-toed, feet turn in Includes: S980.0 Other musculoskeletal symptoms. . Pinworms Includes: Ascaris Bone pain Lice Stump pain Maggots Leeches D035.O Other and unspecified infectious and DISEASE MODULE parasitic dise&es Includes: Infective and Parasitic Diseases (DOOI-D099) Staphylococcal infections Trichomonas vaginitis DO05.0 Intestinal infectious diseases Includes: Neoplasms(D100-D199) Gastroenteritis Enteritis Malignant neoplasms Cholera Salmonella D 100.0 Cancer, gastrointestinal tract Dysentery Includes: DO1 0.0 Streptococci..l infection Esophagus Includes: Stomach Streptococcal tonsillitis Small intestine Scarlet fever Colon DO 15.0 Viral diseases D 105.0 Cancer, respiratory tract Includes: Includes: Chickenpox Bronchus Shingles (Herpes zoster) Lung Herpes simplex Larynx Measles Trachea German measles (rubella) Throat Mumps D 110.0 Cancer, skin and subcutaneous tissues Infectious mononucleosis Includes: Hepatitis (infectious and NOS) h4elanoma Smallpox Basal cell carcinoma Poliomyelitis Squamous cell carcinoma

21 D 115.0 Cancer, breast Endocrine, Nutritionalr and Metabolic D 120.0 Cancer, female genital tract Diseases (D200-D249) Includes: D200.O Diseases of the thyroid gland Uterus Includes: Cervix Thyrotoxicosis Fallopian tube(s) Thyroid nodule Vagina Hyperthyroidism Vulva Goiter Ovary (ies) Myxedema Endometrium Hypothyroidism D 125.0 Cancer, urinary and male genital tract Includes: D205.O Diabetes mellitus Bladder D2 10.0 Gout, hyperuricemia Kidney D2 15.0 Other endocrine, nutritional, and meta- Prostate bolic diseases Includes: D 130.0 Other malignant and unspecified neo- Hypoglycemia plasms Includes: Hyperlipidemia Metastatic carcinoma Disorders of intestinal absorption Ovarian dysfunction Brain tumor Bone cancer D 135.0 Hodgkin’s disease, lymphomata, leuke- Diseases of the Blood and Blood- mias Forming Organs (D250-D299) Includes: D250.O Anemia Multiple myeloma Includes: Polycythemia vera Iron deficiency anemia Lymphosarcoma Sickle cell anemia Cancer of blood Pernicious anemia Anemia, NOS Benign neofdasms D255.O Other diseases of blood and blood- D140,0 Fibroids and other uterine neoplasms forming organs Includes: Myoma Mental Disorders (D300-D349) Leiomyomata Cervical polyp D300.O Organic psychoses Nabothian cyst Includes: D 145.0 Other benign neoplasms Organic brain syndromes Includes: Senile dementia Rectal polyp Alcoholic psychoses Ovarian cyst D305.O Functional psychoses Bartholin’s cyst Includes: Lymphoma Schizophrenia, all types Vaginal inclusion Manic-depressive psychoses Nasal polyp Paranoid states Dermoid cyst (ovary) Psychosis, NOS Excludes: D3 10.0 Neuroses Pilonidal cyst (D825.0) Includes: Sebaceous cyst (D825.0) Depressive neurosis Epidermoid cyst (D825.0) Depressive reaction Cyst, NOS (S855.0) Anxiety reaction

22 D31O.O Neuroses–Con. D405.O Refractive error-Con. Obsessive compulsive neurosis Excludes: Neurosis, NOS Test for refractive errors (X230.0) Excludes: D41O.O Cataract Depression (S1 10.0) D415.O Glaucoma Anxiety (S100.0) D420.O Other diseases of the eye D315.O Personality and character disorders Includes: D320.O Alcoholism and drug dependence Retinal detachment Includes: Strabismus Drug addiction Aphakia D325.O Mental retardation Diseases of the Ear (D450-D499) D330.O Other mental disease Includes: D450.O Otitis media Transient situational disturbances S455.0 Other diseases of the ear Adolescent adjustment reaction Includes: Grief reaction Ruptured tympanic membrane Sexual deviations Labyrinthitis Excludes: Diseases of the Nervous System Infection, NOS (S355.2) (D350-D399) Deafness (S345.1)

D350.O Multiple scIerosis Diseases of the Circulatory System D355.O Parkinson’s dkease (paralysis. agitans) (D500-D599) D360.O Epilepsy D365.O Migraine headache D5 00.0 Rheumatic fever and chronic rheumatic D370.O Other diseases of central nervous heart dkiease system Includes: Includes: Chorea Carpal tunnel syndrome D505.O Hypertension with involvement of tar- Bell’s palsy get organs Cerebral palsy Includes: Demyelinating disease Hypertensive heart disease Paralysis, NOS Renal hypertension HCD HCVD Diseases of the Eye (D400-D449) Hypertensive cardiovascular D400.O Inflammatory diseases of the eye disease Includes: D5 10.0 Hypertension Conjunctivitis Includes: Ophthalmia High blood pressure sty D5 15.0 Ischemic heart disease Blepharitis Includes: Keratitis Myocardial infarction Ulcer Coronary artery disease Excludes: Coronary Infection, NOS (S315.0) Heart attack D405.0 Refractive error Arteriosclerotic heart disease Includes: (ASHD) Myopia, nearsightedness Arteriosclerotic cardiovascular Hyperopia, farsightedness disease (ACVD) Astigmatism Angina pectoris

23 D520.O Other heart disease D625.O Asthma Includes: D630.O Pneumonia Cardiac dysrhythmias Includes: Atrial fibrillation Viral pneumonia Paroxysmal tachycardia Bacterial pneumonia Congestive heart failure Bronchopneumonia Heart failure Pneumonitis Heart murmur D635.O Hay fever D525.0 Cerebrovascular disease Includes: Includes: Allergic rhinitis Cerebrovascular accident (CVA) Nasal allergy Stroke Pollenosis D530.O Atherosclerosis Allergy to: Includes: Dust Arteriosclerosis Pollen Hardening of the arteries Animals D535.O Phlebitis, thrombophlebitis Ragweed Includes: D640.O Other respiratory diseases Phlebothrombosis Includes: D540.O Varicose veins Pulmonary edema D545.O Hemorrhoids Deviated nasal septum D550.O Other disease of circulatory system Pneumothorax Includes: Hemothorax Pulmonary embolism Pleurisy Heart disease, NOS Lymphadenopathy Diseasesof the Digestive System Lymphadenitis (D650-D699)

Diseasesof the Respiratory System D650.O Diseases of the esophagus, stomach, (D600-D649) and duodenum Includes: D600.O Upper respiratory infections except Esophagitis tonsillitis Duodenal ulcer Includes: Peptic ulcer Pharyngitis Gastritis Sinusitis Stomach ulcer Laryngitis Excludes: Croup Stomach flu (S540.0) Rhinitis Gastroenteritis (DO05.0) Excludes: D655.O Appendicitis, all types Allergic rhinitis (D635.0) D660.O Hernia of abdominal cavity Cold (S445.0) Includes: Throat infection, NOS (S450.2) Inguinal Nose infection, NOS (S405.3) Hiatus Sinus infection, NOS (S410.2) .4bdonlinaI D605.O Tonsillitis Femoral D6 10.0 Bronchitis Umbilical Includes: Ventral Chronic bronchitis D665.O Diseases of the intestine and peri- Bronchitis, NOS toneum Acute bronchitis Includes: D620.O Emphysema “ Diverticulitis

24 D665.0 Diseases of the intestine and peri- D7 10.0 Diseases of the male genital or- toneum—Con. ! gans-Con. Diverticulosis Hydrocele Spastic colitis Phimosis Irritable bowel syndrome Epididymitis Ulcerative colitis Peyronie’s disease Crohn’s disease Excludes: IIeitis Prostate infection (S71 0.2) Fistula–rectal, anal D7 15.0 Fibrocystic and other diseases of breast Fissure–rectal, anal Excludes: Excludes: Infection (S810.0) Intestinal virus (S540.0) Cancer (Dl 15.0) D670.O Diseases of liver, gallbladder, and D720.O Pelvic inflammatory disease (PID) pancreas Includes: Includes: %lpingitis Biliary colic Oophoritis Cirrhosis Pelvic peritonitis Liver diseases Excludes: Cholelithiasis (gallstones) Pelvic infection, NOS (S775.3) Cholecystitis Pancreatitis D725.O Cervicitis, vaginitis Includes: D67 5.0 Other diseases of digestive system Includes: Cervical erosion Stomatitis D730.O Other diseases of female reproductive Canker sore system Includes: Endometriosis Diseases of the Genitourinary System Rectal-vaginal fistula (D700-D799) Prolapse of uterus D700.O Cystitis Dysfunctional uterine bleeding Excludes: Vulvitis Bladder infection (S665.2) Polycystic ovaries D705.O Urinary tract disease except cystitis Cystocele Includes: Rectocele Urethritis D73 5.0 Diagnosed complications of pregnancy Pyelonephritis and puerperium Glomerulonephritis Includes: Glomerulonephrosis Placenta previa Ureteral calculus Ectopic pregnancy Renal failure Toxemia Kidney stones Threatened abortion Bladder stones Spontaneous abortion Excludes: Hyperemesis Bladder infection (S665.2) Fetal death in utero Kidney infection, NOS (S670.2) Diabetes during pregnancy Passed stones (S680.0) Edema of pregnancy Urinary tract infection (S675.0) High blood pressure during preg- D7 10.0 Diseases of the male genital organs nancy Includes: RH sensitization Prostatitis Multiple pregnancy Benign prostatic hypertrophy Excludes: (BPH) Abortion induced (X520.0)

25 Diseases of the Skin and Subcutaneous D9 10.0 Other musculoskeletal or connective Tissue (D800-D899) tissue disease—Con. Scoliosis Carbuncle, furuncle, boil, cellulitis, D800.O Kyphoscoliosis abscess, NEC Kyphosis D805.O Impetigo Osteoporosis D8 10.0 Seborrheic dermatitis Degenerative disc diseases Includes: Osteomyelitis Dandi-uff Bone cysts D81 5.0 Eczema and dermatitis, NOS Bunions D820.O Psoriasis D825.O Other diseases of the skin Congenital Anomalies (D950-D989) Includes: Allergic skin reactions D95 0.0 Congenital anomalies of heart and cir- Pilonidal cyst culatory system Urticaria D955.O Undescended testicles Hives Includes: Keloid Hypospadias Sebaceous cyst D960.O Other congenital anomalies Paronychia Includes: Lupus erthematosus discoid Cleft palate Epidermal inclusion cyst Cleft lip Poison ivy Deformed earlobe Poison oak Clubfoot Excludes: Harelip Cyst, NOS (S855.0) Congenital dislocation of hip Acne (S830.0) Blocked tear duct Absence of organs Diseases of the Musculoskeletal System Duplication of organs and Connective Tissue (D900-D949) Perinatal Morbidity and Mortality D900.O Arthritis Conditions (D990-D999) Includes: Osteoarthritis D990.O All perinatal conditions Rheumatoid arthritis Rheumatism, NOS D905.O Nonarticular rheumatism DIAGNOSTIC, SCREENING, AND Includes: PREVENTIVE MODULE Bursitis Synovitis General Examinations (X IOO-X199) Tenosynovitis Tendinitis Xl 00.0 General medical examination Myositis Includes: Lumbago Annual exam Excludes: Checkup, NOS Rheumatism, NOS (D900.0) Checkup, routine D910.0Other musculoskeletal or connective General exam tissue disease Multiphasic screening exam Includes: Regular exam Systemic lupus erythematosus Routine exam Curvatures of spine Physical exam

26 Xl 00.0 General medical examination–Con. X230.OEye examination Excludes: Includes: Administrative exam (AI OO.O- Routine ophthalmological exam A140.0) To test my eyes Followup visit (T800.0) Need new glasses Gynecological exam (X225.0) Test for nearsightedness, far- Prenatal exam (X205.0) sightedness Progress visit (T800.0) For glasses X105.O Well baby examination For contacts X130.O General psychiatric or psychological Vision test examination Excludes: Includes: Fitting glasses or contacts Psychological testing (T515.0) Excludes: X235.O Heart examination Court- or school-ordered examina- Includes: tion (A140.0) Heart checkup Cardiac check Special Examinations (X200-X299) X240.0 Other special examination Includes: X200.O Pregnancy, unconfirmed Neurological exam Includes: Examination of functioning in- Might be pregnant ternal prosthetic devices, Period late implants, shunts, etc. Late menses Pregnancy test Diagnostic Tests (X300-X399) Possible pregnancy Missed period X300.O Sensitization test X205.O Prenatal examination, routine Includes: Includes: Allergy test Routine obstetrical care Excludes: Normal antepartum visit To check results of skin tests Pregnancy, NOS (R600.0) X21 5.0 Postpartum examination X305.0 Skin immunity test X220.O Breast examination Includes: Excludes: Tuberculin test Mammography (X340.0) PPB test Xerography (X340.0) Excludes: Breast thermography (X340.0) To check results of skin tests S225.0 Gynecological examination (R600.0) Includes: X310.0 Glucose level determination Pelvic exam Includes: Excludes: Blood sugar test Repeat or abnormal Pap smear Glucose tolerance test (R300.0) Test for diabetes Examination involving IUD X315.O Other blood test (X51O.O) Includes: Examination for birth control pills Blood count (X505.0). Blood culture Examination for birth control, Blood test, NOS NOS (X500.0) Blood thinning test

27 X315.O Other blood test–Con. X370. 1 Glaucoma test Check cholesterol X370.2 Throat culture Prothrombin time Sickle cell anemia test Other Screening and Preventive Excludes: Procedures (X400-X499) Premarital blood test (A135.1) X400.O Prophylactic inoculations X315.1 Blood test for venereal disease Includes: X320.0 Blood pressure test Vaccination Includes: Immunization Check blood pressure Flu shot Blood pressure check Tetanus shot Urine tests X325.O X405.O Exposure to venereal disease Includes: Includes: Test urine for sugar May have V.D. Urinalysis Check for V.D. Estriol for fetal evaluation X41O.O Exposure to other infectious diseases Urine culture Includes: X330.0Diagnostic endoscopies Chickenpox Includes: Infectious hepatitis Proctoscopy Measles Sigmoidoscopy Mumps Cystoscopy Tuberculosis Laparoscopy X335.OBiopsies Family Planning (X500-X599) X340.OMammography, xerography, breast thermography X500.0 Family planning, NOS Excludes: Includes: Breast examination (X220.0) Counseling, examinations, and X345.ODiagnostic radiography general advice regarding: Includes: Birth control, NOS X-ray Unwanted pregnancy Myelogram Contraceptive, NOS Radioisotope scanning Sterilization IVP Infertility Angiograrn Genetics Venogram Contraception followup, NOS Hysterosalpingogram Excludes: X350.OEKG, ECG, electrocardiogram, tread- Specified types of birth control: mill, stress testing Birth control pill (X505.0) X355.OEEG, electroencephalogram IUD (X51O.O) X360.OHearing test Procedures performed [see Includes: Counseling and examinations for Hearing exam pregnancy interruption (X5 15.0) X365.OPap smear through Sterilization to be per- X370.OOther and unspecified diagnostic tests formed (at this visit) (X525.0)] Includes: X505.0 Contraceptive medication Centesis Includes: Electronic fetal monitoring Examinations, instructions, and Lab test, NOS advice regarding: Spinal tap Birth control pills Pulmonary function test Renewing pill prescription

28 X505.O Contraceptive medication–Con. T1 15.0 Medication, other and unspecified Oral contraceptives kinds-Con. Foams, jellies Request prescription X510.0 Contraceptive device Prescribe medication Includes: Check medication IUD insertion, removal, checkup Excludes: Diaphragm insertion, removal, Birth control medication (X505.0) checkup Eyeglass prescription [see Eye X515.0 Counseling and examinations for preg- examination (X230.0) and nancy interruption Fitting glasses and contact lenses Includes: (T515.0)] Evaluation for and arrangement Antibiotic medication (Tl 10.0) for abortion Wants abortion Preoperative and Postoperative Care S520.0 Abortion to be performed (at this visit) (T200-T299) X525.O Sterilization to be performed (at this visit ) T200.O Preoperative visit for specified and un- Includes: specified types of surgery Male-vasectomy Includes: Female-tubal ligation Discussion of cosmetic surgery X530.O Artificial insemination T205.O Postoperative visit Includes: Postop care TREATMENT MODULE Postop pain Postop suture removal Medications (T IOO-T199)

TIOO.O Allergy medication Specific Types of Therapy (T400-T4W) Includes: T400.O Physical medicine and rehabilitation Allergy shots Allergy treatments Includes: Physical therapy Excludes: Heat therapy Allergy testing (X300.0) Hydrotherapy y T1 10.0 Injections Therapeutic exercises Includes: Back adjustment Hormones Occupational therapy vitamins Recreational therapy Iron Speech therapy Injections, NOS Vocational rehabilitation Shots, NOS T405.O Respiratory therapy Excludes: Includes: Immunizations (X400.0) Inhalation therapy Vaccinations (X400.0) Asthma treatment Inoculations (X400.0) T41O.O Psychotherapy Allergy shots (TIOO.O) Includes: T1 15.0 Medication, other and unspecified Group therapy kinds Psychoanalysis Includes: T41 5.0 Radiation therapy Renew prescription T420.O Acupuncture For medication T425.O Chemotherapy

29 Specific Therapeutic Procedures Medical Counseling (T600-T699) (T500-T599) T600.0 Diet and nutritional counseling Includes: T500.O Tube insertion Check weight Includes: Counseling for weight reduction Chest tube T605.O Counseling, NOS T505.O Cauterization, all sites Wants to talk to doctor T51O.O Urinary tract instrumentation and Medical consultation catheterization Patient education Includes: To learn about a condition Urethral dilation Personal problem Excludes: Disease counseling Cystoscopy [see Diagnostic endoscopies (X330.0)] Social Problem Counseling (T700-T799) T515.O Fitting glasses and contact lenses T700,0 Economic problem Includes: Includes: Prescription renewal Too little income Broken or lost glasses Can’t pay bills Pick up glasses T705.O Marital problems Excludes: Includes: Eye examination (X230.0) Problem with husband, wife T520.o Minor surgery Alcoholic spouse Includes: Marriage counseling, NOS Ears pierced Premarital counseling Joint manipulation Divorce, desertion, separation Tattoo removal T7 10.0 Parent-child problems T520.1 Wart removal Includes: Working mother Kidney dialysis T525.O Concern about childhood T530.O External prosthetic devices, artificial behavior body parts (fit, adjust, remove) Discipline T535.O Corrective appliances Maturation problems Includes: Child neglect and abuse Fitting and adjusting: Adopted or foster child Back brace T715.O Other problems of family relationship Leg brace Includes: Neck brace Aged parents or in-laws Orthopedic shoes Problems with relatives T540.0 Cast, splint–application, removal Family fights and disruptions T545.O Dressing, bandage-application, change T720.0 Educational problems Includes: T550.O Irrigation, lavage Absenteeism, truancy T555.O Suture–insertion, removal Problems with teachers T560.O Other specific therapeutic procedures, Hates school NEC School behavior problems Includes: T725.O Occupational problems Ultraviolet treatment Includes: Enema Unemployment Eye exercises Out of work

30 T725.O Occupational problems–Con. JO1O.O Spinal column Job dissatisfaction Includes: Problem with boss or coworkers Neck, vertebrae, back T730.O Social adjustment problems J015.O Trunk area, except spinal column Includes: Includes: Loneliness Rib, clavicle, collarbone Social isolation J020.O Leg Neighborhood and community Includes: relations problems Knee, femur, tibia, fibula, hip Discrimination problems J025.O Ankle Don’t have any friends J030.O Foot and toes T735.O Legal problems J035.O Arm Includes: Includes: Imprisonment, prosecution Radius, ulna, elbow, shoulder Lawsuits, litigation J040.O Wrist T740.O Other social problems J045.O Hand and fingers Includes: J050.O Fracture, other and unspecified Pregnancy out-of-wedlock Sprains and strains Disasters Housing and clothing problems J105.O Cervical spine, neck Includes: Progress Visit, N EC (T800-T899) Whiplash J11O.O Back T800,0 Progress visit, NOS (Use only when the only information given is progress or J115.O Knee followup) J120.O Ankle Includes: J125.O Wrist Followup, NOS J130.O Sprain or strain, other and unspecified Routine followup Lacerations and cuts I’m better J205.O Head and neck area Excludes: Excludes: General checkup (X1 OO.O) Face (J21O.O) Followup, disease (Code to J21O.O Facial area disease) Includes: Followup, injury (Code to injury) Eye, ear, nose Followup, symptom (Code to J215.O Trunk area symptom) J220.O Lower extremity Followup, test results (Code to Includes: R1OO.O-R7OO.O) Ankle, foot Postoperative followup (T205.0) J225.O Upper extremity Includes: INJURIES AND ADVERSE EFFECTS Hand, fingers, arm, wrist MODULE J230.O Laceration and cuts, site unspecified 1njury by Type and/or Location Puncture wounds (JOOI-J799) J305.O Head, neck, and facial area Fractures and dislocations J31O.O Trunk area JO05.O Head and face J315.O Lower extremity Includes: J320.O Upper extremity Skull, jaw, nose, facial bones J325.O Puncture wound, site unspecified

31 Contusions, abrasions, and bruises J720.O Burn, site unspecified J750.O Sunburn, windburn J405.O Head, neck, and face Excludes: Bites Eye (J41O.O) J41O.O Eye J755.O Insect Includes: Includes: Corneal abrasion Sting Black eye J760.O Animal, human J415.O Trunk area J420.O Lower extremity J425.O Upper extremity Injury, NOS (J800-J899) J430.O Contusion, abrasion, bruise, site unspecified J800.O Late effects of an old injury Includes: Injury, type unspecified Scars J505.O Head, neck, and face Deformities J51O.O Eye J805.O Motor vehicle accident, type of injury J515.O Back unspecified J520.O Chest and abdomen Includes: Includes: Car accident Internal injuries Auto accident J525.O Hip Motorcycle accident J530.O Leg J81O.O Accident, NOS J535.O Knee Includes: J540.O Ankle Fall, type or location of injury J545.O Foot and toe(s) unspecified J550.O Shoulder J815.O Violence, NOS J555.O Arm Includes: J560.O Elbow Beat up J565.O Wrist Stabbing J570.O Hand and finger(s) Gunshot wound J575.O Injury, multiple or unspecified In a fight Excludes: Foreign body Violence against oneself (J820.0) J600.O Eye J820.O Suicide attempt J605.O Nose Includes: J61O.O Skin Found in car with motor running J615.O Digestive tract Hanging oneself Includes: Stabbed oneself Mouth Slashed wrists Throat Code also: Laceration of wrists Rectum (J225.0) J620.O Other and unspecified sites J820.1 Overdose, intentional J830.O Rape Burns, all degrees Includes: J705.O Head, neck, and face Sexual assault J71 0.0 Trunk area Sexual abuse J715.O Extremities Molestation Includes: J835.O Dead on arrival (DOA) Upper Includes: Lower Death

32 J840.O Unconscious on arrival TESTS RESULTS MODULE (Includes Includes: all abnormal test results and followups Coma for test results) Stupor Knocked out R1OO.O For results of blood glucose tests Shock Includes: Cardiac arrest Unresponsive High blood sugar Found unconscious Abnormal glucose tolerance test Sugar in blood Elevated blood sugar Poisoning and Adverse Effects R105.O For results of cholesterol and triglyc- (J900-J999) eride tests Includes: J900.O Accidental poisoning High cholesterol Includes: Food poisoning, ingestion of R11O.O For other findings of blood tests potentially poisonous food Includes: products Positive serology, VDRL Accidental ingestion of: Positive blood culture Household products Elevated sed rate Chemicals R200.0 For results of urine tests Drugs Includes: J905.O Adverse effect of medication Sugar in urine Includes: Positive urine culture Allergy to medication Abnormal urinalysis Penicillin allergy For cytology findings Anaphylactic shock R300.O Includes: Bad reaction to prescribed medication Positive Pap smear J9 10.0 Adverse effect of drug abuse Repeat Pap smear Includes: Atypical Pap smear Drug-induced hallucinations For results of Pap smear of cervix Combination of drugs and alcohol or other area (nonsuicidal) R400.0 For radiological findings Ingestion of drugs for nonmedi- Includes: cinal purposes X-ray results Bad trip Abnormal X-ray Freaked out on drugs R500.O For results of EKG Excludes: Intentional overdose (J820. 1) R600.O For results of skin tests J9 15.0 Adverse effect of alcohol R700.O For other and unspecified test results Includes: Includes: Intoxication Abnormal scans Drunk Abnormal pulmonary function Acute intoxication test ,J920.O Adverse effects of environment Abnormal EEG Includes: Abnormal lab test results, NOS Air pollution To discuss test results with phy- Water pollution sician Noise pollution Ultrasonography results J925.O Adverse effects, other and unspecified Results of fetal evaluation tests

33 ADMINISTRATIVE MODULE A120.O Driver’s license examination Al 25.0 Insurance examination A1OO.O Physical examination required for A130.O Disability examination employment Includes: Includes: Evaluation of a disability Preemployment examination Social Security examination Required company physical Al 35.0 Premarital examination Return to work checkup A135.1 Premarital blood test Teacher’s certificate physical A140.O Other reason for visit required by party Al 05.0 Executive physical examination other than the patient or the health Al 10.0 Physical examination required for care provider school Includes: Includes: Physical examination for adoption High school Psychiatric examination required Nursery school by court or school College Grade school Day care center Al 15.0 Physical examination for extracurricu- UNCODABLE ENTRIES lar activities Includes: Boy Scouts U990.O Problems, complaints, NEC Little Lea~e U997.O Entry of “none” or “no complaint” Camp U99 8.0 Inadequate data base Athletics U999.O Illegible entry

000

34 APPENDIX II REASON FOR VISIT CLASSIFICATION ALPHABETICAL INDEX

Abnormal Abrasion (see also Contusion) blood sugzwtest R1OO.O corneal J410.O blood test R1 10.0 Abscess, NOS D800.O breathing sounds S430.1 kidney D705.O cholesterol R105.O skin D800.O daily consumption, alcohol S145.0 stitch (postoperative) D800.0 (T205.0) drug use s150.o Absence of (see particular function) EGG R500.O (see also Loss of) EEG R700.O Absenteeism, school T720.O EKG R500.O Abuse eye color S330.1 child T71O.O eye movement S325.0 sexual J830.O glucose tolerance test R1OO.O Accident, NOS J81 0.0 palpitations S260.0 auto J805.O Pap smear R300.O car J805.O pulsations S260.0 cerebrovascular D525.O retractions (eye) S325.1 motor vehicle J805.0 sed rate R1 10.0 motorcycle J805.0 sensations S220.3 poisoning J900.0 skin test R600.0 Ache (see also Pain) sugar, urine R200.O all over S060.1 test results, NOS R700.O Acne S830.0 urine tests R200.O Acupuncture T420.O X-ray R400.O ACVD D515.O Abnormality, fluid S035.0 Adjustment Aborting S790.0 back T400.O Abortion corrective appliance T535.O arrangements for X51 5.0 problem S120.0 counseling X51 5.0 prosthetic device T530.0 evaluation for X51 5.0 Adopted child (counseling) T71 0.0 performed X520.O Advice T605.0 repetitive spontaneous D735.O Affect, loss of S165.0 spontaneous D735.O Aftercare, surgical T205.O threatened D735.O wants X51 5.0 Aged parents T715.O Aggressiveness S130.2 NOTE: NEC = not ekewhere classifiable; NOS = not Agitated S130.0 otherwise specified. Agraphia S240.0

35 Alcohol-related problems Appetite–Con. abnormal consumption S 145.0 10SS of S570.2 alcoholic spouse T705.O no S570.2 binge drinking S145.0 Apprehension S1OO.O deniaI of probIem S145.0 Arrest, cardiac J840.O drinking to relieve symptoms S145.0 Arteriosclerosis D530.O gulping drinks S145.0 Arthralgia S975.1 increased tolerance S 145.0 Arthritis, NOS D900.O morning drinking S 145.0 rheumatoid D9 00.0 problems, NOS S145.0 Ascaris D030.O psychological dependence S 145.0 Ascites S565.0 Alcoholism D320.O ASHD D515.O Allergy, NOS S090.0 Asthma D625.O animah D635.O Astigmatism D405.O dust D635.O Atherosclerosis D530.O eye S335.2 Athlete’s foot D025.O medication J905.0 Atrophy nasal D635.O extremities S9 80.0 penicillin J905.O muscles S965.4 pollen D635.O Attack ragweed D635.O convulsion S205.0 skin D825.O heart D515.O shots TIOO.O Avoiding people S130.1 test X300.O Amenorrhea S730.0 Amnesia S2 15.0 Backache, NOS S905.1 Anemia, NOS D250.O low S91O.1 iron deficiency D25 0.0 Bad pernicious D250.O heart S270.0 sickle ceII D250.O nerves S100.0 Anesthesia S220. 1 Bag of water broke S790.3 Anger S115.0 Balance, loss of S225.0 Angina, NOS D5 15.0 Baldness S890.1 pectoris D5 15,0 Bandage (see Dressing) Angiogram X345.O Beatup J815.O Anomaly, congenital, NOS D960.O Bedwetting S655.2 Anorexia S570.2 Behavior Antibiotics T1 10.0 abnormal sexual S160.0 Anxiety S1OO.O antisocial S 130.1 Apathy S165.0 asocial S130.1 Aphakia D420.O bad, NOS T710.O Aphasia S235.0 bad, school T720.0 Appearance bizarre S130.O eyes, abnormal S33 0.0 compulsive S13 0.5 nose, undesirable S405.4 disturbance S 130.0 tongue, abnormal S5 15.4 /.. hostile S130.2 hysterical S130.3 Appendicitis D655.O sexual, change in S 160.0 Appetite Belching, excessive S535.0 abnormaI S570.0 Bent finger back J570.O decreased S570.2 Better, feeling, NOS T800.O excessive S5 70.1 Binge drinking S 145.0

36 Biopsy, any site X335.O Blocked Birth control, NOS X500.O ear S360.0 cwnscling X5 00.0 tear duct (congenital) D960.O medication X505.O Blood (see Condition) (see also Bleeding) prescription renewal X505.O count X3 15.0 Bite, animal J760.O pressure, check X320.O human J760.O pressure, elevated D5 10.0 insect J755.O pressure, high D5 10.0 Bitterness S1 15.0 pressure, low D550.O Black Cy~ J41O.O spots in eye S330.0 Blackhead S830.0 sugar, high R1 00.0 Blackouts S030.0 urine S640.1 Bleeding, NOS S070.0 work, NOS X315.O between periods S 755.1 Bloodshot eyes S330.1 breakthrough S755.1 Blotches S835.0 during pregnancy S790.2 Blowing up S130.4 ear S350.1 Blueness S280.0 eye S310.1 Blushing S280.3 gastrointestinal S580.0 Boil D800.O gums S500.3 Bow-legged S9 75.1 intermenstrwd S755.1 Bowel function, changes in S600.0 lips S505.1 BPHD71O.O mole S845.2 Brace mouth S51O.2 back T535.O multiple sites S070.0 leg T535.O nipple S81O.1 neck T535. O nose S405.1 Brady cardia S260.2 penis S700.0 Breaking postcoital S755.3 nails S885.3 postmenopausal S755.2 out (skin) S830.0 postoperative S070.0, T205.O Breath, breathing postpartum S790.4 bad S615.0 rectal S605.2 difficult S420.0 tonLgue S515.2 holding S130.0 tonsils S460.0 problem S430.0 umbilicus S895.0 rapid S43 0.2 uterine, NOS S755.0 shortness of S415.0 uterine, dysfunctional D 730.0 sounds, abnormal S430.1 vaginal, NOS S755.0 unusual odor S615.0 Blemishes S830.0 Breathlessness S415.0 Blcpharitis D400.O Brittle Blind hair S890.0 Mindness S305.1 naik S885.3 night S305.2 Bronchitis D6 10.0 spots S305.1 Bronchopneumonia D630.O Blinking S340.4 Bruise (see Contusion) Blister Bulge (see Mass) skin S865.0 Bump (see Mass) tongue S51 5.0 Bunion D9 10.0 Bloated, NC)S S035.1 Burn, NOS J720.O before periods S745.1 extremities J7 15.0 ~W S585.0 face J705.O

37 Burn, NOS J720.O–Con. Candidiasis D025.O head J705.O can’t neck J705.O getpregnant S815.0 trunk J710.O hold urine S655.1 Burning open eye S340.1 chest S050.3 see S305.0 eye S320.3 start stream (urination) S660.2 mouth S51O.1 urinate S660.1 sensation (in chest) S050.3 Carbuncle D800.o skin S870.0 Carcinoma (see also Cancer) stomach S535.O basal cell D1 10.0 tongue S5 15.1 metastatic D 130.0 vaginal S765.3 squamous cell D 110.0 Burping, excessive S535.0 Care, postoperative T205.O Bursitis D905.O Cast Butterflies S1OO.O application T540.O Buzzing in ear S345.3 change T540.O loose T540.O Cachexia S020.0 postoperative T540.0, T205.0 &dcuh_ls,NOS D705.O problems with T540.O ureteral D7 05.0 removal T540.O Calluses S855.0 Cataract D41O.O Cancer, NOS D130.O Catheterization, urinary T5 10.0 bladder D125.O Cauterization, NOS T505.O blood D135.O Cellulitis D800.O bone D130.O Centesis X370.0 brain D130.O Certificate, teacher’s A1OO.O breast D115.O Cervicitis D725.O bronchus D105.O Charleyhorse S965.2 cervix D120.O Check colon D1OO.O blood pressure X320.O endometrium D 120.0 for V.D. X405.O esophagus DIOO.O knee S925.0 eyelid D1 10.0 medication T1 15.0 fallopian tubes D120.O throat S455.0 kidney D125.O Checkup, NOS X1OO.O larynx D105.O annual X1OO.O lung D105.O birth control, NOS X500.O OVZLryD120.O following injury J575.O prostate D125.O heart X235.O rectum D1OO.O IUD X51O.O skin D11O.O pacemaker X240.O small intestine D 100.0 return to work A1OO.O stomach D1 10.0 routine Xl 00.0 throat D105.O routine gynecological X225.O trachea D105.O routine postoperative T205.O uterus D120.O routine prenatal X205.O vagina D120.O Chemical bum (see Bum) vulva D120.O Chemotherapy T425.O

38 Chest symptoms, NOS S050.0 Collapse J840.O Chewing Color difficulty S500.0 change in skin S835.0 on hair S165.0 eyes, abnormal S330. 1 Chickenpox DO15.0 lips S505.2 Child care counseling T7 10.0 tongue, abnormal S5 15.4 Chills S005.0 Coma J840.O Chipped tooth JO05.O Complaints, NOS S025.0 Choking S520.0 multiple S025.0 Cholecystitis D670.O Complexion, NOS S830.0 Cholelithiasis D6 70.0 bad S830.0 Cholera DO05.O Compulsions S130.5 Cholesterol, high R105.O Concussion J505.O Chorea D500.O Condition Circulation heart S270.0 poor S280.1 SCdp S890.0 problems S280.1 skin S880.0 Circumcision T520.O Confidence, lack of S120.0 Cirrhosis D670.O Conflict Clammy skin S880.0 job T725.O Clap D020.O marital T705.O exposed to X405.O Confusion S240.0 Cleaning, ears S360.0 Congestion Cleft chest S475.0 lip,D960.O lung S475.0 palate D960,0 nasal S400.0 Closeup, can’t see S305.2 sinus S41 0.3 Clothing problem T740.O Conjunctivitis D400.O Clots, menstrual S740.3 Constipation S590.0 Cloudy Consultation, medical T605.O eye appearance S330.3 Contacts vision S305.3 examination for X230.O Clubfoot D960.O fitting T5 15.0 Clumsiness S095.0 problems with S335.1 Coated tongue S515.4 Contraceptive, followup, NOS X500.O Coitus, painful S825.0 counseling X500,0 Cold, NOS S445,0 oral X505.O body temperature S005,0 renewal (oral) X505.0 chest S475.0 Contractures (see Cramp(s)) head S445.0 Control, loss of (over behavior) S130.0 sore S505.3 Contusion, NOS J430.O Colic, NOS S550.0 face J405.O biliary D670.O head J405.O infantile S550.0 lower extremity J420.O intestinal S550.0 neck J405.O renal S670.1 trunk J415.O Colitis, NOS D665.O upper extremity J425.0 spastic D665.O Convulsions S205.0 ulcerative D665.O febrile S205.0

o 39 Coordination, poor S095.0 Crying Corns S855.0 too much (infancy) S080.1 Coronary D51 5.0 adult S11O.O Coryza S445.0 Culture Cough, coughing up, NOS S440.0 blood X3 15.0 bIood S470.1 throat X370.2 croupy S440.0 urine X325.0 phlegm S470.3 Curvature, spine D9 10.0 smoker’s S440.0 Cut(s) (see Laceration) sputum S470.3 CVA D525.O Counseling, NOS T605.O Cyanosis S280.0 diet T600.O Cyst, NOS S855.0 disease T605.O Bartholin’s D145.O expectant parent T7 10.0 bone D91O.O family planning X500.O breast S805.0 genetic X500.O dermoid D145.O infertility X500.O epidermal D825.0 marriage T7 05.0 Nabothian D140.O nutritional T600.O piIonidd D825.O premarital T705.O sebaceous D825.O sterilization X500.O skin S855.0 Cracked vaginal inclusion D 145.0 lips S505.1 vulva S770.3 nails S885.3 Cystitis D700.O skin S865.0 Cystocele D730.O Cracking, ear S360.0 Cystoscopy X330.O Cramp(s), NOS S060.2 abdominal S550.0 Dandruff D81O.O arm S945.2 Dark urine S640.3 back, low S91O.2 Data, inadequate U998.O back, NOS S905.2 Daughter (see Problem, parent-child T7 10.0) fingers S960.2 DeadJ835.O foot S935.2 on arrivalJ835.O gastrointestinal S545.2 Deafness S345.1 hand S960.2 Death, fetal, in utero D735.O hip S915.2 Decubitus D825.O leg S920.2 Defecation, painful S600.0 menstrual S745.2 Deficiency muscle S965.2 estrogen R7 00.0 neck S900.2 hormone S820.0 stomach S545.2 Deformity Crash, motor vehicle J805.O due to injury J800.o Crazy ear D960.O acting S130.3 nose D960.O going S165.0 Dehydration S035.0 Crick, neck S900.3 Dejected S1 10.0 Criminality S130.2 Delirium tremens D300.O Cross-eyed S325.2 Delusions S155.0 .Croup D600.O Dementia, senile D300.O Cruelty S130.2 Denial, drinking problem S145.0

40 Dependence Discharge-Con. alcoholic S145.0 stools S600.0 drug D320.O tonsik S460.0 psychological, on alcohol S 145.0 umbilical S895.0 Depressants, use of S150.0 urethral S680.0 Depression S1 10.0 vaginal S760.0 Dermatitis, NOS D815.O Discipline T7 10.0 seborrheic D8 10.0 Discoloration, skin S835.0 Dermatophytoses D025.O Discomfort Desertion T705.O chest S050.2 Destructiveness S130.2 stomach S545.0 Detachment, retina D420.O Discontented S1 10.0 Development Discrimination T730.O breasts, uneven S81O.3 Disease early S075.2 Addison’s D215.O lack of S07.5.1 adrenal D2 15,0 sexual, delayed S795.0 artery, coronary D5 15.0 sexual, early S795.0 bIadder, NOS D705.O Deviation blood sugar D205.O eyes S325.4 cardiovascular, arteriosclerotic D5 15.0 nasal septum D640.O cardiovascular, hypertensive D505.O Device cerebrovascular D525.0 contraceptive X51 0.0 Crohn’s D665.O intrauterine X51 0.0 cystic, of breast D7 15.0 Diabetes D205.O demyelinating D3 70.0 during pregnancy D735.O disc, degenerative D9 10.0 mellitus D205.O fibrocystic D7 15.0 Dialysis heart, arteriosclerotic D5 15.0 liidney T525.O heart, congenital D950.O peritoneal T525.O heart, hypertensive D505.O Diaper rash S860.1 heart, ischemic D5 15.0 Diaphragm X510.0 heart, NOS D550.O Diarrhea S595.0 heart, rheumatic D500.O Diet (counseling) T600.O Hodgkin’s D135.O Difficulty (see also particular function) kidney, NOS D705.O coordination SO95.O liver D670.O walking S095.0 mental, NOS D330.O Dilatation and curretage, diagnostic X335.O nutritional D215.O Dilation, urethral T5 10.0 parasitic D030.O Diplopia S305.4 Parkinson’s D355.O Dirty pants S600.4 pelvic inflammatory D720.O Disaster T740.O Peyronie’s D71O.O Discharge respiratory, NOS D640.O breast S81O.O thyroid D200.O ear S350.0 vascular, arteriosclerotic D5 15.0 eye, NOS S31O.O venereal D020,0 eye, white S3 10.3 venereal, check for X405.O nipple S81O.1 venereal, contact with X405.O nasal S400.0 viral D015.O peniIe S705.0 Dislike of self S120.0

41 Dislocation (see also Fracture) Dropping sensation, pelvic region S775.2 congenital D960.O Dropsy S035.1 finger J045.O Drowsiness S135.2 hip J020.O Drug abuse S150.0 shoulder J035.O Drunk J9 15.0 Disorder Dryness character D3 15.0 eyes S335.0 growth S075.0 hair S890.3 menstrual S745.0 lips S505.1 motor function S095.0 mouth S5 10.3 personality D3 15.0 nose S405.0 respiratory rhythm S430.0 skin S880.2 respiratory sound S430. 1 Dysfunction DispIaced intervertebral disc D91O.O ovarian D2 15.0 Dissatisfaction, job T725.0 sexual S825.0 Distances, can’t see S305.2 Dysmenorrhea S745.2 Distention Dyspareunia S825.0 abdominal (gas) S585.0 Dyspepsia S535.0 abdominal, NOS S565.1 Dysphagia S520.0 bladder S665.0 Dysplasia, hips D9 10.0 Distress Dyspnea S420.0 gastrointestinal S6 15.0 Dysrhythmia, cardiac D520.O heart S265.0 Dysuria S650.0 respiratory S420.0 stomach S6 15.0 Earache S355.1 Diverticulitis D665.O Eats too much S570.1 Diverticulosis D665.O ECG X350.O Divorce T705.0 Eczema D815.O Dizziness S225.0 Edema S035.1 DOAJ835.O of pregnancy D735.O Drainage Education, patient, NOS T605.O ear S350.0 EEG X355.O umbilicus S895.0 Effect, adverse, NOS 925.0 Dressing T545.O alcohol .1915.0 injury T545.0, J575.0 drug ab&e J91O.O postoperative T545.0, T205.O environment J920.O Dribbling (urine) S655.1 medication J9 05.0 Drinking (see also Alcohol-related problems) Effects of an old injury, late J800.O morning S145.0 Ejaculation, premature S160.4 on-the-sly S145.0 EKG X350.O problem, NOS S145.0 Electrocardiogram X350.O too much S145.0 Electroencephalogram X355.O to relieve problems S145.0 Embolism, pulmonary D550.O Drip, postnasal S400.0 Embolus D550.O Drooling S51O.O Emesis S530.0 Drooping Emotional upset S165.0 eyelids S340.4 Emphysema D620.O facial S230.0 Encopresis S600.4 Drop Endometriosis D730.O foot S935.O Endoscopy X330.O wrist S955.2 Enema T560.O

42 Engorgerncnt, breasts, postpartum S81O.2 Examination–Con. Enlarged office X1OO.O liver S61 0.0 ophthalmological X230.O lymph glands S275.1 pelvic X225.0 prostate S71O.O physical Xl 00.0 Enteritis DO05,0 postoperative T205.O Enuresis S655.1 postpartum X215.O Epididymitis D7 10.0 premarital A135.O Epilepsy D360.O prenatal X205.O Epistaxis s405. I psychiatric Xl 30.0 Equilibrium, loss of S225.0 psychiatric, required by court or school Erection, painful S700.1 A140.O Erosion, cervical D725.O psychological x130.o Error, refractive D405.O re~lar X1OO.O Eruption, skin S860.0 required, NOS A140.O Erythema S835.0 routine Xl 00.0 Esophagitis D650.O school A11O.O ETOP (elective termination of pregnancy) Social Security A130.O o X515.O well baby X105.O Euphoria S165.0 Excessive Evaluation for surgery T200.O perspiration S035.2 Examination sweating S035.2 adolescent Xl 00.0 thirst S035.3 adoption A140.O use of stimulants or depressants, chronic annual X1OO.O S150.O athletics A 115.0 Exercises Boy Scouts Al 15.0 eye T560.O breast S220.0 therapeutic T400.O camp A115.O Exhaustion SO15.0 cardiac X235.O Exophthalmo3 S330.2 child health .X1OO.O Exposure to child health, NOS X1OO.O chickenpox X410.0 coUege A 110.0 clap X405.O day care Al 10.0 hepatitis X41O.O disability A130.O infectious disease X41 0.0 driver’s license A120.O measles X41 0.0 employment physical A 100.0 mumps X41O.O executive physical Al 05.0 strep throat X410.0 eye X230.O venereal disease X405.0 general X1OO.O gmde school Al 10.0 gynecological X225.O FaiIure hearing X360.O congestive heart D5 20.0 heart S225.0 heart D520.O insurance A 125.0 renal D705.o internal prosthetic devices X240.0 to adjust to school S120.0 medical X1OO.O to thrive S075.1 multiphasic screening Xl 00.0 Fainting S030.O neurological X240.O Fall, faUing out nursery school Al 10.0 hair S890.1 nursing home A140.O injury J810.O

43 FamiIy FIu, NOS S450.0 disruption, NOS T7 15.0 stomach S540.0 plaming, NOS X500.O Fluid problems (see T705.0-T715.0) eardrum S365.0 Farsightedness D405.0 imbalance S035.0 Fatigue S015.0 on abdomen S035.1 Fears S105.O retention S035.0 Febrile S01 0.0 Flushed S280.3 Feeding problem S080.3 Fluttering Feeling, feelings eyes S325.0 faint S030.0 heart S260.3 hostile S1 15.0 Focus, eyes won’t S305.2 loss of S220.1 Followup, NOS T800.O lost Silo.o injury J575.O Iowsllo.o postoperative T205.O not well S025.0 test results (see RI 00. O-R700.0) of uterus falling out S775.2 Foot drop S935.0 panicky S1OO.O For surgery T200.O prickly S220.3 Foreign body, NOS J620.O rejected S120.0 digestive tract J615.0 Fever, NOS SO1O.O ear J620.O blister s505.3 entering through skin J6 10.0 hay D635.O eye J600.O rheumatic D500.O nose J605.O scarlet DO 10.0 rectum J615,0 Fibrillation, atrial D520.O stomach J6 15.0 Fibroid, uterus D140.O throat J615.O Fidgety S080,1 Forgetfulness S2 15.0 Fight J815.O Foster child (counseling) T7 10.0 Fissure Fracture, NOS J050.O anal D665.O ankle J025.O rectal D665.0 arm J035.O FistuIa back JOIO.O anal D665.O clavicle JO 15.0 rectal D665.O collarbone JO 15.0 vaginal D730.O elbow J035.O Fits S205.0 face JO05.O Fitting facial bones JO05.O braces T535.O femur J020.O contact lenses T5 15.0 fibuIa J020.O eyeglasses T515.O finger J045.O prosthesis T535.O footJ030.O Flakiness hand J045.O SCdp S890.3 head JO05.O skin S880.2 jaw JO05.O Flashes knee J020.O hot S750.2 legJ020.O light S305.3 neck JOIO.O Flatulence S585.0 nose JO05.O Floaters S305.3 radius J035.O Fracture, NOS J705.O–Con. Gonorrhea D020.O rib J015.O Gout D21O.O Shall JO05.O Granuloma, NOS D825.O spine JOIO.O Grief S1 10.0 tibia J020.O . Grinding toe J030.O jaw S500.0 ulna J035.O joints S970.0 vertebra JOIO.O teeth S500.0 wrist J040.O Grip S450.0 Freaked out (drugs) J91O.O Growth (see also Mass) Freckles S835.0 lack of physical S075.1 Frequency, NOS S645.0 GTT X31O.O Frigidity S160.0 Guilt S120.0 Frozen waterworks S660.2 Gynecomastia D715.O Fullness abdominal S565.1 Habits, bad NOS S165.0 bladder S665.0 Hair, hairiness Furuncle D800.O abnormal S890.2 Fussy, infants S080, 1 falling out S890.1 Half-vision S305.1 Gagging S530.0 Halitosis S6 15.0 Gin, weight S040.0 Hallucinations S155.0 Gallstones D670.O drug-induced J9 10.0 C&glion D905.O Hallucinogens, use of S150.0 Halos around eyes S305.3 distention S585.0 Harelip D960.0 excessive S5 85.0 Hates school T720.O pain S550.0 HCD D505.O Gasping for breath S415.0 HCVD D505.O Gastritis D650.O 4, Headache S2 10.0 Gastroenteritis DO05.O migraine D365.O General, generalized sinus S410.I ill-feeling S025.0 Hearing pain S060.1 acute S345.2 weakness S020.0 diminished S345.1 Genetics (counseling) X500.O dysfunction S345.0 German measles D015.O extraneous S345.3 Giddiness S225.0 heightened S345.2 Glasses loss of S345.1 broken T5 15.0 noises S345.3 examination for .X230.O trouble S345. 1 fitting T5 15.0 voices S155.0 lost T515.O Heart, heartbeat needs new X230,0 decreased S260.2 Glaucoma D4-15.O increased S260. 1 Glomerulonephritis D705.0 irregular S260.3 Glomerulonephrosis D705.O skipped S250.3 Glue sniffing (habitual) S150.0 S1OW S260.2 Glycosuria R200.O throbbing S260.0 Goiter D200.O weak S270.0

45 Heartburn S535.0 Hyperthyroidism D200.0 Hematemesis S580.2 Hypertrophy, benign prostatic D710.0 Hematoma, site specified (see Contusion) NOS Hyperuricemia D2 10.0 J430.O Hyperventilation S430.2 Hematuria S640.1 Hypoglycemia D2 15.0 Hemorrhage Hypospadias D955.O gastrointestinal S580.0 Hypotension D550.O nose S405.1 Hypothyroidism D200.O subarachnoid J505.O Hysteria S130.3 vaginal S755.0 Hysterosa.lpingogram X345.O Hemoptysis S470.1 Hemorrhoids D545.O Identity Hernoth’orax D640.O crisis S120.0 Hepatitis DO15.0 loss of S120.O Hernia D660.O Ileitis D665.O Herpes Ill, illness, NOS S025.0 simplex DO15.0 feeling, generalized S025.0 zoster DO15.0 Illegible entry U999.O Hesitancy (urination) S660.2 Imbalance, fluid S035.0 Hiccoughs S6 15.0 Immaturity Hiccups S615.0 mental S165.0 High physical S075.0 blood pressure D5 10.0 psychological S165 .0 elevated mood S165.0 Immunization X400.0 temperature SO1O,O Impacted, impaction Hirsutism S890.2 intestinal S590.0 Hives D825.O sinuses S41 0.3 Hoarseness S480,1 teeth S500.0 Homosexuality S160.2 Impetigo D805.O Hopelessness S1 10.0 Impotence S160.3 Hostility S1 15.0 Impris~ment T735.O Housing problem T740.O Inability to Hungry, always S570.1 conceive S8 15.0 Hurt myself, NOS J81O.O cope S165.0 Husband (see Problem, marital T705.0) nurse S81O.2 Hydrocele D7 10.0 stand S095.0 Hydrotherapy T400.0 SWdlOW S520.0 Hyperactivity S125.0 urinate S660.1 Hyperacusis S345.2 walk S095.0 Hyperemesis gravidarum D735.O Incision draining T205.0 Hyperesthesia S220.2 Incontinence Hyperlipidemia D2 15.0 stool S600.4 HypernasaIity S480.2 stress S655.1 Hyperopia D405.O urine S655.1 Hypersomnia S135.2 Incoordination S095.0 Hypertension (without involvement of target Increased heartbeat S260.1 organs) D51O.O Indecision S165.0 essential D5 10.0 Indigestion S535.0 of pregnancy D7 35.0 Infarction, myocardial D515.O renal D505.O Insomnia S135.1

46 Infection, NOS S085.0 Inflammation-Con. mm S840.2 scrotum S715.2 Madder S665.2 SillUS S41O.2 breast, postpartum S81O.2 skin S870.0 breast, NOS S81O.O stomach S545. 1 car S355.2 throat S455.2 eye S315.O tongue S515.3 eyelids S340.1 tonsils S460.0 finger S840.2 Influenza S450.0 foot S840.3 Ingestion of gastrointestinal S540.0 chemicals (accidental) J9 00.0 generalized S085.0 drugs (accidentzd) J900.O gcmtourinary S675.0 drugs (intentional, nonsuicidal) J900.O hand S840.2 drugs (suicidal) J820.O kidney S670.2 household product J900.O leg S840.3 Ingrown nail S885.2 nail S885.1 Injection, NOS T 110.0 (see also Shot and inocu- 11OSCS4-05.3 lations) pelvis S775.3 allergy TIOO.O penis S700.2 antibiotics T1 10.0 prostate S7 10.2 contraceptive X505.0 sinus S41 0.2 estrogen T1 10.0 skin S840.0 hormone T1 10.0 skin, head area S840.1 iron T11O.O skin, neck S840.1 vitamin T1 10.0 staphylococci.1 D035.O Injury, NOS J575.O stmptococcal DO1O.O abdomen J520.O throat s455.3 ankle J540.O toe S840.3 arm J555.O tongue S5 15.3 backJ515.O tonsils S460.0 chest J520.O Trichomonas D035.O elbow J560.O upper respiratory S445.0 eye J510.O urinary tract S675.0 face J505.O urine S675.0 fingers J570.O vaginal S765.2 foot J545.O viral, NOS S085.1 hand J570.O unspecified S085.0 head J505.O wound (postoperative) J575.O (T205.0) hip J525.O yeast D025.O internal J520.O Infertility S815.0 counseling X500.0 knee J535.O Inflammation legJ530.O eye S3 15.0 multiple, NOS S575.0 eyelids S340.1 neck J505.O mouth S51O.1 shoulder J5 50.0 nipple S810.0 toes J545.O nose S405.3 wrist J565.O pelvis S775.3 Inoculations X400.O penis S700.2 Insemination, artificial X530.O

47 Insertion Jock itch s715.4 chest tube T500.O IUD X51O.O Keloid D825.O Instruction for Keratitis D400.O diet change or control T600.O Knife wound J8 15.0 exercise T605.O Knock-kneed S9 75.1 regarding imminent surgery T200.O Knocked out J840.O use of contraception X500.0 Knot, knots use of crutches or cane T605.0 breast S805.0 Intercourse, painful S825.0 stomach S545.1 Interruption, pregnancy X515.0 Kyphoscoliosis D9 10.0 Intoxication Kyphosis D9 10.0 alcohol J915.O drugs J910.O frequent S145.0 Lab tests, NOS X370.O Inversion of nipple S81O.O Labor Irre~lar fake S790.3 heartbeats S260.3 Labyrinthitis D455.O menstruation S735.0 Laceration, NOS J230.O Irregularity S590.0 abdomen J215.O Irrigation (postoperative) T550.O (T205.0) arm J225.O Irritable, irritabilityy back J215.O adult S130.0 ear J210.O infants S080.1 eye J210.O premenstrual S745.1 face J210.O Irritation fingers J225.O eye S320.0 foot J220.O skin, NOS S870.0 hand J225.O throat S455.4 head areaJ205.O vulva S770.1 legJ220.O Isolation, social S130.1 nose J210.O Itching, NOS S870.2 toes J220.O ear S365.1 trunk area J215.O \\rristJ225f) eye S320.2 “ eyelids S340.2 Lack of growth S075.1 nose S405.0 Lacrimation S3 10.2 rectum S605.4 Lactation, improper S81O.2 SCdp S890.4 Laparoscopy X330.O scrotum S71 5.4 Laryngitis D600.O skin S870.2 Lassitude SO15.0 vagina S765.3 Lavage (see h-rigation) vulva S770.1 Lawsuits T735.O IUD X51O.O Leaking IVP X345.O amniotic fluid S790.0 rectal S600.4 Leeches D030.O Legal problem T735.O Jaundice S61O.2 Leiomyomata D140.O Jerking S200.0 Lesion, skin S865.0 Job Lethargy S165.0 out of T725.O Leukemia D135.O problems T725.O Leukorrhea, vaginal S760.0

48 Lice Mass, NOS S065.O--Con. body D030.O eyelid S340.3 head D030.O nose S405.4 Ligation, tubal X525.0 penis S700.3 Light perineal S875.0 ilashes S305.3 rectum S605.3 hurts eyes S305.0 scrotum S7 15.3 Lightheadedness S225.0 skin S875.0 Limping S095.0 testes S7 15.3 Lipoma D 145.0 throat S455.6 Listlessness S1 25.0 vulva S770.2 Litigation T735.O Masturbation Locked bowel S590.0 concerns about S160.5 Loneliness T730.O Loose stools S595.0 excessive S160.5 Losing mind S 165.0 Matter, eye S3 10.3 Measles D015.O Loss of German D015.O appetite S570.2 Medication, NOS T1 15.0 consciousness J840.O allergy TIOO.O control S165.0 birth control X505.O family member T7 15.0 check T1 15.0 hair S890.1 is poisoned S155.0 memory S215.0 physical T400.O sense of balance S225.0 Melanoma D1 10.0 senses S220.4 Melena S580.1 weight S045.0 Membranes, ruptured S790.3 weight, recent S045.1 Memory Lumbago D905,0 disturbance S215.0 Lump (see Mass) 10SS of S215.0 Lupus erythematosus Menarche discoid D825.O delayed S745.0 systemic D9 10.0 early S745.0 Lymphadenitis D550.O Meningitis D3 70.0 Lymphadenopathy D550.O Menopause, menopausal Lymphoma D135.O concerns about S750.0 Lymphosarcoma D 135.0 early S750.1 late onset S750.1 hlaggots D030.O symptoms, NOS S750.0 Maladjustment, social T730.O Menorrhagia S740.1 Malaise S025.0 Menstrual, menstruation Malingering S1 65.0 abnormal material S740.3 Mammography X340.O absent S730.0 Manic-depressive D305.O blood clots S740.3 Manipulation, joint T520.O cramps S745.2 hfarital conflict T705.0 disorders S745.0 Marriage, NOS T705.0 excessive S740.1 M~SS, NOS S065.0 frequent S735.1 abdominal S565.2 heavy flow S740.1 breast S805.0 infrequent S735.2 ear S365.2 irregular S735.0 eye S335.0 painful S745.2

49 Menstrual, menstruation–Con. Nail biting S165.1 scanty flow S740.2 Nausea S~25.O tension S745.0 Navel, symptoms of S895.0 unpredictable S735.3 Nearsightedness D405.O Metastases D130.O Needles and pins S220.3 Metrorrhagia S755.1 Negativism S130.2 Migraine D365.O Neglect, child T7 10.0 Miscarriage S790.0 Neoplasm (see Cancer) Mole Nerves, nervous, nervousness change in S845. 1 breakdown S1 00.0 growth in S845. 1 stomach S525.0 Molestation J830.0 Neurosis, NOS D3 10.0 Money, not enough T700.0 anxiety D3 10.0 MoniIiasis D025.O depressive D3 10.0 Monitoring obsessive-compulsive D3 10.0 fetal X370.O Night sweats S035.2 Helter X350.O Nightmares S135.3 Mono, mononucleosis D015.O No Movement limitation, movements, NOS S060.3 complaint U99 7.0 abnormal S200.0 vital signs J840.O ankle S930.3 Nodes, erdarged S275.1 back S905.3 Nodule, nodules back, low S91O.3 breast S805.0 elbow S950.3 skin S875.0 eye S325.0 thyroid D200.O eyelid, abnormal S340.4 Noises fingers S960.3 hearing (psychiatric) S 155.0 foot S935.3 in ear S345.3 hand S960.3 Nonresponsive J840.0 hip S9 15.3 None or no complaint U99 7.0 involuntary S200.0 Nosebleed S405.1 joints S970.3 Not feeling well S025.0 knee S925.3 Numbness S220.1 neck S900.3 Nursing, difficulty with S8 10.2 shoulder S940.3 Nutrition (counseling) T600.O toes S935.3 wrist S955.3 Obesity S040.0 Mucus, excessive (nose) S400.0 Obsessions S1 30.5 Multiple Obstetrical, obstetrics, NOS X205.O # complaints S025.0 care X205.O sclerosis D350.0 Obstruction, nasal S400.0 Mumps D015.O Odor, vaginal S765.0 Murmur, heart D520.O Oiliness Myelogram X345.O hair S890.0 Myeloma, multiple D135.O skin S880.1 Myoma, uterus D140.O Old age T730.O Myopia D405.O Oligomenorrhea S740.2 Myositis D905.O Oophoritis D720.O Myxedema D200.O Ophthalmia D400.O Orgasm Pain, painful, NOS S060.1–Con, lack of S160.6 foot S935.1 problems with S160.6 gallbladder S6 10.1 Orthopedic shoes T535.0 gas S550.0 Orthopnea S420.0 generzdized S060.1 Osteoarthritis D900.O groin S055.3 Osteomyelitis D9 10.0 gums S500.2 Osteoporosis D9 10.0 hand S960.1 Otitis head S21O.O externa D455.O heart S265.0 media D450.O hip S915.1 out of incision (postoperative) S060.0 (T205.0) breath s415.o inguinal S550.1 work T725.O joint S970.1 Overaggressiveness S130.2 kidney S670.1 Overactivity S125.0 knee S925.1 Overdose, NOS J91O.O labor S790.3 intentional J820. 1 Ieg S920.1 suicide attempt J820. 1 lips S505.0 Oversize LLQ S550.1 breast S81O.3 LUQ S550.2 ears S365.4 menstrual S745.2 nose S405.4 mouth S5 10.1 Overweight S040.O muscIe S965.1 neck S900.1 Pacemaker, check X240.0 nerve S240.0 Pain, painful, NOS S060.1 no response to S220.1 abdominal, lower S550.1 nose S405.0 abdominal, NOS S550.0 over heart S265.0 abdominal, upper S550.2 ovulation S775.1 ankle S930.1 pelvis S775.1 arm S945.1 penis S700.1 back, 10W S910.1 postoperative S060.0, T205.0 back, NOS S905.1 postpartum S790.4 bladder S665.1 precordial S265.0 bone S980.0 prostate S7 10.0 breast S800.0 radiating S055.0 chest S050.1 rectal S605.1 coital S825.0 respiratory S420.0 during pregnancy S790.1 rib S055.1 ear S355.1 RLQ S550.1 elbow s950.1 RUQ S550.2 cpigastric S550.2 scrotum S715.1 erection S700.1 shoulder S940. 1 extremity, lower S920. 1 side S055.2 eye S320.1 sinus S41 O.I facial S055.4 skin S870.1 finger S960.1 sternum S055.1 flank S055.2 stomach S545. 1

51 Pain, painful, NOS S060.1–Con. Phelgm–Con. stump S9 80.0 excessive S470.3 testes S715.1 purulent S470.2 throat S455.2 Phobia S105.O toes S935.1 Photophobia S305.0 tongue S515.1 Photosensitivity S305.0 umbilical region S5 50.2 Physical (see also Examination) umbilicus S89 5.0 examination, NOS Xl 00.0 upper abdominal S550.2 medicine T400.O upper extremity S945.1 executive A 105.0 urinary S650.0 return to work A 100.0 vagina S765.1 therapy T400.O vulva S770.0 Picking at ears S365.3 wrist S955.1 PID D720.O Paleness S280.2 Pierced ears T520.O Pallor S280.2 Pigeon-toed S975.3 Palpitations S260.0 Pigmentation, skin S835.0 Palsy Pill, birth control X505.O Bell’s D370.O Pimples S830.0 cerebral D3 70.0 Pinched nerve S240.0 Pancreatitis D670.O Pinkeye S3 15.1 Panic S1OO.O Pinworms D030.O Pap smear X365.O PKU testX31 5.0 abnormal R300.O Placenta previa D735.O positive R300.O Planning, family X500.O repeat R300.O Pleurisy D640.O Paralysis, NOS D370.O Plugged, ear S360.0 agitans D355.O Pneumonia Paranoia D305.O bacterial D630.O Paresthesia S220.3 viral D630.O Parkinsonism D355.O Pneumonitis D630.O Paronychia D825.O Pneumothorax D640.0 Passed, passing Poison, poisoned, poisoning blood S640.1 accidental J900.O out S030.O blood D035.O stones S680.0 food J900.O ‘ Passive S130.1 ivy D825.O Peeling, skin S880.2 oak D825.O Period (see also Menstrual, menstruation) Poliomyelitis DO 15.0 late X200.O PolIenosis D635.O missed X200.O Pollution Peritonitis, pelvic D720.O air J920.O Personality disturbance S 165.0 noise J920.O Perspiration, excessive S035.2 Pharyngitis D600.O water J920.O Phimosis D71O.O Polycythemia vera D 135.0 Phlebitis D535.O Polydipsia S035.3 Phlegm polyp, NOS D145.O bloody S470.1 cervical D140.o coughing up S47 0.0 endometrid D 140.0

52 Polyp, NOS D145.O–Con. Problem–Con. nasal D145.O feeding S080.3 rectal D145.O hormone S820.0 Polyuria S660.3 housing T 740.0 Pooped S015.0 husband T705.O Poor job T725.O economic problem T7 00.0 learning S165.0 heart S270.0 legal T735.O Popping, ear S360.0 male S720.0 Postoperative visit, NOS T205.O marital T705.O Postpartum, NOS X215.O menstrual, menstruation S 730.0-S 747.0 visit X21 5.0 money T700.O Preoperative visit T200.O neighborhood T730.O Pregnancy, NOS X205.0 occupational T725.O ectopic D 735.0 parents T71O.O examination X205.O parent-child T7 10.0 multiple D735.0 personaI T605.0 out-of-wedlock T740.O postoperative T205.0 possible X200.O postpartum S790.4 unconfirmed X200.O posture S975.2 unwanted (counseling) X500.O pregnancy S790.0 Prenatal visit X205.O school T720.O Prescription, NOS T1 15.0 sexual (psychological) S1 60.0 birth control pill X505.O sinus S41O.O renew (birth control pill) X505.O skin S880.0 Prescription renewal, glasses T5 15.0 social adjustment T73 0.0 Pressure social, NOS T740.0 back, lower S9 10.0 stomach S615.0 chest S050.2 wife T705.0 ear S365.0 Proceedings, divorce T735.O head S21O.O Procedure, postoperative (Code procedure and pelvic S775,2 postoperative visit T205 .0) sinus S41 0.1 Proctoscopy X330.O Prickly sensation S220.3 Products of conception passed S790.0 Problem Progress visit, NOS T800.0 behavior (school) T720.0 Prolapse, uterus D730.O boss T725.O Prosecution T735.O breathing S430.0 Prostatitis D7 10.0 change of life S750.3 Prosthetics T530.O children T7 10.0 fit T530.O community T730.O Prostration SO15.0 complexion S830.0 Protrusion, eyes S330.2 data inadequate U998.O Psoriasis D820.O digestive (infancy) S6 15.0 Psychiatric exam X130.O drinking S 145.0 Psychoanalysis T41 0.0 economic T700.0 Psychosexual disorders S160.0 educational T720.0 Psychosis, NOS D305.O emotional, related to menopause S750.3 alcoholic D300.O employment T725.O senile D300.O family T715.O Psychotherapy T41 0.0

53 Psychotic break S165.0 Regurgitation, infancy S080.2 Pulled, pulling Rehabilitation at ears S365.3 physical T400.O muscle S965.0 vocational T400.O Pulsations, pulse Relatives, problems with T7 15.0 decreased S260.2 Removal, remove increased S2 60.1 IUD X51O.O irregular S2 60.3 lesion T520.O Puncture, NOS J325.O sutures T5 55.0 head and face J305.O sutures (postoperative) T555.0 (T205 .0) lower extremity J3 15.0 tattoo T5 20.0 lumbar X370.O warts T520.1 trunk J310.O Renewal of prescription T1 15.0 upper extremity J320.O Respiration, respiratory Pus insufficiency S41 5.0 ear S350.2 labored S420.0 eye S3 10.3 painfuI S420.0 stool S600.1 rhythm disorders S430.0 urine S640.2 sighing S425.0 Pyelitis D705.O sound disorders S430. 1 Pyelogram, intravenous X345.O Restlessness S 125.0 Pyelonephritis D705.O Results Pylorospasm S545.1 blood test, NOS R1 10.0 Pyuria S640.2 cholesterol test R1 05.0 EKG R500.O Quarrelsome, quarrelsomeness S130.2 glucose test R1OO.O Pap smear R300.O Radio~aphy, diagnostic X345.O serology R1 10.0 Rape J830.O skin tests R600.O Rash, NOS S860.0 test (see R1OO.O-R7OO.O) diaper S860.1 test, NOS R700.O skin S860.0 urine test R200.O Rattle, chest S430.1 X-ray R400.O Reaction Retardation, mental D325.O adjustment D330.O Retching S530.0 adolescent adjustment D330.O Retention allergic, NOS S090.0 fluid S035.1 anxiety D31 0.0 urine S660.1 depressive D3 10.0 Retraction, abnormal (eyes) S325.1 grief D330.O RH factor D735.O medication J9 05.0 Rheumatism, NOS D900.O skin, allergic D825.O nonarticular D905.O Reading, visual difficulty S305.2 Rhinitis, NOS D600.O Recheck, NOS T800.O allergic D635.O Rectocele D730,0 Ridges Red nose S405.3 nails S885.3 Redness tongue S515.4 eyes S330.1 Rigidity, abdominal S565.3 nose S405.3 Ringing in skin S835.0 ears S345.3 Refraction, error in D405.O head S345.3

54 Ringworm D025.O Sense of Roughness, skin S880.0 smell, disturbance of S220.4 Routine taste, disturbance of S220.4 checkup xl 00.0 Sensitization, RH D735.O Mowup T800.O Separation T705.O Rubella D015.O Serology, positive RI 10.0 Rubor S280.3 Sex drive, loss of S160.1 Ruddy, skin S835.0 Sexual Runaway S130.0 disorders, symptoms of S160.0 Rundown SO15.0 partner has V.D. X405.O Runny nose S400.0 perversion S 160.1 Runs S595.0 problem S 160.0 Rupture response, lack of S1 60.1 eardrum D4,55.O Shaken up S165.0 hernia D660.O Shaking S200.0 Shape, ears, abnormal S365.4, Shingles DO15.0 Shock J840.O Sadness S1 10,0 anaphylactic J9 05.0 Sagging, breasts S81O.3 electrical J575.O Saliva, excess S51O.O Short, shortness Salmonella DO05.O of breath S415.0 !Mpingitis D7 20.0 too S075,1 Sarcoid D035.O Shot (see also Injection) Scalded (see Burn) aIIergy TIOO.O Scaliness, skin S880.2 antibiotic T1 10.0 Scanning, radioisotope X345.O flu X400.O ScarJ800.O gun J815.O Schizophrenia D305.O penicillin T1 10.0 School, problem with T720.O tetanus X400.O Sciatica S980.0 Shuffling steps s095.0 Scoliosis D91 0.0 Shyness S130.1 Scratchy throat S455.4 Sick, NOS S025.0 Screaming S1 3043 to stomach S525.0 Seeing things S155.0 Sighing respiration S425.0 Seizures S205.0 Sigmoidoscopy X330.O Self- Sinusitis D600.O -esteem, lack of S120.0 Size hatred S120.0 abdominal, abnormal S5 65.0 Semiconscious J840.O breast, undesirable S8 10.3 Senility D300.O ears, abnornud S365.4 Sensation, sensations, sensation of nose, too large S405.4 abnormal S220.3 Sleep burning S220.3 disturbances S135.0 disturbance of S220.0 inability to S135.1 dropping, pelvis S775.2 sleepiness S 135.2 eye, abnormal S320.0 sleeplessness S 135.1 falling S225.0 too much S135.2 foreign body in eye S320.0 walking S 135.4 increased S220.2 Slowing of, slowness 10ss of S220.1 mental S165.0

55 Slowing of, slowness-Con. Sprain, NOS J130.O–Con. of stream (urination) S660.2 knee Jl15.O physical S075.1 neck J105.O puke S260.2 wrist J125.O Sluggish S025.0 Sputum Slurring S235.2 abnormal S47 0.0 Smell blood in S470.1 disturbance of S220.4 coughing up S47 0.0 unusual S220.0 excessive S470.3 Smoking purulent S740.2 excessive S 140.0 pus in S470.2 probIem S 140.0 Squinting S340.4 Smooth tongue S5 15.4 Stabbing J8 15.0 Sneezing S435.0 Staggering S095.0 Sniffles S400.0 Stammering S235.1 Snoring S430.1 Stand, inability to S095.0 Social maladjustments T730.O Staph infection D035.O Something in throat S455.6 Steam burn (see Bum) Somnolence S135.2 Stenosis, urinary D705.O Son (see Problem, parent-child T7 10.0) Sterility S815.0 Sore Sterilization performed X525.O canker D675.O Sticking out, ea& S365.4 glands S275.2 Stiffness (see also Movement limitation, move- in mouth S5 10.4 ments) in nose S405.2 muscle S970.3 vulva S770.3 Stimulants, use of S1 50.0 Soreness, sore (see also Pain) Sting throat S455.1 bee J755.O Spasm(s) (see Cramp(s)) insect J755.O Speech Stitch, stitches (see Suture) disorder S235.0 Stomatitis D675.O disturbance S235.0 Stoned Spell, spelh S205.0 always S150.0 fainting S030.0 drugs J910.O Spitting up S080.2 Stones blood S470.1 bladder D705.O Splint (we Cast) kidney D705.O Splitting, nails S885.3 passed S680.0 spots stool nails S885.0 blood in S580.1 skin S835.0 bulky S600.3 vision S3 05.3 Spotting fatty S600.3 during pregnancy S790.2 loose S595.0 vagimd, NOS S755.1 mucus in S600.1 Sprain, NOS J 130.0 pus in S600.0 ankle J120.O unusual color S600.3 back Jl10.O unusual odor S600.3 cervical spine J 105.0 worms in S600.2 Stopped up SwelIing, swollen–Con. t!arSS360.0 elbow S950.5 nose S400.0 eye S335.3 sinuses S41 0.3 eyelids S340. 1 Strabismus D420.O face S035.1 Strain (see also Sprain) finger S960.5 eye S320.4 foot S935.5 Strep throat DO 10.0 glands S275.1 Streptococci.1 sore throat DO1 0.0 generalized S035.1 Stricture, urinary D705.O hand S960.5 Strider S430.1 hip S9 15.5 Stroke D525.O jaw S980.5 Stuffed up, stuffiness joints S9 70.5 nose S400.0 knee S925.0 nasal S400.0 leg S920.5 Stumbling SO95.O lips S505.0 StuporJ840.O liver S61O.O Stuttering S235.1 lymph glands S275.1 Sty D400.O neck S900.5 Suffocation, sensation of S415.0 nose S405.3 Sugar pelvic S775.3 blood R1OO.O penis S700.2 urine R200.O perineal S7 70.1 Suicide attempt, suicide, NOS J820.O prostate S7 10.1 desire to commit S165.0 rectal S605.3 overdose, intentional J820.1 scrotum S7 15.2 Vio]ent J820.O shoulder S940.5 Sunburn J750.O shut, eyes S340.1 Superfluous, hair S890.2 skin S875.0 Surgery, surgical testes S715.2 aftercare T205.O throat S455.5 minor T520.O toes S935.5 to schedule T200.O tongue S51 5.3 Suture tonsils S460.0 insertion T5 55.0 vulva S770.1 removal, NOS T555.O with water SO35. 1 removal (injury) T555.O (J5 75.0) wrist S955.5 removal (postoperative) T555.O (T205.0) Swimmer’s ear S350.3 Swallowing Syncope S030.0 difficulty in S520.0 Syndrome pain S520.0 carpal tunnel D370.O Sweating, excessive S035.2 irritabIe boweI D665.O Swelling, swollen organic brain D3 00.0 abdominal S565.3 Synovitis D905.O ankle (one) S930.5 Syphilis D020.O

ankles (both) S035.1 Tachycardia S260. 1 arm S945.5 paroxysmal D520.O breast S800.0 Tall, too S075.2 ear S365.0 Tap, spinaI X370.0

57 Taste Test–Con. ]0SS of S220.4 skin (immunity) X305.O unusual S220.0 stress X350.O Tattoo, remove T520.O sugar X325.0 Tearing sugar (blood) X3 10.0 excessive S31 0.2 tuberculin x305.o eye S31O.2 urine X325.O Temper problems S130.5 urine, for sugar X325.0 Temperature, high SO10.0 V.D. X315.1 Tenderness vision X230.O breast S800.0 Testes, pain S715.1 penis S700.1 Testing, psychological X130.O scrotum S715.1 Texture, skin, change in S880.0 skin S870.0 Therapy Tendinitis D905.O grOUp T41O.O Tennis, elbow S950.0 heat T400.O Tenosynovitis D905.O inhalation T405.0 Tension S1 00.0 occupatiomd T400.O nervous S1OO.O physical T400.O premenstrual S745.1 radiation T4 15.0 sexual S160.0 recreational T400.O Termination, pregnancy X515.0 respiratory T405.O Test speech T400.O allergy X300.O ultraviolet T5 60.0 blood, premarital A135.1 Thermography (breast) X340.O blood cuIture X3 15.0 Thin bIood D250.O blood pressure X320.O Thirst, thirsty blood sugar X310.0 excessive S035.3 blood, for V.D. X315.1 Thrombophlebitis D535.O blood, NOS X315.O Thrombosis D535.O blood, required A135.O Throwing up S530.0 cholesterol X315.0 feel like S525.0 clotting X31 5.0 Thrush D025.O diabetes X310.0 Thumbsucking S165.2 estriol (blood) X315.0 Thyrotoxicosis D200.O estriol (urine) X325.O Tickle, throat S455.4 eye X230.O Tics S200.0 for diabetes X31O.O Tightness, chest S050.2 glaucoma X370.1 Time, prothrombin X3 15.0 glucose X310.0 Time-zone syndrome S135.0 glucose tolerance X31 0.0 Tingling S220.3 hearing X360.O Tinnitus S345.3 lab, NOS X370.O Tired, tiredness S015,0 PKU X315.O blood S015.0 PPB X305.O TonsiIIitis D605.O pregnancy X200.O streptococcal DO1O.O prothrombin time X315.0 Too pulmonary function X370.O large, breasts S81O.3 sensitization X300.O little hair S890.1 sickle cell X31 5.0 small, breasts S81O.3 skin (allergy) X300.O Toothache S500.1 Touch, loss of sense of S220.1 Ultrasonography X3 70.0 Toxemia D735.O Umbilicus, problems of S895.0 Treadmill X350.O Unable to Treatment breathe S420.0 allergy TIOO.O communicate S240.0 asthma T405.O put weight on (leg) S920.4 Tremors S200.0 sleep S135.1 Trichomonas D035.O stop drinking S145.0 Trip, bad J91 0.0 urinate (void) S660.1 Trouble (see also Problem) Unbalanced S225.0 * breathing S420.0 emotionally S165.0 bladder S665.0 Uncodable U990.O contact lens S335.1 Unconscious J840.O ear S365.0 Uncooperative S165.0 eating S6 15.0 Uncoordinated S095.0 eye S335,0 Underweight S045.2 female S795.0 Undescended testicle(s) D955.O hearing S345.1 Unemployment T725.O job T725.O Unequal pupils S325.3 kidney S670.0 Unhappy S1 10.0 learning S165.0 Unresponsive J840.0 marital T705.O Unwanted hair S890.2 prostate S71O.O Upset seeing S305.2 emotional S1OO.O sleeping S135.1 stomach S525.0 waIIiing S095.0 Urethritis D705.O Truancy T720.O Urgency S645.0 Tuberculosis D035.0 Uric acid, high R1OO.O Tumor (see also Mass) Urinalysis X325.O brain D130.O Urination, urinate Turn in, feet S965.3 burning S650.0 Turned difficulty in, NOS S660.0 ankle J120.O difficulty starting S660.2 wrist J565.O discomfort S650.0 Twisted ankle J120.O frequent S645.0 Twitch, NOS S200.0 frequent, at night S645. 1 eyelid S340.4 hesitancy S660.2 inability to S660.1 involuntary S655.1 Ulcer, NOS S865.0 large volume S660.3 duodenal D650.O painful S650.0 eye D400.O urgent S645.0 mouth S5 10.4 Urine nose S405.2 blood in S640.1 penis S700.0 peptic D650.O dark S640.3 perineum S770.3 pus in S640.2 skin S865.0 retention of S600.1 stomach D650.O unusual color S640.3 tongue S51 5.0 unusual odor S640.3 vulva S770.3 Urticaria D825.O

59 V.D. D020.O Wart, NOS S850.O–Con. exposed to X405.O penis S700.3 Vaccination X400.O scrotum S7 15.3 Vaginitis, NOS D725.O Wasting extremities S980.0 Trichomonas D035.O Water broke S790.3 Varicose veins D540.O Watering, watery Vasectomy eye S31O.2 advice regarding X500.O Wax, waxy performed X525.O ear S360.0 VDRL, positive R1 10.0 skin S880.0 Venogram X345.O Weak Vertigo S225.0 blood S020.0 Vestibulitis D455.O eyes S305.2 Violence J81 5.0 heart S270.0 Virus, NOS S085.1 Weakness, NOS S020.0 intestinal S540.0 arm S945.4 stomach s540.0 extremities S230.0 throat S455.3 general S020.0 Vision hip S9 15.4 blurred S305.2 left-sided S230.0 cloudy S305.3 leg S920.4 diminished S305.2 muscle S965.4 disturbance S305.0 necrologic S230.0 double S305.4 right-sided S230.0 dull S305.2 Weight, NOS T600.0 dysfunction S305.0 failure to gain S075.1 extraneous S305.3 gain S040.0 floaters S305.3 loss S045.O half S305.1 loss, recent S045.1 hazy S305.3 Well baby exam X105.O poor S305.2 Welts S875.0 tunnel S305.0 Wheals S875.0 Visit Wheezing S425.0 followup T800.O WheIps S875.0 postoperative, NOS T205.O Whiplash J 105.0 preoperative T200.0 Whiteheads S830.0 progress T800.O Widowhood T730.O referraI U998.O Wife (see ProbIem, marital T705,0) testing X370.O Windburn J750.0 Voice Withdrawal S130.1 disorder S480.0 woozy S225.0 10SS of S480.1 Working mother T71O.O Vomiting S530.0 Worms D030.O blood S580.1 worn out S015.O Vulvitis D730.O Worried S100.0 Wound Walking, difficulty S095.0 gunshot J815.O Wart, NOS S850.0 knife J815.O Plantar’s DO15.0 skin J575.O vulva S770.3 Wrinkles S880.3

60 Wrist drop S955.2 Xerography (breast) X340.O Writing, disturbances in S240.0 Yellow eyes S61O.2 X-rays X345.O skin S61O.2

000

61 APPENDIX Ill CODING RULES AND INSTRUCTIONS

Coding guidelines for the use of the RVC are (S135.0). The code for “Nightmares” presented below. In addition to general coding is, therefore, S 135.3. However, if the instructions, rules for coding within each mod- data simply stated “Sleep problem,” it ule and clarifications of the content of selected should be assigned to category S 135.0, categories of the tabular list are also presented. since the type of sleep disturbance is These guidelines have been implemented in the not specified. In cases where the infor- NAMCS medical coding operation; however, mation is specific, but there is no lower other users of the RVC may find it necessary to hierarchy code to fit it, the coder should restructure these rules to meet their specific code to the broad category. For exam- needs. ple,. “Sore on the tongue” would be coded to “Symptoms of the tongue” 1. The reason for visit should be coded (S515.0), since it does not fit under exactly as recorded, that is, no infer- “Pain” (S515.1), “Bleeding” (S515.2), ences regarding what the patient really or the other specified tongue symptoms. meant to say should be made. Upper hierarchy codes (.0) should be used for not elsewhere classifiable (NEC) 2. The alphabetical index should be con- and not otherwise specified (NOS) en- sulted first in assigning codes, and the tries, unless specific codes are given for code should then be verified with the these entries. designated category in the tabular list. 6. For terms with multiple interpretations, 3. If a term cannot be found in the alpha- for example, the term “Hurt” could betical index, synonymous terms should refer to “Pain” as “My arm hurts” or to be consulted. A Iist shouId be main- “Injury” as “I hurt my arm,” the coder tained of these nonindexed terms so that should first determine whether the entry they may be added periodically to the refers to a symptom or injury before index to make it as complete as possible. assigning a code from the appropriate 4. Unspecified problems of a body part or module. system should be coded to the body part or system using the upper hierarchy Symptomatic data should be coded into the code, that is, the .0 code, of the appro- Symptom Module regardless of whether the de- priate category. For example, “Check scription is given in lay or medicz-d terrninology, my nose” is coded S405.0, and “Prob- for example, “Hematuria” and “Blood in urine” lem with my ears” to S365.0. are both coded to category S640. 1. An attempt 5. Data should be coded as specifically as has been made to include both lay terminology possible. For example, “Nightmares” and medical jargon in the alphabetical index. (S135.3) is a specific code under the Xloo.o, “General medical examination,” broader code of “Disturbances of sleep” should be used to code visits for examinations of

62 a comprehensive nature, that is, an examination J225.O. The exclusions under T800.0, “Progress of all or most body systems. “Family planning” visit, NOS, ” should be noted. requests should be coded as specifically as possi- Fractures, sprains, lacerations, contusions, ~ ble according to the type of service requested. burns, foreign bodies, and bites are always coded Reasons for visit, such as “For birth control” or into the Injuries and Adverse Effects Module. “For contraception” should be coded X500.0, The injury should be coded by type and loca- “Family planning, NOS .“ tion. If this information is not available, refer to Visits indicating only that the visit was a fol- “Injury, NOS.” The codes for adverse effects Iowup for a previously performed surgery, that of drugs and alcohol, J9 10.0 and J9 15.0, respec- is, a postoperative visit, should be coded T205.O. tively, refer to acute conditions of intoxication. When additional information about the reason U9 90.0 should be used when the entry is not for visit is known, as “Postoperative visit, suture codable elsewhere in the scheme. U997.0 should removal,” both data items should be coded with be used to code entries of “None” or “No com- the suture removal being coded first and the plaint.” U998.O should be used to code inade- postoperative visit second. This rule also applies quate entries, that is, entries whose meaning can- to posttraumatic visits, that is, “Suture removal, not be determined from the available data. lacerated arm,” should be coded T555.0, U999.O should be used to code illegible entries.

000

*U.S. G12VESM2NT PS2NRNG OFFICE: 1979 0-2S1-259/3 63 VITAL AND HEALTH STATISTICS Series

Series 1, Programs and Collection Procedures. –Reports which describe the general programs of the National Center for Health Statistics and its offices and divisions and data collection methods used and include definitions and other material necessary for understanding the data.

Series 2. Data Evaluation and Methods Research. –Studies of new statistical methodology including experimental tests of new survey methods, studies of vital statistics collection methods, new analytical techniques, objective evaluations of reliability of collected data, and contributions to statistical theory.

Series 3. Analytical Studies. –Reports presenting analytical or interpretive studies based on vital and health statistics, cwrying the analysis further than the expository types of reports in the other series.

Series 4. Documents and Committee Reports. – Final reports of major committees concerned with vital and health statistics and documents such as recommended model vital registration Iaws and revised birth and death certificates.

Series 10. Data From the Health Interview Survey. –Statistics on illness, accidental injuries, disability, use of hospital, medical, dental, and other services, and other heaIth-reIated topics, all based on data collected in a continuing national household interview survey.

Sericx 11. Data From the Health Examination Survey and the Health and Nutrition Examination Survey .–Data from direct examination, testing, and measurement of national samples of the civilian noninstitu- tionalized population provide the basis for two types of reports: (1) estimates of the medically defined prevalence of specific diseases in the United States and the distributions of the population with respect to physical, physiological, and psychological characteristics and (2) analysis of relationships among the various measurements without reference to an explicit fhite universe of persons.

Series 12. Data From the Institutionalized Population Survey s.–Discontinued effective 1975. Future reports from these surveys will be in Series 13.

Series 13. Data on Health Resources Utilization. –Statistics on the utilization of health manpower and facilities providing long-term care, ambulatory care, hospitaI care, and family planning services.

Series 14. Data on Health Resources: Manpower and Facilities. –Statistics on the numbers, geographic distribution, and characteristics of health resources including physicians, dentists, nurses, other health occupations, hospitals, nursing homes, and outpatient facilities.

Series 20. Data on Mortality. –Various statistics on mortality other than as included in regular annual or monthly reports. Special analyses by cause of death, age, and other demographic variables; geographic and time series analyses; asrd statistics on characteristics of deaths not available from the vital records based on sample surveys of those records.

Series 21. Data on Natality, Marriage, and Divorce. –Various statistics on natality, marriage, and divorce other than as included in regular annual or monthly reports. Special analyses by demographic variables; geographic and time series analyses; studies of fertility; and statistics on characteristics of births not available from the vital records based on sample surveys of those records.

Series 22. Data From the National .kfortatity and Natality Survey s.–Discontinued effective 1975. Future reports from these sample surveys based on vital records will be included in Series 20 and 21, respectively.

Series 23. Data From the National Survey of Family Gro wth. –Statistics on fertility, family formation and dis- solution, family planning, and related maternal and infant health topics derived from a biennial survey of a nationwide probability sample of ever-married women 15-44 years of age.

For a list of titles of reports published in these series, write to: Scientific and Technical Information Branch National Center for Health Statistics Public Health Service Hyattsville, Md, 20782 NCHS P<.ISTAGE ANu FEES PAID US DEPARTMENT OF HEALTH EDUCATION, ANO WELFARE us L) EPA RTMt W1 (>F HFW HEW 396 P.blm Health Semce Of f,ce of Ihe Ass,siant Secretarv for Health u. S.MAIL N,t(onal Center for Health Stal(sr,cs * THIRD CLASS 3700 East West H ,ghway Hyattsv!lle, Maryland 20782 BLK. RATE El OFFICIAL BuSINESS PENALTY FOR PRIVATE USE S300

For publmtmns m the V,rd and Health.Ttat,stsc, ISC”.,cdlSO1436-SCI{S. I