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ICD-10-CM-Chapter 18

Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99)

Note

This chapter includes symptoms, signs, abnormal results of clinical or other investigative procedures, and ill-defined

conditions regarding which no diagnosis classifiable elsewhere is recorded

Signs and symptoms that point rather definitely to a given diagnosis have been assigned to a category in other

chapters of the classification. In general, categories in this chapter include the less well-defined conditions and

symptoms that, without the necessary study of the case to establish a final diagnosis, point perhaps equally to

two or more diseases or to two or more systems of the body. Practically all categories in the chapter could be

designated 'not otherwise specified', 'unknown etiology' or 'transient'. The Alphabetical Index should be

consulted to determine which symptoms and signs are to be allocated here and which to other chapters. The

residual subcategories, numbered .8, are generally provided for other relevant symptoms that cannot be

allocated elsewhere in the classification

The conditions and signs or symptoms included in categories R00-R94 consist of

(a) cases for which no more specific diagnosis can be made even after all the facts bearing on the case have been

investigated;

(b) signs or symptoms existing at the time of initial encounter that proved to be transient and whose causes could

not be determined;

(c) provisional diagnosis in a patient who failed to return for further investigation or care;

(d) cases referred elsewhere for investigation or treatment before the diagnosis was made;

(e) cases in which a more precise diagnosis was not available for any other reason;

(f) certain symptoms, for which supplementary information is provided, that represent important problems in medical

care in their own right

Excludes2

abnormal findings on antenatal screening of mother (O28.-)

certain conditions originating in the perinatal period (P04-P96)

signs and symptoms classified in the body system chapters

signs and symptoms of breast (N63, N64.5)

This chapter contains the following blocks

Symptoms and signs involving the circulatory and respiratory systems

Symptoms and signs involving the digestive system and abdomen

Symptoms and signs involving the skin and subcutaneous tissue

Symptoms and signs involving the nervous and musculoskeletal systems

Symptoms and signs involving the genitourinary system

Symptoms and signs involving cognition, perception, emotional state and behavior

Symptoms and signs involving speech and voice

General symptoms and signs

Abnormal findings on examination of blood, without diagnosis

Abnormal findings on examination of urine, without diagnosis

Abnormal findings on examination of other body fluids, substances and tissues, without diagnosis

Abnormal findings on diagnostic imaging and in function studies, without diagnosis

Abnormal tumor markers

Ill-defined and unknown cause of mortality

Symptoms and signs involving the circulatory and respiratory systems (R00-R09)

  • R00 Abnormalities of heart beat

Excludes1

abnormalities originating in the perinatal period (P29.1-)

Excludes2

specified arrhythmias (I47-I49)

  • R00.0 Tachycardia, unspecified

Rapid heart beat

Sinoauricular tachycardia NOS

Sinus (sinusal) tachycardia NOS

Excludes1

neonatal tachycardia (P29.11)

paroxysmal tachycardia (I47.-)

  • R00.1 Bradycardia, unspecified

Sinoatrial bradycardia

Sinus bradycardia

Slow heart beat

Vagal bradycardia Use additional

code for adverse effect, if applicable, to identify drug (T36-T50 with fifth or sixth character 5)

Excludes1

neonatal bradycardia (P29.12)

Awareness of heart beat

  • R00.8 Other abnormalities of heart beat
  • R00.9 Unspecified abnormalities of heart beat
  • R01 Cardiac murmurs and other cardiac sounds

Excludes1

cardiac murmurs and sounds originating in the perinatal period (P29.8)

  • R01.0 Benign and innocent cardiac murmurs

Functional cardiac murmur

  • R01.1 Cardiac murmur, unspecified

Cardiac bruit NOS

Heart murmur NOS

Systolic murmur NOS

  • R01.2 Other cardiac sounds

Cardiac dullness, increased or decreased

Precordial friction

  • R03 Abnormal blood-pressure reading, without diagnosis
  • R03.0 Elevated blood-pressure reading, without diagnosis of hypertension

Note

This category is to be used to record an episode of elevated blood pressure in a patient in whom no

formal diagnosis of hypertension has been made, or as an isolated incidental finding

  • R03.1 Nonspecific low blood-pressure reading

Excludes1

hypotension (I95.-)

maternal hypotension syndrome (O26.5-)

neurogenic orthostatic hypotension (G90.3)

  • R04 Hemorrhage from respiratory passages

Hemorrhage from nose

Nosebleed

  • R04.1 Hemorrhage from throat

Excludes2

hemoptysis (R04.2)

Blood-stained sputum

Cough with hemorrhage

  • R04.8 Hemorrhage from other sites in respiratory passages
  • R04.81 Acute idiopathic pulmonary hemorrhage in infants

AIPHI

Acute idiopathic hemorrhage in infants over 28 days old

Excludes1

perinatal pulmonary hemorrhage (P26.-)

von Willebrand's disease (D68.0)

  • R04.89 Hemorrhage from other sites in respiratory passages

Pulmonary hemorrhage NOS

  • R04.9 Hemorrhage from respiratory passages, unspecified

Excludes1

cough with hemorrhage (R04.2)

smoker's cough (J41.0)

  • R06 Abnormalities of breathing

Excludes1

acute respiratory distress syndrome (J80)

respiratory arrest (R09.2)

respiratory arrest of newborn (P28.81)

respiratory distress syndrome of newborn (P22.-)

respiratory failure (J96.-)

respiratory failure of newborn (P28.5)

Excludes1

tachypnea NOS (R06.82)

transient tachypnea of newborn (P22.1)

  • R06.03 Acute respiratory distress

Excludes1

congenital laryngeal stridor (P28.89)

laryngismus (stridulus) (J38.5)

Excludes1

Asthma (J45.-)

Cheyne-Stokes breathing

Excludes1

psychogenic hyperventilation (F45.8)

Excludes2

dry mouth NOS (R68.2)

Excludes1

psychogenic hiccough (F45.8)

  • R06.8 Other abnormalities of breathing
  • R06.81 Apnea, not elsewhere classified

Apnea NOS

Excludes1

apnea (of) newborn (P28.4)

sleep apnea (G47.3-)

sleep apnea of newborn (primary) (P28.3)

  • R06.82 Tachypnea, not elsewhere classified

Tachypnea NOS

Excludes1

transitory tachypnea of newborn (P22.1)

  • R06.89 Other abnormalities of breathing

Breath-holding (spells)

Sighing

  • R06.9 Unspecified abnormalities of breathing
  • R07 Pain in throat and chest

Excludes1

epidemic myalgia (B33.0)

Excludes2

jaw pain R68.84

pain in breast (N64.4)

Excludes1

chronic sore throat (J31.2)

sore throat (acute) NOS (J02.9)

Excludes2

dysphagia (R13.1-)

pain in neck (M54.2)

  • R07.1 Chest pain on breathing

Painful respiration

Pleurodynia NOS

Excludes1

epidemic pleurodynia (B33.0)

Anterior chest-wall pain NOS

  • R07.9 Chest pain, unspecified
  • R09 Other symptoms and signs involving the circulatory and respiratory system

Excludes1

acute respiratory distress syndrome (J80)

respiratory arrest of newborn (P28.81)

respiratory distress syndrome of newborn (P22.0)

respiratory failure (J96.-)

respiratory failure of newborn (P28.5)

  • R09.0 Asphyxia and hypoxemia

Excludes1

asphyxia due to carbon monoxide (T58.-)

asphyxia due to foreign body in respiratory tract (T17.-)

birth (intrauterine) asphyxia (P84)

hyperventilation (R06.4)

traumatic asphyxia (T71.-)

Excludes2

hypercapnia (R06.89)

Excludes1

pleurisy with effusion (J90)

Cardiorespiratory failure

Excludes1

cardiac arrest (I46.-)

respiratory arrest of newborn (P28.81)

respiratory distress of newborn (P22.0)

respiratory failure (J96.-)

respiratory failure of newborn (P28.5)

respiratory insufficiency (R06.89)

respiratory insufficiency of newborn (P28.5)

Abnormal amount of sputum

Abnormal color of sputum

Abnormal odor of sputum

Excessive sputum

Excludes1

blood-stained sputum (R04.2)

  • R09.8 Other specified symptoms and signs involving the circulatory and respiratory systems
  • R09.89 Other specified symptoms and signs involving the circulatory and respiratory systems

Bruit (arterial)

Abnormal chest percussion

Feeling of foreign body in throat

Friction sounds in chest

Chest tympany

Choking sensation

Rales

Weak pulse

Excludes2

foreign body in throat (T17.2-)

wheezing (R06.2)

Symptoms and signs involving the digestive system and abdomen (R10-R19)

Excludes2

congenital or infantile pylorospasm (Q40.0)

gastrointestinal hemorrhage (K92.0-K92.2)

intestinal obstruction (K56.-)

newborn gastrointestinal hemorrhage (P54.0-P54.3)

newborn intestinal obstruction (P76.-)

pylorospasm (K31.3)

signs and symptoms involving the urinary system (R30-R39)

symptoms referable to female genital organs (N94.-)

symptoms referable to male genital organs (N48-N50)

  • R10 Abdominal and pelvic pain

Excludes1

renal colic (N23)

Excludes2

dorsalgia (M54.-)

flatulence and related conditions (R14.-)

Severe abdominal pain (generalized) (with abdominal rigidity)

Excludes1

abdominal rigidity NOS (R19.3)

generalized abdominal pain NOS (R10.84)

localized abdominal pain (R10.1-R10.3-)

  • R10.1 Pain localized to upper abdomen
  • R10.10 Upper abdominal pain, unspecified
  • R10.11 Right upper quadrant pain
  • R10.12 Left upper quadrant pain

Dyspepsia

Excludes1

functional dyspepsia (K30)

  • R10.2 Pelvic and perineal pain

Excludes1

vulvodynia (N94.81)

  • R10.3 Pain localized to other parts of lower abdomen
  • R10.30 Lower abdominal pain, unspecified
  • R10.31 Right lower quadrant pain
  • R10.32 Left lower quadrant pain
  • R10.8 Other abdominal pain

Abdominal tenderness NOS

  • R10.811 Right upper quadrant abdominal tenderness
  • R10.812 Left upper quadrant abdominal tenderness
  • R10.813 Right lower quadrant abdominal tenderness
  • R10.814 Left lower quadrant abdominal tenderness
  • R10.815 Periumbilic abdominal tenderness
  • R10.816 Epigastric abdominal tenderness
  • R10.817 Generalized abdominal tenderness
  • R10.819 Abdominal tenderness, unspecified site
  • R10.82 Rebound abdominal tenderness
  • R10.821 Right upper quadrant rebound abdominal tenderness
  • R10.822 Left upper quadrant rebound abdominal tenderness
  • R10.823 Right lower quadrant rebound abdominal tenderness
  • R10.824 Left lower quadrant rebound abdominal tenderness
  • R10.825 Periumbilic rebound abdominal tenderness
  • R10.826 Epigastric rebound abdominal tenderness
  • R10.827 Generalized rebound abdominal tenderness
  • R10.829 Rebound abdominal tenderness, unspecified site

Colic NOS

Infantile colic

Excludes1

colic in adult and child over 12 months old (R10.84)

  • R10.84 Generalized abdominal pain

Excludes1

generalized abdominal pain associated with acute abdomen (R10.0)

  • R10.9 Unspecified abdominal pain
  • R11 Nausea and vomiting

Excludes1

cyclical vomiting associated with migraine (G43.A-)

excessive vomiting in pregnancy (O21.-)

hematemesis (K92.0)

neonatal hematemesis (P54.0)

newborn vomiting (P92.0-)

psychogenic vomiting (F50.89)

vomiting associated with bulimia nervosa (F50.2)

vomiting following gastrointestinal surgery (K91.0)

Nausea NOS

Nausea without vomiting

Vomiting NOS

  • R11.11 Vomiting without nausea
  • R11.13 Vomiting of fecal matter

Bilious emesis

  • R11.15 Cyclical vomiting syndrome unrelated to migraine

Cyclic vomiting syndrome NOS

Persistent vomiting

Excludes1

cyclical vomiting in migraine (G43.A-)

Excludes2

bulimia nervosa (F50.2)

diabetes mellitus due to underlying condition (E08.-)

  • R11.2 Nausea with vomiting, unspecified

Persistent nausea with vomiting NOS

Excludes1

dyspepsia NOS (R10.13)

functional dyspepsia (K30)

  • R13 Aphagia and dysphagia

Inability to swallow

Excludes1

psychogenic aphagia (F50.9)

  • R13.1 Dysphagia Code first

, if applicable, dysphagia following cerebrovascular disease (I69. with final characters -91)

Excludes1

psychogenic dysphagia (F45.8)

Difficulty in swallowing NOS

  • R13.12 Dysphagia, oropharyngeal phase
  • R13.13 Dysphagia, pharyngeal phase
  • R13.14 Dysphagia, pharyngoesophageal phase

Cervical dysphagia

Neurogenic dysphagia

  • R14 Flatulence and related conditions

Excludes1

psychogenic aerophagy (F45.8)

  • R14.0 Abdominal distension (gaseous)

Bloating

Tympanites (abdominal) (intestinal)

  • R15 Fecal incontinence

Includes

encopresis NOS

Excludes1

fecal incontinence of nonorganic origin (F98.1)

  • R15.0 Incomplete defecation

Excludes1

constipation (K59.0-)

fecal impaction (K56.41)

Fecal soiling

  • R15.9 Full incontinence of feces

Fecal incontinence NOS

  • R16 Hepatomegaly and splenomegaly, not elsewhere classified
  • R16.0 Hepatomegaly, not elsewhere classified

Hepatomegaly NOS

  • R16.1 Splenomegaly, not elsewhere classified

Splenomegaly NOS

  • R16.2 Hepatomegaly with splenomegaly, not elsewhere classified

Hepatosplenomegaly NOS

  • R17 Unspecified jaundice

Excludes1

neonatal jaundice (P55, P57-P59)

Includes

fluid in peritoneal cavity

Excludes1

ascites in alcoholic cirrhosis (K70.31)

ascites in alcoholic hepatitis (K70.11)

ascites in toxic liver disease with chronic active hepatitis (K71.51)

  • R18.0 Malignant ascites Code first

malignancy, such as

malignant neoplasm of ovary (C56.-)

secondary malignant neoplasm of retroperitoneum and peritoneum (C78.6)

Ascites NOS

Peritoneal effusion (chronic)

  • R19 Other symptoms and signs involving the digestive system and abdomen

Excludes1

acute abdomen (R10.0)

  • R19.0 Intra-abdominal and pelvic swelling, mass and lump

Excludes1

abdominal distension (gaseous) (R14.-)

ascites (R18.-)

  • R19.00 Intra-abdominal and pelvic swelling, mass and lump, unspecified site
  • R19.01 Right upper quadrant abdominal swelling, mass and lump
  • R19.02 Left upper quadrant abdominal swelling, mass and lump
  • R19.03 Right lower quadrant abdominal swelling, mass and lump
  • R19.04 Left lower quadrant abdominal swelling, mass and lump
  • R19.05 Periumbilic swelling, mass or lump

Diffuse or generalized umbilical swelling or mass

  • R19.06 Epigastric swelling, mass or lump
  • R19.07 Generalized intra-abdominal and pelvic swelling, mass and lump

Diffuse or generalized intra-abdominal swelling or mass NOS

Diffuse or generalized pelvic swelling or mass NOS

  • R19.09 Other intra-abdominal and pelvic swelling, mass and lump
  • R19.1 Abnormal bowel sounds
  • R19.12 Hyperactive bowel sounds
  • R19.15 Other abnormal bowel sounds

Abnormal bowel sounds NOS

  • R19.2 Visible peristalsis

Hyperperistalsis

Excludes1

abdominal rigidity with severe abdominal pain (R10.0)

  • R19.30 Abdominal rigidity, unspecified site
  • R19.31 Right upper quadrant abdominal rigidity
  • R19.32 Left upper quadrant abdominal rigidity
  • R19.33 Right lower quadrant abdominal rigidity
  • R19.34 Left lower quadrant abdominal rigidity
  • R19.35 Periumbilic abdominal rigidity
  • R19.36 Epigastric abdominal rigidity
  • R19.37 Generalized abdominal rigidity
  • R19.4 Change in bowel habit

Excludes1

constipation (K59.0-)

functional diarrhea (K59.1)

  • R19.5 Other fecal abnormalities

Abnormal stool color

Bulky stools

Mucus in stools

Occult blood in feces

Occult blood in stools

Excludes1

melena (K92.1)

neonatal melena (P54.1)

  • R19.7 Diarrhea, unspecified

Diarrhea NOS

Excludes1

functional diarrhea (K59.1)

neonatal diarrhea (P78.3)

psychogenic diarrhea (F45.8)

  • R19.8 Other specified symptoms and signs involving the digestive system and abdomen

Symptoms and signs involving the skin and subcutaneous tissue (R20-R23)

Excludes2

symptoms relating to breast (N64.4-N64.5)

  • R20 Disturbances of skin sensation

Excludes1

dissociative anesthesia and sensory loss (F44.6)

psychogenic disturbances (F45.8)

  • R20.1 Hypoesthesia of skin
  • R20.2 Paresthesia of skin

Formication

Pins and needles

Tingling skin

Excludes1

acroparesthesia (I73.8)

  • R20.8 Other disturbances of skin sensation
  • R20.9 Unspecified disturbances of skin sensation
  • R21 Rash and other nonspecific skin eruption

Includes

rash NOS

Excludes1

specified type of rash- code to condition

vesicular eruption (R23.8)

  • R22 Localized swelling, mass and lump of skin and subcutaneous tissue

Includes

subcutaneous nodules (localized)(superficial)

Excludes1

abnormal findings on diagnostic imaging (R90-R93)

edema (R60.-)

enlarged lymph nodes (R59.-)

localized adiposity (E65)

swelling of joint (M25.4-)

  • R22.0 Localized swelling, mass and lump, head
  • R22.1 Localized swelling, mass and lump, neck
  • R22.2 Localized swelling, mass and lump, trunk

Excludes1

intra-abdominal or pelvic mass and lump (R19.0-)

intra-abdominal or pelvic swelling (R19.0-)

Excludes2

breast mass and lump (N63)

  • R22.3 Localized swelling, mass and lump, upper limb
  • R22.30 Localized swelling, mass and lump, unspecified upper limb
  • R22.31 Localized swelling, mass and lump, right upper limb
  • R22.32 Localized swelling, mass and lump, left upper limb
  • R22.33 Localized swelling, mass and lump, upper limb, bilateral
  • R22.4 Localized swelling, mass and lump, lower limb
  • R22.40 Localized swelling, mass and lump, unspecified lower limb
  • R22.41 Localized swelling, mass and lump, right lower limb
  • R22.42 Localized swelling, mass and lump, left lower limb
  • R22.43 Localized swelling, mass and lump, lower limb, bilateral
  • R22.9 Localized swelling, mass and lump, unspecified
  • R23 Other skin changes

Excludes1

acrocyanosis (I73.8)

cyanotic attacks of newborn (P28.2)

Clammy skin

Excessive blushing Code first

, if applicable, menopausal and female climacteric states (N95.1)

  • R23.3 Spontaneous ecchymoses

Petechiae

Excludes1

ecchymoses of newborn (P54.5)

purpura (D69.-)

  • R23.4 Changes in skin texture

Desquamation of skin

Induration of skin

Scaling of skin

Excludes1

epidermal thickening NOS (L85.9)

  • R23.9 Unspecified skin changes

Symptoms and signs involving the nervous and musculoskeletal systems (R25-R29)

  • R25 Abnormal involuntary movements

Excludes1

specific movement disorders (G20-G26)

stereotyped movement disorders (F98.4)

tic disorders (F95.-)

  • R25.0 Abnormal head movements
  • R25.1 Tremor, unspecified

Excludes1

chorea NOS (G25.5)

essential tremor (G25.0)

hysterical tremor (F44.4)

intention tremor (G25.2)

Excludes2

carpopedal spasm (R29.0)

charley-horse (M62.831)

infantile spasms (G40.4-)

muscle spasm of back (M62.830)

muscle spasm of calf (M62.831)

Twitching NOS

  • R25.8 Other abnormal involuntary movements
  • R25.9 Unspecified abnormal involuntary movements
  • R26 Abnormalities of gait and mobility

Excludes1

ataxia NOS (R27.0)

hereditary ataxia (G11.-)

locomotor (syphilitic) ataxia (A52.11)

immobility syndrome (paraplegic) (M62.3)

Staggering gait

Spastic gait

  • R26.2 Difficulty in walking, not elsewhere classified

Excludes1

falling (R29.6)

unsteadiness on feet (R26.81)

  • R26.8 Other abnormalities of gait and mobility
  • R26.89 Other abnormalities of gait and mobility
  • R26.9 Unspecified abnormalities of gait and mobility
  • R27 Other lack of coordination

Excludes1

ataxic gait (R26.0)

hereditary ataxia (G11.-)

vertigo NOS (R42)

  • R27.0 Ataxia, unspecified

Excludes1

ataxia following cerebrovascular disease (I69. with final characters -93)

  • R27.8 Other lack of coordination
  • R27.9 Unspecified lack of coordination
  • R29 Other symptoms and signs involving the nervous and musculoskeletal systems

Carpopedal spasm

Excludes1

hysterical tetany (F44.5)

neonatal tetany (P71.3)

parathyroid tetany (E20.9)

post-thyroidectomy tetany (E89.2)

Excludes2

abnormal pupillary reflex (H57.0)

hyperactive gag reflex (J39.2)

vasovagal reaction or syncope (R55)

Excludes1

congenital deformities of hip (Q65.-)

  • R29.5 Transient paralysis Code first

any associated spinal cord injury (S14.0, S14.1-, S24.0, S24.1-, S34.0-, S34.1-)

Excludes1

transient ischemic attack (G45.9)

Falling

Tendency to fall

Excludes2

at risk for falling (Z91.81)

history of falling (Z91.81)

  • R29.7 National Institutes of Health Stroke Scale (NIHSS) score Code first

the type of cerebral infarction (I63-)

  • R29.8 Other symptoms and signs involving the nervous and musculoskeletal systems
  • R29.81 Other symptoms and signs involving the nervous system

Facial droop

Excludes1

Bell's palsy (G51.0)

facial weakness following cerebrovascular disease (I69. with final characters -92)

  • R29.818 Other symptoms and signs involving the nervous system
  • R29.89 Other symptoms and signs involving the musculoskeletal system

Excludes2

pain in limb (M79.6-)

Excludes1

osteoporosis (M80-M81)

Excludes1

congenital (sternomastoid) torticollis Q68.0

psychogenic torticollis (F45.8)

spasmodic torticollis (G24.3)

torticollis due to birth injury (P15.8)

torticollis NOS M43.6

  • R29.898 Other symptoms and signs involving the musculoskeletal system
  • R29.9 Unspecified symptoms and signs involving the nervous and musculoskeletal systems
  • R29.90 Unspecified symptoms and signs involving the nervous system
  • R29.91 Unspecified symptoms and signs involving the musculoskeletal system

Symptoms and signs involving the genitourinary system (R30-R39)

  • R30 Pain associated with micturition

Excludes1

psychogenic pain associated with micturition (F45.8)

Strangury

  • R30.9 Painful micturition, unspecified

Painful urination NOS

Excludes1

hematuria included with underlying conditions, such as

acute cystitis with hematuria (N30.01)

recurrent and persistent hematuria in glomerular diseases (N02.-)

  • R31.1 Benign essential microscopic hematuria
  • R31.2 Other microscopic hematuria
  • R31.21 Asymptomatic microscopic hematuria

AMH

  • R31.29 Other microscopic hematuria
  • R31.9 Hematuria, unspecified
  • R32 Unspecified urinary incontinence

Enuresis NOS

Excludes1

functional urinary incontinence (R39.81)

nonorganic enuresis (F98.0)

stress incontinence and other specified urinary incontinence (N39.3-N39.4-)

urinary incontinence associated with cognitive impairment (R39.81)

  • R33 Retention of urine

Excludes1

psychogenic retention of urine (F45.8)

  • R33.0 Drug induced retention of urine Use additional

code for adverse effect, if applicable, to identify drug (T36-T50 with fifth or sixth character 5)

  • R33.8 Other retention of urine Code first

, if applicable, any causal condition, such as

enlarged prostate (N40.1)

  • R33.9 Retention of urine, unspecified
  • R34 Anuria and oliguria

Excludes1

anuria and oliguria complicating abortion or ectopic or molar pregnancy (O00-O07, O08.4)

anuria and oliguria complicating pregnancy (O26.83-)

anuria and oliguria complicating the puerperium (O90.4)

  • R35 Polyuria Code first

, if applicable, any causal condition, such as

enlarged prostate (N40.1)

Excludes1

psychogenic polyuria (F45.8)

  • R35.0 Frequency of micturition

Polyuria NOS

  • R36 Urethral discharge
  • R36.0 Urethral discharge without blood
  • R36.9 Urethral discharge, unspecified

Penile discharge NOS

Urethrorrhea

  • R37 Sexual dysfunction, unspecified
  • R39 Other and unspecified symptoms and signs involving the genitourinary system
  • R39.0 Extravasation of urine
  • R39.1 Other difficulties with micturition Code first

, if applicable, any causal condition, such as

enlarged prostate (N40.1)

  • R39.11 Hesitancy of micturition

Weak urinary steam

  • R39.13 Splitting of urinary stream
  • R39.14 Feeling of incomplete bladder emptying

Excludes1

urge incontinence (N39.41, N39.46)

  • R39.19 Other difficulties with micturition
  • R39.191 Need to immediately re-void
  • R39.192 Position dependent micturition
  • R39.198 Other difficulties with micturition

Prerenal uremia

Excludes1

uremia NOS (N19)

  • R39.8 Other symptoms and signs involving the genitourinary system
  • R39.81 Functional urinary incontinence

Urinary incontinence due to cognitive impairment, or severe physical disability or immobility

Excludes1

stress incontinence and other specified urinary incontinence (N39.3-N39.4-)

urinary incontinence NOS (R32)

  • R39.83 Unilateral non-palpable testicle
  • R39.84 Bilateral non-palpable testicles
  • R39.89 Other symptoms and signs involving the genitourinary system
  • R39.9 Unspecified symptoms and signs involving the genitourinary system

Symptoms and signs involving cognition, perception, emotional state and behavior (R40-R46)

Excludes2

symptoms and signs constituting part of a pattern of mental disorder (F01-F99)

  • R40 Somnolence, stupor and coma

Excludes1

neonatal coma (P91.5)

somnolence, stupor and coma in diabetes (E08-E13)

somnolence, stupor and coma in hepatic failure (K72.-)

somnolence, stupor and coma in hypoglycemia (nondiabetic) (E15)

Drowsiness

Excludes1

coma (R40.2-)

Catatonic stupor

Semicoma

Excludes1

catatonic schizophrenia (F20.2)

coma (R40.2-)

depressive stupor (F31-F33)

dissociative stupor (F44.2)

manic stupor (F30.2)

any associated

fracture of skull (S02.-)

intracranial injury (S06.-)

Note

One code from each subcategory, R40.21-R40.23, is required to complete the coma scale

Coma NOS

Unconsciousness NOS

The following appropriate 7th character is to be added to subcategory R40.21-

0 - unspecified time

1 - in the field (EMT or ambulance)

2 - at arrival to emergency department

3 - at hospital admission

4 - 24 hours or more after hospital admission

  • R40.211 Coma scale, eyes open, never

Coma scale eye opening score of 1

  • R40.212 Coma scale, eyes open, to pain

Coma scale eye opening score of 2

  • R40.213 Coma scale, eyes open, to sound

Coma scale eye opening score of 3

  • R40.214 Coma scale, eyes open, spontaneous

Coma scale eye opening score of 4

  • R40.22 Coma scale, best verbal response

The following appropriate 7th character is to be added to subcategory R40.22-

0 - unspecified time

1 - in the field (EMT or ambulance)

2 - at arrival to emergency department

3 - at hospital admission

4 - 24 hours or more after hospital admission

  • R40.221 Coma scale, best verbal response, none

Coma scale verbal score of 1

  • R40.222 Coma scale, best verbal response, incomprehensible words

Coma scale verbal score of 2

Incomprehensible sounds (2-5 years of age)

Moans/grunts to pain; restless (<2 years old)

  • R40.223 Coma scale, best verbal response, inappropriate words

Coma scale verbal score of 3

Inappropriate crying or screaming (< 2 years of age)

Screaming (2-5 years of age)

  • R40.224 Coma scale, best verbal response, confused conversation

Coma scale verbal score of 4

Inappropriate words (2-5 years of age)

Irritable cries (< 2 years of age)

  • R40.225 Coma scale, best verbal response, oriented

Coma scale verbal score of 5

Cooing or babbling or crying appropriately (< 2 years of age)

Uses appropriate words (2- 5 years of age)

  • R40.23 Coma scale, best motor response

The following appropriate 7th character is to be added to subcategory R40.23-

0 - unspecified time

1 - in the field (EMT or ambulance)

2 - at arrival to emergency department

3 - at hospital admission

4 - 24 hours or more after hospital admission

  • R40.231 Coma scale, best motor response, none

Coma scale motor score of 1

  • R40.232 Coma scale, best motor response, extension

Abnormal extensor posturing to pain or noxious stimuli (< 2 years of age)

Coma scale motor score of 2

Extensor posturing to pain or noxious stimuli (2-5 years of age)

  • R40.233 Coma scale, best motor response, abnormal flexion

Abnormal flexure posturing to pain or noxious stimuli (2-5 years of age)

Coma scale motor score of 3

Flexion/decorticate posturing (< 2 years of age)

  • R40.234 Coma scale, best motor response, flexion withdrawal

Coma scale motor score of 4

Withdraws from pain or noxious stimuli (2-5 years of age)

  • R40.235 Coma scale, best motor response, localizes pain

Coma scale motor score of 5

Localizes pain (2-5 years of age)

Withdraws to touch (< 2 years of age)

  • R40.236 Coma scale, best motor response, obeys commands

Coma scale motor score of 6

Normal or spontaneous movement (< 2 years of age)

Obeys commands (2-5 years of age)

  • R40.24 Glasgow coma scale, total score

Note

Assign a code from subcategory R40.24, when only the total coma score is documented

The following appropriate 7th character is to be added to subcategory R40.24-

0 - unspecified time

1 - in the field (EMT or ambulance)

2 - at arrival to emergency department

3 - at hospital admission

4 - 24 hours or more after hospital admission

  • R40.241 Glasgow coma scale score 13-15
  • R40.242 Glasgow coma scale score 9-12
  • R40.243 Glasgow coma scale score 3-8
  • R40.244 Other coma, without documented Glasgow coma scale score, or with partial score

reported

  • R40.3 Persistent vegetative state
  • R40.4 Transient alteration of awareness
  • R41 Other symptoms and signs involving cognitive functions and awareness

Excludes1

dissociative (conversion) disorders (F44.-)

mild cognitive impairment, so stated (G31.84)

  • R41.0 Disorientation, unspecified

Confusion NOS

Delirium NOS

  • R41.1 Anterograde amnesia

Amnesia NOS

Memory loss NOS

Excludes1

amnestic disorder due to known physiologic condition (F04)

amnestic syndrome due to psychoactive substance use (F10-F19 with 5th character .6)

mild memory disturbance due to known physiological condition (F06.8)

transient global amnesia (G45.4)

  • R41.4 Neurologic neglect syndrome

Asomatognosia

Hemi-akinesia

Hemi-inattention

Hemispatial neglect

Left-sided neglect

Sensory neglect

Visuospatial neglect

Excludes1

visuospatial deficit (R41.842)

  • R41.8 Other symptoms and signs involving cognitive functions and awareness
  • R41.81 Age-related cognitive decline

Senility NOS

  • R41.82 Altered mental status, unspecified

Change in mental status NOS

Excludes1

altered level of consciousness (R40.-)

altered mental status due to known condition - code to condition

delirium NOS (R41.0)

  • R41.83 Borderline intellectual functioning

IQ level 71 to 84

Excludes1

intellectual disabilities (F70-F79)

  • R41.84 Other specified cognitive deficit

Excludes1

cognitive deficits as sequelae of cerebrovascular disease (I69.01-, I69.11-, I69.21-, I69.31-

, I69.81-, I69.91-)

  • R41.840 Attention and concentration deficit

Excludes1

attention-deficit hyperactivity disorders (F90.-)

  • R41.841 Cognitive communication deficit
  • R41.844 Frontal lobe and executive function deficit
  • R41.89 Other symptoms and signs involving cognitive functions and awareness

Anosognosia

  • R41.9 Unspecified symptoms and signs involving cognitive functions and awareness

Unspecified neurocognitive disorder

  • R42 Dizziness and giddiness

Light-headedness

Vertigo NOS

Excludes1

vertiginous syndromes (H81.-)

vertigo from infrasound (T75.23)

  • R43 Disturbances of smell and taste
  • R43.8 Other disturbances of smell and taste

Mixed disturbance of smell and taste

  • R43.9 Unspecified disturbances of smell and taste
  • R44 Other symptoms and signs involving general sensations and perceptions

Excludes1

alcoholic hallucinations (F1.5)

hallucinations in drug psychosis (F11-F19 with .5)

hallucinations in mood disorders with psychotic symptoms (F30.2, F31.5, F32.3, F33.3)

hallucinations in schizophrenia, schizotypal and delusional disorders (F20-F29)

Excludes2

disturbances of skin sensation (R20.-)

  • R44.0 Auditory hallucinations
  • R44.1 Visual hallucinations
  • R44.2 Other hallucinations
  • R44.3 Hallucinations, unspecified
  • R44.8 Other symptoms and signs involving general sensations and perceptions
  • R44.9 Unspecified symptoms and signs involving general sensations and perceptions
  • R45 Symptoms and signs involving emotional state

Nervous tension

  • R45.1 Restlessness and agitation
  • R45.3 Demoralization and apathy

Excludes1

anhedonia (R45.84)

  • R45.4 Irritability and anger
  • R45.7 State of emotional shock and stress, unspecified
  • R45.8 Other symptoms and signs involving emotional state
  • R45.83 Excessive crying of child, adolescent or adult

Excludes1

excessive crying of infant (baby) R68.11

  • R45.85 Homicidal and suicidal ideations

Excludes1

suicide attempt (T14.91)

  • R45.89 Other symptoms and signs involving emotional state
  • R46 Symptoms and signs involving appearance and behavior

Excludes1

appearance and behavior in schizophrenia, schizotypal and delusional disorders (F20-F29)

mental and behavioral disorders (F01-F99)

  • R46.0 Very low level of personal hygiene
  • R46.1 Bizarre personal appearance
  • R46.2 Strange and inexplicable behavior
  • R46.4 Slowness and poor responsiveness

Excludes1

stupor (R40.1)

  • R46.5 Suspiciousness and marked evasiveness
  • R46.6 Undue concern and preoccupation with stressful events
  • R46.7 Verbosity and circumstantial detail obscuring reason for contact
  • R46.8 Other symptoms and signs involving appearance and behavior
  • R46.81 Obsessive-compulsive behavior

Excludes1

obsessive-compulsive disorder (F42-)

  • R46.89 Other symptoms and signs involving appearance and behavior

Symptoms and signs involving speech and voice (R47-R49)

  • R47 Speech disturbances, not elsewhere classified

Excludes1

autism (F84.0)

cluttering (F80.81)

specific developmental disorders of speech and language (F80.-)

stuttering (F80.81)

  • R47.0 Dysphasia and aphasia

Excludes1

aphasia following cerebrovascular disease (I69. with final characters -20)

progressive isolated aphasia (G31.01)

Excludes1

dysphasia following cerebrovascular disease (I69. with final characters -21)

  • R47.1 Dysarthria and anarthria

Excludes1

dysarthria following cerebrovascular disease (I69. with final characters -22)

  • R47.8 Other speech disturbances

Excludes1

dysarthria following cerebrovascular disease (I69. with final characters -28)

  • R47.82 Fluency disorder in conditions classified elsewhere

Stuttering in conditions classified elsewhere Code first

underlying disease or condition, such as

Parkinson's disease (G20)

Excludes1

adult onset fluency disorder (F98.5)

childhood onset fluency disorder (F80.81)

fluency disorder (stuttering) following cerebrovascular disease (I69. with final characters -

23)

  • R47.89 Other speech disturbances
  • R47.9 Unspecified speech disturbances
  • R48 Dyslexia and other symbolic dysfunctions, not elsewhere classified

Excludes1

specific developmental disorders of scholastic skills (F81.-)

  • R48.0 Dyslexia and alexia

Astereognosia (astereognosis)

Autotopagnosia

Excludes1

visual object agnosia (R48.3)

Excludes1

apraxia following cerebrovascular disease (I69. with final characters -90)

Prosopagnosia

Simultanagnosia (asimultagnosia)

  • R48.8 Other symbolic dysfunctions

Acalculia

Agraphia

  • R48.9 Unspecified symbolic dysfunctions
  • R49 Voice and resonance disorders

Excludes1

psychogenic voice and resonance disorders (F44.4)

Hoarseness

Loss of voice

  • R49.2 Hypernasality and hyponasality
  • R49.8 Other voice and resonance disorders
  • R49.9 Unspecified voice and resonance disorder

Change in voice NOS

Resonance disorder NOS

General symptoms and signs (R50-R69)

  • R50 Fever of other and unknown origin

Excludes1

chills without fever (R68.83)

febrile convulsions (R56.0-)

fever of unknown origin during labor (O75.2)

fever of unknown origin in newborn (P81.9)

hypothermia due to illness (R68.0)

malignant hyperthermia due to anesthesia (T88.3)

puerperal pyrexia NOS (O86.4)

  • R50.2 Drug induced fever Use additional

code for adverse effect, if applicable, to identify drug (T36-T50 with fifth or sixth character 5)

Excludes1

postvaccination (postimmunization) fever (R50.83)

  • R50.8 Other specified fever
  • R50.81 Fever presenting with conditions classified elsewhere Code first

underlying condition when associated fever is present, such as with

leukemia (C91-C95)

neutropenia (D70.-)

sickle-cell disease (D57.-)

Excludes1

postprocedural infection (T81.4-)

posttransfusion fever (R50.84)

postvaccination (postimmunization) fever (R50.83)

Postimmunization fever

  • R50.84 Febrile nonhemolytic transfusion reaction

FNHTR

Posttransfusion fever

Fever NOS

Fever of unknown origin (FUO)

Fever with chills

Fever with rigors

Hyperpyrexia NOS

Persistent fever

Pyrexia NOS

Facial pain NOS

Excludes1

atypical face pain (G50.1)

migraine and other headache syndromes (G43-G44)

trigeminal neuralgia (G50.0)

  • R52 Pain, unspecified

Acute pain NOS

Generalized pain NOS

Pain NOS

Excludes1

acute and chronic pain, not elsewhere classified (G89.-)

localized pain, unspecified type - code to pain by site, such as

abdomen pain (R10.-)

back pain (M54.9)

breast pain (N64.4)

chest pain (R07.1-R07.9)

ear pain (H92.0-)

eye pain (H57.1)

headache (R51)

joint pain (M25.5-)

limb pain (M79.6-)

lumbar region pain (M54.5)

pelvic and perineal pain (R10.2)

shoulder pain (M25.51-)

spine pain (M54.-)

throat pain (R07.0)

tongue pain (K14.6)

tooth pain (K08.8)

renal colic (N23)

pain disorders exclusively related to psychological factors (F45.41)

  • R53 Malaise and fatigue
  • R53.0 Neoplastic (malignant) related fatigue Code first

associated neoplasm

Asthenia NOS

Excludes1

age-related weakness (R54)

muscle weakness (M62.8-)

sarcopenia (M62.84)

senile asthenia (R54)

  • R53.2 Functional quadriplegia

Complete immobility due to severe physical disability or frailty

Excludes1

frailty NOS (R54)

hysterical paralysis (F44.4)

immobility syndrome (M62.3)

neurologic quadriplegia (G82.5-)

quadriplegia (G82.50)

  • R53.8 Other malaise and fatigue

Excludes1

combat exhaustion and fatigue (F43.0)

congenital debility (P96.9)

exhaustion and fatigue due to excessive exertion (T73.3)

exhaustion and fatigue due to exposure (T73.2)

exhaustion and fatigue due to heat (T67.-)

exhaustion and fatigue due to pregnancy (O26.8-)

exhaustion and fatigue due to recurrent depressive episode (F33)

exhaustion and fatigue due to senile debility (R54)

Chronic debility

Debility NOS

General physical deterioration

Malaise NOS

Nervous debility

Excludes1

age-related physical debility (R54)

  • R53.82 Chronic fatigue, unspecified

Chronic fatigue syndrome NOS

Excludes1

postviral fatigue syndrome (G93.3)

Fatigue NOS

Lack of energy

Lethargy

Tiredness

Excludes2

exhaustion and fatigue due to depressive episode (F32.-)

  • R54 Age-related physical debility

Frailty

Old age

Senescence

Senile asthenia

Senile debility

Excludes1

age-related cognitive decline (R41.81)

sarcopenia (M62.84)

senile psychosis (F03)

senility NOS (R41.81)

  • R55 Syncope and collapse

Blackout

Fainting

Vasovagal attack

Excludes1

cardiogenic shock (R57.0)

carotid sinus syncope (G90.01)

heat syncope (T67.1)

neurocirculatory asthenia (F45.8)

neurogenic orthostatic hypotension (G90.3)

orthostatic hypotension (I95.1)

postprocedural shock (T81.1-)

psychogenic syncope (F48.8)

shock NOS (R57.9)

shock complicating or following abortion or ectopic or molar pregnancy (O00-O07, O08.3)

shock complicating or following labor and delivery (O75.1)

Stokes-Adams attack (I45.9)

unconsciousness NOS (R40.2-)

  • R56 Convulsions, not elsewhere classified

Excludes1

dissociative convulsions and seizures (F44.5)

epileptic convulsions and seizures (G40.-)

newborn convulsions and seizures (P90)

  • R56.0 Febrile convulsions
  • R56.00 Simple febrile convulsions

Febrile convulsion NOS

Febrile seizure NOS

  • R56.01 Complex febrile convulsions

Atypical febrile seizure

Complex febrile seizure

Complicated febrile seizure

Excludes1

status epilepticus (G40.901)

  • R56.1 Post traumatic seizures

Excludes1

post traumatic epilepsy (G40.-)

  • R56.9 Unspecified convulsions

Convulsion disorder

Fit NOS

Recurrent convulsions

Seizure(s) (convulsive) NOS

  • R57 Shock, not elsewhere classified

Excludes1

anaphylactic shock NOS (T78.2)

anaphylactic reaction or shock due to adverse food reaction (T78.0-)

anaphylactic shock due to adverse effect of correct drug or medicament properly administered (T88.6)

anaphylactic shock due to serum (T80.5-)

anesthetic shock (T88.3)

electric shock (T75.4)

obstetric shock (O75.1)

postprocedural shock (T81.1-)

psychic shock (F43.0)

shock complicating or following ectopic or molar pregnancy (O00-O07, O08.3)

shock due to lightning (T75.01)

traumatic shock (T79.4)

toxic shock syndrome (A48.3)

Excludes2

septic shock (R65.21)

Failure of peripheral circulation NOS

  • R58 Hemorrhage, not elsewhere classified

Hemorrhage NOS

Excludes1

hemorrhage included with underlying conditions, such as

acute duodenal ulcer with hemorrhage (K26.0)

acute gastritis with bleeding (K29.01)

ulcerative enterocolitis with rectal bleeding (K51.01)

  • R59 Enlarged lymph nodes

Includes

swollen glands

Excludes1

lymphadenitis NOS (I88.9)

acute lymphadenitis (L04.-)

chronic lymphadenitis (I88.1)

mesenteric (acute) (chronic) lymphadenitis (I88.0)

  • R59.0 Localized enlarged lymph nodes
  • R59.1 Generalized enlarged lymph nodes

Lymphadenopathy NOS

  • R59.9 Enlarged lymph nodes, unspecified
  • R60 Edema, not elsewhere classified

Excludes1

angioneurotic edema (T78.3)

ascites (R18.-)

cerebral edema (G93.6)

cerebral edema due to birth injury (P11.0)

edema of larynx (J38.4)

edema of nasopharynx (J39.2)

edema of pharynx (J39.2)

gestational edema (O12.0-)

hereditary edema (Q82.0)

hydrops fetalis NOS (P83.2)

hydrothorax (J94.8)

hydrops fetalis NOS (P83.2)

newborn edema (P83.3)

pulmonary edema (J81.-)

Excludes2

nutritional edema (E40-E46)

Fluid retention NOS

  • R61 Generalized hyperhidrosis

Excessive sweating

Night sweats

Secondary hyperhidrosis Code first

, if applicable, menopausal and female climacteric states (N95.1)

Excludes1

focal (primary) (secondary) hyperhidrosis (L74.5-)

Frey's syndrome (L74.52)

localized (primary) (secondary) hyperhidrosis (L74.5-)

  • R62 Lack of expected normal physiological development in childhood and adults

Excludes1

delayed puberty (E30.0)

gonadal dysgenesis (Q99.1)

hypopituitarism (E23.0)

  • R62.0 Delayed milestone in childhood

Delayed attainment of expected physiological developmental stage

Late talker

Late walker

  • R62.5 Other and unspecified lack of expected normal physiological development in childhood

Excludes1

HIV disease resulting in failure to thrive (B20)

physical retardation due to malnutrition (E45)

  • R62.50 Unspecified lack of expected normal physiological development in childhood

Infantilism NOS

  • R62.51 Failure to thrive (child)

Failure to gain weight

Excludes1

failure to thrive in child under 28 days old (P92.6)

Lack of growth

Physical retardation

Short stature NOS

Excludes1

short stature due to endocrine disorder (E34.3)

  • R62.59 Other lack of expected normal physiological development in childhood
  • R62.7 Adult failure to thrive
  • R63 Symptoms and signs concerning food and fluid intake

Excludes1

bulimia NOS (F50.2)

Loss of appetite

Excludes1

anorexia nervosa (F50.0-)

loss of appetite of nonorganic origin (F50.89)

Excessive thirst

Excessive eating

Hyperalimentation NOS

  • R63.3 Feeding difficulties

Feeding problem (elderly) (infant) NOS

Picky eater

Excludes1

eating disorders (F50.-)

feeding problems of newborn (P92.-)

infant feeding disorder of nonorganic origin (F98.2-)

  • R63.4 Abnormal weight loss
  • R63.5 Abnormal weight gain

Excludes1

excessive weight gain in pregnancy (O26.0-)

obesity (E66.-)

  • R63.6 Underweight Use additional

code to identify body mass index (BMI), if known (Z68.-)

Excludes1

abnormal weight loss (R63.4)

anorexia nervosa (F50.0-)

malnutrition (E40-E46)

  • R63.8 Other symptoms and signs concerning food and fluid intake

Wasting syndrome Code first

underlying condition, if known

Excludes1

abnormal weight loss (R63.4)

nutritional marasmus (E41)

  • R65 Symptoms and signs specifically associated with systemic inflammation and infection
  • R65.1 Systemic inflammatory response syndrome (SIRS) of non-infectious origin Code first

underlying condition, such as

heatstroke (T67.0-)

injury and trauma (S00-T88)

Excludes1

sepsis- code to infection

severe sepsis (R65.2)

  • R65.10 Systemic inflammatory response syndrome (SIRS) of non-infectious origin without acute organ

dysfunction

Systemic inflammatory response syndrome (SIRS) NOS

  • R65.11 Systemic inflammatory response syndrome (SIRS) of non-infectious origin with acute organ

dysfunction Use additional

code to identify specific acute organ dysfunction, such as

acute kidney failure (N17.-)

acute respiratory failure (J96.0-)

critical illness myopathy (G72.81)

critical illness polyneuropathy (G62.81)

disseminated intravascular coagulopathy (DIC) (D65)

encephalopathy (metabolic) (septic) (G93.41)

hepatic failure (K72.0-)

Infection with associated acute organ dysfunction

Sepsis with acute organ dysfunction

Sepsis with multiple organ dysfunction

Systemic inflammatory response syndrome due to infectious process with acute organ dysfunction Code first

underlying infection, such as

infection following a procedure (T81.4-)

infections following infusion, transfusion and therapeutic injection (T80.2-)

puerperal sepsis (O85)

sepsis following complete or unspecified spontaneous abortion (O03.87)

sepsis following ectopic and molar pregnancy (O08.82)

sepsis following incomplete spontaneous abortion (O03.37)

sepsis following (induced) termination of pregnancy (O04.87)

sepsis NOS (A41.9) Use additional

code to identify specific acute organ dysfunction, such as

acute kidney failure (N17.-)

acute respiratory failure (J96.0-)

critical illness myopathy (G72.81)

critical illness polyneuropathy (G62.81)

disseminated intravascular coagulopathy (DIC) (D65)

encephalopathy (metabolic) (septic) (G93.41)

hepatic failure (K72.0-)

  • R65.20 Severe sepsis without septic shock

Severe sepsis NOS

  • R65.21 Severe sepsis with septic shock
  • R68 Other general symptoms and signs
  • R68.0 Hypothermia, not associated with low environmental temperature

Excludes1

hypothermia NOS (accidental) (T68)

hypothermia due to anesthesia (T88.51)

hypothermia due to low environmental temperature (T68)

newborn hypothermia (P80.-)

  • R68.1 Nonspecific symptoms peculiar to infancy

Excludes1

colic, infantile (R10.83)

neonatal cerebral irritability (P91.3)

teething syndrome (K00.7)

  • R68.11 Excessive crying of infant (baby)

Excludes1

excessive crying of child, adolescent, or adult (R45.83)

Irritable infant

  • R68.13 Apparent life threatening event in infant (ALTE)

Apparent life threatening event in newborn

Brief resolved unexplained event (BRUE) Code first

confirmed diagnosis, if known Use additional

code(s) for associated signs and symptoms if no confirmed diagnosis established, or if

signs and symptoms are not associated routinely with confirmed diagnosis, or

provide additional information for cause of ALTE

  • R68.19 Other nonspecific symptoms peculiar to infancy
  • R68.2 Dry mouth, unspecified

Excludes1

dry mouth due to dehydration (E86.0)

dry mouth due to sicca syndrome (Sjögren) (M35.0-)

salivary gland hyposecretion (K11.7)

  • R68.3 Clubbing of fingers

Clubbing of nails

Excludes1

congenital clubfinger (Q68.1)

  • R68.8 Other general symptoms and signs

Decreased sexual desire

Chills NOS

Excludes1

chills with fever (R50.9)

Mandibular pain

Maxilla pain

Excludes1

temporomandibular joint arthralgia (M26.62-)

  • R68.89 Other general symptoms and signs
  • R69 Illness, unspecified

Unknown and unspecified cases of morbidity

Abnormal findings on examination of blood, without diagnosis (R70-R79)

Excludes2

abnormal findings on antenatal screening of mother (O28.-)

abnormalities of lipids (E78.-)

abnormalities of platelets and thrombocytes (D69.-)

abnormalities of white blood cells classified elsewhere (D70-D72)

coagulation hemorrhagic disorders (D65-D68)

diagnostic abnormal findings classified elsewhere - see Alphabetical Index

hemorrhagic and hematological disorders of newborn (P50-P61)

  • R70 Elevated erythrocyte sedimentation rate and abnormality of plasma viscosity
  • R70.0 Elevated erythrocyte sedimentation rate
  • R70.1 Abnormal plasma viscosity
  • R71 Abnormality of red blood cells

Excludes1

anemias (D50-D64)

anemia of premature infant (P61.2)

benign (familial) polycythemia (D75.0)

congenital anemias (P61.2-P61.4)

newborn anemia due to isoimmunization (P55.-)

polycythemia neonatorum (P61.1)

polycythemia NOS (D75.1)

polycythemia vera (D45)

secondary polycythemia (D75.1)

  • R71.0 Precipitous drop in hematocrit

Drop (precipitous) in hemoglobin

Drop in hematocrit

  • R71.8 Other abnormality of red blood cells

Abnormal red-cell morphology NOS

Abnormal red-cell volume NOS

Anisocytosis

Poikilocytosis

  • R73 Elevated blood glucose level

Excludes1

diabetes mellitus (E08-E13)

diabetes mellitus in pregnancy, childbirth and the puerperium (O24.-)

neonatal disorders (P70.0-P70.2)

postsurgical hypoinsulinemia (E89.1)

Excludes1

abnormal glucose in pregnancy (O99.81-)

diabetes mellitus (E08-E13)

dysmetabolic syndrome X (E88.81)

gestational diabetes (O24.4-)

glycosuria (R81)

hypoglycemia (E16.2)

  • R73.01 Impaired fasting glucose

Elevated fasting glucose

  • R73.02 Impaired glucose tolerance (oral)

Elevated glucose tolerance

Latent diabetes

Abnormal glucose NOS

Abnormal non-fasting glucose tolerance

  • R73.9 Hyperglycemia, unspecified
  • R74 Abnormal serum enzyme levels
  • R74.0 Nonspecific elevation of levels of transaminase and lactic acid dehydrogenase (LDH)
  • R74.8 Abnormal levels of other serum enzymes

Abnormal level of acid phosphatase

Abnormal level of alkaline phosphatase

Abnormal level of amylase

Abnormal level of lipase (triacylglycerol lipase)

  • R74.9 Abnormal serum enzyme level, unspecified
  • R75 Inconclusive laboratory evidence of human immunodeficiency virus (HIV)

Nonconclusive HIV-test finding in infants

Excludes1

asymptomatic human immunodeficiency virus (HIV) infection status (Z21)

human immunodeficiency virus (HIV) disease (B20)

  • R76 Other abnormal immunological findings in serum
  • R76.0 Raised antibody titer

Excludes1

isoimmunization in pregnancy (O36.0-O36.1)

isoimmunization affecting newborn (P55.-)

  • R76.1 Nonspecific reaction to test for tuberculosis
  • R76.11 Nonspecific reaction to tuberculin skin test without active tuberculosis

Abnormal result of Mantoux test

PPD positive

Tuberculin (skin test) positive

Tuberculin (skin test) reactor

Excludes1

nonspecific reaction to cell mediated immunity measurement of gamma interferon antigen

response without active tuberculosis (R76.12)

  • R76.12 Nonspecific reaction to cell mediated immunity measurement of gamma interferon antigen

response without active tuberculosis

Nonspecific reaction to QuantiFERON-TB test (QFT) without active tuberculosis

Excludes1

nonspecific reaction to tuberculin skin test without active tuberculosis (R76.11)

positive tuberculin skin test (R76.11)

  • R76.8 Other specified abnormal immunological findings in serum

Raised level of immunoglobulins NOS

  • R76.9 Abnormal immunological finding in serum, unspecified
  • R77 Other abnormalities of plasma proteins

Excludes1

disorders of plasma-protein metabolism (E88.0-)

  • R77.0 Abnormality of albumin
  • R77.1 Abnormality of globulin

Hyperglobulinemia NOS

  • R77.2 Abnormality of alphafetoprotein
  • R77.8 Other specified abnormalities of plasma proteins
  • R77.9 Abnormality of plasma protein, unspecified
  • R78 Findings of drugs and other substances, not normally found in blood Use additional

code to identify the any retained foreign body, if applicable (Z18.-)

Excludes1

mental or behavioral disorders due to psychoactive substance use (F10-F19)

  • R78.0 Finding of alcohol in blood Use additional

external cause code (Y90.-), for detail regarding alcohol level

  • R78.1 Finding of opiate drug in blood
  • R78.2 Finding of cocaine in blood
  • R78.3 Finding of hallucinogen in blood
  • R78.4 Finding of other drugs of addictive potential in blood
  • R78.5 Finding of other psychotropic drug in blood
  • R78.6 Finding of steroid agent in blood
  • R78.7 Finding of abnormal level of heavy metals in blood
  • R78.71 Abnormal lead level in blood

Excludes1

lead poisoning (T56.0-)

  • R78.79 Finding of abnormal level of heavy metals in blood
  • R78.8 Finding of other specified substances, not normally found in blood

Excludes1

sepsis-code to specified infection

  • R78.89 Finding of other specified substances, not normally found in blood

Finding of abnormal level of lithium in blood

  • R78.9 Finding of unspecified substance, not normally found in blood
  • R79 Other abnormal findings of blood chemistry Use additional

code to identify any retained foreign body, if applicable (Z18.-)

Excludes1

asymptomatic hyperuricemia (E79.0)

hyperglycemia NOS (R73.9)

hypoglycemia NOS (E16.2)

neonatal hypoglycemia (P70.3-P70.4)

specific findings indicating disorder of amino-acid metabolism (E70-E72)

specific findings indicating disorder of carbohydrate metabolism (E73-E74)

specific findings indicating disorder of lipid metabolism (E75.-)

  • R79.0 Abnormal level of blood mineral

Abnormal blood level of cobalt

Abnormal blood level of copper

Abnormal blood level of iron

Abnormal blood level of magnesium

Abnormal blood level of mineral NEC

Abnormal blood level of zinc

Excludes1

abnormal level of lithium (R78.89)

disorders of mineral metabolism (E83.-)

neonatal hypomagnesemia (P71.2)

nutritional mineral deficiency (E58-E61)

  • R79.1 Abnormal coagulation profile

Abnormal or prolonged bleeding time

Abnormal or prolonged coagulation time

Abnormal or prolonged partial thromboplastin time (PTT)

Abnormal or prolonged prothrombin time (PT)

Excludes1

coagulation defects (D68.-)

Excludes2

abnormality of fluid, electrolyte or acid-base balance (E86-E87)

  • R79.8 Other specified abnormal findings of blood chemistry
  • R79.81 Abnormal blood-gas level
  • R79.82 Elevated C-reactive protein (CRP)
  • R79.89 Other specified abnormal findings of blood chemistry
  • R79.9 Abnormal finding of blood chemistry, unspecified

Abnormal findings on examination of urine, without diagnosis (R80-R82)

Excludes1

abnormal findings on antenatal screening of mother (O28.-)

diagnostic abnormal findings classified elsewhere - see Alphabetical Index

specific findings indicating disorder of amino-acid metabolism (E70-E72)

specific findings indicating disorder of carbohydrate metabolism (E73-E74)

  • R80 Proteinuria

Excludes1

gestational proteinuria (O12.1-)

  • R80.0 Isolated proteinuria

Idiopathic proteinuria

Excludes1

isolated proteinuria with specific morphological lesion (N06.-)

  • R80.1 Persistent proteinuria, unspecified
  • R80.2 Orthostatic proteinuria, unspecified

Postural proteinuria

  • R80.3 Bence Jones proteinuria
  • R80.9 Proteinuria, unspecified

Albuminuria NOS

Excludes1

renal glycosuria (E74.8)

  • R82 Other and unspecified abnormal findings in urine

Includes

chromoabnormalities in urine Use additional

code to identify any retained foreign body, if applicable (Z18.-)

Excludes2

hematuria (R31.-)

Excludes1

filarial chyluria (B74.-)

Excludes1

hemoglobinuria due to hemolysis from external causes NEC (D59.6)

hemoglobinuria due to paroxysmal nocturnal (Marchiafava-Micheli) (D59.5)

Ketonuria

  • R82.5 Elevated urine levels of drugs, medicaments and biological substances

Elevated urine levels of catecholamines

Elevated urine levels of indoleacetic acid

Elevated urine levels of 17-ketosteroids

Elevated urine levels of steroids

  • R82.6 Abnormal urine levels of substances chiefly nonmedicinal as to source

Abnormal urine level of heavy metals

  • R82.7 Abnormal findings on microbiological examination of urine

Excludes1

colonization status (Z22.-)

  • R82.79 Other abnormal findings on microbiological examination of urine

Positive culture findings of urine

  • R82.8 Abnormal findings on cytological and histological examination of urine

Sterile pyuria

  • R82.89 Other abnormal findings on cytological and histological examination of urine
  • R82.9 Other and unspecified abnormal findings in urine
  • R82.90 Unspecified abnormal findings in urine
  • R82.91 Other chromoabnormalities of urine

Chromoconversion (dipstick)

Idiopathic dipstick converts positive for blood with no cellular forms in sediment

Excludes1

hemoglobinuria (R82.3)

myoglobinuria (R82.1)

  • R82.99 Other abnormal findings in urine

Excludes1

Primary hyperoxaluria (E72.53)

Idiopathic hypercalciuria

  • R82.998 Other abnormal findings in urine

Cells and casts in urine

Crystalluria

Melanuria

Abnormal findings on examination of other body fluids, substances and tissues, without diagnosis (R83-R89)

Excludes1

abnormal findings on antenatal screening of mother (O28.-)

diagnostic abnormal findings classified elsewhere - see Alphabetical Index

Excludes2

abnormal findings on examination of blood, without diagnosis (R70-R79)

abnormal findings on examination of urine, without diagnosis (R80-R82)

abnormal tumor markers (R97.-)

  • R83 Abnormal findings in cerebrospinal fluid
  • R83.0 Abnormal level of enzymes in cerebrospinal fluid
  • R83.1 Abnormal level of hormones in cerebrospinal fluid
  • R83.2 Abnormal level of other drugs, medicaments and biological substances in cerebrospinal fluid
  • R83.3 Abnormal level of substances chiefly nonmedicinal as to source in cerebrospinal fluid
  • R83.4 Abnormal immunological findings in cerebrospinal fluid
  • R83.5 Abnormal microbiological findings in cerebrospinal fluid

Positive culture findings in cerebrospinal fluid

Excludes1

colonization status (Z22.-)

  • R83.6 Abnormal cytological findings in cerebrospinal fluid
  • R83.8 Other abnormal findings in cerebrospinal fluid

Abnormal chromosomal findings in cerebrospinal fluid

  • R83.9 Unspecified abnormal finding in cerebrospinal fluid
  • R84 Abnormal findings in specimens from respiratory organs and thorax

Includes

abnormal findings in bronchial washings

abnormal findings in nasal secretions

abnormal findings in pleural fluid

abnormal findings in sputum

abnormal findings in throat scrapings

Excludes1

blood-stained sputum (R04.2)

  • R84.0 Abnormal level of enzymes in specimens from respiratory organs and thorax
  • R84.1 Abnormal level of hormones in specimens from respiratory organs and thorax
  • R84.2 Abnormal level of other drugs, medicaments and biological substances in specimens from respiratory

organs and thorax

  • R84.3 Abnormal level of substances chiefly nonmedicinal as to source in specimens from respiratory organs

and thorax

  • R84.4 Abnormal immunological findings in specimens from respiratory organs and thorax
  • R84.5 Abnormal microbiological findings in specimens from respiratory organs and thorax

Positive culture findings in specimens from respiratory organs and thorax

Excludes1

colonization status (Z22.-)

  • R84.6 Abnormal cytological findings in specimens from respiratory organs and thorax
  • R84.7 Abnormal histological findings in specimens from respiratory organs and thorax
  • R84.8 Other abnormal findings in specimens from respiratory organs and thorax

Abnormal chromosomal findings in specimens from respiratory organs and thorax

  • R84.9 Unspecified abnormal finding in specimens from respiratory organs and thorax
  • R85 Abnormal findings in specimens from digestive organs and abdominal cavity

Includes

abnormal findings in peritoneal fluid

abnormal findings in saliva

Excludes1

cloudy peritoneal dialysis effluent (R88.0)

fecal abnormalities (R19.5)

  • R85.0 Abnormal level of enzymes in specimens from digestive organs and abdominal cavity
  • R85.1 Abnormal level of hormones in specimens from digestive organs and abdominal cavity
  • R85.2 Abnormal level of other drugs, medicaments and biological substances in specimens from digestive

organs and abdominal cavity

  • R85.3 Abnormal level of substances chiefly nonmedicinal as to source in specimens from digestive organs

and abdominal cavity

  • R85.4 Abnormal immunological findings in specimens from digestive organs and abdominal cavity
  • R85.5 Abnormal microbiological findings in specimens from digestive organs and abdominal cavity

Positive culture findings in specimens from digestive organs and abdominal cavity

Excludes1

colonization status (Z22.-)

  • R85.6 Abnormal cytological findings in specimens from digestive organs and abdominal cavity
  • R85.61 Abnormal cytologic smear of anus

Excludes1

abnormal cytological findings in specimens from other digestive organs and abdominal

cavity (R85.69)

carcinoma in situ of anus (histologically confirmed) (D01.3)

anal intraepithelial neoplasia I (AIN I) (K62.82)

anal intraepithelial neoplasia II (AIN II) (K62.82)

anal intraepithelial neoplasia III (AIN III) (D01.3)

dysplasia (mild) (moderate) of anus (histologically confirmed) (K62.82)

severe dysplasia of anus (histologically confirmed) (D01.3)

Excludes2

anal high risk human papillomavirus (HPV) DNA test positive (R85.81)

anal low risk human papillomavirus (HPV) DNA test positive (R85.82)

  • R85.610 Atypical squamous cells of undetermined significance on cytologic smear of anus

(ASC-US)

  • R85.611 Atypical squamous cells cannot exclude high grade squamous intraepithelial lesion on

cytologic smear of anus (ASC-H)

  • R85.612 Low grade squamous intraepithelial lesion on cytologic smear of anus (LGSIL)
  • R85.613 High grade squamous intraepithelial lesion on cytologic smear of anus (HGSIL)
  • R85.614 Cytologic evidence of malignancy on smear of anus
  • R85.615 Unsatisfactory cytologic smear of anus

Inadequate sample of cytologic smear of anus

  • R85.616 Satisfactory anal smear but lacking transformation zone
  • R85.618 Other abnormal cytological findings on specimens from anus
  • R85.619 Unspecified abnormal cytological findings in specimens from anus

Abnormal anal cytology NOS

Atypical glandular cells of anus NOS

  • R85.69 Abnormal cytological findings in specimens from other digestive organs and abdominal cavity
  • R85.7 Abnormal histological findings in specimens from digestive organs and abdominal cavity
  • R85.8 Other abnormal findings in specimens from digestive organs and abdominal cavity
  • R85.81 Anal high risk human papillomavirus (HPV) DNA test positive

Excludes1

anogenital warts due to human papillomavirus (HPV) (A63.0)

condyloma acuminatum (A63.0)

  • R85.82 Anal low risk human papillomavirus (HPV) DNA test positive Use additional

code for associated human papillomavirus (B97.7)

  • R85.89 Other abnormal findings in specimens from digestive organs and abdominal cavity

Abnormal chromosomal findings in specimens from digestive organs and abdominal cavity

  • R85.9 Unspecified abnormal finding in specimens from digestive organs and abdominal cavity
  • R86 Abnormal findings in specimens from male genital organs

Includes

abnormal findings in prostatic secretions

abnormal findings in semen, seminal fluid

abnormal spermatozoa

Excludes1

azoospermia (N46.0-)

oligospermia (N46.1-)

  • R86.0 Abnormal level of enzymes in specimens from male genital organs
  • R86.1 Abnormal level of hormones in specimens from male genital organs
  • R86.2 Abnormal level of other drugs, medicaments and biological substances in specimens from male

genital organs

  • R86.3 Abnormal level of substances chiefly nonmedicinal as to source in specimens from male genital

organs

  • R86.4 Abnormal immunological findings in specimens from male genital organs
  • R86.5 Abnormal microbiological findings in specimens from male genital organs

Positive culture findings in specimens from male genital organs

Excludes1

colonization status (Z22.-)

  • R86.6 Abnormal cytological findings in specimens from male genital organs
  • R86.7 Abnormal histological findings in specimens from male genital organs
  • R86.8 Other abnormal findings in specimens from male genital organs

Abnormal chromosomal findings in specimens from male genital organs

  • R86.9 Unspecified abnormal finding in specimens from male genital organs
  • R87 Abnormal findings in specimens from female genital organs

Includes

abnormal findings in secretion and smears from cervix uteri

abnormal findings in secretion and smears from vagina

abnormal findings in secretion and smears from vulva

  • R87.0 Abnormal level of enzymes in specimens from female genital organs
  • R87.1 Abnormal level of hormones in specimens from female genital organs
  • R87.2 Abnormal level of other drugs, medicaments and biological substances in specimens from female

genital organs

  • R87.3 Abnormal level of substances chiefly nonmedicinal as to source in specimens from female genital

organs

  • R87.4 Abnormal immunological findings in specimens from female genital organs
  • R87.5 Abnormal microbiological findings in specimens from female genital organs

Positive culture findings in specimens from female genital organs

Excludes1

colonization status (Z22.-)

  • R87.6 Abnormal cytological findings in specimens from female genital organs
  • R87.61 Abnormal cytological findings in specimens from cervix uteri

Excludes1

abnormal cytological findings in specimens from other female genital organs (R87.69)

abnormal cytological findings in specimens from vagina (R87.62-)

carcinoma in situ of cervix uteri (histologically confirmed) (D06.-)

cervical intraepithelial neoplasia I (CIN I) (N87.0)

cervical intraepithelial neoplasia II (CIN II) (N87.1)

cervical intraepithelial neoplasia III (CIN III) (D06.-)

dysplasia (mild) (moderate) of cervix uteri (histologically confirmed) (N87.-)

severe dysplasia of cervix uteri (histologically confirmed) (D06.-)

Excludes2

cervical high risk human papillomavirus (HPV) DNA test positive (R87.810)

cervical low risk human papillomavirus (HPV) DNA test positive (R87.820)

  • R87.610 Atypical squamous cells of undetermined significance on cytologic smear of cervix

(ASC-US)

  • R87.611 Atypical squamous cells cannot exclude high grade squamous intraepithelial lesion on

cytologic smear of cervix (ASC-H)

  • R87.612 Low grade squamous intraepithelial lesion on cytologic smear of cervix (LGSIL)
  • R87.613 High grade squamous intraepithelial lesion on cytologic smear of cervix (HGSIL)
  • R87.614 Cytologic evidence of malignancy on smear of cervix
  • R87.615 Unsatisfactory cytologic smear of cervix

Inadequate sample of cytologic smear of cervix

  • R87.616 Satisfactory cervical smear but lacking transformation zone
  • R87.618 Other abnormal cytological findings on specimens from cervix uteri
  • R87.619 Unspecified abnormal cytological findings in specimens from cervix uteri

Abnormal cervical cytology NOS

Abnormal Papanicolaou smear of cervix NOS

Abnormal thin preparation smear of cervix NOS

Atypical endocervial cells of cervix NOS

Atypical endometrial cells of cervix NOS

Atypical glandular cells of cervix NOS

  • R87.62 Abnormal cytological findings in specimens from vagina Use additional

code to identify acquired absence of uterus and cervix, if applicable (Z90.71-)

Excludes1

abnormal cytological findings in specimens from cervix uteri (R87.61-)

abnormal cytological findings in specimens from other female genital organs (R87.69)

carcinoma in situ of vagina (histologically confirmed) (D07.2)

vaginal intraepithelial neoplasia I (VAIN I) (N89.0)

vaginal intraepithelial neoplasia II (VAIN II) (N89.1)

vaginal intraepithelial neoplasia III (VAIN III) (D07.2)

dysplasia (mild) (moderate) of vagina (histologically confirmed) (N89.-)

severe dysplasia of vagina (histologically confirmed) (D07.2)

Excludes2

vaginal high risk human papillomavirus (HPV) DNA test positive (R87.811)

vaginal low risk human papillomavirus (HPV) DNA test positive (R87.821)

  • R87.620 Atypical squamous cells of undetermined significance on cytologic smear of vagina

(ASC-US)

  • R87.621 Atypical squamous cells cannot exclude high grade squamous intraepithelial lesion on

cytologic smear of vagina (ASC-H)

  • R87.622 Low grade squamous intraepithelial lesion on cytologic smear of vagina (LGSIL)
  • R87.623 High grade squamous intraepithelial lesion on cytologic smear of vagina (HGSIL)
  • R87.624 Cytologic evidence of malignancy on smear of vagina
  • R87.625 Unsatisfactory cytologic smear of vagina

Inadequate sample of cytologic smear of vagina

  • R87.628 Other abnormal cytological findings on specimens from vagina
  • R87.629 Unspecified abnormal cytological findings in specimens from vagina

Abnormal Papanicolaou smear of vagina NOS

Abnormal thin preparation smear of vagina NOS

Abnormal vaginal cytology NOS

Atypical endocervical cells of vagina NOS

Atypical endometrial cells of vagina NOS

Atypical glandular cells of vagina NOS

  • R87.69 Abnormal cytological findings in specimens from other female genital organs

Abnormal cytological findings in specimens from female genital organs NOS

Excludes1

dysplasia of vulva (histologically confirmed) (N90.0-N90.3)

  • R87.7 Abnormal histological findings in specimens from female genital organs

Excludes1

carcinoma in situ (histologically confirmed) of female genital organs (D06-D07.3)

cervical intraepithelial neoplasia I (CIN I) (N87.0)

cervical intraepithelial neoplasia II (CIN II) (N87.1)

cervical intraepithelial neoplasia III (CIN III) (D06.-)

dysplasia (mild) (moderate) of cervix uteri (histologically confirmed) (N87.-)

dysplasia (mild) (moderate) of vagina (histologically confirmed) (N89.-)

vaginal intraepithelial neoplasia I (VAIN I) (N89.0)

vaginal intraepithelial neoplasia II (VAIN II) (N89.1)

vaginal intraepithelial neoplasia III (VAIN III) (D07.2)

severe dysplasia of cervix uteri (histologically confirmed) (D06.-)

severe dysplasia of vagina (histologically confirmed) (D07.2)

  • R87.8 Other abnormal findings in specimens from female genital organs
  • R87.81 High risk human papillomavirus (HPV) DNA test positive from female genital organs

Excludes1

anogenital warts due to human papillomavirus (HPV) (A63.0)

condyloma acuminatum (A63.0)

  • R87.810 Cervical high risk human papillomavirus (HPV) DNA test positive
  • R87.811 Vaginal high risk human papillomavirus (HPV) DNA test positive
  • R87.82 Low risk human papillomavirus (HPV) DNA test positive from female genital organs Use additional

code for associated human papillomavirus (B97.7)

  • R87.820 Cervical low risk human papillomavirus (HPV) DNA test positive
  • R87.821 Vaginal low risk human papillomavirus (HPV) DNA test positive
  • R87.89 Other abnormal findings in specimens from female genital organs

Abnormal chromosomal findings in specimens from female genital organs

  • R87.9 Unspecified abnormal finding in specimens from female genital organs
  • R88 Abnormal findings in other body fluids and substances
  • R88.0 Cloudy (hemodialysis) (peritoneal) dialysis effluent
  • R88.8 Abnormal findings in other body fluids and substances
  • R89 Abnormal findings in specimens from other organs, systems and tissues

Includes

abnormal findings in nipple discharge

abnormal findings in synovial fluid

abnormal findings in wound secretions

  • R89.0 Abnormal level of enzymes in specimens from other organs, systems and tissues
  • R89.1 Abnormal level of hormones in specimens from other organs, systems and tissues
  • R89.2 Abnormal level of other drugs, medicaments and biological substances in specimens from other

organs, systems and tissues

  • R89.3 Abnormal level of substances chiefly nonmedicinal as to source in specimens from other organs,

systems and tissues

  • R89.4 Abnormal immunological findings in specimens from other organs, systems and tissues
  • R89.5 Abnormal microbiological findings in specimens from other organs, systems and tissues

Positive culture findings in specimens from other organs, systems and tissues

Excludes1

colonization status (Z22.-)

  • R89.6 Abnormal cytological findings in specimens from other organs, systems and tissues
  • R89.7 Abnormal histological findings in specimens from other organs, systems and tissues
  • R89.8 Other abnormal findings in specimens from other organs, systems and tissues

Abnormal chromosomal findings in specimens from other organs, systems and tissues

  • R89.9 Unspecified abnormal finding in specimens from other organs, systems and tissues

Abnormal findings on diagnostic imaging and in function studies, without diagnosis (R90-R94)

Includes

nonspecific abnormal findings on diagnostic imaging by computerized axial tomography (CAT scan)

nonspecific abnormal findings on diagnostic imaging by magnetic resonance imaging (MRI)(NMR)

nonspecific abnormal findings on diagnostic imaging by positron emission tomography (PET scan)

nonspecific abnormal findings on diagnostic imaging by thermography

nonspecific abnormal findings on diagnostic imaging by ultrasound (echogram)

nonspecific abnormal findings on diagnostic imaging by X-ray examination

Excludes1

abnormal findings on antenatal screening of mother (O28.-)

diagnostic abnormal findings classified elsewhere - see Alphabetical Index

  • R90 Abnormal findings on diagnostic imaging of central nervous system
  • R90.0 Intracranial space-occupying lesion found on diagnostic imaging of central nervous system
  • R90.8 Other abnormal findings on diagnostic imaging of central nervous system
  • R90.81 Abnormal echoencephalogram
  • R90.82 White matter disease, unspecified
  • R90.89 Other abnormal findings on diagnostic imaging of central nervous system

Other cerebrovascular abnormality found on diagnostic imaging of central nervous system

  • R91 Abnormal findings on diagnostic imaging of lung
  • R91.1 Solitary pulmonary nodule

Coin lesion lung

Solitary pulmonary nodule, subsegmental branch of the bronchial tree

  • R91.8 Other nonspecific abnormal finding of lung field

Lung mass NOS found on diagnostic imaging of lung

Pulmonary infiltrate NOS

Shadow, lung

  • R92 Abnormal and inconclusive findings on diagnostic imaging of breast
  • R92.0 Mammographic microcalcification found on diagnostic imaging of breast

Excludes2

mammographic calcification (calculus) found on diagnostic imaging of breast (R92.1)

  • R92.1 Mammographic calcification found on diagnostic imaging of breast

Mammographic calculus found on diagnostic imaging of breast

  • R92.2 Inconclusive mammogram

Dense breasts NOS

Inconclusive mammogram NEC

Inconclusive mammography due to dense breasts

Inconclusive mammography NEC

  • R92.8 Other abnormal and inconclusive findings on diagnostic imaging of breast
  • R93 Abnormal findings on diagnostic imaging of other body structures
  • R93.0 Abnormal findings on diagnostic imaging of skull and head, not elsewhere classified

Excludes1

intracranial space-occupying lesion found on diagnostic imaging (R90.0)

  • R93.1 Abnormal findings on diagnostic imaging of heart and coronary circulation

Abnormal echocardiogram NOS

Abnormal heart shadow

  • R93.2 Abnormal findings on diagnostic imaging of liver and biliary tract

Nonvisualization of gallbladder

  • R93.3 Abnormal findings on diagnostic imaging of other parts of digestive tract
  • R93.4 Abnormal findings on diagnostic imaging of urinary organs

Excludes2

hypertrophy of kidney (N28.81)

  • R93.41 Abnormal radiologic findings on diagnostic imaging of renal pelvis, ureter, or bladder

Filling defect of bladder found on diagnostic imaging

Filling defect of renal pelvis found on diagnostic imaging

Filling defect of ureter found on diagnostic imaging

  • R93.42 Abnormal radiologic findings on diagnostic imaging of kidney
  • R93.421 Abnormal radiologic findings on diagnostic imaging of right kidney
  • R93.422 Abnormal radiologic findings on diagnostic imaging of left kidney
  • R93.429 Abnormal radiologic findings on diagnostic imaging of unspecified kidney
  • R93.49 Abnormal radiologic findings on diagnostic imaging of other urinary organs
  • R93.5 Abnormal findings on diagnostic imaging of other abdominal regions, including retroperitoneum
  • R93.6 Abnormal findings on diagnostic imaging of limbs

Excludes2

abnormal finding in skin and subcutaneous tissue (R93.8-)

  • R93.7 Abnormal findings on diagnostic imaging of other parts of musculoskeletal system

Excludes2

abnormal findings on diagnostic imaging of skull (R93.0)

  • R93.8 Abnormal findings on diagnostic imaging of other specified body structures
  • R93.81 Abnormal radiologic findings on diagnostic imaging of testis
  • R93.811 Abnormal radiologic findings on diagnostic imaging of right testicle
  • R93.812 Abnormal radiologic findings on diagnostic imaging of left testicle
  • R93.813 Abnormal radiologic findings on diagnostic imaging of testicles, bilateral
  • R93.819 Abnormal radiologic findings on diagnostic imaging of unspecified testicle
  • R93.89 Abnormal findings on diagnostic imaging of other specified body structures

Abnormal finding by radioisotope localization of placenta

Abnormal radiological finding in skin and subcutaneous tissue

Mediastinal shift

  • R93.9 Diagnostic imaging inconclusive due to excess body fat of patient
  • R94 Abnormal results of function studies

Includes

abnormal results of radionuclide (radioisotope) uptake studies

abnormal results of scintigraphy

  • R94.0 Abnormal results of function studies of central nervous system
  • R94.01 Abnormal electroencephalogram (EEG)
  • R94.09 Abnormal results of other function studies of central nervous system
  • R94.1 Abnormal results of function studies of peripheral nervous system and special senses
  • R94.11 Abnormal results of function studies of eye
  • R94.110 Abnormal electro-oculogram (EOG)
  • R94.111 Abnormal electroretinogram (ERG)

Abnormal retinal function study

  • R94.112 Abnormal visually evoked potential (VEP)
  • R94.118 Abnormal results of other function studies of eye
  • R94.12 Abnormal results of function studies of ear and other special senses
  • R94.120 Abnormal auditory function study
  • R94.121 Abnormal vestibular function study
  • R94.128 Abnormal results of other function studies of ear and other special senses
  • R94.13 Abnormal results of function studies of peripheral nervous system
  • R94.130 Abnormal response to nerve stimulation, unspecified
  • R94.131 Abnormal electromyogram (EMG)

Excludes1

electromyogram of eye (R94.113)

  • R94.138 Abnormal results of other function studies of peripheral nervous system
  • R94.2 Abnormal results of pulmonary function studies

Reduced ventilatory capacity

Reduced vital capacity

  • R94.3 Abnormal results of cardiovascular function studies
  • R94.30 Abnormal result of cardiovascular function study, unspecified
  • R94.31 Abnormal electrocardiogram (ECG) (EKG)

Excludes1

long QT syndrome (I45.81)

  • R94.39 Abnormal result of other cardiovascular function study

Abnormal electrophysiological intracardiac studies

Abnormal phonocardiogram

Abnormal vectorcardiogram

  • R94.4 Abnormal results of kidney function studies

Abnormal renal function test

  • R94.5 Abnormal results of liver function studies
  • R94.6 Abnormal results of thyroid function studies
  • R94.7 Abnormal results of other endocrine function studies

Excludes2

abnormal glucose (R73.0-)

  • R94.8 Abnormal results of function studies of other organs and systems

Abnormal basal metabolic rate (BMR)

Abnormal bladder function test

Abnormal splenic function test

Abnormal tumor markers (R97)

  • R97 Abnormal tumor markers

Elevated tumor associated antigens (TAA)

Elevated tumor specific antigens (TSA)

  • R97.0 Elevated carcinoembryonic antigen (CEA)
  • R97.1 Elevated cancer antigen 125 (CA 125)
  • R97.2 Elevated prostate specific antigen (PSA)
  • R97.20 Elevated prostate specific antigen (PSA)
  • R97.21 Rising PSA following treatment for malignant neoplasm of prostate
  • R97.8 Other abnormal tumor markers

Ill-defined and unknown cause of mortality (R99)

  • R99 Ill-defined and unknown cause of mortality

Death (unexplained) NOS

Unspecified cause of mortality

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