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Home , Genitourinary system

1997 REASON FOR VISIT CLASSIFICATION

SYMPTOM MODULE 1046.0 Symptoms of face, NEC GENERAL SYMPTOMS (1001-1099) Excludes: Facial pain 1055.4 1005.0 Chills Facial paralysis 1230.0

1010.0 Fever 1050.0 Chest pain and related symptoms (not referable to a specific body Includes: system) High temperature 1050.1 Chest pain Excludes: 1015.0 Tiredness, exhaustion pain (1265.0) Includes: 1050.2 Chest discomfort, pressure, tightness Fatigue Includes: No energy C - pressure Run down 1050.3 Burning sensation in the chest Worn out 1055.0 Pain, specified site not referable to a specific body system 1020.0 General weakness Includes: Buttock pain 1025.0 General ill feeling Gluteal pain Includes: Perineal pain Not feeling well Excludes: Multiple complaints Chest pain (1050.1) Diffuse Cx (see 1545.1-1545.3) Malaise Illness, NOS 1055.1 pain Sick, NOS 1055.2 Side pain, flank pain 1055.3 Groin pain 1030.0 Fainting (syncope) Includes: Includes: Pubic pain Blacking out 1055.4 Facial pain Passing out Includes: Fainting spells Jaw pain Excludes: Pain over eye Unconsciousness (5840.0) 1060.0 Pain and related symptoms, generalized, site unspecified 1035.0 Symptoms of fluid abnormalities 1060.1 Pain, unspecified Includes: 1035.1 Edema Ache all over Includes: 1060.2 Cramps, spasms, site unspecified Bloated Excludes: Holding water Menstrual cramps (1745.2) Swollen with water 1060.3 Stiffness, site unspecified Dropsy Ankles swelling (both) 1065.0 Tumor or mass, site unspecified Excludes: Swelling of one ankle (1930.5) 1070.0 Bleeding, multiple or unspecified sites

1035.2 Excessive sweating, perspiration 1075.0 Symptoms of growth and developmental disorders 1035.3 Excessive thirst 1075.1 Lack of growth Includes: 1040.0 Weight gain Failure to thrive Includes: Slowness, physical Obesity Too short Overweight Immaturity, physical Too fat Poor weight gain Excludes: 1075.2 Excessive growth Counseling for weight problem (4600.0) Includes: Too tall 1045.0 Weight loss Too big for age 1045.1 Recent weight loss Development, early (physical) 1045.2 Underweight 1080.0 General symptoms of infants, NEC 1120.0 Problems with identity and self-esteem 1080.1 Crying too much, fussy, fidgety, irritable Includes: 1080.2 Regurgitation, spitting up No confidence Excludes: Loss of identity Vomiting (1530.0) Identity crisis 1080.3 Feeding problem No goals Don't like myself Guilt 1085.0 General or unspecified nonviral infection Poor boundaries Includes: Co-dependency Infection, NOS Dependency Too much is expected of me 1090.0 Allergy, NOS Insecurity, emotional Includes: Allergic reaction, NOS 1120.0 Problems with identity and self-esteem Food allergy, NOS Milk allergy, NOS 1125.0 Restlessness Excludes: Includes: Allergic reaction (2825.0) Hyperactivity Allergy to (5905.0) Overactivity Nasal allergy (2635.0) 1130.0 Behavioral disturbances 1095.0 Disorders of motor functions Includes: Includes: Staring spells Ataxia Gambling problem Difficulty in walking 1130.1 Antisocial behavior Clumsiness Includes: Limping Avoiding people Staggering Excessive shyness Stumbling Social isolation Uncoordinated Withdrawal Dyskinesia Lying 1130.2 Hostile behavior SYMPTOMS REFERABLE TO PSYCHOLOGICAL AND MENTAL Includes: DISORDERS (1100-1199) Aggressiveness Criminality 1100.0 Anxiety and nervousness Cruelty Includes: Destructiveness Apprehension Negativism Bad Quarrelsome Jittery Child abuser Panicky feeling Child neglecter Stress Elder abuser Tension Spouse abuser Upset Wife batterer Worried 1130.3 Hysterical behavior 1130.4 Temper problems 1105.0 Fears and phobias Includes: Includes: Blowing up General fearfulness Irritability Losing temper 1110.0 Depression Temper tantrums Includes: 1130.5 Obsessions and compulsions Crying excessively Dejected 1135.0 Disturbances of sleep Feeling low Includes: Grief Night terrors Hopelessness 1135.1 Insomnia Sadness Includes: Unhappy Sleeplessness Feeling down Can't sleep Trouble falling asleep 1115.0 Anger 1135.2 Sleepiness (hypersomnia) Includes: Includes: Bitterness Drowsiness Hostile feelings Can't stay awake Excludes: 1135.3 Nightmares Temper problems (1130.4) 1135.4 Sleepwalking 1140.0 problems 1165.0 Other symptoms or problems relating to psychological and mental Includes: disorders, NEC (cont.) Smoking too much Can't quit smoking Excludes: Excludes: Character disorder (2315.0) Smoker's cough (1440.0) Personality disorder (2315.0) Physical symptoms of smoking (see particular symptom) 1165.1 Nailbiting 1165.2 Thumbsucking 1145.0 Alcohol-related problems Includes: Drinking problem SYMPTOMS REFERABLE TO THE (EXCLUDING Excludes: SENSE ORGANS) (1200 - 1259) Adverse effects of alcohol (5915.0) Alcoholism (2320.0) 1200.0 Abnormal involuntary movements Includes: 1150.0 Abnormal drug usage Shaking Includes: Jerking Drug abuse Tics Frequent or excessive use of stimulants, Tremors hallucinogens, depressants, etc. Twitch Excludes: Excludes: Drug addiction (2321.0) Eye movements (see 1325.0-1325.4) Drug dependence (2321.0) Eyelid twitch (1340.4) Intoxication with drugs (5910.0) Overdose, intentional (5820.1) 1205.0 Convulsions Overdose, unintentional, NOS (5910.0) Includes: Fits 1155.0 Delusions or hallucinations Febrile convulsions Includes: Seizures Seeing things Spells Hearing voices Excludes: Medicine is poisoned Fainting (1030.0) Grandiosity Ideas of reference 1210.0 Headache, pain in head Excludes: 1160.0 Psychosexual disorders Sinus headache (1410.1) 1160.1 Frigidity, loss of sex drive, lack of Migraine (2365.0) response, lack of libido 1160.2 Homosexuality, concerns with 1215.0 Memory, disturbances of 1160.3 Impotence Includes: 1160.4 Premature ejaculation Amnesia 1160.5 Masturbation excessive, concerns about Forgetfulness 1160.6 Orgasm, problem with Lack or loss of memory Temporary loss of memory 1165.0 Other symptoms or problems relating to psychological and mental disorders, NEC 1220.0 Disturbances of sensation Includes: 1220.1 Loss of feeling (anesthesia) Can't cope Includes: Going crazy Numbness Losing my mind No response to pain Disoriented 1220.2 Increased sensation (hyperesthesia) Difficulty concentrating 1220.3 Abnormal sensation (paresthesia) Trouble concentrating Includes: Hate everybody Prickly feeling Mood fluctuation Burning, tingling sensation Mood swings Needles and pins Blunted affect 1220.4 Other disturbances of sense, including Constricted affect smell and taste Peculiar thinking Inhibited 1225.0 Vertigo - dizziness Non-communicative Includes: Communications issues Falling sensation Deja vu feelings Giddiness (dizziness) Psychological problems, NOS Lightheadedness Wandering around Loss of sense of equilibrium or balance Room spinning 1230.0 Weakness (neurologic) Includes: 1305.0 Vision dysfunctions (cont.) Right- or left-sided weakness 1305.1 Blindness and half vision Drooping, facial or NOS 1305.2 Diminished vision Excludes: Includes: General weakness (1020.0) Blurred vision Difficulty reading 1235.0 Disorders of speech, speech disturbance Poor vision Includes: Trouble seeing Groping for words Can't see distances 1235.1 Stuttering, stammering Weak eyes 1235.2 Slurring Scotoma

1240.0 Other symptoms referable to the nervous system 1305.3 Extraneous vision Includes: Includes: Pinched Cloudy vision Confusion Hazy vision Cognitive decline Spots in front of eyes (floaters) 1305.4 Double vision (diplopia) SYMPTOMS REFERABLE TO THE CARDIOVASCULAR AND LYMPHATIC SYSTEMS (1260-1299) 1310.0 Discharge from eye 1310.1 Bleeding 1260.0 Abnormal pulsations and palpitations 1310.2 Tearing, watering (lacrimation) 1260.1 Increased heartbeat 1310.3 Pus, matter, white discharge Includes: Pulse too fast 1315.0 Eye infection and inflammation Rapid heartbeat 1315.1 Pinkeye 1260.2 Decreased heartbeat Includes: 1320.0 Abnormal sensations of the eye Pulse too slow Includes: Slow heart Foreign body sensation 1260.3 Irregular heartbeat 1320.1 Pain Includes: Includes: Fluttering Irritation Skipped beat 1320.2 Itching 1265.0 Heart pain 1320.3 Burning Includes: 1320.4 Strain Heart distress Anginal pain 1325.0 Abnormal eye movements Pain over heart Excludes: 1325.1 Abnormal retraction Angina pectoris (2515.0) 1325.2 Cross-eyed Chest pain (1050.1) 1325.3 Pupils unequal 1325.4 Deviation 1270.0 Other symptoms of the heart Includes: 1330.0 Abnormal appearance of eyes Bad heart 1330.1 Abnormal color Poor heart Includes: Weak heart Bloodshot Heart condition Red Excludes: 1275.0 Symptoms of lymph glands (or nodes) Yellow (1610.2) 1275.1 Swollen or enlarged glands 1275.2 Sore glands 1330.2 Protrusion (exophthalmos) 1330.3 Cloudy, dull, hazy appearance 1280.0 Other symptoms referable to the cardiovascular/, NEC 1335.0 Other and unspecified symptoms referable to eye, NEC 1280.1 Poor circulation Includes: 1280.2 Pallor, paleness Defect, NOS 1280.3 Flushed, blushing 1335.1 Contact lens problems SYMPTOMS REFERABLE TO THE EYES AND (1300-1399) 1335.2 Allergy 1335.3 Swelling 1305.0 Vision dysfunctions Excludes: Excludes: Foreign body (5600.0) Refractive errors (2405.0) Injury (5510.0) Abrasion (5410.0) 1340.0 Symptoms of eyelids 1405.0 Other symptoms of nose (cont.) 1340.1 Infection, inflammation, swelling 1405.4 Problem with appearance of nose 1340.2 Itching Includes: 1340.3 Mass or growth Too large 1340.4 Abnormal movement Bump(s) Includes: Undesirable appearance Twitching Blinking 1410.0 Sinus problems Squinting Includes: Drooping Sinus drainage 1410.1 Pain and pressure 1345.0 Hearing dysfunctions Includes: 1345.1 Diminished hearing Sinus headache Includes: Deafness 1410.2 Sinus inflammation, infection Trouble hearing 1410.3 Sinus congestion Hearing loss 1415.0 Shortness of breath 1345.2 Heightened or acute hearing Includes: 1345.3 Extraneous hearing Breathlessness Includes: Sensation of suffocation Ringing (tinnitus) Excludes: 1420.0 Labored or difficult breathing (dyspnea) Hearing things (1155.0) Includes: Smothering 1350.0 Discharge from Respiratory distress Includes: Trouble breathing Fluid in ear 1350.1 Bleeding 1425.0 Wheezing 1350.2 Pus (purulent drainage) Includes: 1350.3 Swimmer's ear Sighing respiration

1355.0 Earache, or ear infection 1430.0 Breathing problems, NEC 1355.1 Earache, pain Includes: 1355.2 Ear infection Hurts to breathe 1430.1 Disorders of respiratory sound, NEC 1360.0 Plugged feeling in ear Includes: Includes: Abnormal breathing sounds Ear wax Snoring Ear feels full Rattles Congestion in ear Stridor Blocked 1430.2 Rapid breathing (hyperventilation) Cracking Popping 1435.0 Sneezing Ears need cleaning 1440.0 Cough 1365.0 Other and unspecified symptoms referable to the ears, NEC Includes: 1365.1 Itching Croupy cough 1365.2 Growths or mass Smoker's cough 1365.3 Pulling at ears, picking at ears 1365.4 Abnormal size or shape, "ears stick out" 1445.0 Head cold, upper respiratory infection (coryza) Excludes: Includes: Foreign body in ear (5620.0) Cold, NOS Excludes: SYMPTOMS REFERABLE TO THE (1400-1499) Chest cold (1475.0)

1400.0 Nasal congestion 1450.0 General viral infection Includes: 1450.1 Flu Drippy nose Includes: Runny nose Grip Post-nasal drip Sniffles Excludes: Stuffy nose Croup (2600.0) Nasal obstruction Excess 1455.0 Symptoms referable to throat 1405.0 Other symptoms of nose 1455.1 Soreness Excludes: Includes: Nasal allergy (2635.0) Throat hurts 1405.1 Nosebleed (epistaxis) 1455.2 Pain 1405.2 Sore in nose 1455.3 Infection 1405.3 Inflammation and swelling Includes: Includes: Throat virus Sore nose Excludes: Infection Strep throat (2010.0) Red nose 1455.4 Irritation, scratch, tickle Sick to 1455.0 Symptoms referable to throat (cont.) Nervous stomach 1455.5 Swelling Feel like throwing up 1455.6 Lump or mass Includes: 1530.0 Vomiting Sensation of something in throat Includes: Excludes: Can't keep food down Foreign body in throat (5615.0) Throwing up Retching 1460.0 Symptoms referable to tonsils Excludes: Includes: Regurgitation, infants (1080.2) Infection Vomiting blood (1580.2) Inflammation 1535.0 Heartburn and indigestion (dyspepsia) 1470.0 Abnormalities of sputum or Includes: Excessive belching 1470.1 Coughing up blood Includes: 1540.0 Gastrointestinal infection Hemophysis Includes: 1470.2 Pus in sputum Stomach flu 1470.3 Excessive sputum Stomach virus Intestinal virus 1475.0 Congestion in chest Includes: 1545.0 Stomach and abdominal pain, cramps and spasms congestion Includes: Chest cold Gastric pain Excludes: 1480.0 Disorders of voice Groin pain (1055.3) 1480.1 Hoarseness, loss of voice 1480.2 Hypernasality 1545.1 Abdominal pain, cramps, spasms, NOS Includes: 1485.0 Other symptoms referable to the respiratory system, NEC Intestinal colic Includes: Gas pains Drainage in throat Abdominal discomfort, NOS 1545.2 Lower abdominal pain, cramps, spasms, SYMPTOMS REFERABLE TO THE DIGESTIVE SYSTEM (1500-1639) Includes: Right lower quadrant (RLQ) pain 1500.0 Symptoms of teeth and gums Left lower quadrant (LLQ) pain Includes: Inguinal pain Tooth knocked out 1545.3 Upper abdominal pain, cramps, spasms 1500.1 Toothache Includes: 1500.2 Gum pain Epigastric pain 1500.3 Bleeding gums Left upper quadrant (LUQ) pain Pain in umbilical region 1505.0 Symptoms referable to Right upper quadrant (RUQ) pain

1505.1 Cracked, bleeding, dry 1565.0 Change in abdominal size 1505.2 Abnormal color 1565.1 Distention, fullness, NOS 1505.3 Cold sore Includes: Abdominal bloating 1510.0 Symptoms referable to mouth Stomach fullness Includes: 1565.2 Mass or tumor Saliva too thick Includes: Foaming at the mouth Mass in groin 1510.1 Pain, burning, soreness Mass, inguinal 1510.2 Bleeding 1565.3 Abdominal swelling, NOS 1510.3 Dryness 1510.4 Ulcer, sore 1570.0 Appetite, abnormal 1570.1 Excessive appetite 1515.0 Symptoms referable to Eats too much Includes: Always hungry Ulcer on tongue 1570.2 Decreased appetite 1515.1 Pain Not hungry 1515.2 Bleeding Loss of appetite 1515.3 Inflammation, infection, swelling 1515.4 Abnormal color, ridges, coated 1580.0 Gastrointestinal bleeding 1580.1 Blood in stool (melena) 1520.0 Difficulty in swallowing (dysphagia) 1580.2 Vomiting blood (hematemesis) Includes: Choking 1585.0 Flatulence Inability to swallow Includes: Gas 1525.0 Nausea Bloated, gas Includes: Excessive gas Upset stomach Distention due to gas Excludes: 1655.2 Bedwetting Gas pains (1545.1) 1660.0 Other urinary dysfunctions Includes: 1590.0 Constipation Trouble going 1660.1 Retention of urine Includes: 1595.0 Diarrhea Weak stream Includes: Can't urinate Loose stools 1660.2 Hesitancy The runs Includes: Difficulty in starting stream 1600.0 Other symptoms or changes in bowel function 1660.3 Large volume 1600.1 Discharge in stools Includes: Includes: Polyuria Mucus Pus 1665.0 Symptoms of bladder 1600.2 Worms Includes: 1600.3 Changes in size, color, shape, or odor Bladder trouble Includes: 1665.1 Pain Bulky stools 1665.2 Infection Too narrow Unusual odor or color 1670.0 Symptoms of the kidneys 1600.4 Incontinence of stool Includes: Includes: trouble Dirty pants (encopresis) 1670.1 Pain Leaking stools 1670.2 Infection

1605.0 Symptoms referable to anus- 1675.0 Urinary tract infection, NOS 1605.1 Pain Includes: Includes: Genitourinary infection Burning Urine infection Irritation 1605.2 Bleeding 1680.0 Other symptoms referable to urinary tract 1605.3 Swelling or mass Includes: 1605.4 Itching Passed stones Excludes: 1610.0 Symptoms of , gallbladder, and Kidney stones or bladder stones 1610.1 Pain (2705.0) 1610.2 Jaundice Includes: 1700.0 Symptoms of penis Yellow eyes 1700.1 Pain, aching, soreness, tenderness, Yellow skin painful erection 1700.2 Infection, inflammation, swelling 1615.0 Other and unspecified symptoms referable to digestive system 1700.3 Lumps, bumps, growths, warts Includes: Bad breath 1705.0 Penile discharge Halitosis Stomach problem 1710.0 Symptoms of Stomach trouble Includes: Hiccoughs Prostate trouble Gastrointestinal distress 1710.1 Swelling Epigastric distress 1710.2 Infection

SYMPTOMS REFERABLE TO THE GENITOURINARY SYSTEM 1715.0 Symptoms of the and testes (1640-1829) 1715.1 Pain, aching, tenderness 1715.2 Swelling, inflammation 1640.0 Abnormalities of urine 1715.3 Growths, warts, lumps, bumps Excludes: 1715.4 Itching, jock itch Abnormal findings of urine tests (6200.0) 1640.1 Blood in urine (hematuria) 1720.0 Other symptoms of male 1640.2 Pus in urine Excludes: 1640.3 Unusual color or odor Psychosexual problems (1160.0-1160.6)

1645.0 Frequency and urgency of urination 1730.0 Absence of menstruation (amenorrhea) 1645.1 Excessive urination, night (nocturia) Excludes: Suspected pregnancy (3200.0) 1650.0 Painful urination Missed a period (3200.0) Includes: Period late (3200.0) Burning, discomfort

1655.0 Incontinence of urine (enuresis) 1735.0 Irregularity of menstrual interval 1655.1 Involuntary urination, can't hold urine, 1735.1 Frequent dribbling 1735.2 Infrequent 1735.3 Unpredictable Pain Excludes: 1740.0 Irregularity of menstrual flow Postpartum examination, routine (3215.0) 1740.1 Excessively heavy (menorrhagia) 1740.2 Scanty flow (oligomenorrhea) 1795.0 Other symptoms referable to the female reproductive system 1740.3 Abnormal material, including clots Includes: Frequent miscarriage 1745.0 Menstrual symptoms, other and unspecified Includes: 1800.0 Pain or soreness of Long periods Includes: Tenderness 1745.1 Premenstrual symptoms Includes: 1805.0 Lump or mass of breast Premenstrual tension or irritability Includes: Bloating before periods Bump Knot 1745.2 Painful menstruation (dysmenorrhea) Nodule Includes: Cyst Menstrual cramps Pain in legs and back during 1810.0 Other symptoms referable to breast menstruation 1810.1 Bleeding or discharge from nipple 1810.2 Postpartum problems 1750.0 Menopausal symptoms Includes: 1750.1 Early or late onset of menopause Engorgement 1750.2 Vasomotor symptoms-hot flashes Postpartum infection 1750.3 Emotional symptoms, change of life Nursing difficulties problems 1810.3 Problems with shape or size 1755.0 Uterine and vaginal bleeding Includes: Excludes: Too large Bleeding during pregnancy (1790.2) Too small 1755.1 Intermenstrual bleeding (metrorrhagia) Sagging Includes: Uneven development Breakthrough bleeding Bleeding between periods 1815.0 Symptoms of infertility 1755.2 Postmenopausal bleeding Includes: 1755.3 Postcoital bleeding, female Can't get pregnant Inability to conceive 1760.0 Vaginal discharge Sterility Includes: Bloody, brown, white (leukorrhea), 1820.0 Hormone deficiency or problem excessive 1825.0 Symptoms of sexual dysfunction 1765.0 Other vaginal symptoms Includes: 1765.1 Pain Dyspareunia 1765.2 Infection Painful intercourse 1765.3 Itching, burning Excludes: Psychological disorders (see 1160.0- 1770.0 Vulvar disorders 1160.6) 1770.1 Itching and irritation, swelling 1770.2 Mass, lump SYMPTOMS REFERABLE TO THE SKIN, NAILS, AND HAIR (1830-1899) 1770.3 Growth, wart, cyst, ulcer, sore 1830.0 Acne or pimples 1775.0 Pelvic symptoms Includes: 1775.1 Pain Bad complexion 1775.2 Pressure or dropping sensation Blackheads Includes: Blemishes Feeling of falling out Breaking out 1775.3 Infection, inflammation Complexion, NOS Whiteheads 1790.0 Problems of pregnancy Excludes: 1835.0 Discoloration or abnormal pigmentation Routine prenatal visits (3205.0) Includes: 1790.1 Pain during pregnancy Freckles 1790.2 Spotting, bleeding during pregnancy Blotches 1790.3 Symptoms of onset of labor Redness Includes: Spots Water broke Circles under eyes Ruptured membranes Birthmark Labor pain, contractions Excludes: Labor, NOS Jaundice (1610.2) Bruise (see 5405.0-5430.0) 1791.0 Postpartum problems Flushing (1280.3) Includes: Blushing (1280.3) Bleeding 1840.0 Infections of skin, NOS 1890.0 Symptoms referable to hair and scalp Includes: 1890.1 Too little hair Infected blister Includes: Excludes: Baldness Athlete's foot (2025.0) Alopecia 1840.1 Infection of skin of head or neck area Falling out 1840.2 Infection of skin of arm, hand, or finger Losing hair 1840.3 Infection of skin of leg, foot, or toe 1890.2 Unwanted hair Includes: Superfluous hair 1845.0 Symptoms of skin moles Abnormal hairiness Includes: Hirsutism Skin mole, NOS 1890.3 Dryness, flaky scalp 1845.1 Change in size or color 1890.4 Itching

1845.2 Bleeding mole 1895.0 Navel problems Includes: Umbilicus not healing

1850.0 Warts, NOS Includes: SYMPTOMS REFERABLE TO THE MUSCULOSKELETAL SYSTEM Condyloma (1900-1999) Condyloma acuminatum Excludes: These codes exclude all injuries (See Injuries and Adverse Effects Module.) Plantar's warts (2015.0) The following fifth digits should be used with categories 1900-1970: 1855.0 Other growths of skin Includes: .1 pain, ache, soreness, discomfort Skin growth, NOS .2 cramps, contractures, spasms Skin tag .3 limitation of movement, stiffness Cysts, NOS .4 weakness Callus .5 swelling Corns .6 lump, mass, tumor

1860.0 Skin rash 1900.0 Neck symptoms Includes: Rash 1905.0 Back symptoms Skin eruption Excludes: 1910.0 Low back symptoms Poison ivy (2825.0) Poison oak (2825.0) 1915.0 Hip symptoms 1860.1 Diaper rash 1920.0 Leg symptoms 1865.0 Skin lesion Includes: 1925.0 Knee symptoms Ulcer Sore 1930.0 Ankle symptoms Blister Pustule 1935.0 Foot and toe symptoms Raw area 1940.0 Shoulder symptoms 1870.0 Skin irritations, NEC 1870.1 Pain 1945.0 Arm symptoms 1870.2 Itching 1950.0 Elbow symptoms 1875.0 Swelling of skin Includes: 1955.0 Wrist symptoms Bumps, lumps Nodules 1960.0 Hand and finger symptoms Welts, except hives (2825.0) Tumor, skin 1965.0 Symptoms of unspecified muscles

1880.0 Other symptoms referable to skin 1970.0 Symptoms of unspecified Excludes: Navel problems (1895.0) 1975.0 Musculoskeletal deformities 1880.1 Oiliness Excludes: 1880.2 Dryness, peeling, scaliness, roughness Clubfoot (2960.0) 1880.3 Wrinkles Curvature of spine (2910.0) 1975.1 Bowlegged, knock-kneed 1885.0 Symptoms referable to nails 1975.2 Posture problems 1885.1 Infected 1975.3 Pigeon-toed, feet turn in 1885.2 Ingrown 1885.3 Brittle, breaking, splitting, cracked, ridged 1980.0 Other musculoskeletal symptoms Includes: pain Staphylococcal infections Stump pain Trichomonas vaginitis

DISEASE MODULE (2100-2199)

INFECTIVE AND PARASITIC (2001-2099) Malignant neoplasms:

2005.0 Intestinal infectious diseases 2100.0 Cancer, Includes: Includes: Enteritis Stomach Cholera Salmonella Colon Dysentery

2010.0 Streptococcal infection 2105.0 Cancer, Includes: Includes: Streptococcal tonsillitis Scarlet fever Lung 2015.0 Viral diseases Includes: Throat Chickenpox Shingles (Herpes zoster) 2110.0 Cancer, skin and subcutaneous tissues Herpes simplex Includes: Measles Melanoma German measles (rubella) Basal cell carcinoma Squamous cell carcinoma Hepatitis (infectious and NOS) 2115.0 Cancer, breast Smallpox Poliomyelitis 2120.0 Cancer, female genital tract Verruca Includes: Plantar's warts Uterus 2015.1 Human immunodeficiency virus (HIV) with or without associated conditions Fallopian tube(s) Includes: Acquired immunodeficiency syndrome AIDS (ies) AIDS-like syndrome Endometrium AIDS-related complex ARC 2125.0 Cancer, urinary and male genital tract HIV positive Includes: Excludes: Bladder Results, follow-up of test for HIV (6106.0) Kidney Prostate 2020.0 Venereal diseases Includes: 2130.0 Other malignant neoplasms Syphilis Includes: Gonorrhea Metastatic carcinoma Venereal diseases, NOS Brain tumor Bone cancer 2025.0 Fungus infections (mycoses) Carcinoma-in-situ, NOS Includes: Candidiasis 2135.0 Hodgkin's , lymphomata, leukemias Yeast infection Includes: Moniliasis Multiple myeloma Dermatophytoses Polycythemia vera Athlete's foot Lymphosarcoma Ringworm Cancer of blood Thrush Tinea Benign and uncertain nature neoplasms:

2030.0 Parasitic diseases 2140.0 Fibroids and other uterine neoplasms Includes: Includes: Pinworms Myoma Ascaris Leiomyomata Lice Cervical polyp Maggots Nabothian cyst Leeches 2145.0 Other benign neoplasms Includes: 2035.0 Other and unspecified infectious and parasitic diseases Rectal polyp Includes: Ovarian cyst Bartholin's cyst Anxiety reaction Lipoma Obsessive compulsive neurosis Vaginal inclusion Neurosis, NOS Nasal polyp Excludes: Dermoid cyst (ovary) Depression (1110.0) Nevus Anxiety (1100.0) Excludes: Pilonidal cyst (2825.0) 2315.0 Personality and character disorders Sebaceous cyst (2825.0) Epidermoid cyst (2825.0) 2320.0 Alcoholism Cyst, NOS (1855.0) Excludes: Alcohol-related problems (1145.0) 2150.0 of uncertain nature Adverse effect of alcohol (5915.0) Excludes: Neoplasm, NOS 2321.0 Drug dependence Brain tumor (2130.0) Includes: Drug addiction ENDOCRINE, NUTRITIONAL, AND METABOLIC DISEASES (2200-2249) Excludes: Abnormal drug usage (1150.0) 2200.0 Diseases of the gland Adverse effect of drug abuse (5910.0) Includes: Overdose, intentional (5820.1) Thyrotoxicosis Thyroid nodule 2325.0 Mental retardation Hyperthyroidism Goiter 2330.0 Other and unspecified mental disorders Myxedema Includes: Hypothyroidism Transient situational disturbances Adolescent adjustment reaction 2205.0 Diabetes mellitus Grief reaction Sexual deviations 2210.0 Gout, hyperuricemia Attention deficit disorder

2215.0 Other endocrine, nutritional, and metabolic diseases Includes: DISEASES OF THE NERVOUS SYSTEM (2350-2399) Hypoglycemia Hyperlipidemia 2350.0 Multiple sclerosis Hypercholesterolemia Disorders of intestinal absorption 2355.0 Parkinson's disease (paralysis agitans) Ovarian dysfunction Poor nutrition 2360.0 Epilepsy Low blood sugar 2365.0 Migraine headache DISEASES OF THE BLOOD AND BLOOD-FORMING ORGANS (2250- 2299) 2370.0 Other and unspecified diseases of the nervous system Includes: 2250.0 Anemia Carpal tunnel syndrome Includes: Bell's palsy Iron deficiency anemia Cerebral palsy Sickle cell anemia Demyelinating disease Pernicious anemia Paralysis, NEC Anemia, NOS Meningitis Muscular dystrophy 2255.0 Other diseases of blood and blood-forming organs Morton's neuroma Myasthenia gravis MENTAL DISORDERS (2300-2349) Alzheimer's disease

2300.0 Organic psychoses Includes: Organic brain syndromes Senile dementia Alcoholic psychoses

2305.0 Functional psychoses DISEASES OF THE EYE (2400-2449) Includes: Schizophrenia, all types 2400.0 Inflammatory diseases of the eye Manic-depressive psychoses Includes: Paranoid states Conjunctivitis Psychosis, NOS Ophthalmia Autism Sty Blepharitis 2310.0 Neuroses Keratitis Includes: Ulcer Depressive neurosis Excludes: Depressive reaction Infection, NOS (1315.0) Paroxysmal tachycardia Congestive heart failure Heart failure Heart murmur Premature ventricular contractions 2405.0 Refractive error (PVCs) Includes: Mitral valve prolapse Myopia, nearsightedness Hyperopia, farsightedness 2525.0 Cerebrovascular disease Astigmatism Includes: Excludes: Cerebrovascular accident (CVA) Test for refractive errors (3230.0) Cerebral hemorrhage Stroke 2410.0 Cataract 2530.0 Atherosclerosis 2415.0 Glaucoma Includes: Arteriosclerosis 2420.0 Other diseases of the eye Hardening of the Includes: Retinal detachment 2535.0 Phlebitis, thrombophlebitis Strabismus Includes: Aphakia Phlebothrombosis Amblyopia Color blindness 2540.0 Varicose Iritis Esotropia Pterygium 2545.0 Hemorrhoids Macular degeneration Includes: Perineal tags DISEASES OF THE EAR (2450-2499) 2550.0 Other disease of 2450.0 Otitis media Includes: Pulmonary embolism 2455.0 Other diseases of the ear Heart disease, NOS Includes: Lymphadenopathy Ruptured tympanic membrane Lymphadenitis Labyrinthitis Venous insufficiency Excludes: Aneurysm Infection, NOS (1355.2) Infarct(s), NOS Deafness (1345.1)

DISEASES OF THE RESPIRATORY SYSTEM (2600-2649) DISEASES OF THE CIRCULATORY SYSTEM (2500-2599) 2600.0 Upper respiratory infections except tonsillitis 2500.0 Rheumatic fever and chronic rheumatic heart disease Includes: Includes: Pharyngitis Chorea Sinusitis Laryngitis 2505.0 Hypertension with involvement of target organs Croup Includes: Rhinitis Hypertensive heart disease Excludes: Renal hypertension Allergic rhinitis (2635.0) HCD Cold (1445.0) HCVD Throat infection, NOS (1455.3) Hypertensive cardiovascular disease Nose infection, NOS (1405.3) Sinus infection, NOS (1410.2) 2510.0 Hypertension Includes: 2605.0 Tonsillitis High blood pressure 2610.0 Bronchitis 2515.0 Ischemic heart disease Includes: Includes: Chronic bronchitis Myocardial infarction Bronchitis, NOS Coronary disease Acute bronchitis Coronary Heart attack 2620.0 Emphysema Arteriosclerotic heart disease (ASHD) Arteriosclerotic cardiovascular disease 2625.0 Asthma (ACVD) Angina pectoris 2630.0 Pneumonia Includes: 2520.0 Other heart disease Includes: Bacterial pneumonia Cardiac dysrhythmias Bronchopneumonia Atrial fibrillation Pneumonitis 2635.0 Hay fever Temperomandibular (TMJ) syndrome Includes: Allergic rhinitis DISEASES OF THE GENITOURINARY SYSTEM (2700-2799) Nasal allergy Pollenosis 2700.0 Cystitis Allergy to: Excludes: Dust Bladder infection (1665.2) Pollen Animals 2705.0 Urinary tract disease except cystitis Ragweed Includes: Urethritis 2640.0 Other respiratory diseases Pyelonephritis Includes: Glomerulonephritis Pulmonary edema Glomerulonephrosis Deviated nasal septum Ureteral calculus Pneumothorax Renal failure Hemothorax Kidney stones Pleurisy Bladder stones Chronic obstructive pulmonary disease Neurogenic bladder Excludes: Bladder infection (1665.2) DISEASES OF THE DIGESTIVE SYSTEM (2650-2699) Kidney infection, NOS (1670.2) Passed stones (1680.0) 2650.0 Diseases of the esophagus, stomach, and duodenum Urinary tract infection (1675.0) Includes: Esophagitis 2710.0 Diseases of the male genital organs Duodenal ulcer Includes: Peptic ulcer Prostatitis Gastritis Benign prostatic hypertrophy (BPH) Stomach ulcer Hydrocele Excludes: Phimosis Stomach flu (1540.0) Epididymitis Gastroenteritis (2005.0) Peyronie's disease Excludes: 2655.0 Appendicitis, all types Prostate infection (1710.2)

2660.0 Hernia of abdominal cavity 2715.0 Fibrocystic and other diseases of breast Includes: Includes: Inguinal Mastitis Hiatus Excludes: Abdominal Infection (1810.0) Femoral Cancer (2115.0) Umbilical Ventral 2720.0 Pelvic inflammatory disease (PID) Includes: 2665.0 Diseases of the intestine and peritoneum Salpingitis Includes: Oophoritis Diverticulitis Pelvic peritonitis Diverticulosis Excludes: Spastic colitis Pelvic infection, NOS (1775.3) Ulcerative colitis 2725.0 Cervicitis, vaginitis Crohn's disease Includes: Ileitis Cervical erosion Fistula - rectal, anal Vulvovaginitis Fissure - rectal, anal Small bowel obstruction 2730.0 Other diseases of female reproductive system Excludes: Includes: Intestinal virus (1540.0) Endometriosis Rectal-vaginal fistula 2670.0 Diseases of the liver, gallbladder, and Prolapse of uterus Includes: Dysfunctional uterine bleeding Biliary colic Vulvitis Cirrhosis Polycystic Liver diseases Cystocele Cholelithiasis (gallstones) Rectocele Cholecystitis Pancreatitis 2735.0 Diagnosed complications of pregnancy and puerperium Includes: 2675.0 Other diseases of digestive system previa Includes: Canker sore Toxemia Dental abscess Threatened abortion Stomatitis Spontaneous abortion Temperomandibular joint (TMJ) pain Hyperemesis Fetal death in utero Bunions Diabetes during pregnancy Dupuytren's contracture Edema of pregnancy High blood pressure during pregnancy CONGENITAL ANOMALIES (2950-2979) RH sensitization Multiple pregnancy 2950.0 Congenital anomalies of heart and circulatory system Excludes: Abortion induced (3520.0) 2955.0 Undescended Includes: DISEASES OF THE SKIN AND (2800-2899)

2800.0 Carbuncle, furuncle, boil, cellulitis, abscess, NEC 2960.0 Other and unspecified congenital anomalies Includes: 2805.0 Impetigo Cleft palate Cleft 2810.0 Seborrheic dermatitis Deformed earlobe Includes: Clubfoot Dandruff Harelip Congenital dislocation of hip 2815.0 Eczema and dermatitis, NOS Blocked tear duct Absence of organs 2820.0 Psoriasis Duplication of organs

2825.0 Other diseases of the skin Includes: PERINATAL MORBIDITY AND MORTALITY CONDITIONS (2980-2999) Allergic skin reactions Pilonidal cyst 2980.0 Prematurity Urticaria Includes: Hives Premature infant Keloid Late effects of prematurity Keratosis Sebaceous cyst 2990.0 All other perinatal conditions Paronychia Lupus erythematosus discoid DIAGNOSTIC, SCREENING, AND PREVENTIVE MODULE Epidermal inclusion cyst Poison ivy GENERAL EXAMINATIONS (3100-3199) Poison oak Excludes: 3100.0 General medical examination Cyst, NOS (1855.0) Includes: Acne (1830.0) Annual exam Checkup, NOS Checkup, routine DISEASES OF THE MUSCULOSKELETAL SYSTEM AND CONNECTIVE General exam TISSUE (2900-2949) Multiphasic screening exam Regular exam 2900.0 Arthritis Routine exam Includes: Physical exam Osteoarthritis History and physical (H&P) Rheumatoid arthritis Excludes: Rheumatism, NOS Administrative exam (7100.0-7140.0) Followup visit (4800.0) 2905.0 Nonarticular rheumatism Gynecological exam (3225.0) Includes: Prenatal exam (3205.0) Bursitis Progress visit (4800.0) Synovitis Tenosynovitis 3105.0 Well baby examination Tendinitis Myositis 3130.0 General psychiatric or psychological examination Lumbago Includes: Ganglion cyst Psychological testing Excludes: Excludes: Rheumatism, NOS (2900.0) Court- or school-ordered examination (7140.0) 2910.0 Other musculoskeletal or connective tissue disease Includes: SPECIAL EXAMINATIONS (3200-3299) Systemic lupus erythematosus Curvatures of spine 3200.0 Pregnancy, unconfirmed Scoliosis Includes: Kyphoscoliosis Might be pregnant Kyphosis Period late Osteoporosis Late menses Degenerative disc diseases Pregnancy test Slipped disc Possible pregnancy Osteomyelitis Missed period Bone cysts 3205.0 Prenatal examination, routine Includes: Includes: AIDS test Routine obstetrical care Excludes: Normal antepartum visit To check results of human immunodeficiency virus test Pregnancy, NOS (6106.0)

3215.0 Postpartum examination, routine 3315.0 Other blood test Includes: 3220.0 Breast examination Blood count Excludes: Blood culture Mammography (3340.0) Blood test, NOS Xerography (3340.0) Blood thinning test Breast thermography (3340.0) Check cholesterol Prothrombin time 3225.0 Gynecological examination Sickle cell anemia test Includes: Excludes: Pelvic exam Premarital blood test (7135.1) Excludes: Repeat or abnormal Pap smear (6300.0) 3315.1 Blood test for venereal disease Examination involving IUD (3510.0) Examination for birth control (3505.0) 3320.0 Blood pressure test Examination for birth control, NOS (3500.0) Includes: Check blood pressure 3230.0 Eye examination Blood pressure check Includes: Routine ophthalmological exam 3325.0 Urine test To test my eyes Includes: Need new glasses Test urine for sugar Glasses, NOS Urinalysis Test for nearsightedness, farsightedness Estriol for fetal evaluation For glasses Urine culture Check glasses For contacts 3330.0 Diagnostic endoscopies Check contacts Includes: Vision test Proctoscopy Excludes: Sigmoidoscopy Fitting glasses or contacts (4515.0) Cystoscopy Laparoscopy 3235.0 Heart examination Includes: 3335.0 Heart checkup Cardiac checkup 3340.0 Mammography, xerography, breast thermography Excludes: 3240.0 Other special examination Breast examination (3220.0) Includes: Neurological exam 3345.0 Diagnostic Check tubes Includes: AICD check X-ray ICD check Myelogram Examination of functioning internal prosthetic devices, Radioisotope scanning implants, shunts, etc. IVP Angiogram DIAGNOSTIC TESTS (3300-3399) Venogram Hysterosalpingogram 3300.0 Sensitization test Includes: 3350.0 EKG, ECG, electrocardiogram, treadmill, stress testing Allergy test Excludes: 3355.0 EEG, electroencephalogram To check results of skin tests (6600.0) 3360.0 Hearing test 3305.0 Skin immunity test Includes: Includes: Hearing exam Tuberculin test PPD test 3365.0 Pap smear Excludes: To check results of skin tests (6600.0) 3370.0 Other and unspecified diagnostic tests Includes: 3310.0 Glucose level determination Centesis Includes: Electronic fetal monitoring Blood sugar test Lab test, NOS Check sugar Spinal tap Glucose tolerance test Pulmonary function test Test for diabetes Drug screening 3370.1 Glaucoma test 3314.0 Human immunodeficiency virus (HIV) test Includes: Check intraocular pressure 3520.0 Abortion to be performed (at this visit) 3370.2 Throat culture 3525.0 Sterilization to be performed (at this visit) Includes: OTHER SCREENING AND PREVENTIVE PROCEDURES (3400-3499) Male - vasectomy Female - tubal ligation 3400.0 Prophylactic inoculations Includes: 3530.0 Artificial insemination Vaccination Immunization Flu shot TREATMENT MODULE Tetanus shot MEDICATIONS (4100-4199) 3405.0 Exposure to venereal disease Includes: 4100.0 Allergy medication May have V.D. Includes: Check for V.D. Allergy shots Allergy treatments 3409.0 Exposure to human immunodeficiency virus (HIV) Excludes: Includes: Allergy testing (3300.0) Exposed to AIDS 4110.0 Injections 3410.0 Exposure to other infectious diseases Includes: Includes: Hormones Chickenpox Vitamins Infectious hepatitis Iron Measles Injections, NOS Mumps Shots, NOS Tuberculosis Excludes: Immunizations (3400.0) 3415.0 Exposure to bodily fluids of another person, NOS Vaccinations (3400.0) Includes: Inoculations (3400.0) Blood exposure Allergy shots (4100.0) Exposure to another's secretions 4115.0 Medication, other and unspecified kinds FAMILY PLANNING (3500-3599) Includes: Renew prescription 3500.0 Family Planning, NOS For medication Includes: Request prescription Counseling, examinations, and general advice regarding: Prescribe medication Birth control, NOS Check medication Unwanted pregnancy Scripts Contraceptive, NOS Renew scripts Sterilization Drug studies Infertility Excludes: Genetics Birth control medication (3505.0) Contraception followup, NOS Eyeglass prescription [see Eye examination (3230.0) Excludes: and Fitting glasses and contact lenses (4515.0)] Specified types of birth control: Antibiotic medication (4110.0) Birth control medication (3505.0) IUD (3510.0) PREOPERATIVE AND POSTOPERATIVE CARE (4200-4299) Procedures performed [See Counseling and examinations for pregnancy interruption (3515.0) through Artificial 4200.0 Preoperative visit for specified and unspecified types of surgery insemination (3530.0)] Includes: Discussion of cosmetic surgery 3505.0 Contraceptive medication Includes: 4205.0 Postoperative visit Examinations, instructions, and advice regarding: Includes: Birth control pills Postop care Renewing pill prescription Postop pain Oral contraceptives Postop suture removal Contraceptive implants Check surgical wound Foams, jellies Norplant checkup SPECIFIC TYPES OF THERAPY (4400-4499) Norplant insertion (also code 4520.0) 4400.0 Physical medicine and rehabilitation 3510.0 Contraceptive device Includes: Includes: Physical therapy IUD insertion, removal, checkup Heat therapy Diaphragm insertion, removal, checkup Hydrotherapy Therapeutic exercises 3515.0 Counseling and examinations for pregnancy interruption Back adjustment Includes: Occupational therapy Evaluation for an arrangement for abortion Recreational therapy Wants abortion Speech therapy Vocational rehabilitation 4535.0 Corrective appliances Includes: 4401.0 Cardiopulmonary resuscitation (CPR) Fitting and adjusting: Back brace 4405.0 Respiratory therapy Leg brace Includes: Neck brace therapy Orthopedic shoes Asthma treatment 4540.0 Cast, splint - application, removal 4410.0 Psychotherapy Includes: 4545.0 Dressing, bandage - application, change Group therapy Psychoanalysis 4550.0 Irrigation, lavage

4415.0 Radiation therapy 4555.0 Suture - insertion, removal

4420.0 Acupuncture 4560.0 Other specific therapeutic procedures, NEC Includes: 4425.0 Chemotherapy Ultraviolet treatment Eye exercises SPECIFIC THERAPEUTIC PROCEDURES (4500-4599) Cryotherapy Wound care, NOS 4500.0 Tube insertion TENS unit, NOS Includes: Chest tube Bad tube MEDICAL COUNSELING (4600-4699) Catheter plugged 4600.0 Diet and nutritional counseling 4505.0 Cauterization, all sites Includes: Check weight 4510.0 Urinary tract instrumentation and catheterization Counseling for weight reduction Includes: Urethral dilation 4604.0 Human immunodeficiency virus (HIV) counseling Excludes: Includes: Cystoscopy [see Diagnostic endoscopies (3330.0)] AIDS counseling ARC counseling 4515.0 Fitting glasses and contact lenses Worried, concerned about getting, transmitting AIDS Includes: AIDS information, education Prescription renewal Broken or lost glasses or contacts 4605.0 Medical Counseling, NOS Pick up glasses or contacts Includes: Clean glasses or contacts Wants to talk to doctor Excludes: To meet doctor Eye examination (3230.0) Medical consultation Patient education 4518.0 Detoxification To learn about a condition 4518.1 Alcohol Personal problem 4518.2 Drug Disease counseling Referral 4520.0 Minor surgery Second opinion Includes: Ears pierced 4605.1 Family history of cardiovascular disease Joint manipulation 4605.2 Family history of cancer Tattoo removal 4605.3 Family history of diabetes Norplant insertion (also code 3505.0) 4605.4 Family history of other disease or condition Ear tube removal Tube removal 4520.1 Wart removed SOCIAL PROBLEM COUNSELING (4700-4799) 4521. Major surgery Includes: 4700.0 Economic problem Cholecystectomy Includes: Lens extraction Too little income Liver Can't pay bills

4525.0 Kidney dialysis 4702.0 Problem with access to medical care Includes: 4529.0 Internal prosthetic devices (fit, adjust, remove) Limited access to medical care Includes: Blocked access to medical care Breast implants Joint prostheses 4705.0 Marital problems Cardiac pacemaker Includes: Problem with husband, wife 4530.0 External prosthetic devices, artificial body parts (fit, adjust, remove) Alcoholic spouse Marriage counseling, NOS Same problems, NOS Premarital counseling Excludes: Divorce, desertion, separation General checkup (3100.0) Custody battle Followup, disease (Code to disease) Followup, injury (Code to injury) 4710.0 Parent-child problems Followup, symptom (Code to symptom) Includes: Followup, test results (Code to 6100.0-6700.0) Working mother Postoperative followup (4205.0) Concern about childhood behavior Discipline Maturation problems INJURIES AND ADVERSE EFFECTS MODULE Adopted or foster child INJURY BY TYPE AND/OR LOCATION (5001-5799) 4715.0 Other problems of family relationship Includes: Fractures and dislocations: Aged parents or in-laws Problems with relatives 5005.0 Head and face Family fights and disruptions Includes: 4720.0 Educational problems Jaw Includes: Nose Absenteeism, truancy Facial Problems with teachers Hates school 5010.0 Spinal column School behavior problems Includes: Neck 4725.0 Occupational problems Vertebrae Includes: Back Unemployment Out of work 5015.0 Trunk area, except spinal column Job dissatisfaction Includes: Problem with boss or coworkers Rib Unable to work Collarbone 4730.0 Social adjustment problems Pelvic scapula Includes: Loneliness 5020.0 Leg Social isolation Includes: Neighborhood and community relations problems Knee Discrimination problems Don't have any friends 4735.0 Legal problems Hip Includes: Imprisonment, prosecution 5025.0 Ankle Lawsuits, litigation 5030.0 Foot and toes 4735.1 Police involvement in outpatient visit circumstances Includes: 5035.0 Arm Police called Includes: Brought in by police 4740.0 Other social problems Elbow Includes: Pregnancy out-of-wedlock Shoulder Disasters Housing and clothing problems 5040.0 Wrist Problem with boyfriend or girlfriend Problems of aging 5045.0 Hand and fingers

5050.0 Fracture, other and unspecified PROGRESS VISIT, NEC (4800-4899) Sprains and strains: 4800.0 Progress visit, NOS (Use only when the only information given is progress or followup) 5105.0 Cervical spine, neck Includes: Includes: Followup, NOS Whiplash Routine followup Routine, NOS 5110.0 Back I'm better I'm worse 5115.0 Knee I'm the same Chronic, NOS 5120.0 Ankle Touching base Ongoing treatment, NOS 5125.0 Wrist 5130.0 Sprain or strain, other and unspecified 5510.0 Eye

5515.0 Back Lacerations and cuts: Includes: Tail bone 5205.0 Head and neck area Excludes: 5520.0 Chest and abdomen Face (5210.0) Includes: Internal injuries

5210.0 Facial area 5525.0 Hip Includes: Eye 5530.0 Leg Ear Nose 5535.0 Knee Forehead 5540.0 Ankle 5215.0 Trunk area 5545.0 Foot and toe(s) 5220.0 Lower extremity Includes: 5550.0 Shoulder Ankle Foot 5555.0 Arm

5225.0 Upper extremity 5560.0 Elbow Includes: Hand 5565.0 Wrist Fingers Arm 5570.0 Hand and finger(s) Wrist 5575.0 Injury, multiple or unspecified 5230.0 Laceration and cuts, site unspecified Foreign body: Puncture wounds: 5600.0 Eye 5305.0 Head, neck and facial area 5605.0 Nose 5310.0 Trunk area 5610.0 Skin 5315.0 Lower extremity 5615.0 Digestive tract 5320.0 Upper extremity Includes: Mouth 5325.0 Puncture wound, site unspecified Throat Includes: Rectum Needlestick, NOS 5620.0 Other and unspecified sites Contusions, abrasions, and bruises: Burns, all degrees: 5405.0 Head, neck, and face Excludes: 5705.0 Head, neck, and face Eye (5410.0) 5710.0 Trunk area 5410.0 Eye Includes: 5715.0 Extremities Corneal abrasion Includes: Black eye Upper Lower 5415.0 Trunk area Includes: 5720.0 Burn, site unspecified Injury to scrotum 5750.0 Sunburn, windburn 5420.0 Lower extremity Includes: Sun poisoning 5425.0 Upper extremity Bites: 5430.0 Contusion, abrasion, bruise, site unspecified 5755.0 Insect Includes: Injury, other and unspecified type: Sting

5505.0 Head, neck, and face 5760.0 Animal, human Includes: Traumatic brain injury TBI INJURY, NOS (5800-5899) 5800.0 Late effects of an old injury Includes: Includes: Near drowning Scars Deformities 5839.0 Cardiopulmonary arrest Excludes: 5805.0 Motor vehicle accident, type of injury unspecified Respiratory arrest (5836.0) Includes: Cardiac arrest (5837.0) Car accident Auto accident 5840.0 Unconscious on arrival Motorcycle accident Includes: Coma 5810.0 Accident, NOS Stupor Includes: Knocked out Fall, type or location of injury unspecified Shock Unresponsive 5815.0 Violence, NOS Found unconscious Includes: Beat up 5841.0 State of consciousness not specified Stabbing Includes: In a fight Verbally unresponsive Excludes: Brought in by ambulance Violence against oneself (5818.0, 5820.0) Found on floor 5815.1 Child abuse or neglect Excludes: 5842.0 Altered level of consciousness, NOS Child sexual abuse (5830.1) Excludes: 5815.2 Battered spouse Adverse effect of drug abuse (5910.0) 5815.3 Elder abuse Adverse effect of alcohol (5915.0) 5815.4 Gunshot wound POISONING AND ADVERSE EFFECTS (5900-5999) 5818.0 Intentional self-mutilation Includes: 5900.0 Accidental poisoning Self-abuse Tried to hurt self 5900.1 Food poisoning Excludes: 5900.2 Ingestion, inhalation, or exposure to potentially Suicide attempt (5820.0) poisonous products Includes: 5820.0 Suicide attempt Household products Includes: Chemicals Found in car with motor running Drugs Hanging oneself Gas Stabbed oneself Smoke Slashed wrists Code also: Laceration of wrists (5225.0) 5905.0 Adverse effect of medication 5820.1 Overdose, intentional Includes: Allergy to medication 5830.0 Rape Penicillin allergy Includes: Anaphylactic shock Sexual assault Bad reaction to prescribed medication 5830.1 Sexual abuse Includes: 5910.0 Adverse effect of drug abuse Molestation Includes: Drug-induced hallucinations 5835.0 Dead on arrival (DOA) Combination of drugs and alcohol (nonsuicidal) Includes: Ingestion of drugs for nonmedicinal purposes Death Bad trip Excludes: Freaked out on drugs Respiratory arrest (5836.0) Unintentional overdose Cardiac arrest (5837.0) Excludes: Cardiopulmonary arrest (5839.0) Intentional overdose (5820.1)

5836.0 Respiratory arrest 5915.0 Adverse effect of alcohol Excludes: Includes: Cardiac arrest (5837.0) Intoxication Cardiopulmonary arrest (5839.0) Drunk Dead on arrival (5835.0) Acute intoxication Drowning (5838.0) Near drowning (5838.0) 5920.0 Adverse effects of environment Includes: 5837.0 Cardiac arrest Air pollution Excludes: Water pollution Cardiopulmonary arrest (5839.0) Noise pollution Respiratory arrest (5836.0) Frostbite Dead on arrival (5835.0) Sun damage

5838.0 Drowning 5925.0 Adverse effects, other and unspecified Includes: High school Seasickness Nursery school College Grade school TEST RESULTS MODULE Day care center (Includes all abnormal test results and followups for test results) 7100.4 Physical examination for extracurricular activities Includes: Boy Scouts or Girl Scouts 6100.0 For results of blood glucose tests Little League Includes: Camp High blood sugar Athletics Abnormal glucose tolerance test Sugar in blood 7120.0 Driver's license examination Elevated blood sugar 7125.0 Insurance examination 6105.0 For results of cholesterol and triglyceride tests Includes: 7130.0 Disability examination High cholesterol Includes: Evaluation of disability 6106.0 For results of test for human immunodeficiency virus (HIV) Social Security examination Includes: Results of AIDS test 7135.0 Premarital examination 7135.1 Premarital blood test 6110.0 For other findings of blood tests Includes: 7137.0 Direct admission to hospital Positive serology, VDRL Includes: Positive blood culture For admission Elevated sed rate Here for admission Direct admit 6200.0 For results of urine tests Admit to hospital Includes: Voluntary commitment Sugar in urine Involuntary commitment Positive urine culture Abnormal urinalysis 7140.0 Other reason for visit required by party other than the patient or the health care provider 6300.0 For cytology findings Includes: Includes: Physical examination for adoption Positive Pap smear Psychiatric examination required by court Repeat Pap smear Atypical Pap smear UNCODABLE ENTRIES For results of Pap smear of cervix or other area 8990.0 Problems, complaints, NEC 6400.0 For radiological findings 8991.0 Patient unable to speak English Includes: 8993.0 Patient (or patient's spokesperson) refused care X-ray results Includes: Abnormal X-ray Left AMA Xeromammography results Walked out 8997.0 Entry of "none" or "no complaint" 6500.0 For results of EKG Includes: Asymptomatic, NOS 6600.0 For results of skin tests 8998.0 Inadequate data base 8999.0 Illegible entry 6700.0 For other and unspecified test results Includes: SPECIAL CODE Abnormal scans Abnormal pulmonary function test 90000 Blank entry Abnormal EEG Abnormal lab test results, NOS To discuss test results with physician Ultrasonography results Results of fetal evaluation tests

ADMINISTRATIVE MODULE

7100.0 Physical examination required for school or employment 7100.1 Physical examination required for employment Includes: Preemployment examination Required company physical Return to work checkup Teacher's certificate physical 7100.2 Executive physical examination 7100.3 Physical examination required for school Includes: