DATA EVALUATION AND METHODS RESEARCH

A Reasonfor Visit Classification

for AmbulatoryCare

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

.

DHEW Publication No. (PHS) 79-1352

U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE

Public Health Service

Office of the Assistant Secretary for Health

National Center for Health Statistics

Hyattsville, Md. February 1979

Series 2

Number 78
Library of Congress Cataloging in Publication Data

Schneider, Don.

A reason for visit classification for ambulatory care.

(Vital and health statistics: Series 2, Data evaluation and methods research; no. 78)

(DHEW publication; no. (PHS) 79-1352)

Includes bibliographical references and index.

1. Nosology. 2. Ambulatory medical care. I. Appleton, Linda, joint author. II. McLemore,

Thomas, ,joint author. III. Title. IV. Series: United States. National Center for Health Statistics. Vital and health statistics: Series 2, Data evaluation and methods research; no. 78.

V. Series: United States. Dept. of Health, Education and Welfare. DHEW publication;

no. (PHS) 79-1352. [DNLM: 1. Ambulatory care. 2. Classification. W2 A N148vb no. 78]

RA409.U45 no. 78 [RB115] 312’.07’23s [616’.001’2]

78-11549
NATIONAL CENTER FOR HEALTH STATISTICS

DOROTHY P. RICE, Director

ROBERT A. ISRAEL, Deputy Director

JACOB J. FELDMAN, Ph.D., Associate Director for Analysis

GAIL F. FISHER, Ph.D., Associate Director for the Cooperative Health Statistics System

ELIJAH L. WHITE, Associate Director for Data Systems

JAMES T. BAIRD, JR., Ph.D., Associate .Directorfor International Statistics

ROBERT C, HUBER, Associate Director for Management

MONROE G. SIRKEN, Ph. D., Associate Director for Mathematiccd Statistics

PETER L. HURLEY, Associate Director for Operations

JAMES M. ROBEY, Ph.D., Associate Director for Program Development

PAUL E. LEAVERTON, Ph. D., Associate Director for Research

ALICE HAYWOOD, Information Officer

DIVISION OF HEALTH RESOURCES UTILIZATION STATISTICS

SIEGFRIED A. HOERMANN, Director

JOAN F. VAN NOSTRAND, Chiefi Long-Term Care Statistics Branch

SIEGFRIED A. HOERMANN, Acting C)ziej Hospital Care Statistics Branch

STEWART C. RICE, Chief Family Pknning Statistics Branch

JAMES E. DeLOZIER, Chief Ambukztory Care Statistics Branch

MANOOCHEHR K. NOZARY, Chief Technical Services Branch

Vital and Health Statistics-Series 2-No. 78

DHEW Publication No. (PHS) 79-1352

Library of Congress Catalog Card No. 78-11549
PREFACE

This report presents a Reason for Visit Classification for Ambulatory Care.

The Reason for Visit Classification (RVC), developed by The American Medical

Records Association under the auspices of the National Center for Health Statistics (NCHS) for use in the National Ambulatory Medical Care Survey and by

others, is primarily a classification of patient or lay terminology encountered in

the ambulatory care setting. The emphasis of the RVC is on the patient’s motivation for seeking medical care and his perspective of the probIem or reason for

visit. This is an important conceptual difference distinguishing the RVC from the

Ninth Revision of the International Classification of Diseases (ICD-9) and its U.S.

adaptation, International Classification of Diseases, Ninth Revision, Clinical

Modification (ICD-9-CM). The ICD-9 is an official World Health Organization

(WHO) publication and will be used in the United States for mortality coding

beginning in 1979. The ICD-9-CM has been prepared jointly by the Government

and private sector and has resulted in an expanded, but compatible, version of

the ICD-9 which is used in the United States to classify diseases and conditions

in clinical settings.

The WHO Center for Classification of Diseases for North America at the

NCHS is responsible for the ICD in the United States and for the official U.S.

and Canadian input into future revisions of the ICD. The WHO reco~izes that

the ICD-9 does not entirely meet the needs of an ambulatory care classification.

It is hoped that the experience gained through the use of the RVC will provide

an important contribution to future revisions of the ICD.

It is the policy of NCHS that methodological reports are to be given peer

review for technicaI merit and readabilityy by one or more persons familiax with

the subject matter of the report, but not invoIved in producing the report. Ms.

Alice Hetzel of the Division of Vital Statistics performed the peer review for

this report.

...

Ill
ACKNOWLEDGMENT

The classification presented in this report is based primarily on the work of the American Medical Records Association

(AMRA) under contract number HRA 230-75-0197 with the

National Center for Health Statistics. The contribution of the

AMRA and its staff is ,gratefully acknowledged.
CONTENTS

Preface ................................................................................................................................ ...................

...

111

Acknowledgment ................................................................................................................................... iv

Summary ................................................................................................................................................ 1

Introduction ........................................................................................................................................... 1

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

Reason for Visit Classification ................................................................................................................ 4

Basic Design Features ....................................................................................................................... 4

Tabular List ...................................................................................................................................... 4

Alphabetical Index ........................................................................................................................... 6

Applications .......................................................................................................................................... 6

Revision ................................................................................................................................................ 7

References ............................................................................................................................................. 8

Appendixes

L Reason for Visit Classification Tabular Lkt .............................................................................. 10

IL Reason for Visit Classification Alphabetical Index ................................................................... 35

111. Coding Rules and Instructions .................................................................................................. 62

FIGURE

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

v
Comments, suggestions, and criticisms of the Reason for Visit Classification are solicited and should be addressed to the Ambulatory

Care Statistics Branch, Division of Health Resources Utilization

Statistics, National Center for Health Statistics, Room 2-12,3700

East-West Highway, HyattsvilIe, Maryland 20782.
A REASON FOR VISIT CLASSIFICATION

FOR AMBULATORY CARE

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

SUMMARY

In May 1974, the National Ambulatory Medical Care Survey Symptom Classification was

published as “the first attempt of the National

Center for Health Statistics to develop a methodolo~y for classifying patients’ symptoms, complaints, problems, and reasons for seeking

ambulatory medical care.”1 The Symptom

Classification has been used since that time in

the National Ambulatory Medical Care Survey

and by others. In 1975, an evaluation of the

National Ambulatory Medical Care Survey

Symptom Classification and other existing classifications that might be used to classify reasons

fur ambulatory medical care visits was undertdwm by the American Medical Record Association under contract to the National Center for

Hm.lth Statistics. As a finaJ product of the contract, a model system for classifying reason for

visit data was developed. This report, abstracting

mtiterial from the contractor’s final report and

related sources, presents the Reason for Visit

Classification for Ambulatory Care (RVC) along

with a summary of events leading to its development. The philosophy and structure of the RVC

are presented, along with comments on possible

applications and on updating or revision of the

3Mr. Schneider is Director, Health Systems Management Engineering, Rensselaer Polytechnic Institute,

Troy, N.Y. Ms. Appleton is Manager, Medical Records,

Ellis Hospital, Schenectady, N.Y. Both worked for the

American Medical Records Association during the development of the RVC. Mr. McLemore is Survey Statistician, Ambulatory Care Statistics Branch, National

Center for Health Statistics.

RVC. The tabukw list of the RVC is presented

in appendix I; the alphabetical index is found in

appendix II; and general coding rules and instructions appear in appendix III.

INTRODUCTION

In an effort to provide national baseline data

concerning the Nation’s utilization of ambulatory medical care resources, the National Center

for Health Statistics (NCHS) of the Department

of Health, Education, and Welfare launched the

National, Ambulatory Medical Care Survey

(NAMCS) in May 1973. In its current scope,

this continuous survey is designed to provide

natiomd statistics on the volume and characteristics of office visits to non-Federal, office-based

physicians. When appropriate methodologies are

developed, the NAMCS target population will

be expanded to include other settings and professionals, for example, outpatient departments,

emergency rooms, and non-office-based physicians. A more detailed description of the background and methodological development of the

NAMCS is available in an earlier report.z

The actual data collection for the NAMCS is

carried out by participating physicians who complete Patient Record forms for a sample of the

patients that they see during a randomly assigned

week of practice. One of the unique aspects of

this survey is its attempt to incorporate the

dimension of perceived need for seeking medical

care as expressed by the patient; that is, the reason for visit in the patient’s own words. This

information is one of the data elements in the
uniform minimum basic data set for ambulatory

care approved by the U.S. National Committee

on Vital and Health Statistics.3 During the

1973-74 NAMCS, reason for visit data were collected in item 5 of the Patient Record in which

the physician was requested to record,

“PATIENT’S PRINCIPAL PROBLEM(S), COMPLAINT(S), OR SYMPTOM(S) THIS VISIT (h

patient’s own words).” (See fi~re 1.)

During 1970-72 when the NAMCS was field

tested, it was apparent that an adequate classification scheme was not available to code these

reason for visit data. Consequently, a new classification was developed by Meads and McLemore,l based largely on data from the

NAMCS pilot studies and on schemes expounded by Bain and Spaulding,4 and Renner

and Piernot.s The NAMCS Symptom Classification, as this earlier scheme was called, was

designed to be simple and flexible; and consisted

of some 200 rubrics or codes grouped into 13

classes, primarily around a body system axis.

It was developed to code the patient’s symptoms, complaints, and other reasons for visit, in

the patient’s own words, and, thus, is primarily

a classification of lay terminology. Although

the Symptom Classification was originally designed as a processing instrument for the

NAMCS, and was used in that capacity from

1973 through 1976, it has been adopted, usually

ASSURANCE OF CONFIDENTIALITY-AII mformz.tton which would permtt identtftcatton of .“ mdw,d. al,

a prmwce. m an estabhshmmt WIII be held conf,denttal, wdl be used only by persom engaged m and for

the purposes of the survey and WIII not be d,sclosed or released lo other persons or used for any other purwse. 1A

1. DATE OF VISIT PATl ENT RECORD

.~

NATIONAL AMBULATORY MEDICAL CARE SURVEY

2. DATE OF BIRTH 4. COLOR OR 5. PATIENT’S PRINCIPAL PROBLEM(S) 6. SERIOUSNESS OF

RACE COMPLAINT(S), OR SYMPTOM(S) ~ VISIT PROBLEM IN ITEM 50

* ;: ;:’., —

[In patient’s own words) (Check one)

, ❑ VERY SERIOUS

3. SEX

a MOST

BLACK IMPORTANT D SERIOUS

, ❑ FEMALE I

J❑ OTHER I

,uSLIGHTLY SERIOUS

, ~ MALE . i_ UNKNOWN b OTHER . ~ NOT SERIOUS ,-

8. MAJOR REASON(S) FOR THIS VISIT — [Check*//major reasmd

I ❑ ACUTE PROBLEM . D WELL AOULT/CHILO EXAM

? ❑ ACUTE PROBLEM. FOLLOW-UP . ❑ FAMILY PLANNING

,, ❑ CHRONIC PROBLEM, ROUTINE ~ ❑ COUNSELING/ADVICE

,4 ❑ CHRONIC PROBLEM, FLARE. UP ,, 0 IMMUNIZATION

5 ❑ PRENATAL CARE . IJ REFERREO BY OTHER PHYS/AGENCY

6 ❑ POSTNATAL CARE I ❑ ADMINISTRATIVE PURPOSE

I ❑ POSTOPERATIVE CARE

7

. IJ OTHER (SW’CIIY)

(Operatwe procedure)

10. DIAGNOSTICflHERAPEUTIC SERVICES ORDEREO/PROVIOEO THIS VISIT (Checks//that apply,

01 ❑ NONE 11 ❑ DRUG PRESCRIBED

02 ❑ LIMITED HISTORYIEXAM 12 ❑ X-RAY

03 ❑ GENERAL HISTORY/EXAM 13 ❑ INJECTION

04 ❑ CLINICAL LAB. TEST 14 ❑ lMMUNIZATION/OESENSITIZATION

05 ❑ BLOOO PRESSURE CHECK 15 ❑ PHYSIOTHERAPY

06 ❑ EKG 16 ❑ MEDICAL COUNSELING

07 ❑ HEARING TEST 17 ❑ PSYCHOTHERAPY~HE RAPEUTIC

08 ❑ VISION TEST LISTENING

09 U ENOOSCOPY 18 tl OTHER [Spec,fy)

10 1=1 OFFICE SURGERY

4RA-34-2 DEPARTMENT OF HEALTH, EDUCATIC

REV. 8-74 PUBLIC HEALTH SERV

HEALTH RESOURCES ADMINI!

NATIONAL CENTER FOR HEALTt

7. HAVE YOU EVER SEEN

THIS PATIENT BEFORE?

f a Y;s , ➤ NO

If YES. for the problem

mdmated m ITEM 5a 7

I 1

9. PHYSICIAN’S PRINCIPAL OIAGNOSIS ~ VISIT

a OIAGNOSIS ASSOCIATE WITH ITEM Sa ENTRY

b OTHER SIGNIFICANT CURRENT OIAGNOSES

(In order of importance)

11. DISPOSITION TM VISIT

(Checkall [hat apply]

NO FOLLOW. UP PLANNEO

RETURN AT SPECIFIEO TIME

RETURN IF NEEDED, P R N

TELEPHONE FOLLOW. UP PLANNED

REFERRED TO OTHER

PHYSICIAN, AGENCY

RETURNEO TO REFERRING

PHYSICIAN

AOMIT TO HOSPITAL

OTHER (Spec@)

I ANO WELFARE O.M.B

12. OURATION OF

US VISIT (T/nM

●mrallf spent w{lh

ph)’wcm)

MINUTES

Y6S-S72106 q EXPIRATION DATE 12/31fT5

RATION

TATISTICS

Figure 1. National Ambulatory Medical Care Survey Patient Record form

2
after some modification, in a number of other

settings, for example, in the Rand Corporation’s

Health Insurance Study.G

Through analysis of NAMCS data and data

requests, and feedback from users of the Symptom Classification, some problems or deficiencies in this scheme were identified. The most

important of these concerned the lack of specificity or detail in some areas, especially in the

nonsymptomatic reason for visit section and in

the residual or “other” categories. These considerations indicated the need for a more comprehensive classification and were, in part, responsible for the decision to initiate the evaluation

contract discussed in the next section of the

report.

DEVELOPMENT OF THE REASON

FOR VISIT CLASSIFICATION

In July 1975, the American Medical Record

Association (AMRA) was awarded a contract to

evaluate, the NAMCS Symptom Classification

and other existing medical taxonomies that

might be used to classify patients’ reasons for

seeking ambulatory medical care, and to develop

and test a model system for classifying this type

of information. One of the many requirements

of this model system was that it meet not only

the needs of the NAMCS, but also the needs of

a wide variety of other users.

An initial research phase included an extensive review of the literature pertaining to medical and health care classifications and the compilation of an annotated bibliography relating

to the design, development, description, use,

evaluation, and analysis of medical classification

systems. Consultations with over 100 individuals involved in fields relating to the classification of health care data provided the necessary

input to determine the needs and purposes for a

classification of reason for visit data.

This preliminary research paved the way for

the Conference on Symptom Classifications for

Ambulatory Care held in November 1975. This

‘conference provided a forum for national experts in the field of ambulatory medical care

classifications and users of the NAMCS Symptom Classification for input into the project.

The specific goals of the conference included

establishing criteria for evaluation of reason for

visit classifications and concepts leading to the

development of a methodology for the design of

health care classification systems. Information

was gathered from a variety of users of the

NAMCS Symptom Classification, and problems

associated with the Symptom Classification were

identified.

A methodology for the evaluation and design of medical classification systems was subsequently developed. The principles set forth in

this methodology provided the conceptual

framework from which the model reason for

visit classification was deveIoped and tested. A

complete description of the background for the

evaluation and design methodology has been

presented by Schneider and Parziale.T

Six existing classification systems were

selected, tested, and evaluated for their applicability in coding reason for visit data; (1) NAMCS

Symptom Classification,l (2) Patient Request

Code,s (3) CR Alpha Code,g (4) Columbia

Medical Plan Classification,l O (5) International

Classification of Health Problems in Primary

Care,l 1 and (6) International Classification of

Diseases (ICD-9).1 z The last two classifications

are primarily diagnostic codes and are not specifically designed to classify reason for visit data,

particularly in lay terminology. They were included in the evaluation because of their widespread use, and because they may be considered

by many users for coding reason for visit data.

Reason for visit data from the 1974 NAMCS

and from the State of Wisconsin emergency

room study]s were used to test each of the

above system’s applicability to code these data.

Each system was evaluated according to the following criteria: ease of understanding, clarity,

accuracy, specificity, efficiency, conciseness,

comprehensiveness, flexibility of revision, and

computer applicability. These evaluations helped

to pinpoint the strengths and weaknesses of the

existing systems, and the findings from these

evaluations were used as a basis for the development of the RVC.

The RVC underwent several revisions before

reaching the version presented in this report.

The modular structure, which is discussed later

in the report, was introduced in the first version.

3
This version was tested using reason for visit

data from the NAMCS and from emergency

room and outpatient clinic studies. The results

of the coding tests were incorporated into a second version which was evaluated by representatives of 10 professional associations and by an

evaluation workshop of classification experts in

May 1976. Recommendations from these

sources were considered and included whenever

possible in the final RVC. Minor modifications

prompted by further coding tests and evaluations at NCHS resulted in the RVC as presented

in this report.

REASON FOR VISIT CLASSIFICATION

Basic Design Features

The structural philosophy of the RVC is best

explained by describing its modular design. The

RVC utilizes a modular structure with the following modules representing basic categorizations of the patient’s reason for visit:

1.

2.

3.

4.

5.

6.

7.

Symptom

Disease

Diagnostic, screening, and preventive

Treatment

Injuries and adverse effects

Test results

Administrative

When the modules were designed, the primary emphasis on the selection of the modules

and the categories within the modules was that

they discriminate well with respect to

1. The patient’s motivation or reason for

seeking medical care, and

2. The physician’s response to that reason

for visit.

This does not imply that all or nearly all of

tlie patient visits falling into a particular module

are uniform with respect to the two characteristics just listed. Instead, it is implied that a

randomly selected patient visit coded into a paxtitular module is expected to be more highly

correlated with other patient visits in the same

module than it is with patient visits coded int{~

other modules.

This hypothesis was tested by comparing the

modules with respect to their correlation with

several attributes or characteristics of a patient

visit, for example, visit initiator and patient

status, and with other items on the NAMCS

Patient Record form: seriousness of the problem

(item 6), visit status (item 7), reason(s) fur visit

categories (item 8), treatments/services ordered

or provided (item 10), and disposition (item 11).

Generally, the results, which are discussed in detail in the contractor’s final report, show that

the modules represent distinctly different SToupings of patient visits.14

Strengths of the modular structure include:

1. Aggregated at the modular level, the data

provide a description of the basic types

of reasons for visit,

2. The RVC is flexible in that the modules

can be expanded or contracted according

to the particular needs of the user. For

example, if a hospital outpatient department desires greater specificity in coding

therapeutic procedures, that module

could be expanded, as required, without

disturbing the remaining modules.

3. Categories for some of the modules may

be abstracted from other classification

systems that are specific to that particular module, for example, sections of the

International Classification Oj- Diseases,

Adapted (ICDA)15 or the International

Classification of Health Problems in Primary Care (ICHPPC),l 1 may be inserted

into the Disease Module.

4. Coding decisions are simplified because

the modules represent logical ~groupings

for reasons for visit.

Tabular List

The RVC consists of two parts: a tabular list

of categories and an alphabetical index of terms.

4
The tabular list is divided into the seven previously listed modules. The listing of inclusive

terms for each category in the tabular list is not

exhaustive, but is meant to be illustrative of the

reasons for visit contained within each category.

A brief description of the types of patient visits

falling into each module and the categorical content of each module follow. The reader may

find it useful to refer to the appendixes while

reading the following sections.

Symptom Module. –The reasons for visit

classified in this module represent visits in which

the patient expresses his or her reason for visit

as a complaint, symptom, or problem. Often

these are initial visits for the problem, and the

physician generally responds by collecting information through examination, history, and/or

tests. A tentative diagnosis is the probable outcome.

In the Symptom Module, symptoms are

grouped by body system. Each symptom has

been assigned to the body system in which it is

primarily manifested. For example, cough is assigned to the respiratory system and nausea to

the digestive system. In cases where the symptom manifests itself in several systems or in the

entire body, the symptom has been assigned to a

category in the General Symptoms section. The

General Symptoms section also includes symptoms in which the problem descriptor is listed

without reference to a body part or system, for

example, bleeding, or where no body system is

applicable, as fatigue.

It may appear that some of the codes in the

Symptom Module represent diseases, for example, the term “infection” to indicate an unspecified infection of a body part. Distinguishing between what is a symptom and what is a disease

is, at best, a very tenuous and difficult problem.

The tendency in the RVC is to treat the reason

for visit as a symptom, rather than a disease.

Thus in the example, when a patient states that

hc or she has an infection, the patient is really

expressing a symptom complex, rather than an

established diagnosis. Unspecified allergies,

warts, and moles are likewise coded into the

Symptom Module. However, specified infections, as “staphylococcal infection” are coded

into the Disease Module.

Disease Module. –Reasons coded into this

section represent visits at which the patient gives

a diagnosis as the reason for visit. This could be

either a diagnosis previously supplied by the

physician or a condition that the patient has experienced before and/or has self-diagnosed. Most

folIowup visits for chronic diseases will be coded

into this module. Physician’s response is probably a checkup or observation of the condition.

The Disease Module, also arranged by body system, is based on a condensation of the International Classification of Health Problems In Primary Care. *1

Diagnostic, Screening, and Preventive hlodule. —The reasons for visit coded into this module usually represent nonillness visits, for

example, visits for routine physicals and preventive care, visits by patients in high-risk groups, or

visits for family planning services or pregnancyrelated examinations. The physician’s response

is to directly carry out the patient’s request and

generally involves the provision of some type of

test or diagnostic procedure.

Treatment Module. –These visits are, generally, for the purpose of providing specific therapeutic care, treatment, or counseling; the physician’s response is to carry out the request and

usually includes the provision of a therapeutic

procedure.

Injuries and Adverse Efji?cts Module. –This

module includes reasons for visit that are clearly

the result of an injury or adverse effect. These

visits are often emergency visits that require immediate care, and the physician’s response is to

aIleviate the patient’s immediate problem.

Test Results Module. –Reasons coded into

this module represent return visits to receive test

results. The patient may have been toId that

results from previously administered tests were

abnormal or may be returning to receive test

results. The dia~osis may or may not yet be

established. The physician’s response is usually

to carry out further diagnostic tests or to

initiate a therapeutic regimen.

Administrative Module. –Reasons for visit

coded into this module are unique in that they

are initiated by an outside party rather than by

the patient or the physician. The visits usually

involve completion of a form or other paperwork to verify that the physician has seen the

patient and fulfilled the request. For example,

insurance physicals, return-to-work certificates,

and court-ordered examinations fall into this

5
module. Physician’s response is to carry out the

administrative request.

The list is designed to provide the option of

coding and aggregating at two levels. Code numbers with decimal point zero (.0) represent the

upper hierarchy or broad codes, and c, de numbers ending in .1-.9, the lower hierarchy or more

specific codes. For example,

(Upper level) – S310.0 Discharge from eye

(Lower level) – S31O.1 Bleeding from eye

– S310.2 Excessive tearing

– S31O.3 Pus in eye

Thus, depending on the reliability of the data

and the needs of the user, two levels of specificity are provided.

Alphabetical Index

The second part of the RVC is the alphabetical index of terms, an extensive list of words and

terms with their appropriate code numbers. The

alphabetical index includes many synonyms and

patients’ expressions to facilitate the coding of

the reason for visit data. As discussed in the section “Revision,” the alphabetical index will be

continuously expanding as new terms are added.

Entries are alphabetically indexed according

to the following general rules:

1. When the reason for visit is given as a

problem descriptor along with a body

part, for example, “skin itching” or “eye

pain,” the entry is indexed by the descriptor, not by the body part. Thus,

“eye pain” is located under “pain, eye. ”

2. When a problem of a body function is

given as the reason for visit, for example,

“blurred vision,” the reason for visit is

indexed by the body function. Thus,

“blurred vision” is located under “vision,

blurred.”

Users of the RVC should refer to appendix

III for guidelines for using the alphabetical

index.

APPLICATIONS

The RVC has been developed to classify the

patients’ stated reasons for seeking ambulatory

medical care. It should be recognized that the

quality of the output of the RVC is affected by

both the code and the data. Data collection

considerations, such as who records the reason

for visit and when it is recorded, are important

factors affecting the distribution of the reasons

for visit. Utilization of the RVC will generally

be enhanced if instructions in the following

areas are provided and adhered to by the recorder of the reason for visit:

1.

2.

3.

4.

5.

List the diagnosis as the reason for visit

only if so stated by the patient.

Specify administrative examinations as

such, and not simply state “general examination, ” for example.

State if the reason for visit is related to

an injury, and specify the injury.

Specify what followup visits are for.

Avoid recording “none” or “no complaint” as the re&on for visit.

The RVC has been adopted for use in

the NAMCS beginning with the 1977 survey, The

RVC has been purposely designed to allow application in a variety of ambulatory settings, including clinics, outpatient departments, and

emergency rooms. Use of the RVC outside the

NAMCS, and feedback regarding its use, are

encouraged.

Potential uses of data classified using the

RVC are many and varied. Selected examples

are to provide descriptive information indicating

why patients are seeking ambulatory medical

care; to indicate which visits might be delegated

to particular members of the health care team

(immunizations and well baby care might be

seen by a nurse practitioner or physician assistant); and to aid in resource allocation and patient scheduling decisions. Specific applications

of the RVC to quality assurance and other areas

of patient and clinic management have been discussed by Schneider and Appleton.] 6
REVISION

Because basic reasons for seeking ambulatory medical care change little from year to

year, it is unlikely that the tabular list of the

RVC will become quickly outdated and in need

of large-scale revision. Therefore, no specific

timetable has been set to revise this part of the

RVC. The time and extent of revision will be

dictated by several factors, including analysis of

NAMCS data and feedback from other users of

the RVC. Reason for visit data from the 1977

NAMCS will be analyzed when it becomes available and should provide several measures of the

need for revision: low frequency codes and

residual or “catchall” codes that occur with high

frequencies wilI be analyzed to determine if

modifications of the RVC are necessary. And, as

mentioned before, comments and criticisms regarding the use of the RVC are solicited, as this

feedback will be valuable in determining future

alterations in the RVC.

Every attempt has been made to make the

alphabetical index as compIete as possible; however, it is still far from exhaustive. Periodic updates of the index are, therefore, anticipated.

NAMCS coding procedures call for each medical

coder to maintain a list of nonindexed and unclassifiable terms as they are encountered. These

lists are periodically compiled and reviewed and

necessary additions will be made to the index.

Users of the RVC are also urged to maintain

such lists and to forward copies of these lists to

the address given on page vi so that new terms

may be added to the index to make it as comprehensive as possible.

000
REFERENCES

1National Center for Health statistics: National

Ambulatory Medical Care Survey: Symptom classification, United States, by Sue Meads and Thomas McLemore. Vital and Health Statistics. Series 2-No. 63.

DHEW Pub. No. (HRA) 74-1337. Health Resources Administration. Washington. U.S. Government Printing

Office, May 1974.

2Nation~ Center for He~th Statistics: National

Ambulatory h4edical Care Survey: Background and

methodology, United States, by James B. Tenney, M.D.,

Kerr L. White, M.D., and John W. Williamson, M.D.

Vital and Health Statistics. Series 2-No. 61. DHEW

Pub. No. (HRA) 74-1335. Health Resources Administration. Washington. U.S. Government Printing Office,

Mar. 1974.

3Nation~ Center for He~th Statistics: Ambulatory

medical care records: Uniform minimum basic data set,

United States. Vital and Health Statistics. Series 4-

No. 16. DHEW Pub. No. (HRA) 75-1453. Health Resources Administration. Washington. U.S. Government

Printing Office, Aug. 1974

4Bain, S. T., and Spaulding, W. B.: The importance

of coding presenting symptoms. Can. Med. Assoc. J.

97(16):953-959, 1967.

5 Renner, J. H., and Piernot, R. W.: A revised symptom code list for ambulatory medical record data. Paper

prepared for Family Practice Program, University of Wisconsin, hladison, 1972.

6Newhouse, J. p.: A summary of the experimental

portion of the Rand health insurance study. Santa

Monica, Calif. The Rand Corporation, 1975.

7Schneider, D., ~d parziale, A.: Development of

medical classification systems for productivity analysis.

Proceedings. Seventh Conference of the Hospital and

Health Services Division of the American Institute of

Industrial Engineers, Colorado Springs, Feb. 1976.

8Weinstein, P., Gordon, M. J., and Gilson, J. S.: A

system for coding the presenting problems of ambulatory patients. Group Health Cooperative of Puget

Sound, Seattle, Wash. Unpublished paper.

‘Martin, L. R., and Werblun, M. N.: The CR alpha

diagnostic coding system for ambulatory care. ]. Fare.

Pratt. 4(3):563-566, 1977.

10Steinwachs, D. M., and MushEn, A. I: The Johns

Hopkins ambulatory-care coding scheme. Health Serv.

Res. 13(1):36-49, 1978.

11 World Orgmizationof National Colleges, Academies, and Academic Associations of General Practitioners/Family Physicians: International Classification of

Health Problems in Primary Care. Chicago. American

Hospital Association, 1975.

12World Health Organization: Manual of the International Statistical Classification of Diseases, Injuries, and

Causes of Death, Based on the Recommendations of the

Ninth Revision Conference, 1975. Geneva. World Health

Organization, 1977. Preliminary draft.

13Bureau of He&h Statistics: History and Development of the Emergency Department Encounter Form,

an unpublished paper by T. Engstrom. Wisconsin Department of Health and Social Services, Division of

Health, Madison, Wis., May 1978.

14Americm Medic~ Record Association: Evaluation

of the National Ambulatory Medical Care Survey Symptom Classification contractor’s final report. Contract

No. HRA 230-75-0197. Chicago. Oct. 1976.

15 Nation~ Center for HeAth Statistics: Eighth Revision International Classification of Diseases, Adapted

for Use in the United States. PHS Pub. No. 1693. Public

Health Service. Washington. U.S. Government Printing

Office, 1967.

16Schneider, D., ~d Appleton, L.: Reason for visit

classification system for patient records in an ambulatory care system. dual. Rev. Bull. 3(1): 20-26, Jan.

1977.
APPENDIXES

CONTENTS

L Reason for Vkit Classification Tabular List .............................................................. ................... ...

Symptom Module ......................................................................................... ............................

Disease Module .........................................................................................................................

Diagnostic, Screening, and Preventive Module ..........................................................................

Treatment Module ...................................................................................................................

Injuries and Adverse Effects Module ........................................................................................

Test Results Module ........................................................................................ .........................

Administrative Module ............ .................................................................................................

Uncodable Entries ........................................................................................ ............................

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

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

10

;:

26

29

31

33

34

34

35

62

9
APPENDIX I

REASON FOR VISIT CLASSIFICATION

TABULAR LIST

Module

SYMPTOM MODULE

General Symptoms ....................................

Symptoms Referable to Psychological and

Mental Disorders .....................................

Symptoms Referable to the Nervous System (excluding senseorgans) ...................

Symptoms Raferable to the Cardiovascular

and Lymphatic Systems ..........................

Symptoms Referable to the Eyes end

Ears .........................................................

Symptoms Referable to the Respiratory

System ....................................................

Symptoms Referable to the Digestive

System ....................................................

Symptoms Referable to the Genitourinary System ...........................................

Symptoms Referable to the Skin, Nails,

and Hair ..................................................

Symptoms Referable to the Musculoskeletal System ...............................................

DISEASE MODULE

Infective and Parasitic Diseases.................

Neoplasms .................................................

Endocrine, Nutritional, and Metabolic

Diseases...................................................

Diseases of the Blood and Blood-Forming

Organs .....................................................

Mental Disorders .......................................

Diseases of the Nervous System ................

Diseases of the Eye ...................................

Diseases of the Ear ....................................

Diseases of the Circulatory System ...........

Diseasesof the Respiratory System ...........

Diseases of the Digestive System ...............

Diseases of the Genitourinary System .......

Disaases of the Skin and Subcutaneous

Tissue ......................................................

Code

number

SOOI-S099

SIOO-S199

S200-S259

S260-S299

S300-S399

S400-S499

S500*639

S6405829

S830-SB99

S900-S999

DOOI-D099

DIOO-D199

D200-D249

D250-D299

D300-D349

D350-D399

D400-D449

D450-D499

D500-D599

D600-D649

D650-D699

D700-D799

D800-D899

Module

DISEASE MODULE–Con.

Diseases of the Musculoskeletal System

and Connective Tissue ............................

Congenital Anomalies ...............................

Perinatal Morbidity and Mortality Conditions ........................................................

DIAGNOSTIC, SCREEN ING, AND PREVENTIVE MODULE

General Examinations ...............................

Special Examinations ................................

Diagnostic Tests ........................................

Other Screening and Preventive Procedures ....................................................

Family Planning ........................................

TREATMENT MODULE

Medications ...............................................

Preoperative and Postoperative Care .........

Specific Types of Therapy ........................

Specific Therapeutic Procedures ...............

Medical Counseling ...................................

Social Problem Counseling ........................

Progress Visit, NEC ...................................

INJURIES AND ADVERSE EFFECTS

MODULE

Injury by Type and/or Location ...............

Injury, NOS ...............................................

Poisoning and Adverse Effects ..................

TEST RESULTS MODULE ............................

ADMINISTRATIVE MODULE ......................

UNCODABLE ENTRIES ...............................

Code

number

D900-D949

D950-D989

D990-D999

xlOo-x199

X200-X299

X300-X399

X400-X499

X500-X599

T100-T1 99

T200-T299

T400-T499

T500-T599

T600-T699

T700-T799

T800-T899

JOO1-J799

J800-J899

J900-J999

R 1OO-R7OO

A1OO-AI4O

U990-U999

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

10
SYMPTOM MODULE

General Symptoms (S001-S099)

S005.0 Chills

SO1O.O Fever

Includes:

High temperature

SO15.0 Tiredness, exhaustion

Includes:

Fatigue

No energy

Run down

Worn out

S020.0 General weakness

S025.0 General ill feeling

Includes:

Not feeling well

Multiple complaints

Malaise

Illness, NOS

S030.0 Fainting (syncope)

Includes:

Blacking out

Passing out

Fainting spells

Excludes:

Unconsciousness (J840.0)

S035.0 Symptoms of fluid abnormalities

S035.1 Edema

Includes:

Bloated

Swollen with water

Dropsy

Ankles swelling (both)

Excludes:

Swelling of one ankle

(s930.3)

S035.2 Excessive sweating, perspiration

S035.3 Excessive thirst

S040.0 Weight gain

Includes:

Obesity

Overweight

Excludes:

Counseling for weight problem

(T600.0)

NOTE: NEC = not elsewhere classifiable; NOS = not

otherwise specified.

S04500

S050.O

S055.O

S060.0

S065.0

S070.O

S075.O

S080.0

Weight loss

S045.1 Recent weight loss

S045.2 Underweight

Chest pain and related symptoms (not

referable to body system)

S050.1 Chest pain

Excludes:

Heart pain (S265.0)

S050.2 Chest discomfort, pressure,

tightness

S050.3 Burning sensation in the chest

Pain, site not referable to a specific

body system

Excludes:

Chest pain (S050.1)

Abdominal pain (see S550.0)

S055.1 Rib pain

S055.2 Side pain, flank pain

S055.3 Groin pain

S055.4 Facial pain

Pain and related symptoms, generalized, site unspecified

S060.1 Pain, site unspecified

Includes:

Ache all over

S060.2 Cramps, spasms, site unspecified

Excludes:

Menstrual cramps

(S745.2)

S060.3 Stiffness, site unspecified

Tumor or mass, site unspecified

Bleeding, site unspecified

Symptoms of growth and developmental disorders

S075.1 Lack of growth

Includes:

Failure to thrive

Slowness, physical

Too short

Immaturity, physical

Poor weight gain

S075.2 Excessive growth

Includes:

Too tall

Too big for age

Development, early

(physical)

General symptoms of infants, NEC

S080.1 Crying too much, fussy,

fidgetv, irritable

11
S080.0 General symptoms of infants, NEC–Con.

SO80.2 Regurgitation, spitting up

Excludes:

Vomiting (S530.0)

S080.3 Feeding problem

S085.0 General or unspecified infection

S085. 1 General viral infection

S090.0 Allergy, NOS

Includes:

Allergic reaction, NOS

Excludes:

Allergic skin reaction (D825.0)

Allergy to medications (J905.0)

Nasal allergy (D635.0)

S095.0 Disorders of motor functions

Includes:

Difficulty in walking

Clumsiness

Limping

Staggering

Stumbling

Uncoordinated

Symptoms Referable to Psychological

and Mental Disorders (S100-S199)

S 100.0 Anxiety and nervousness

Includes:

Apprehension

Bad nerves

Panicky feeling

Tension

Upset

Worried

S105.O Fears and phobias

S1 10.0 Depression

Includes:

Crying excessively

Dejected

Feeling low

Hopelessness

Sadness

Unhappy

S1 15.0 Anger

Includes:

Bitterness

Hostile feelings

Excludes:

Temper problems (S130.4)

S120.0 Problems with identity and self-esteem

Includes:

No confidence

Loss of identity

Identity crisis

Don’t like myself

Guilt

S125.0 Restlessness

Includes:

Hyperactivity

Overactivity

S130.0 Behavioral disturbances

S 130.1 Antisocial behavior

Includes:

Avoiding people

Excessive shyness

Social isolation

Withdrawal

S130.2 Hostile behavior

Includes:

Aggressiveness

Criminality

Cruelty

Destructiveness

Negativism

Quarrelsome

S 130.3 Hysterical behavior

S1 30.4 Temper problems

Includes:

Blowing up

Losing temper

Temper tantrums

S130.5 Obsessions and compulsions

S 135.0 Disturbances of sleep

S135.1 Insomnia

Includes:

Sleeplessness

Can’t sleep

Trouble falling asleep

S135.2 Sleepiness (hypersomnia)

Includes:

Drowsiness

Can’t stay awake

S135.3 Nightmares

S1 35.4 Sleepwalking

S140.0 Smoking problems

Includes:

Smoking too much

Can’t quit smoking

12
S140.0 Smoking probIems–Con.

Excludes:

Smoker’s cough (S440.0)

Physical symptoms of smoking

(see particular symptom)

S145.0 Alcohol-related problems

Includes:

,

Drinking problem

Excludes:

Adverse effects of alcohol

(J915.0)

Alcoholism (D320.0)

S150.0 Abnormal drug usage “

Includes:

Drug abuse

Frequent or excessive use of

8 stimulants, hallucinogens, depressants, etc.

Excludes:

Drug addiction (D320.0)

Overdose, unintention~ (J910.())

Intoxication with drugs (J9 10.0)

S 155.0 Delusions or hallucinations

Includes:

Seeing things

Hearing voices

Medicine is poisoned

S1 60.0 Psychosexual disorders

S160.1 Frigidity, loss of sex drive,

lack of response

S160.2 Homosexuality, concerns with

S1 60.3 Impotence

S160.4 Premature ejaculation

S1 60.5 h4asturbation excessive, concerns about

S160.6 Orgasm, problem with

S 165.0 Other symptoms or problems relating

to psychological and mental disorders,

NEC

Includes:

Can’t cope

Going cr;zy

Losing my mind

Excludes:

Character disorder (D315.0)

Personality disorder (D3 15.0)

S 165.1 Nailbiting

S1 65.2 Thumb sucking

Symptoms Referable to the Nervous

System (excluding sense organs)

(S200-S259)

S2 00.0 Abnormal involuntary movements

Includes:

Shaking

Jerking

Tics

Tremors

Twitch

Excludes:

Eye movements (S320.0)

Eyelid twitch (S335.4)

S205.0 Convulsions

Includes:

Fits

Febrile convulsions

Seizures

Spells

Excludes:

Fainting (S030.0)

S2 10.0 Headache, pain in head

Excludes:

Sinus headache (S410.1)

Migraine (D365.0)

S21 5.0 Memory, disturbances of

Includes:

Amnesia

Forgetfulness

Lack or loss of memory

Temporary loss of memory

S220.0 Disturbances of sensation

S220.1 Loss of feeling (anesthesia)

Includes:

Numbness

., No response to pain

S220.2 Increased sensation (hyperesthesia)

S220.3 Abnormal sensation (paresthesia)

Includes:

Prickly feeling

Burning, tingling sensation

Needles and pins

S220.4 Other disturbances of sense,

including smell and taste

S225.0 Vertigo–dizziness

Includes:

Falling sensation

13
S225.0

S230.0

S235.0

S240.0

Vertigo–dizziness–Con.

Giddiness (dizziness)

Lightheadedness

Loss of sense of equilibrium or

balance

Room spinning

Weakness (necrologic)

Includes:

Right- or left-sided weakness

Drooping, facial or NOS

Excludes:

General weakness (S020.0)

Disorders of speech, speech disturbance

S2 35.1 Stuttering, stammering

S235.2 Slurring

Other symptoms referable to the nervous system

Includes:

Pinched nerve “

Confusion

Symptoms Referable to the Cardiovascular

and Lymphatic Systems (S260-S299)

S2 60.0 Abnormal pulsations and palpitations

S260.1 Increased heartbeat

Includes:

Pulse too fast

Rapid heartbeat

S260.2 Decreased heartbeat

Includes:

Pulse too slow

Slow heart

S260.3 Irregular heartbeat

Includes:

Fluttering

Skipped beat

S26.5.0 Heart pain

Includes:

Heart distress

Pain over heart

Excludes:

Angina pectoris (D515.0)

Chest pain (S050.1)

S270.0 Other symptoms of the heart

Includes:

Bad heart

Poor heart

Weak heart

Heart condition

S275.0

S280.0

Symptoms of lymph glands (or nodes)

S2 75.1 Swollen or enlarged glands

S275.2 Sore glands

Other symptoms referable to cardiovascul;r/iymphatic system, NEC

S2 80.1 Poor circulation

S280,2 Pallor, paleness

S280.3 Flushed, blushing

Symptoms Referable to the Eyes and

Ears (S300-S399)

S305.0 Vision dysfunctions

Excludes:

Refractive errors (D405.0)

S305. 1 Blindness and half vision

S31O.O

S315.O

S320.0

S325.0

S330.O

S305.2 Diminished vision

Includes:

Blurred vision

Difficulty reading

Poor vision

Trouble seeing

Can’t see distances

Weak eyes

S305.3 Extraneous vision

Includes:

Cloudy vision

Hazy vision

Spots in front of eyes

(floaters)

S305.4 Double vision (diplopia)

Discharge from eye

S3 10.1 Bleeding

S3 10.2 Tearing, watering (Iacrimation)

S3 10.3 Pus, matter, white discharge

Eye infection and inflammation

S3 15.1 Pinkeye

Abnormal sensations of the eye

S320.1 Pain

S320.2 Itching

S320.3 Burning

S320.4 Strain

Abnormal eye movements

S325.1 Abnormal retraction

S325.2 Cross-eyed

S325.3 Pupils unequal

S325.4 Deviation

Abnormal appearance of eyes

S330.1 Abnormal color

14
S330.0 Abnormal appearance of eyes–Con.

Includes:

Bloodshot

Red

Excludes:

Yellow (S610.2)

S330.2 Protrusion (exophthalmos)

S330.3 Cloudy, dull, hazy appearance

S335.0 Other symptoms referable to eye, NEC

S335.1 Contact lens problems

S335.2 Allergy

S335.3 Swelling

Excludes:

Foreign body (J600.0)

Injury (J51 0.0)

Abrasion (J41O.O)

S340,0 Symptoms of eyelids

S340.1 Infection, inflammation, swelling

S340.2 Itching

S340.3 Mass or growth

S340,4 Abnormal movement

Includes:

Twitching

Blinking

Squinting

Drooping

S345.0 Hearing dysfunctions

S345.1 Diminished hearing

Includes:

Deafness

Trouble hearing

Hearing loss

S345.2 Heightened or acute hearing

S345.3 Extraneous hearing

Includes:

Ringing (tinnitus)

Excludes:

Hearing things (S155.0)

S350.0 Discharge from ear

S350.1 Bleeding

S350.2 Pus (purulent drainage)

S350.3 Swimmer’s ear

S355.0 Earache, or ear infection

S355.1 Earache, pain’

S355.2 Ear infection

S360.0 Plugged feeling in ear

Includes:

Ear wax

S360.0 Plugged feeling in ear–Con.

Blocked

Cracking

Popping

Ears need cleaning

S365.0 Other symptoms referable to the ears,

NEC

S3 65.1 Itching

S365.2 Growths or mass

S365.3 Pulling at ears, picking at ears

S365.4 Abnormal size or shape, “ears

stick out”

Excludes:

Foreign body in ear

(J620.0)

Symptoms Referable to the Respiratory

System (S400-S499)

S400.0 Nasal congestion

Includes:

Drippy nose, runny nose, postnasal drip, sniffles, stuffy nose

Nasal obstruction

S405.0 Other symptoms of nose

Excludes:

Allergy (D635.0)

S405.1 Nosebleed (epistaxis)

S405.2 Sore in nose

S405.3 Inflammation and swelling

Includes:

Sore nose

Infection

Red nose

S405.4 Problem with appearance of

nose

Includes:

Too large

Bump(s)

Undesirable appearance

S410.0 Sinus problems

S410.1 Pain and pressure

Includes:

Sinus headache

S410.2 Sinus inflammation, infection

S410.3 Sinus congestion

S415.0 Shortness of breath

Includes:

Breathlessness

Sensation of suffocation

15
S420.0

S425.0

S430.0

S435.0

S440.O

S4’45.O

S450.0

S455.0

Labored or difficult breathing

(dyspnea)

Wheezing

Includes:

Sighing respiration

Breathing problems, NEC

S430.1 Disorders of respiratory

sound, NEC

Includes:

Abnormal breathing

sounds

Snoring

Rattles

Strider

S430.2 Rapid breathing (hyperventilation)

Sneezing

Cough

Includes:

Croupy cough

Smoker’s cough

Head cold, upper respiratory infection

(coryza)

Includes:

Cold, NOS

Excludes:

Chest cold (S475.0)

Flu

Includes:

Grip

Influenza

Excludes:

Croup (D600.0)

Symptoms referable to throat

S455.1 Soreness

S455.2 Pain

S455.3 Infection

Includes:

Throat virus

Excludes:

Strep throat (DO1O.O)

S455.4 Irritation, scratch, tickle

S455.5 Swelling

S455.6 Lump or mass

Includes:

Sensation of something

in throat

Excludes:

Foreign body in throat

(J615.0)

S460.0 Symptoms referable to tonsils

Includes:

Infection

Inflammation

S470.0 Abnormalities of sputum or phlegm

S470.1 Coughing up blood

S470.2 Pus in sputum

S470.3 Excessive sputum

S475.0 Congestion in chest

Includes:

Lung congestion

Chest cold

S480.0 Disorders of voice

S480.1 Hoarseness, loss of voice

S480.2 Hypernasality

S485.0 Other symptoms referable to the respiratory system, NEC

Symptoms Referable to the Digestive

System (S500-S639)

S500.O

S505.O

S51O.O

S515.O

S520.0

S525.0

Symptoms of teeth and gums

S500.1 Toothache

S500.2 Gum pain

S500.3 Bleeding gums

Symptoms referable to lips

S505.1 Cracked, bleeding, dry

S5 05.2 Abnormal color

S505.3 Cold sore

Symptoms referable to mouth

S5 10.1 Pain, burning, soreness

S5 10.2 Bleeding

S5 10.3 Dryness

S51 0.4 Ulcer, sore

Symptoms referable to tongue

S515.1 Pain

S5 15.2 Bleeding

S5 15.3 Inflammation, infection, swelling

S5 15.4 Abnormal color, ridges, coated

Difficulty in swallowing (dysphagia)

Includes:

Choking

Inability to swallow

Nausea

Includes:

Upset stomach

Sick to stomach

Nervous stomach

Feel like throwing up

16
S530.0 Vomiting

Includes:

Can’t keep food down

Throwing up

Retching

Excludes:

Regurgitation, infants (S080.2)

Vomiting blood (S580.2)

S535.0 Heartburn and indigestion (dyspepsia)

Includes:

Excessive belching

S540.0 Gastrointestinal infection

Includes:

Stomach flu

Stomach virus

Intestinal virus

S545.0 Stomach pain, cramps and spasms

S545.1 Pain

Includes:

Stomachache, inflammation

S545.2 Cramps, spasms

S550.0 Abdominal pain, cramps, spasms

Includes:

Intestinal colic

Gas pains

Excludes:

Groin pain (S055.3)

S550.1 Lower abdominal pain

Includes:

Right lower quadrant

(RLQ) pain

Left lower quadrant

(LLQ) pain

S550.2 Upper abdominal pain

Includes:

Epigastric pain

Left upper quadrant

(LUQ) pain

Pain in umbilical region

Right upper quadrant

(RUQ) pain

S565.0 Change in abdominal size

S565.1 Distention, fullness, NOS

S565.2 Mass or tumor

S565.3 Abdominal swelling, NOS

S5 70.0 Appetite, abnormal

S5 70.1 Excessive appetite

Eats too much

Always hungry

S570.O

S580.0

S585.0

S590.O

S595.O

S600.0

S605.0

S61O.O

Appetite abnormaI-Con.

S5 70.2 Decreased appetite

Not hungry

Loss of appetite

Gastrointestinal bleeding

S580.1 Blood in stool (melena)

S580.2 Vomiting blood (hematemesis)

Flatulence

Includes:

Bloated, gas

Excessive gas

Distention due to gas

Excludes:

Gas pains (S550.0)

Constipation

Diarrhea

Includes:

Loose stools

The runs

Other symptoms or changes in bowel

function

S600.1 Discharge in stools

Includes:

Mucus

Pus

S600.2 Worms

S600.3 Changes in size, color, shape,

or odor

Includes:

Bulky stools

Too narrow

Unusual odor or color

S600.4 Incontinence of stool

Includes:

Dirty pants (encopresis)

Leaking stools

Symptoms referable to anus-rectum

S605.1 Pain

S605.2 Bleeding

S605.3 Swelling or mass

S605.4 Itching

Symptoms of liver, gallbladder, and

biliary tract

S61O.1 Pain

S61O.2 Jaundice

Includes:

Yellow eyes

Yellow skin

l-i
S61 5.0 Other symptoms referable to digestive

system

Includes:

Bad breath (halitosis)

Stomach problem

Hiccoughs

Gastrointestinal distress

Symptoms Referable to the Genitourinary

System (S640-S829)

S640.0 Abnormalities of urine

Excludes:

Abnormal findings of urine tests

(R200.0)

S640.1 Blood in urine (hematuria)

S640.2 Pus in urine

S640.3 Unusual color or odor

S645.0 Frequency and urgency of urination

S645.1 Excessive urination, night

(nocturia)

S650.0 Painful urination

Includes:

Burning, discomfort

S655.0 Incontinence of urine (enuresis)

S655.1 Involuntary urination, can’t

hold urine, dribbling

S655.2 Bedwetting

S660.0 Other urinary dysfunctions

S660.1 Retention of urine

Can’t urinate

S660.2 Hesitancy

Difficulty in starting stream

S660.3 Large volume

S665.0 Symptoms of the bladder

Includes:

Bladder trouble

S665.1 Pain

S665.2 Infection

S670.0 Symptoms of the kidneys

Includes:

Kidney trouble

S670.1 Pain

S6 70.2 Infection

S675.0 Urinary tract infection, NOS

Includes:

Genitourinary infection

Urine infection

S680.0 Other symptoms referable to urinary

tract

Includes:

Passed stones

Sb6U.U

S700.O

S705.O

S71O.O

S715.O

S720.0

S730.O

S735.O

S740.O

S745.O

“” ““ “ Other symptoms referable to urinary

tract—Coti.

Excludes:

Kidney stones or bladder stones

(D705.0)

Symptoms of penis

S700. 1 Pain, aching, soreness, tenderness, painful erection

S700.2 Infection, inflammation, swelling

S700.3 Lumps, bumps, growths, warts

Penile discharge

Symptoms of prostate

Includes:

Prostate trouble

S7 10.1 Swelling

S7 10.2 Infection

Symptoms of scrotum and testes

S7 15.1 Pain, aching, tenderness

S7 15.2 Swelling, inflammation

S7 15.3 Growths, warts, lumps, bumps

S7 15.4 Itching, jock itch

Other symptoms of male reproductive

system

Excludes:

Psychosexual problems (S160.0)

Absence of menstruation (amenorrhea)

Excludes:

Suspected pre~ancy (X200.0)

Missed a period (X200.0)

Period late (X200.0)

Irregularity of menstrual interval

S735.1 Frequent

S735.2 Infrequent

S735.3 Unpredictable

Irrewlarity of menstrual flow

S740.1 Excessively heavy (menorrhagia)

S740.2 Scanty flow (oligomenorrhca)

S740.3 Abnormal material, including

clots

Menstrual symptoms, other and unspecified

S745. 1 Premenstrual symptoms

Includes:

Premenstrual tension or

irritability

Bloating before periods

S745.2 Painful menstruation (dysmenorrhea)

Includes:

Menstrual cramps

18
S745.O

S750.O

S755.O

S760.0

S765.0

S770.O

S775.O

S790.O

Menstrual symptoms, other and unspecified—Con.

Pain in legs and back during menstruation

Menopausal symptoms

S750.-1

S750.2

S750.3

Early o; late onset of menopause

Vasomotor symptoms–hot

flashes

Emotional symptoms, change

of life problems

Uterine and vaginal bleeding

Excludes:

Bleeding during pregnancy

(S790.2)

S755.1 Intermenstrual bleeding

(metrorrhagia)

Includes:

Breakthrough bleeding

Bleeding between periods

S755.2 Postmenopausal bleeding

S755.3 Postcoital bleeding

Vaginal discharge

Includes:

Bloody, brown, white (leukorrhea), excessive

Other vaginal symptoms

S765.1 Pain

S765.2 Infection

S765.3 Itching, burning

Vulvar disorders

S7 70.1 Itching and irritation, swelling

S770.2 Mass, lump

S7 70.3 Growth, wart, cyst, ulcer, sore

Pelvic symptoms

S775.1 Pain

S7 75.2 Pressure or dropping sensation

Includes:

Feeling of uterus falling

Out

S775.3 Infection, inflammation

Problems of pregnancy and the postpartum period

Excludes:

Routine prenatal visits (X205.0)

S790.1 Pain during pre~ancy

S790.2 Spotting, bleedingduringpregnancy

S790.3 Symptoms of onset of labor

Includes:

Water broke

S790.0 Problems of pregnancy and the postpartum period-Con.

Ruptured membranes

Labor pain, contractions

S790.4 Postpartum problems

I;cludes: -

Bleeding

Pain

S795.0 Other symptoms referable to

female reproductive system

S800.0 Pain or soreness of breast

Includes:

Tenderness

S805.0 Lump or mass of breast

Includes:

the

Bump, knot, nodule, cyst

S8 10.0 Other symptoms referable to breast

S8 10.1 Bleedlng or dkcharge from

nipple

S8 10.2 Postpartum problems

Includes:

Engorgement

Postpartum infection

Nursing difficulties

S8 10.3 Problems with shape or size

Includes:

Too large

Too small

Sagging

Uneven development

S81 5.0 Symptoms of infertility

Includes:

Can’t get pregnant

Inability to conceive

Sterility

S820.0 Hormone deficiency or problem

S825.0 Symptoms of sexual dysfunction

Includes:

Dyspareunia

Painful intercourse

Excludes:

Psychological disorders (S160.0)

Symptoms Referable to the Skin, Nails,

and Hair (S830-S899)

S830.0 Acne or pimples

Includes:

Bad complexion

Blackheads

Blemishes

Breaking out

19
S830.0 Acne or pimples–Con.

Complexion, NOS

Whiteheads

S835.0 Discoloration or pigmentation

Includes:

Freckles

Blotches

Redness

spots

Circles under eyes

Excludes:

Jaundice (S610.2)

Bruise (J405.0-J430.0)

Flushing (S280.3)

Blushing (S280.3)

S840.0 Infections of skin, NOS

Excludes:

Athlete’s foot (D025.0)

S840.1 Infection of skin of head or

neck area

S840.2 Infection of skin of arm, hand,

or finger

S840.3 Infection of skin of leg, foot,

or toe

S845.0 Symptoms of skin moles

Includes:

Skin mole, NOS

S845.1 Change in size or color

S845.2 Bleeding mole

S850.0 Warts, NOS

Excludes:

Plantar’s warts (DO 15.0)

S855.0 Other growths of skin

Includes:

Skin growth, NOS

Cysts, NOS

callus

Corns

S860.0 Skin rash

Excludes:

Poison ivy (D825.0)

Poison oak (D825.0)

S860.1 Diaper rash

S865.0 Skin lesion

Includes:

Ulcer, sore, blister

S870.0 Skin irritations, NEC

S870.1 Pain

S870.2 Itching

S875.0 Swelling of skin

Includes:

Bumps, lumps

Nodules

Welts, except hives (D825.0)

Tumor, skin

S880.0 Other symptoms referable t.o skin

S880.1 Oiliness

S880.2 Dryness, peeling, scaliness

S880.3 Wrinkles

S885.0 Symptoms referable to nails

S885.1 Infected

S885.2 Ingrown

S885.3 Brittle, breaking, splitting,

cracked, ridged

S890.0 Symptoms referable to hair and scalp

S890.1 Too little hair

Baldness (alopecia)

Falling out

Losing hair

S890.2 Unwanted hair

Superfluous hair

Abnormal hairiness (hirsutism)

S890.3 Dryness, flaky scalp

S890.4 Itching

S895.0 Other symptoms of skin, nails, and hair

Includes:

Navel problems

Umbilicus not healing

Symptoms Referable to the Musculoskeletal

System (S900-S999)

These codes exclude all injuries. (See Injuries

and Adverse Effects Module.)

The following fourth di~ts should be used with

categories S900-S9 70.

.1 pain, ache, soreness

.2 cramps, contractures, spasms

.3 limitation of movement, stiffness

.4 weakness

.5 swelling

.6 lump, mass, tumor

S900.0 Neck symptoms

S905.0 Back symptoms

S91O.O Low back symptoms

S9 15.0 Hip symptoms

S920.0 Leg symptoms

S925.0 Knee symptoms

20
S930.O

S935.O

S94’O.O

S945.O

S950.O

S955.O

S960.0

S965.0

S970.O

S975.O

S980.0

Ankle symptoms

Foot and toe symptoms

Shoulder symptoms

Arm symptoms

Elbow symptoms

Wrist symptoms

Hand and finger symptoms

Symptoms of unspecified muscles

Symptoms of unspecified joints

Musculoskeletal deformities

Excludes:

Clubfoot (D960.0)

Curvature of spine (D91O.O)

S9 75.1 Bowlegged, knock-kneed

S9 75.2 Posture problems

S9 75.3 Pigeon-toed, feet turn in

Other musculoskeletal symptoms . .

Includes:

Bone pain

Stump pain

DISEASE MODULE

Infective and Parasitic Diseases (DOOI-D099)

DO05.0 Intestinal infectious diseases

Includes:

Gastroenteritis

Enteritis

Cholera

Salmonella

Dysentery

DO1 0.0 Streptococci..l infection

Includes:

Streptococcal tonsillitis

Scarlet fever

DO 15.0 Viral diseases

Includes:

Chickenpox

Shingles (Herpes zoster)

Herpes simplex

Measles

German measles (rubella)

Mumps

Infectious mononucleosis

Hepatitis (infectious and NOS)

Smallpox

Poliomyelitis

D020.O Venereal diseases

Includes:

Syphilis

Gonorrhea

Venereal diseases, NOS

D025.O Fungus infections (mycoses)

Includes:

Candidiasis

Yeast infection

Moniliasis

Dermatophytoses

Athlete’s foot

Ringworm

Thrush

D03 0.0 Parasitic diseases

Includes:

Pinworms

Ascaris

Lice

Maggots

Leeches

D035.O Other and unspecified infectious and

parasitic dise&es

Includes:

Staphylococcal infections

Trichomonas vaginitis

Neoplasms(D100-D199)

Malignant neoplasms

D 100.0 Cancer, gastrointestinal tract

Includes:

Esophagus

Stomach

Small intestine

Colon

D 105.0 Cancer, respiratory tract

Includes:

Bronchus

Lung

Larynx

Trachea

Throat

D 110.0 Cancer, skin and subcutaneous tissues

Includes:

h4elanoma

Basal cell carcinoma

Squamous cell carcinoma

21
D 115.0 Cancer, breast

D 120.0 Cancer, female genital tract

Includes:

Uterus

Cervix

Fallopian tube(s)

Vagina

Vulva

Ovary (ies)

Endometrium

D 125.0 Cancer, urinary and male genital tract

Includes:

Bladder

Kidney

Prostate

D 130.0 Other malignant and unspecified neoplasms

Includes:

Metastatic carcinoma

Brain tumor

Bone cancer

D 135.0 Hodgkin’s disease, lymphomata, leukemias

Includes:

Multiple myeloma

Polycythemia vera

Lymphosarcoma

Cancer of blood

Benign neofdasms

D140,0 Fibroids and other uterine neoplasms

Includes:

Myoma

Leiomyomata

Cervical polyp

Nabothian cyst

D 145.0 Other benign neoplasms

Includes:

Rectal polyp

Ovarian cyst

Bartholin’s cyst

Lymphoma

Vaginal inclusion

Nasal polyp

Dermoid cyst (ovary)

Excludes:

Pilonidal cyst (D825.0)

Sebaceous cyst (D825.0)

Epidermoid cyst (D825.0)

Cyst, NOS (S855.0)

Endocrine, Nutritionalr and Metabolic

Diseases (D200-D249)

D200.O Diseases of the thyroid gland

Includes:

Thyrotoxicosis

Thyroid nodule

Hyperthyroidism

Goiter

Myxedema

Hypothyroidism

D205.O Diabetes mellitus

D2 10.0 Gout, hyperuricemia

D2 15.0 Other endocrine, nutritional, and metabolic diseases

Includes:

Hypoglycemia

Hyperlipidemia

Disorders of intestinal absorption

Ovarian dysfunction

Diseases of the Blood and BloodForming Organs (D250-D299)

D250.O Anemia

Includes:

Iron deficiency anemia

Sickle cell anemia

Pernicious anemia

Anemia, NOS

D255.O Other diseases of blood and bloodforming organs

Mental Disorders (D300-D349)

D300.O Organic psychoses

Includes:

Organic brain syndromes

Senile dementia

Alcoholic psychoses

D305.O Functional psychoses

Includes:

Schizophrenia, all types

Manic-depressive psychoses

Paranoid states

Psychosis, NOS

D3 10.0 Neuroses

Includes:

Depressive neurosis

Depressive reaction

Anxiety reaction

22
D31O.O

D315.O

D320.O

D325.O

D330.O

Neuroses–Con.

Obsessive compulsive neurosis

Neurosis, NOS

Excludes:

Depression (S1 10.0)

Anxiety (S100.0)

Personality and character disorders

Alcoholism and drug dependence

Includes:

Drug addiction

Mental retardation

Other mental disease

Includes:

Transient situational disturbances

Adolescent adjustment reaction

Grief reaction

Sexual deviations

Diseases of the Nervous System

(D350-D399)

D350.O

D355.O

D360.O

D365.O

D370.O

Multiple scIerosis

Parkinson’s dkease (paralysis agitans)

.

Epilepsy

Migraine headache

Other diseases of central nervous

system

Includes:

Carpal tunnel syndrome

Bell’s palsy

Cerebral palsy

Demyelinating disease

Paralysis, NOS

Diseases of the Eye (D400-D449)

D400.O Inflammatory diseases of the eye

Includes:

Conjunctivitis

Ophthalmia

sty

Blepharitis

Keratitis

Ulcer

Excludes:

Infection, NOS (S315.0)

D405.0 Refractive error

Includes:

Myopia, nearsightedness

Hyperopia, farsightedness

Astigmatism

D405.O

D41O.O

D415.O

D420.O

Refractive error-Con.

Excludes:

Test for refractive errors (X230.0)

Cataract

Glaucoma

Other diseases of the eye

Includes:

Retinal detachment

Strabismus

Aphakia

Diseases of the Ear (D450-D499)

D450.O Otitis media

S455.0 Other diseases of the ear

Includes:

Ruptured tympanic membrane

Labyrinthitis

Excludes:

Infection, NOS (S355.2)

Deafness (S345.1)

Diseases of the Circulatory System

(D500-D599)

D5 00.0 Rheumatic fever and chronic rheumatic

heart dkiease

Includes:

Chorea

D505.O Hypertension with involvement of target organs

Includes:

Hypertensive heart disease

Renal hypertension

HCD

HCVD

Hypertensive cardiovascular

disease

D5 10.0 Hypertension

Includes:

High blood pressure

D5 15.0 Ischemic heart disease

Includes:

Myocardial infarction

Coronary artery disease

Coronary

Heart attack

Arteriosclerotic heart disease

(ASHD)

Arteriosclerotic cardiovascular

disease (ACVD)

Angina pectoris

23
D520.O Other heart disease

Includes:

Cardiac dysrhythmias

Atrial fibrillation

Paroxysmal tachycardia

Congestive heart failure

Heart failure

Heart murmur

D525.0 Cerebrovascular disease

Includes:

Cerebrovascular accident (CVA)

Stroke

D530.O Atherosclerosis

Includes:

Arteriosclerosis

Hardening of the arteries

D535.O Phlebitis, thrombophlebitis

Includes:

Phlebothrombosis

D540.O Varicose veins

D545.O Hemorrhoids

D550.O Other disease of circulatory system

Includes:

Pulmonary embolism

Heart disease, NOS

Lymphadenopathy

Lymphadenitis

Diseasesof the Respiratory System

(D600-D649)

D600.O Upper respiratory infections except

tonsillitis

Includes:

Pharyngitis

Sinusitis

Laryngitis

Croup

Rhinitis

Excludes:

Allergic rhinitis (D635.0)

Cold (S445.0)

Throat infection, NOS (S450.2)

Nose infection, NOS (S405.3)

Sinus infection, NOS (S410.2)

D605.O Tonsillitis

D6 10.0 Bronchitis

Includes:

Chronic bronchitis

Bronchitis, NOS

Acute bronchitis

D620.O Emphysema “

D625.O Asthma

D630.O Pneumonia

Includes:

Viral pneumonia

Bacterial pneumonia

Bronchopneumonia

Pneumonitis

D635.O Hay fever

Includes:

Allergic rhinitis

Nasal allergy

Pollenosis

Allergy to:

Dust

Pollen

Animals

Ragweed

D640.O Other respiratory diseases

Includes:

Pulmonary edema

Deviated nasal septum

Pneumothorax

Hemothorax

Pleurisy

Diseasesof the Digestive System

(D650-D699)

D650.O Diseases of the esophagus, stomach,

and duodenum

Includes:

Esophagitis

Duodenal ulcer

Peptic ulcer

Gastritis

Stomach ulcer

Excludes:

Stomach flu (S540.0)

Gastroenteritis (DO05.0)

D655.O Appendicitis, all types

D660.O Hernia of abdominal cavity

Includes:

Inguinal

Hiatus

.4bdonlinaI

Femoral

Umbilical

Ventral

D665.O Diseases of the intestine and peritoneum

Includes:

Diverticulitis

24
D665.0 Diseases of the intestine and peritoneum—Con. !

Diverticulosis

Spastic colitis

Irritable bowel syndrome

Ulcerative colitis

Crohn’s disease

IIeitis

Fistula–rectal, anal

Fissure–rectal, anal

Excludes:

Intestinal virus (S540.0)

D670.O Diseases of liver, gallbladder, and

pancreas

Includes:

Biliary colic

Cirrhosis

Liver diseases

Cholelithiasis (gallstones)

Cholecystitis

Pancreatitis

D67 5.0 Other diseases of digestive system

Includes:

Stomatitis

Canker sore

Diseases of the Genitourinary System

(D700-D799)

D700.O Cystitis

Excludes:

Bladder infection (S665.2)

D705.O Urinary tract disease except cystitis

Includes:

Urethritis

Pyelonephritis

Glomerulonephritis

Glomerulonephrosis

Ureteral calculus

Renal failure

Kidney stones

Bladder stones

Excludes:

Bladder infection (S665.2)

Kidney infection, NOS (S670.2)

Passed stones (S680.0)

Urinary tract infection (S675.0)

D7 10.0 Diseases of the male genital organs

Includes:

Prostatitis

Benign prostatic hypertrophy

(BPH)

D7 10.0 Diseases of the male genital organs-Con.

Hydrocele

Phimosis

Epididymitis

Peyronie’s disease

Excludes:

Prostate infection (S71 0.2)

D7 15.0 Fibrocystic and other diseases of breast

Excludes:

Infection (S810.0)

Cancer (Dl 15.0)

D720.O Pelvic inflammatory disease (PID)

Includes:

%lpingitis

Oophoritis

Pelvic peritonitis

Excludes:

Pelvic infection, NOS (S775.3)

D725.O Cervicitis, vaginitis

Includes:

Cervical erosion

D730.O Other diseases of female reproductive

system

Includes:

Endometriosis

Rectal-vaginal fistula

Prolapse of uterus

Dysfunctional uterine bleeding

Vulvitis

Polycystic ovaries

Cystocele

Rectocele

D73 5.0 Diagnosed complications of pregnancy

and puerperium

Includes:

Placenta previa

Ectopic pregnancy

Toxemia

Threatened abortion

Spontaneous abortion

Hyperemesis

Fetal death in utero

Diabetes during pregnancy

Edema of pregnancy

High blood pressure during pregnancy

RH sensitization

Multiple pregnancy

Excludes:

Abortion induced (X520.0)

25
Diseases of the Skin and Subcutaneous

Tissue (D800-D899)

D800.O Carbuncle, furuncle, boil, cellulitis,

abscess, NEC

D805.O Impetigo

D8 10.0 Seborrheic dermatitis

Includes:

Dandi-uff

D81 5.0 Eczema and dermatitis, NOS

D820.O Psoriasis

D825.O Other diseases of the skin

Includes:

Allergic skin reactions

Pilonidal cyst

Urticaria

Hives

Keloid

Sebaceous cyst

Paronychia

Lupus erthematosus discoid

Epidermal inclusion cyst

Poison ivy

Poison oak

Excludes:

Cyst, NOS (S855.0)

Acne (S830.0)

Diseases of the Musculoskeletal System

and Connective Tissue (D900-D949)

D900.O Arthritis

Includes:

Osteoarthritis

Rheumatoid arthritis

Rheumatism, NOS

D905.O Nonarticular rheumatism

Includes:

Bursitis

Synovitis

Tenosynovitis

Tendinitis

Myositis

Lumbago

Excludes:

Rheumatism, NOS (D900.0)

D910.0Other musculoskeletal or connective

tissue disease

Includes:

Systemic lupus erythematosus

Curvatures of spine

D9 10.0 Other musculoskeletal or connective

tissue disease—Con.

Scoliosis

Kyphoscoliosis

Kyphosis

Osteoporosis

Degenerative disc diseases

Osteomyelitis

Bone cysts

Bunions

Congenital Anomalies (D950-D989)

D95 0.0 Congenital anomalies of heart and circulatory system

D955.O Undescended testicles

Includes:

Hypospadias

D960.O Other congenital anomalies

Includes:

Cleft palate

Cleft lip

Deformed earlobe

Clubfoot

Harelip

Congenital dislocation of hip

Blocked tear duct

Absence of organs

Duplication of organs

Perinatal Morbidity and Mortality

Conditions (D990-D999)

D990.O All perinatal conditions

DIAGNOSTIC, SCREENING, AND

PREVENTIVE MODULE

General Examinations (X IOO-X199)

Xl 00.0 General medical examination

Includes:

Annual exam

Checkup, NOS

Checkup, routine

General exam

Multiphasic screening exam

Regular exam

Routine exam

Physical exam

26
Xl 00.0 General medical examination–Con.

Excludes:

Administrative exam (AI OO.OA140.0)

Followup visit (T800.0)

Gynecological exam (X225.0)

Prenatal exam (X205.0)

Progress visit (T800.0)

X105.O Well baby examination

X130.O General psychiatric or psychological

examination

Includes:

Psychological testing

Excludes:

Court- or school-ordered examination (A140.0)

Special Examinations (X200-X299)

X200.O Pregnancy, unconfirmed

Includes:

Might be pregnant

Period late

Late menses

Pregnancy test

Possible pregnancy

Missed period

X205.O Prenatal examination, routine

Includes:

Routine obstetrical care

Normal antepartum visit

Pregnancy, NOS

X21 5.0 Postpartum examination

X220.O Breast examination

Excludes:

Mammography (X340.0)

Xerography (X340.0)

Breast thermography (X340.0)

S225.0 Gynecological examination

Includes:

Pelvic exam

Excludes:

Repeat or abnormal Pap smear

(R300.0)

Examination involving IUD

(X51O.O)

Examination for birth control pills

(X505.0).

Examination for birth control,

NOS (X500.0)

X230.OEye examination

Includes:

Routine ophthalmological exam

To test my eyes

Need new glasses

Test for nearsightedness, farsightedness

For glasses

For contacts

Vision test

Excludes:

Fitting glasses or contacts

(T515.0)

X235.O Heart examination

Includes:

Heart checkup

Cardiac check

X240.0 Other special examination

Includes:

Neurological exam

Examination of functioning internal prosthetic devices,

implants, shunts, etc.

Diagnostic Tests (X300-X399)

X300.O Sensitization test

Includes:

Allergy test

Excludes:

To check results of skin tests

(R600.0)

X305.0 Skin immunity test

Includes:

Tuberculin test

PPB test

Excludes:

To check results of skin tests

(R600.0)

X310.0 Glucose level determination

Includes:

Blood sugar test

Glucose tolerance test

Test for diabetes

X315.O Other blood test

Includes:

Blood count

Blood culture

Blood test, NOS

Blood thinning test

27
X315.O Other blood test–Con.

Check cholesterol

Prothrombin time

Sickle cell anemia test

Excludes:

Premarital blood test (A135.1)

X315.1 Blood test for venereal disease

X320.0

X325.O

X330.0

X335.O

X340.O

X345.O

X350.O

X355.O

X360.O

X365.O

X370.O

Blood pressure test

Includes:

Check blood pressure

Blood pressure check

Urine tests

Includes:

Test urine for sugar

Urinalysis

Estriol for fetal evaluation

Urine culture

Diagnostic endoscopies

Includes:

Proctoscopy

Sigmoidoscopy

Cystoscopy

Laparoscopy

Biopsies

Mammography, xerography, breast

thermography

Excludes:

Breast examination (X220.0)

Diagnostic radiography

Includes:

X-ray

Myelogram

Radioisotope scanning

IVP

Angiograrn

Venogram

Hysterosalpingogram

EKG, ECG, electrocardiogram, treadmill, stress testing

EEG, electroencephalogram

Hearing test

Includes:

Hearing exam

Pap smear

Other and unspecified diagnostic tests

Includes:

Centesis

Electronic fetal monitoring

Lab test, NOS

Spinal tap

Pulmonary function test

X370. 1 Glaucoma test

X370.2 Throat culture

Other Screening and Preventive

Procedures (X400-X499)

X400.O Prophylactic inoculations

Includes:

Vaccination

Immunization

Flu shot

Tetanus shot

X405.O Exposure to venereal disease

Includes:

May have V.D.

Check for V.D.

X41O.O Exposure to other infectious diseases

Includes:

Chickenpox

Infectious hepatitis

Measles

Mumps

Tuberculosis

Family Planning (X500-X599)

X500.0 Family planning, NOS

Includes:

Counseling, examinations, and

general advice regarding:

Birth control, NOS

Unwanted pregnancy

Contraceptive, NOS

Sterilization

Infertility

Genetics

Contraception followup, NOS

Excludes:

Specified types of birth control:

Birth control pill (X505.0)

IUD (X51O.O)

Procedures performed [see

Counseling and examinations for

pregnancy interruption (X5 15.0)

through Sterilization to be performed (at this visit) (X525.0)]

X505.0 Contraceptive medication

Includes:

Examinations, instructions, and

advice regarding:

Birth control pills

Renewing pill prescription

28
X505.O Contraceptive medication–Con.

Oral contraceptives

Foams, jellies

X510.0 Contraceptive device

Includes:

IUD insertion, removal, checkup

Diaphragm insertion, removal,

checkup

X515.0 Counseling and examinations for pregnancy interruption

Includes:

Evaluation for and arrangement

for abortion

Wants abortion

S520.0 Abortion to be performed (at this visit)

X525.O Sterilization to be performed (at this

visit )

Includes:

Male-vasectomy

Female-tubal ligation

X530.O Artificial insemination

TREATMENT MODULE

Medications (T IOO-T199)

TIOO.O Allergy medication

Includes:

Allergy shots

Allergy treatments

Excludes:

Allergy testing (X300.0)

T1 10.0 Injections

Includes:

Hormones

vitamins

Iron

Injections, NOS

Shots, NOS

Excludes:

Immunizations (X400.0)

Vaccinations (X400.0)

Inoculations (X400.0)

Allergy shots (TIOO.O)

T1 15.0 Medication, other and unspecified

kinds

Includes:

Renew prescription

For medication

T1 15.0 Medication, other and

kinds-Con.

Request prescription

Prescribe medication

Check medication

Excludes:

unspecified

Birth control medication (X505.0)

Eyeglass prescription [see Eye

examination (X230.0) and

Fitting glasses and contact lenses

(T515.0)]

Antibiotic medication (Tl 10.0)

Preoperative and Postoperative Care

(T200-T299)

T200.O Preoperative visit for specified and unspecified types of surgery

Includes:

Discussion of cosmetic surgery

T205.O Postoperative visit

Includes:

Postop care

Postop pain

Postop suture removal

Specific Types of Therapy (T400-T4W)

T400.O Physical medicine and rehabilitation

Includes:

Physical therapy

Heat therapy

Hydrotherapy y

Therapeutic exercises

Back adjustment

Occupational therapy

Recreational therapy

Speech therapy

Vocational rehabilitation

T405.O Respiratory therapy

Includes:

Inhalation therapy

Asthma treatment

T41O.O Psychotherapy

Includes:

Group therapy

Psychoanalysis

T41 5.0 Radiation therapy

T420.O Acupuncture

T425.O Chemotherapy

29
Specific Therapeutic Procedures

(T500-T599)

T500.O

T505.O

T51O.O

T515.O

T520.o

T525.O

T530.O

T535.O

T540.0

T545.O

T550.O

T555.O

T560.O

Tube insertion

Includes:

Chest tube

Cauterization, all sites

Urinary tract instrumentation and

catheterization

Includes:

Urethral dilation

Excludes:

Cystoscopy [see Diagnostic endoscopies (X330.0)]

Fitting glasses and contact lenses

Includes:

Prescription renewal

Broken or lost glasses

Pick up glasses

Excludes:

Eye examination (X230.0)

Minor surgery

Includes:

Ears pierced

Joint manipulation

Tattoo removal

T520.1 Wart removal

Kidney dialysis

External prosthetic devices, artificial

body parts (fit, adjust, remove)

Corrective appliances

Includes:

Fitting and adjusting:

Back brace

Leg brace

Neck brace

Orthopedic shoes

Cast, splint–application, removal

Dressing, bandage-application, change

Irrigation, lavage

Suture–insertion, removal

Other specific therapeutic procedures,

NEC

Includes:

Ultraviolet treatment

Enema

Eye exercises

Medical Counseling (T600-T699)

T600.0

T605.O

Diet and nutritional counseling

Includes:

Check weight

Counseling for weight reduction

Counseling, NOS

Wants to talk to doctor

Medical consultation

Patient education

To learn about a condition

Personal problem

Disease counseling

Social Problem Counseling (T700-T799)

T700,0 Economic problem

Includes:

Too little income

Can’t pay bills

T705.O Marital problems

Includes:

Problem with husband, wife

Alcoholic spouse

Marriage counseling, NOS

Premarital counseling

Divorce, desertion, separation

T7 10.0 Parent-child problems

Includes:

Working mother

Concern about childhood

behavior

Discipline

Maturation problems

Child neglect and abuse

Adopted or foster child

T715.O Other problems of family relationship

Includes:

Aged parents or in-laws

Problems with relatives

Family fights and disruptions

T720.0 Educational problems

Includes:

Absenteeism, truancy

Problems with teachers

Hates school

School behavior problems

T725.O Occupational problems

Includes:

Unemployment

Out of work

30
T725.O Occupational problems–Con.

Job dissatisfaction

Problem with boss or coworkers

T730.O Social adjustment problems

Includes:

Loneliness

Social isolation

Neighborhood and community

relations problems

Discrimination problems

Don’t have any friends

T735.O Legal problems

Includes:

Imprisonment, prosecution

Lawsuits, litigation

T740.O Other social problems

Includes:

Pregnancy out-of-wedlock

Disasters

Housing and clothing problems

Progress Visit, N EC (T800-T899)

T800,0 Progress visit, NOS (Use only when the

only information given is progress or

followup)

Includes:

Followup, NOS

Routine followup

I’m better

Excludes:

General checkup (X1 OO.O)

Followup, disease (Code to

disease)

Followup, injury (Code to injury)

Followup, symptom (Code to

symptom)

Followup, test results (Code to

R1OO.O-R7OO.O)

Postoperative followup (T205.0)

INJURIES AND ADVERSE EFFECTS

MODULE

1njury by Type and/or Location

(JOOI-J799)

Fractures and dislocations

JO05.O Head and face

Includes:

Skull, jaw, nose, facial bones

JO1O.O

J015.O

J020.O

J025.O

J030.O

J035.O

J040.O

J045.O

J050.O

Spinal column

Includes:

Neck, vertebrae, back

Trunk area, except spinal column

Includes:

Rib, clavicle, collarbone

Leg

Includes:

Knee, femur, tibia, fibula, hip

Ankle

Foot and toes

Arm

Includes:

Radius, ulna, elbow, shoulder

Wrist

Hand and fingers

Fracture, other and unspecified

Sprains and strains

J105.O Cervical spine, neck

Includes:

Whiplash

J11O.O Back

J115.O Knee

J120.O Ankle

J125.O Wrist

J130.O Sprain or strain, other and unspecified

Lacerations and cuts

J205.O Head and neck area

Excludes:

Face (J21O.O)

J21O.O Facial area

Includes:

Eye, ear, nose

J215.O Trunk area

J220.O Lower extremity

Includes:

Ankle, foot

J225.O Upper extremity

Includes:

Hand, fingers, arm, wrist

J230.O Laceration and cuts, site unspecified

Puncture wounds

J305.O

J31O.O

J315.O

J320.O

J325.O

Head, neck, and facial area

Trunk area

Lower extremity

Upper extremity

Puncture wound, site unspecified

31
Contusions, abrasions, and bruises

J405.O Head, neck, and face

Excludes:

Eye (J41O.O)

J41O.O Eye

Includes:

Corneal abrasion

Black eye

J415.O Trunk area

J420.O Lower extremity

J425.O Upper extremity

J430.O Contusion, abrasion, bruise, site unspecified

Injury, type unspecified

J505.O

J51O.O

J515.O

J520.O

J525.O

J530.O

J535.O

J540.O

J545.O

J550.O

J555.O

J560.O

J565.O

J570.O

J575.O

Foreign

J600.O

J605.O

J61O.O

J615.O

J620.O

Head, neck, and face

Eye

Back

Chest and abdomen

Includes:

Internal injuries

Hip

Leg

Knee

Ankle

Foot and toe(s)

Shoulder

Arm

Elbow

Wrist

Hand and finger(s)

Injury, multiple or unspecified

body

Eye

Nose

Skin

Digestive tract

Includes:

Mouth

Throat

Rectum

Other and unspecified sites

Burns, all degrees

J705.O Head, neck, and face

J71 0.0 Trunk area

J715.O Extremities

Includes:

Upper

Lower

J720.O Burn, site unspecified

J750.O Sunburn, windburn

Bites

J755.O Insect

Includes:

Sting

J760.O Animal, human

Injury, NOS (J800-J899)

J800.O

J805.O

J81O.O

J815.O

J820.O

J830.O

J835.O

Late effects of an old injury

Includes:

Scars

Deformities

Motor vehicle accident, type of injury

unspecified

Includes:

Car accident

Auto accident

Motorcycle accident

Accident, NOS

Includes:

Fall, type or location of injury

unspecified

Violence, NOS

Includes:

Beat up

Stabbing

Gunshot wound

In a fight

Excludes:

Violence against oneself (J820.0)

Suicide attempt

Includes:

Found in car with motor running

Hanging oneself

Stabbed oneself

Slashed wrists

Code also: Laceration of wrists

(J225.0)

J820.1 Overdose, intentional

Rape

Includes:

Sexual assault

Sexual abuse

Molestation

Dead on arrival (DOA)

Includes:

Death

32
J840.O Unconscious on arrival

Includes:

Coma

Stupor

Knocked out

Shock

Cardiac arrest

Unresponsive

Found unconscious

Poisoning and Adverse Effects

(J900-J999)

J900.O Accidental poisoning

Includes:

Food poisoning, ingestion of

potentially poisonous food

products

Accidental ingestion of:

Household products

Chemicals

Drugs

J905.O Adverse effect of medication

Includes:

Allergy to medication

Penicillin allergy

Anaphylactic shock

Bad reaction to prescribed medication

J9 10.0 Adverse effect of drug abuse

Includes:

Drug-induced hallucinations

Combination of drugs and alcohol

(nonsuicidal)

Ingestion of drugs for nonmedicinal purposes

Bad trip

Freaked out on drugs

Excludes:

Intentional overdose (J820. 1)

J9 15.0 Adverse effect of alcohol

Includes:

Intoxication

Drunk

Acute intoxication

,J920.O Adverse effects of environment

Includes:

Air pollution

Water pollution

Noise pollution

J925.O Adverse effects, other and unspecified

TESTS RESULTS MODULE (Includes

all abnormal test resultsand followups

for test results)

R1OO.O

R105.O

R11O.O

R200.0

R300.O

R400.0

R500.O

R600.O

R700.O

For results of blood glucose tests

Includes:

High blood sugar

Abnormal glucose tolerance test

Sugar in blood

Elevated blood sugar

For results of cholesterol and triglyceride tests

Includes:

High cholesterol

For other findings of blood tests

Includes:

Positive serology, VDRL

Positive blood culture

Elevated sed rate

For results of urine tests

Includes:

Sugar in urine

Positive urine culture

Abnormal urinalysis

For cytology findings

Includes:

Positive Pap smear

Repeat Pap smear

Atypical Pap smear

For results of Pap smear of cervix

or other area

For radiological findings

Includes:

X-ray results

Abnormal X-ray

For results of EKG

For results of skin tests

For other and unspecified test results

Includes:

Abnormal scans

Abnormal pulmonary function

test

Abnormal EEG

Abnormal lab test results, NOS

To discuss test results with physician

Ultrasonography results

Results of fetal evaluation tests

33
ADMINISTRATIVE MODULE

A1OO.O Physical examination required for

employment

Includes:

Preemployment examination

Required company physical

Return to work checkup

Teacher’s certificate physical

Al 05.0 Executive physical examination

Al 10.0 Physical examination required for

school

Includes:

High school

Nursery school

College

Grade school

A120.O Driver’s license examination

Al 25.0 Insurance examination

A130.O Disability examination

Includes:

Evaluation of a disability

Social Security examination

Al 35.0 Premarital examination

A135.1 Premarital blood test

A140.O Other reason for visit required by party

other than the patient or the health

care provider

Includes:

Physical examination for adoption

Psychiatric examination required

by court or school

Day care center

Al 15.0 Physical examination for extracurricular activities

UNCODABLE ENTRIES

Includes:

Boy Scouts U990.O Problems, complaints, NEC

Little Lea~e U997.O Entry of “none” or “no complaint”

Camp U99 8.0 Inadequate data base

Athletics U999.O Illegible entry

000

34
APPENDIX II

REASON FOR VISIT CLASSIFICATION

ALPHABETICAL INDEX

Abnormal

blood sugzwtest R1OO.O

blood test R1 10.0

breathing sounds S430.1

cholesterol R105.O

daily consumption, alcohol S145.0

drug use s150.o

EGG R500.O

EEG R700.O

EKG R500.O

eye color S330.1

eye movement S325.0

glucose tolerance test R1OO.O

palpitations S260.0

Pap smear R300.O

pulsations S260.0

retractions (eye) S325.1

sed rate R1 10.0

sensations S220.3

skin test R600.0

sugar, urine R200.O

test results, NOS R700.O

urine tests R200.O

X-ray R400.O

Abnormality, fluid S035.0

Aborting S790.0

Abortion

arrangements for X51 5.0

counseling X51 5.0

evaluation for X51 5.0

performed X520.O

repetitive spontaneous D735.O

spontaneous D735.O

threatened D735.O

wants X51 5.0

NOTE: NEC = not ekewhere classifiable; NOS = not

otherwise specified.

Abrasion (see also Contusion)

corneal J410.O

Abscess, NOS D800.O

kidney D705.O

skin D800.O

stitch (postoperative) D800.0 (T205.0)

Absence of (see particular function)

(see also Loss of)

Absenteeism, school T720.O

Abuse

child T71O.O

sexual J830.O

Accident, NOS J81 0.0

auto J805.O

carJ805.O

cerebrovascular D525.O

motor vehicle J805.0

motorcycle J805.0

poisoning J900.0

Ache (see also Pain)

all over S060.1

Acne S830.0

Acupuncture T420.O

ACVD D515.O

Adjustment

back T400.O

corrective appliance T535.O

problem S120.0

prosthetic device T530.0

Adopted child (counseling) T71 0.0

Advice T605.0

Affect, loss of S165.0

Aftercare, surgical T205.O

Aged parents T715.O

Aggressiveness S130.2

Agitated S130.0

Agraphia S240.0

35
Alcohol-related problems

abnormal consumption S145.0

alcoholic spouse T705.O

binge drinking S145.0

deniaI of probIem S145.0

drinking to relieve symptoms S145.0

gulping drinks S145.0

increased tolerance S145.0

morning drinking S145.0

problems, NOS S145.0

psychological dependence S 145.0

Alcoholism D320.O

Allergy, NOS S090.0

animah D635.O

dust D635.O

eye S335.2

medication J905.0

nasal D635.O

penicillin J905.O

pollen D635.O

ragweed D635.O

skin D825.O

shots TIOO.O

test X300.O

Amenorrhea S730.0

Amnesia S2 15.0

Anemia, NOS D250.O

iron deficiency D25 0.0

pernicious D250.O

sickle ceII D250.O

Anesthesia S220. 1

Anger S115.0

Angina, NOS D5 15.0

pectoris D5 15,0

Angiogram X345.O

Anomaly, congenital, NOS D960.O

Anorexia S570.2

Antibiotics T1 10.0

Anxiety S1OO.O

Apathy S165.0

Aphakia D420.O

Aphasia S235.0

Appearance

eyes, abnormal S33 0.0

nose, undesirable S405.4

tongue, abnormal S5 15.4

Appendicitis D655.O

Appetite

abnormaI S570.0

decreased S570.2

excessive S5 70.1

Appetite–Con.

10SS of S570.2

no S570.2

Apprehension S1OO.O

Arrest, cardiac J840.O

Arteriosclerosis D530.O

Arthralgia S975.1

Arthritis, NOS D900.O

rheumatoid D9 00.0

Ascaris D030.O

Ascites S565.0

ASHD D515.O

Asthma D625.O

Astigmatism D405.O

Atherosclerosis D530.O

Athlete’s foot D025.O

Atrophy

extremities S9 80.0

muscles S965.4

Attack

convulsion S205.0

heart D515.O

Avoiding people S130.1

Backache, NOS S905.1

low S91O.1

Bad

heart S270.0

nerves S100.0

Bag of water broke S790.3

Balance, loss of S225.0

Baldness S890.1

Bandage (see Dressing)

Beatup J815.O

Bedwetting S655.2

Behavior

abnormal sexual S160.0

antisocial S130.1

asocial S130.1

bad, NOS T710.O

bad, school T720.0

bizarre S130.O

compulsive S13 0.5

disturbance S130.0

hostile S130.2 /..

hysterical S130.3

sexual, change in S 160.0

Belching, excessive S535.0

Bent finger back J570.O

Better, feeling, NOS T800.O

Binge drinking S 145.0

36
Biopsy, any site X335.O

Birth control, NOS X500.O

cwnscling X5 00.0

medication X505.O

prescription renewal X505.O

Bite, animal J760.O

human J760.O

insect J755.O

Bitterness S1 15.0

Black Cy~ J41O.O

Blackhead S830.0

Blackouts S030.0

Bleeding, NOS S070.0

between periodsS755.1

breakthrough S755.1

during pregnancy S790.2

ear S350.1

eye S310.1

gastrointestinal S580.0

gums S500.3

intermenstrwd S755.1

lips S505.1

mole S845.2

mouth S51O.2

multiple sites S070.0

nipple S81O.1

nose S405.1

penis S700.0

postcoital S755.3

postmenopausal S755.2

postoperative S070.0, T205.O

postpartum S790.4

rectal S605.2

tonLgue S515.2

tonsils S460.0

umbilicus S895.0

uterine, NOS S755.0

uterine, dysfunctionalD 730.0

vaginal, NOS S755.0

Blemishes S830.0

Blcpharitis D400.O

Blind

Mindness S305.1

night S305.2

spots S305.1

Blinking S340.4

Blister

skin S865.0

tongue S51 5.0

Bloated, NC)S S035.1

before periods S745.1

~W S585.0

Blocked

ear S360.0

tear duct (congenital) D960.O

Blood (see Condition) (see also Bleeding)

count X3 15.0

pressure, check X320.O

pressure, elevated D5 10.0

pressure, high D5 10.0

pressure, low D550.O

spots in eye S330.0

sugar, high R1 00.0

urine S640.1

work, NOS X315.O

Bloodshot eyes S330.1

Blotches S835.0

Blowing up S130.4

Blueness S280.0

Blushing S280.3

Boil D800.O

Bow-legged S9 75.1

Bowel function, changes in S600.0

BPHD71O.O

Brace

back T535.O

leg T535.O

neck T535.O

Brady cardia S260.2

Breaking

nails S885.3

out (skin) S830.0

Breath, breathing

bad S615.0

difficult S420.0

holding S130.0

problem S430.0

rapid S43 0.2

shortness of S415.0

sounds, abnormal S430.1

unusual odor S615.0

Breathlessness S415.0

Brittle

hair S890.0

naik S885.3

Bronchitis D6 10.0

Bronchopneumonia D630.O

Bruise (see Contusion)

Bulge (see Mass)

Bump (see Mass)

Bunion D9 10.0

Burn, NOS J720.O

extremities J7 15.0

face J705.O

37
Burn, NOS J720.O–Con.

head J705.O

neck J705.O

trunk J710.O

Burning

chest S050.3

eye S320.3

mouth S51O.1

sensation (in chest) S050.3

skin S870.0

stomach S535.O

tongue S5 15.1

vaginal S765.3

Burping, excessive S535.0

Bursitis D905.O

Butterflies S1OO.O

Buzzing in ear S345.3

Cachexia S020.0

&dcuh_ls,NOS D705.O

ureteral D705.0

Calluses S855.0

Cancer, NOS D130.O

bladder D125.O

blood D135.O

bone D130.O

brain D130.O

breast D115.O

bronchus D105.O

cervix D120.O

colon D1OO.O

endometriumD120.0

esophagus DIOO.O

eyelid D1 10.0

fallopian tubes D120.O

kidney D125.O

larynx D105.O

lung D105.O

OVZLryD120.O

prostate D125.O

rectum D1OO.O

skin D11O.O

small intestineD 100.0

stomach D1 10.0

throat D105.O

trachea D105.O

uterus D120.O

vagina D120.O

vulva D120.O

Candidiasis D025.O

can’t

getpregnant S815.0

hold urine S655.1

open eye S340.1

see S305.0

start stream (urination) S660.2

urinate S660.1

Carbuncle D800.o

Carcinoma (see also Cancer)

basal cell D1 10.0

metastaticD130.0

squamous cellD 110.0

Care, postoperative T205.O

Cast

application T540.O

change T540.O

loose T540.O

postoperative T540.0, T205.0

problems with T540.O

removal T540.O

Cataract D41O.O

Catheterization, urinary T5 10.0

Cauterization, NOS T505.O

Cellulitis D800.O

Centesis X370.0

Certificate, teacher’s A1OO.O

Cervicitis D725.O

Charleyhorse S965.2

Check

blood pressure X320.O

for V.D. X405.O

knee S925.0

medication T1 15.0

throat S455.0

Checkup, NOS X1OO.O

annual X1OO.O

birth control, NOS X500.O

following injury J575.O

heart X235.O

IUD X51O.O

pacemaker X240.O

return to work A1OO.O

routine Xl 00.0

routine gynecological X225.O

routine postoperative T205.O

routine prenatal X205.O

Chemical bum (see Bum)

Chemotherapy T425.O

38
Chest symptoms, NOS S050.0

Chewing

difficulty S500.0

on hair S165.0

Chickenpox DO15.0

Child care counseling T7 10.0

Chills S005.0

Chipped tooth JO05.O

Choking S520.0

Cholecystitis D670.O

Cholelithiasis D6 70.0

Cholera DO05.O

Cholesterol, high R105.O

Chorea D500.O

Circulation

poor S280.1

problems S280.1

Circumcision T520.O

Cirrhosis D670.O

Clammy skin S880.0

Clap D020.O

exposed to X405.O

Cleaning, ears S360.0

Cleft

lip,D960.O

palate D960,0

Closeup, can’t see S305.2

Clothing problem T740.O

Clots, menstrual S740.3

Cloudy

eye appearance S330.3

vision S305.3

Clubfoot D960.O

Clumsiness S095.0

Coated tongue S515.4

Coitus, painful S825.0

Cold, NOS S445,0

body temperature S005,0

chest S475.0

head S445.0

sore S505.3

Colic, NOS S550.0

biliary D670.O

infantile S550.0

intestinal S550.0

renal S670.1

Colitis, NOS D665.O

spastic D665.O

ulcerative D665.O

Collapse J840.O

Color

change in skin S835.0

eyes, abnormal S330.1

lips S505.2

tongue, abnormal S515.4

Coma J840.O

Complaints, NOS S025.0

multiple S025.0

Complexion, NOS S830.0

bad S830.0

Compulsions S130.5

Concussion J505.O

Condition

heart S270.0

SCdp S890.0

skin S880.0

Confidence, lack of S120.0

Conflict

job T725.O

marital T705.O

Confusion S240.0

Congestion

chest S475.0

lung S475.0

nasal S400.0

sinus S410.3

Conjunctivitis D400.O

Constipation S590.0

Consultation, medical T605.O

Contacts

examination for X230.O

fitting T5 15.0

problems with S335.1

Contraceptive, followup, NOS X500.O

counseling X500,0

oral X505.O

renewal (oral) X505.0

Contractures (see Cramp(s))

Control, loss of (over behavior) S130.0

Contusion, NOS J430.O

face J405.O

head J405.O

lower extremity J420.O

neck J405.O

trunk J415.O

upper extremity J425.0

Convulsions S205.0

febrile S205.0

o

39
Coordination, poor S095.0

Corns S855.0

Coronary D51 5.0

Coryza S445.0

Cough, coughing up, NOS S440.0

bIood S470.1

croupy S440.0

phlegm S470.3

smoker’s S440.0

sputum S470.3

Counseling, NOS T605.O

diet T600.O

disease T605.O

expectant parent T7 10.0

family planning X500.O

genetic X500.O

infertility X500.O

marriage T7 05.0

nutritional T600.O

premarital T705.O

sterilization X500.O

Cracked

lips S505.1

nails S885.3

skin S865.0

Cracking, ear S360.0

Cramp(s), NOS S060.2

abdominal S550.0

arm S945.2

back, low S91O.2

back, NOS S905.2

fingers S960.2

foot S935.2

gastrointestinal S545.2

hand S960.2

hip S915.2

leg S920.2

menstrual S745.2

muscle S965.2

neck S900.2

stomach S545.2

Crash, motor vehicle J805.O

Crazy

acting S130.3

going S165.0

Crick, neck S900.3

Criminality S130.2

Cross-eyed S325.2

.Croup D600.O

Cruelty S130.2

Crying

too much (infancy) S080.1

adult S11O.O

Culture

blood X3 15.0

throat X370.2

urine X325.0

Curvature, spine D9 10.0

Cut(s) (see Laceration)

CVA D525.O

Cyanosis S280.0

Cyst, NOS S855.0

Bartholin’s D145.O

bone D91O.O

breast S805.0

dermoid D145.O

epidermal D825.0

Nabothian D140.O

piIonidd D825.O

sebaceous D825.O

skin S855.0

vaginal inclusionD 145.0

vulva S770.3

Cystitis D700.O

Cystocele D730.O

Cystoscopy X330.O

Dandruff D81O.O

Dark urine S640.3

Data, inadequate U998.O

Daughter (see Problem, parent-child T7 10.0)

DeadJ835.O

on arrivalJ835.O

Deafness S345.1

Death, fetal, in utero D735.O

Decubitus D825.O

Defecation, painful S600.0

Deficiency

estrogen R700.0

hormone S820.0

Deformity

due to injury J800.o

ear D960.O

nose D960.O

Dehydration S035.0

Dejected S110.0

Delirium tremens D300.O

Delusions S155.0

Dementia, senile D300.O

Denial, drinking problemS145.0

40
Dependence

alcoholic S145.0

drug D320.O

psychological, on alcohol S 145.0

Depressants, use of S150.0

Depression S1 10.0

Dermatitis, NOS D815.O

seborrheic D8 10.0

Dermatophytoses D025.O

Desertion T705.O

Destructiveness S130.2

Detachment, retina D420.O

Development

breasts, uneven S81O.3

early S075.2

lack of S07.5.1

sexual, delayed S795.0

sexual, early S795.0

Deviation

eyes S325.4

nasal septum D640.O

Device

contraceptive X51 0.0

intrauterine X51 0.0

Diabetes D205.O

during pregnancy D735.O

mellitus D205.O

Dialysis

liidney T525.O

peritoneal T525.O

Diaper rash S860.1

Diaphragm X510.0

Diarrhea S595.0

Diet (counseling) T600.O

Difficulty (see also particular function)

coordination SO95.O

walking S095.0

Dilatation and curretage, diagnostic X335.O

Dilation, urethral T5 10.0

Diplopia S305.4

Dirty pants S600.4

Disaster T740.O

Discharge

breast S81O.O

ear S350.0

eye, NOS S31O.O

eye, white S3 10.3

nipple S81O.1

nasal S400.0

peniIe S705.0

Discharge-Con.

stools S600.0

tonsik S460.0

umbilical S895.0

urethral S680.0

vaginal S760.0

Discipline T7 10.0

Discoloration, skin S835.0

Discomfort

chest S050.2

stomach S545.0

Discontented S1 10.0

Discrimination T730.O

Disease

Addison’s D215.O

adrenal D2 15,0

artery, coronary D5 15.0

bIadder, NOS D705.O

blood sugar D205.O

cardiovascular, arteriosclerotic D5 15.0

cardiovascular, hypertensive D505.O

cerebrovascular D525.0

Crohn’s D665.O

cystic, of breast D7 15.0

demyelinating D3 70.0

disc, degenerative D9 10.0

fibrocystic D7 15.0

heart, arteriosclerotic D5 15.0

heart, congenital D950.O

heart, hypertensive D505.O

heart, ischemic D5 15.0

heart, NOS D550.O

heart, rheumatic D500.O

Hodgkin’s D135.O

kidney, NOS D705.O

liver D670.O

mental, NOS D330.O

nutritional D215.O

parasitic D030.O

Parkinson’s D355.O

pelvic inflammatory D720.O

Peyronie’s D71O.O

respiratory, NOS D640.O

thyroid D200.O

vascular, arteriosclerotic D5 15.0

venereal D020,0

venereal, check for X405.O

venereal, contact with X405.O

viral D015.O

Dislike of self S120.0

41
Dislocation (see also Fracture)

congenital D960.O

finger J045.O

hip J020.O

shoulder J035.O

Disorder

character D3 15.0

growth S075.0

menstrual S745.0

motor function S095.0

personality D3 15.0

respiratory rhythm S430.0

respiratory sound S430. 1

DispIaced intervertebral disc D91O.O

Dissatisfaction, job T725.0

Distances, can’t see S305.2

Distention

abdominal (gas) S585.0

abdominal, NOS S565.1

bladder S665.0

Distress

gastrointestinal S615.0

heart S265.0

respiratory S420.0

stomach S615.0

Diverticulitis D665.O

Diverticulosis D665.O

Divorce T705.0

Dizziness S225.0

DOAJ835.O

Drainage

ear S350.0

umbilicus S895.0

Dressing T545.O

injury T545.0, J575.0

postoperative T545.0, T205.O

Dribbling (urine) S655.1

Drinking (see also Alcohol-related problems)

morning S145.0

on-the-sly S145.0

problem, NOS S145.0

too much S145.0

to relieve problems S145.0

Drip, postnasal S400.0

Drooling S51O.O

Dropping sensation, pelvic region S775.2

Dropsy S035.1

Drowsiness S135.2

Drug abuse S150.0

Drunk J9 15.0

Dryness

eyes S335.0

hair S890.3

lips S505.1

mouth S510.3

nose S405.0

skin S880.2

Dysfunction

ovarian D2 15.0

sexual S825.0

Dysmenorrhea S745.2

Dyspareunia S825.0

Dyspepsia S535.0

Dysphagia S520.0

Dysplasia, hips D9 10.0

Dyspnea S420.0

Dysrhythmia, cardiac D520.O

Dysuria S650.0

Earache S355.1

Eats too much S570.1

ECG X350.O

Eczema D815.O

Edema S035.1

of pregnancy D735.O

Education, patient, NOS T605.O

EEG X355.O

Effect, adverse, NOS 925.0

alcohol .1915.0

drug ab&e J91O.O

environment J920.O

medication J9 05.0

Effects of an old injury, lateJ800.O

Ejaculation, premature S160.4

EKG X350.O

Electrocardiogram X350.O

Electroencephalogram X355.O

Embolism, pulmonary D550.O

Embolus D550.O

Emesis S530.0

Drooping Emotional upset S165.0

eyelids S340.4 Emphysema D620.O

facial S230.0 Encopresis S600.4

Drop Endometriosis D730.O

foot S935.O Endoscopy X330.O

wrist S955.2 Enema T560.O

42
Engorgerncnt, breasts, postpartum S81O.2

Enlarged

liver S61 0.0

lymph glands S275.1

prostate S71O.O

Enteritis DO05,0

Enuresis S655.1

Epididymitis D7 10.0

Epilepsy D360.O

Epistaxis s405. I

Equilibrium, loss of S225.0

Erection, painful S700.1

Erosion, cervical D725.O

Error, refractive D405.O

Eruption, skin S860.0

Erythema S835.0

Esophagitis D650.O

ETOP (elective termination of pregnancy)

X515.O

Euphoria S165.0

Evaluation for surgery T200.O

Examination

adolescent Xl 00.0

adoption A140.O

annual X1OO.O

athletics A 115.0

Boy Scouts Al 15.0

breast S220.0

camp A115.O

cardiac X235.O

child health .X1OO.O

child health, NOS X1OO.O

coUege A 110.0

day care Al 10.0

disability A130.O

driver’s license A120.O

employment physical A 100.0

executive physical Al 05.0

eye X230.O

general X1OO.O

gmde school Al 10.0

gynecological X225.O

hearing X360.O

heart S225.0

insurance A 125.0

internal prosthetic devices X240.0

medical X1OO.O

multiphasic screening Xl 00.0

neurological X240.O

nursery school Al 10.0

nursing home A140.O

Examination–Con.

office X1OO.O

ophthalmological X230.O

pelvic X225.0

physical Xl 00.0

postoperative T205.O

postpartum X215.O

premarital A135.O

prenatal X205.O

psychiatric Xl 30.0

psychiatric, required by court or school

A140.O

psychological x130.o

re~lar X1OO.O

required, NOS A140.O

routine Xl 00.0

school A11O.O

Social Security A130.O o

well baby X105.O

Excessive

perspiration S035.2

sweating S035.2

thirst S035.3

use of stimulants or depressants, chronic

S150.O

Exercises

eye T560.O

therapeutic T400.O

Exhaustion SO15.0

Exophthalmo3 S330.2

Exposure to

chickenpox X410.0

clap X405.O

hepatitis X41O.O

infectious disease X41 0.0

measles X41 0.0

mumps X41O.O

strep throat X410.0

venereal disease X405.0

FaiIure

congestive heart D5 20.0

heart D520.O

renal D705.o

to adjust to school S120.0

to thrive S075.1

Fainting S030.O

Fall, faUing out

hair S890.1

injury J810.O

43
FamiIy

disruption, NOS T7 15.0

plaming, NOS X500.O

problems (see T705.0-T715.0)

Farsightedness D405.0

Fatigue S015.0

Fears S105.O

Febrile S01 0.0

Feeding problem S080.3

Feeling, feelings

faint S030.0

hostile S1 15.0

loss of S220.1

lost Silo.o

Iowsllo.o

not well S025.0

of uterus falling out S775.2

panicky S1OO.O

prickly S220.3

rejected S120.0

Fever, NOS SO1O.O

blister s505.3

hay D635.O

rheumatic D500.O

scarlet DO 10.0

Fibrillation, atrial D520.O

Fibroid, uterus D140.O

Fidgety S080,1

Fight J815.O

Fissure

anal D665.O

rectal D665.0

FistuIa

anal D665.O

rectal D665.O

vaginal D730.O

Fits S205.0

Fitting

braces T535.O

contact lenses T5 15.0

eyeglasses T515.O

prosthesis T535.O

Flakiness

SCdp S890.3

skin S880.2

Flashes

hot S750.2

light S305.3

Flatulence S585.0

Floaters S305.3

FIu, NOS S450.0

stomach S540.0

Fluid

eardrum S365.0

imbalance S035.0

on abdomen S035.1

retention S035.0

Flushed S280.3

Fluttering

eyes S325.0

heart S260.3

Focus, eyes won’t S305.2

Followup, NOS T800.O

injury J575.O

postoperative T205.O

test results (see RI 00. O-R700.0)

Foot drop S935.0

For surgery T200.O

Foreign body, NOS J620.O

digestive tract J615.0

ear J620.O

entering through skin J6 10.0

eye J600.O

nose J605.O

rectum J615,0

stomach J6 15.0

throat J615.O

Forgetfulness S2 15.0

Foster child (counseling) T7 10.0

Fracture, NOS J050.O

ankle J025.O

arm J035.O

back JOIO.O

clavicle JO 15.0

collarbone JO 15.0

elbow J035.O

face JO05.O

facial bones JO05.O

femur J020.O

fibuIa J020.O

finger J045.O

footJ030.O

hand J045.O

head JO05.O

jaw JO05.O

knee J020.O

legJ020.O

neck JOIO.O

nose JO05.O

radius J035.O
Fracture, NOS J705.O–Con.

rib J015.O

Shall JO05.O

spine JOIO.O

tibia J020.O

.

toe J030.O

ulna J035.O

vertebra JOIO.O

wrist J040.O

Freaked out (drugs) J91O.O

Freckles S835.0

Frequency, NOS S645.0

Frigidity S160.0

Frozen waterworks S660.2

Fullness

abdominal S565.1

bladder S665.0

Furuncle D800.O

Fussy, infants S080,1

Gagging S530.0

Gin, weight S040.0

Gallstones D670.O

C&glion D905.O

distention S585.0

excessive S5 85.0

pain S550.0

Gasping for breath S415.0

Gastritis D650.O

Gastroenteritis DO05.O 4,

General, generalized

ill-feeling S025.0

pain S060.1

weakness S020.0

Genetics (counseling) X500.O

German measles D015.O

Giddiness S225.0

Glasses

broken T5 15.0

examination for .X230.O

fitting T5 15.0

lost T515.O

needs new X230,0

Glaucoma D4-15.O

Glomerulonephritis D705.0

Glomerulonephrosis D705.O

Glue sniffing (habitual) S150.0

Glycosuria R200.O

Goiter D200.O

Gonorrhea D020.O

Gout D21O.O

Granuloma, NOS D825.O

Grief S1 10.0

Grinding

jaw S500.0

joints S970.0

teeth S500.0

Grip S450.0

Growth (see also Mass)

lack of physical S075.1

GTT X31O.O

Guilt S120.0

Gynecomastia D715.O

Habits, bad NOS S165.0

Hair, hairiness

abnormal S890.2

falling out S890.1

Half-vision S305.1

Halitosis S6 15.0

Hallucinations S155.0

drug-induced J9 10.0

Hallucinogens, use of S150.0

Halos around eyes S305.3

Harelip D960.0

Hates school T720.O

HCD D505.O

HCVD D505.O

Headache S2 10.0

migraine D365.O

sinus S410.

I

Hearing

acute S345.2

diminished S345.1

dysfunction S345.0

extraneous S345.3

heightened S345.2

loss of S345.1

noises S345.3

trouble S345.1

voices S155.0

Heart, heartbeat

decreased S260.2

increased S260.1

irregular S260.3

skipped S250.3

S1OW S260.2

throbbing S260.0

weak S270.0

45
Heartburn S535.0

Hematemesis S580.2

Hematoma, site specified (see Contusion) NOS

J430.O

Hematuria S640.1

Hemorrhage

gastrointestinal S580.0

nose S405.1

subarachnoid J505.O

vaginal S755.0

Hemoptysis S470.1

Hemorrhoids D545.O

Hernoth’orax D640.O

Hepatitis DO15.0

Hernia D660.O

Herpes

simplex DO15.0

zoster DO15.0

Hesitancy (urination) S660.2

Hiccoughs S615.0

Hiccups S615.0

High

blood pressure D5 10.0

elevated mood S165.0

temperature SO1O,O

Hirsutism S890.2

Hives D825.O

Hoarseness S480,1

Homosexuality S160.2

Hopelessness S110.0

Hostility S115.0

Housing problem T740.O

Hungry, always S570.1

Hurt myself, NOS J81O.O

Husband (see Problem, marital T705.0)

Hydrocele D7 10.0

Hydrotherapy T400.0

Hyperactivity S125.0

Hyperacusis S345.2

Hyperemesis gravidarum D735.O

Hyperesthesia S220.2

Hyperlipidemia D2 15.0

HypernasaIity S480.2

Hyperopia D405.O

Hypersomnia S135.2

Hypertension (without involvement of target

organs) D51O.O

essential D5 10.0

of pregnancy D7 35.0

renal D505.O

Hyperthyroidism D200.0

Hypertrophy, benign prostatic D710.0

Hyperuricemia D2 10.0

Hyperventilation S430.2

Hypoglycemia D2 15.0

Hypospadias D955.O

Hypotension D550.O

Hypothyroidism D200.O

Hysteria S130.3

Hysterosa.lpingogram X345.O

Identity

crisis S120.0

loss of S120.O

Ileitis D665.O

Ill, illness, NOS S025.0

feeling, generalized S025.0

Illegible entry U999.O

Imbalance, fluid S035.0

Immaturity

mental S165.0

physical S075.0

psychological S165 .0

Immunization X400.0

Impacted, impaction

intestinal S590.0

sinuses S410.3

teeth S500.0

Impetigo D805.O

Impotence S160.3

Impris~ment T735.O

Inability to

conceive S815.0

cope S165.0

nurse S81O.2

stand S095.0

SWdlOW S520.0

urinate S660.1

walk S095.0

Incision draining T205.0

Incontinence

stool S600.4

stress S655.1

urine S655.1

Incoordination S095.0

Increased heartbeat S260.1

Indecision S165.0

Indigestion S535.0

Infarction, myocardial D515.O

Insomnia S135.1

46
Infection, NOS S085.0

mm S840.2

Madder S665.2

breast, postpartum S81O.2

breast, NOS S81O.O

car S355.2

eye S315.O

eyelids S340.1

finger S840.2

foot S840.3

gastrointestinal S540.0

generalized S085.0

gcmtourinary S675.0

hand S840.2

kidney S670.2

leg S840.3

nail S885.1

11OSCS4-05.3

pelvis S775.3

penis S700.2

prostate S7 10.2

sinus S41 0.2

skin S840.0

skin, head area S840.1

skin, neck S840.1

staphylococci.1 D035.O

stmptococcal DO1O.O

throat s455.3

toe S840.3

tongue S5 15.3

tonsils S460.0

Trichomonas D035.O

upper respiratory S445.0

urinary tract S675.0

urine S675.0

vaginal S765.2

viral, NOS S085.1

unspecified S085.0

wound (postoperative) J575.O (T205.0)

yeast D025.O

Infertility S815.0

counseling X500.0

Inflammation

eye S3 15.0

eyelids S340.1

mouth S51O.1

nipple S810.0

nose S405.3

pelvis S775.3

penis S700.2

Inflammation-Con.

scrotum S715.2

SillUS S41O.2

skin S870.0

stomach S545. 1

throat S455.2

tongue S515.3

tonsils S460.0

Influenza S450.0

Ingestion of

chemicals (accidental) J9 00.0

drugs (accidentzd) J900.O

drugs (intentional, nonsuicidal) J900.O

drugs (suicidal) J820.O

household product J900.O

Ingrown nail S885.2

Injection, NOS T 110.0 (see also Shot and inoculations)

allergy TIOO.O

antibiotics T1 10.0

contraceptive X505.0

estrogen T1 10.0

hormone T1 10.0

iron T11O.O

vitamin T1 10.0

Injury, NOS J575.O

abdomen J520.O

ankle J540.O

arm J555.O

backJ515.O

chest J520.O

elbow J560.O

eye J510.O

face J505.O

fingers J570.O

foot J545.O

hand J570.O

head J505.O

hip J525.O

internal J520.O

knee J535.O

legJ530.O

multiple, NOS S575.0

neck J505.O

shoulder J5 50.0

toes J545.O

wrist J565.O

Inoculations X400.O

Insemination, artificial X530.O

47
Insertion

chest tube T500.O

IUD X51O.O

Instruction for

diet change or control T600.O

exercise T605.O

regarding imminent surgery T200.O

use of contraception X500.0

use of crutches or cane T605.0

Intercourse, painful S825.0

Interruption, pregnancy X515.0

Intoxication

alcohol J915.O

drugs J910.O

frequent S145.0

Inversion of nipple S81O.O

Irre~lar

heartbeats S260.3

menstruation S735.0

Irregularity S590.0

Irrigation (postoperative) T550.O (T205.0)

Irritable, irritabilityy

adult S130.0

infants S080.1

premenstrual S745.1

Irritation

eye S320.0

skin, NOS S870.0

throat S455.4

vulva S770.1

Isolation, social S130.1

Itching, NOS S870.2

ear S365.1

eye S320.2 “

eyelids S340.2

nose S405.0

rectum S605.4

SCdp S890.4

scrotum S71 5.4

skin S870.2

vagina S765.3

vulva S770.1

IUD X51O.O

IVP X345.O

Jaundice S61O.2

Jerking S200.0

Job

out of T725.O

problems T725.O

Jock itch s715.4

Keloid D825.O

Keratitis D400.O

Knife wound J8 15.0

Knock-kneed S9 75.1

Knocked out J840.O

Knot, knots

breast S805.0

stomach S545.1

Kyphoscoliosis D9 10.0

Kyphosis D9 10.0

Lab tests, NOS X370.O

Labor

fake S790.3

Labyrinthitis D455.O

Laceration, NOS J230.O

abdomen J215.O

arm J225.O

back J215.O

ear J210.O

eye J210.O

face J210.O

fingers J225.O

foot J220.O

hand J225.O

head areaJ205.O

legJ220.O

nose J210.O

toes J220.O

trunk area J215.O

\\rristJ225f)

Lack of growth S075.1

Lacrimation S3 10.2

Lactation, improper S81O.2

Laparoscopy X330.O

Laryngitis D600.O

Lassitude SO15.0

Lavage (see h-rigation)

Lawsuits T735.O

Leaking

amniotic fluid S790.0

rectal S600.4

Leeches D030.O

Legal problem T735.O

Leiomyomata D140.O

Lesion, skin S865.0

Lethargy S165.0

Leukemia D135.O

Leukorrhea, vaginal S760.0

48
Lice

body D030.O

head D030.O

Ligation, tubal X525.0

Light

ilashes S305.3

hurts eyes S305.0

Lightheadedness S225.0

Limping S095.0

LipomaD 145.0

Listlessness S1 25.0

Litigation T735.O

Locked bowel S590.0

Loneliness T730.O

Loose stools S595.0

Losing mindS 165.0

Loss of

appetite S570.2

consciousness J840.O

control S165.0

family member T7 15.0

hair S890.1

memory S215.0

sense of balance S225.0

senses S220.4

weight S045.0

weight, recent S045.1

Lumbago D905,0

Lump (see Mass)

Lupus erythematosus

discoid D825.O

systemic D9 10.0

Lymphadenitis D550.O

Lymphadenopathy D550.O

Lymphoma D135.O

LymphosarcomaD 135.0

hlaggots D030.O

Maladjustment, social T730.O

Malaise S025.0

Malingering S1 65.0

Mammography X340.O

Manic-depressive D305.O

Manipulation, joint T520.O

hfarital conflict T705.0

Marriage, NOS T705.0

M~SS, NOS S065.0

abdominal S565.2

breast S805.0

ear S365.2

eye S335.0

Mass, NOS S065.O--Con.

eyelid S340.3

nose S405.4

penis S700.3

perineal S875.0

rectum S605.3

scrotum S7 15.3

skin S875.0

testes S7 15.3

throat S455.6

vulva S770.2

Masturbation

concerns about S160.5

excessive S160.5

Matter, eye S3 10.3

Measles D015.O

German D015.O

Medication, NOS T1 15.0

allergy TIOO.O

birth control X505.O

check T1 15.0

is poisoned S155.0

physical T400.O

Melanoma D1 10.0

Melena S580.1

Membranes, ruptured S790.3

Memory

disturbance S215.0

10SS of S215.0

Menarche

delayed S745.0

early S745.0

Meningitis D3 70.0

Menopause, menopausal

concerns about S750.0

early S750.1

late onset S750.1

symptoms, NOS S750.0

Menorrhagia S740.1

Menstrual, menstruation

abnormal material S740.3

absent S730.0

blood clots S740.3

cramps S745.2

disorders S745.0

excessive S740.1

frequent S735.1

heavy flow S740.1

infrequent S735.2

irregular S735.0

painful S745.2

49
Menstrual, menstruation–Con.

scanty flow S740.2

tension S745.0

unpredictable S735.3

Metastases D130.O

Metrorrhagia S755.1

Migraine D365.O

Miscarriage S790.0

Mole

change in S845.1

growth in S845.1

Molestation J830.0

Money, not enough T700.0

MoniIiasis D025.O

Monitoring

fetal X370.O

Helter X350.O

Mono, mononucleosis D015.O

Movement limitation, movements, NOS S060.3

abnormal S200.0

ankle S930.3

back S905.3

back, low S91O.3

elbow S950.3

eye S325.0

eyelid, abnormal S340.4

fingers S960.3

foot S935.3

hand S960.3

hip S9 15.3

involuntary S200.0

joints S970.3

knee S925.3

neck S900.3

shoulder S940.3

toes S935.3

wrist S955.3

Mucus, excessive (nose) S400.0

Multiple

complaints S025.0

sclerosis D350.0

Mumps D015.O

Murmur, heart D520.O

Myelogram X345.O

Myeloma, multiple D135.O

Myoma, uterus D140.O

Myopia D405.O

Myositis D905.O

Myxedema D200.O

Nail biting S165.1

Nausea S~25.O

Navel, symptoms of S895.0

Nearsightedness D405.O

Needles and pins S220.3

Negativism S130.2

Neglect, child T7 10.0

Neoplasm (see Cancer)

Nerves, nervous, nervousness

breakdown S1 00.0

stomach S525.0

Neurosis, NOS D3 10.0

anxiety D3 10.0

depressive D3 10.0

obsessive-compulsive D3 10.0

Night sweats S035.2

Nightmares S135.3

No

complaint U99 7.0

vital signs J840.O

Nodes, erdarged S275.1

Nodule, nodules

breast S805.0

skin S875.0

thyroid D200.O

Noises

hearing (psychiatric)S 155.0

in ear S345.3

Nonresponsive J840.0

None or no complaint U99 7.0

Nosebleed S405.1

Not feeling well S025.0

Numbness S220.1

Nursing, difficulty with S8 10.2

Nutrition (counseling) T600.O

Obesity S040.0

Obsessions S1 30.5

Obstetrical, obstetrics, NOS X205.O

#

care X205.O

Obstruction, nasal S400.0

Odor, vaginal S765.0

Oiliness

hair S890.0

skin S880.1

Old age T730.O

Oligomenorrhea S740.2

Oophoritis D720.O

Ophthalmia D400.O
Orgasm

lack of S160.6

problems with S160.6

Orthopedic shoes T535.0

Orthopnea S420.0

Osteoarthritis D900.O

Osteomyelitis D9 10.0

Osteoporosis D9 10.0

Otitis

externa D455.O

media D450.O

out of

breath s415.o

work T725.O

Overaggressiveness S130.2

Overactivity S125.0

Overdose, NOS J91O.O

intentional J820.1

suicide attempt J820.1

Oversize

breast S81O.3

ears S365.4

nose S405.4

Overweight S040.O

Pacemaker, check X240.0

Pain, painful, NOS S060.1

abdominal, lower S550.1

abdominal, NOS S550.0

abdominal, upper S550.2

ankle S930.1

arm S945.1

back, 10W S910.1

back, NOS S905.1

bladder S665.1

bone S980.0

breast S800.0

chest S050.1

coital S825.0

during pregnancy S790.1

ear S355.1

elbow s950.1

cpigastric S550.2

erectionS700.1

extremity, lower S920.1

eye S320.1

facial S055.4

finger S960.1

flank S055.2

Pain, painful, NOS S060.1–Con,

foot S935.1

gallbladder S610.1

gas S550.0

generzdized S060.1

groin S055.3

gums S500.2

hand S960.1

head S21O.O

heart S265.0

hip S915.1

incision (postoperative) S060.0 (T205.0)

inguinal S550.1

joint S970.1

kidney S670.1

knee S925.1

labor S790.3

Ieg S920.1

lips S505.0

LLQ S550.1

LUQ S550.2

menstrual S745.2

mouth S510.1

muscIe S965.1

neck S900.1

nerve S240.0

no response to S220.1

nose S405.0

over heart S265.0

ovulation S775.1

pelvis S775.1

penis S700.1

postoperative S060.0, T205.0

postpartum S790.4

precordial S265.0

prostate S710.0

radiating S055.0

rectal S605.1

respiratory S420.0

rib S055.1

RLQ S550.1

RUQ S550.2

scrotum S715.1

shoulder S940.1

side S055.2

sinus S41 O.I

skin S870.1

sternum S055.1

stomach S545.1

51
Pain, painful, NOS S060.1–Con.

stump S9 80.0

testes S715.1

throat S455.2

toes S935.1

tongue S515.1

umbilical region S5 50.2

umbilicus S89 5.0

upper abdominal S550.2

upper extremity S945.1

urinary S650.0

vagina S765.1

vulva S770.0

wrist S955.1

Paleness S280.2

Pallor S280.2

Palpitations S260.0

Palsy

Bell’s D370.O

cerebral D3 70.0

Pancreatitis D670.O

Panic S1OO.O

Pap smear X365.O

abnormal R300.O

positive R300.O

repeat R300.O

Paralysis, NOS D370.O

agitans D355.O

Paranoia D305.O

Paresthesia S220.3

Parkinsonism D355.O

Paronychia D825.O

Passed, passing

blood S640.1

out S030.O

stones S680.0

Passive S130.1

Peeling, skin S880.2

Period (see also Menstrual, menstruation)

late X200.O

missed X200.O

Peritonitis, pelvic D720.O

Personality disturbance S165.0

Perspiration, excessive S035.2

Pharyngitis D600.O

Phimosis D71O.O

Phlebitis D535.O

Phlegm

bloody S470.1

coughing up S47 0.0

Phelgm–Con.

excessive S470.3

purulent S470.2

Phobia S105.O

Photophobia S305.0

Photosensitivity S305.0

Physical (see also Examination)

examination, NOS Xl 00.0

medicine T400.O

executive A 105.0

return to work A 100.0

therapy T400.O

Picking at ears S365.3

PID D720.O

Pierced ears T520.O

Pigeon-toed S975.3

Pigmentation, skin S835.0

Pill, birth control X505.O

Pimples S830.0

Pinched nerve S240.0

Pinkeye S3 15.1

Pinworms D030.O

PKU testX31 5.0

Placenta previa D735.O

Planning, family X500.O

Pleurisy D640.O

Plugged, ear S360.0

Pneumonia

bacterial D630.O

viral D630.O

Pneumonitis D630.O

Pneumothorax D640.0

Poison, poisoned, poisoning

accidental J900.O

blood D035.O

food J900.O ‘

ivy D825.O

oak D825.O

Poliomyelitis DO 15.0

PolIenosis D635.O

Pollution

air J920.O

noise J920.O

water J920.O

Polycythemia vera D 135.0

Polydipsia S035.3

polyp, NOS D145.O

cervical D140.o

endometrid D 140.0

52
Polyp, NOS D145.O–Con.

nasal D145.O

rectal D145.O

Polyuria S660.3

Pooped S015.0

Poor

economic problem T7 00.0

heart S270.0

Popping, ear S360.0

Postoperative visit, NOS T205.O

Postpartum, NOS X215.O

visit X21 5.0

Preoperative visit T200.O

Pregnancy, NOS X205.0

ectopic D 735.0

examination X205.O

multiple D735.0

out-of-wedlock T740.O

possible X200.O

unconfirmed X200.O

unwanted (counseling) X500.O

Prenatal visit X205.O

Prescription, NOS T1 15.0

birth control pill X505.O

renew (birth control pill) X505.O

Prescription renewal, glasses T5 15.0

Pressure

back, lower S9 10.0

chest S050.2

ear S365.0

head S21O.O

pelvic S775,2

sinus S41 0.1

Prickly sensation S220.3

Problem

behavior (school) T720.0

boss T725.O

breathing S430.0

change of life S750.3

children T7 10.0

community T730.O

complexion S830.0

data inadequate U998.O

digestive (infancy) S6 15.0

drinking S 145.0

economic T700.0

educational T720.0

emotional, related to menopause S750.3

employment T725.O

family T715.O

Problem–Con.

feeding S080.3

hormone S820.0

housing T 740.0

husband T705.O

job T725.O

learning S165.0

legal T735.O

male S720.0

marital T705.O

menstrual, menstruation S730.0-S 747.0

money T700.O

neighborhood T730.O

occupational T725.O

parents T71O.O

parent-child T7 10.0

personaI T605.0

postoperative T205.0

postpartum S790.4

posture S975.2

pregnancy S790.0

school T720.O

sexual (psychological) S1 60.0

sinus S41O.O

skin S880.0

social adjustment T73 0.0

social, NOS T740.0

stomach S615.0

wife T705.0

Proceedings, divorce T735.O

Procedure, postoperative (Code procedure and

postoperative visit T205 .0)

Proctoscopy X330.O

Products of conception passed S790.0

Progress visit, NOS T800.0

Prolapse, uterus D730.O

Prosecution T735.O

Prostatitis D7 10.0

Prosthetics T530.O

fit T530.O

Prostration SO15.0

Protrusion, eyes S330.2

Psoriasis D820.O

Psychiatric exam X130.O

Psychoanalysis T41 0.0

Psychosexual disorders S160.0

Psychosis, NOS D305.O

alcoholic D300.O

senile D300.O

Psychotherapy T41 0.0

53
Psychotic break S165.0

Pulled, pulling

at ears S365.3

muscle S965.0

Pulsations, pulse

decreased S260.2

increased S2 60.1

irregular S2 60.3

Puncture, NOS J325.O

head and face J305.O

lower extremity J3 15.0

lumbar X370.O

trunk J310.O

upper extremity J320.O

Pus

ear S350.2

eye S3 10.3

stool S600.1

urine S640.2

Pyelitis D705.O

Pyelogram, intravenous X345.O

Pyelonephritis D705.O

Pylorospasm S545.1

Pyuria S640.2

Quarrelsome, quarrelsomeness S130.2

Radio~aphy, diagnostic X345.O

Rape J830.O

Rash, NOS S860.0

diaper S860.1

skin S860.0

Rattle, chest S430.1

Reaction

adjustment D330.O

adolescent adjustment D330.O

allergic, NOS S090.0

anxiety D31 0.0

depressive D3 10.0

grief D330.O

medication J9 05.0

skin, allergic D825.O

Reading, visual difficulty S305.2

Recheck, NOS T800.O

Rectocele D730,0

Red nose S405.3

Redness

eyes S330.1

nose S405.3

skin S835.0

Refraction, error in D405.O

Regurgitation, infancy S080.2

Rehabilitation

physical T400.O

vocational T400.O

Relatives, problems with T7 15.0

Removal, remove

IUD X51O.O

lesion T520.O

sutures T5 55.0

sutures (postoperative) T555.0 (T205 .0)

tattoo T5 20.0

warts T520.1

Renewal of prescription T1 15.0

Respiration, respiratory

insufficiency S41 5.0

labored S420.0

painfuI S420.0

rhythm disorders S430.0

sighing S425.0

sound disorders S430. 1

Restlessness S 125.0

Results

blood test, NOS R1 10.0

cholesterol test R1 05.0

EKG R500.O

glucose test R1OO.O

Pap smear R300.O

serology R1 10.0

skin tests R600.O

test (see R1OO.O-R7OO.O)

test, NOS R700.O

urine test R200.O

X-ray R400.O

Retardation, mental D325.O

Retching S530.0

Retention

fluid S035.1

urine S660.1

Retraction, abnormal (eyes) S325.1

RH factor D735.O

Rheumatism, NOS D900.O

nonarticular D905.O

Rhinitis, NOS D600.O

allergic D635.O

Ridges

nails S885.3

tongue S515.4

Rigidity, abdominal S565.3

Ringing in

ears S345.3

head S345.3

54
Ringworm D025.O

Roughness, skin S880.0

Routine

checkup xl 00.0

Mowup T800.O

Rubella D015.O

Rubor S280.3

Ruddy, skin S835.0

Runaway S130.0

Rundown SO15.0

Runny nose S400.0

Runs S595.0

Rupture

eardrum D4,55.O

hernia D660.O

Sadness S1 10,0

Sagging, breasts S81O.3

Saliva, excess S51O.O

Salmonella DO05.O

!Mpingitis D7 20.0

Sarcoid D035.O

Scalded (see Burn)

Scaliness, skin S880.2

Scanning, radioisotope X345.O

ScarJ800.O

Schizophrenia D305.O

School, problem with T720.O

Sciatica S980.0

Scoliosis D91 0.0

Scratchy throat S455.4

Screaming S1 3043

Seeing things S155.0

Seizures S205.0

Self-

-esteem, lack of S120.0

hatred S120.0

Semiconscious J840.O

Senility D300.O

Sensation, sensations, sensation of

abnormal S220.3

burning S220.3

disturbance of S220.0

dropping, pelvis S775.2

eye, abnormal S320.0

falling S225.0

foreign body in eye S320.0

increased S220.2

10ss of S220.1

Sense of

smell, disturbance of S220.4

taste, disturbance of S220.4

Sensitization, RH D735.O

Separation T705.O

Serology, positive RI 10.0

Sex drive, loss of S160.1

Sexual

disorders, symptoms of S160.0

partner has V.D. X405.O

perversionS160.1

problemS160.0

response, lack of S1 60.1

Shaken up S165.0

Shaking S200.0

Shape, ears, abnormal S365.4,

Shingles DO15.0

Shock J840.O

anaphylactic J9 05.0

electrical J575.O

Short, shortness

of breath S415.0

too S075,1

Shot (see also Injection)

aIIergy TIOO.O

antibiotic T1 10.0

flu X400.O

gun J815.O

penicillin T1 10.0

tetanus X400.O

Shuffling steps s095.0

Shyness S130.1

Sick, NOS S025.0

to stomach S525.0

Sighing respiration S425.0

Sigmoidoscopy X330.O

Sinusitis D600.O

Size

abdominal, abnormal S5 65.0

breast, undesirable S8 10.3

ears, abnornud S365.4

nose, too large S405.4

Sleep

disturbances S135.0

inability to S135.1

sleepinessS135.2

sleeplessnessS135.1

too much S135.2

walkingS135.4

Slowing of, slowness

mental S165.0

55
Slowing of, slowness-Con.

of stream (urination) S660.2

physical S075.1

puke S260.2

Sluggish S025.0

Slurring S235.2

Smell

disturbance of S220.4

unusual S220.0

Smoking

excessiveS140.0

probIemS140.0

Smooth tongue S5 15.4

Sneezing S435.0

Sniffles S400.0

Snoring S430.1

Social maladjustments T730.O

Something in throat S455.6

Somnolence S135.2

Son (see Problem, parent-child T7 10.0)

Sore

canker D675.O

glands S275.2

in mouth S5 10.4

in nose S405.2

vulva S770.3

Soreness, sore (see also Pain)

throat S455.1

Spasm(s) (see Cramp(s))

Speech

disorder S235.0

disturbance S235.0

Spell, spelh S205.0

fainting S030.0

Spitting up S080.2

blood S470.1

Splint (we Cast)

Splitting, nails S885.3

spots

nails S885.0

skin S835.0

vision S3 05.3

Spotting

during pregnancy S790.2

vagimd, NOS S755.1

Sprain, NOSJ 130.0

ankle J120.O

back Jl10.O

cervical spineJ 105.0

Sprain, NOS J130.O–Con.

knee Jl15.O

neck J105.O

wrist J125.O

Sputum

abnormal S47 0.0

blood in S470.1

coughing up S47 0.0

excessive S470.3

purulent S740.2

pus in S470.2

Squinting S340.4

Stabbing J8 15.0

Staggering S095.0

Stammering S235.1

Stand, inability to S095.0

Staph infection D035.O

Steam burn (see Bum)

Stenosis, urinary D705.O

Sterility S815.0

Sterilization performed X525.O

Sticking out, ea& S365.4

Stiffness (see also Movement limitation, movements)

muscle S970.3

Stimulants, use of S1 50.0

Sting

bee J755.O

insect J755.O

Stitch, stitches (see Suture)

Stomatitis D675.O

Stoned

always S150.0

drugs J910.O

Stones

bladder D705.O

kidney D705.O

passed S680.0

stool

blood in S580.1

bulky S600.3

fatty S600.3

loose S595.0

mucus in S600.1

pus in S600.0

unusual color S600.3

unusual odor S600.3

worms in S600.2
Stopped up

t!arSS360.0

nose S400.0

sinuses S41 0.3

Strabismus D420.O

Strain (see also Sprain)

eye S320.4

Strep throat DO 10.0

Streptococci.1 sore throat DO1 0.0

Stricture, urinary D705.O

Strider S430.1

Stroke D525.O

Stuffed up, stuffiness

nose S400.0

nasal S400.0

Stumbling SO95.O

StuporJ840.O

Stuttering S235.1

Sty D400.O

Suffocation, sensation of S415.0

Sugar

blood R1OO.O

urine R200.O

Suicide attempt, suicide, NOS J820.O

desire to commit S165.0

overdose, intentional J820.1

Vio]ent J820.O

Sunburn J750.O

Superfluous, hair S890.2

Surgery, surgical

aftercare T205.O

minor T520.O

to schedule T200.O

Suture

insertion T5 55.0

removal, NOS T555.O

removal (injury) T555.O (J5 75.0)

removal (postoperative) T555.O (T205.0)

Swallowing

difficulty in S520.0

pain S520.0

Sweating, excessive S035.2

Swelling, swollen

abdominal S565.3

ankle (one) S930.5

ankles (both) S035.1

arm S945.5

breast S800.0

ear S365.0

SwelIing, swollen–Con.

elbow S950.5

eye S335.3

eyelids S340.1

face S035.1

finger S960.5

foot S935.5

glands S275.1

generalized S035.1

hand S960.5

hip S9 15.5

jaw S980.5

joints S9 70.5

knee S925.0

leg S920.5

lips S505.0

liver S61O.O

lymph glands S275.1

neck S900.5

nose S405.3

pelvic S775.3

penis S700.2

perineal S7 70.1

prostate S7 10.1

rectal S605.3

scrotum S7 15.2

shoulder S940.5

shut, eyes S340.1

skin S875.0

testes S715.2

throat S455.5

toes S935.5

tongue S51 5.3

tonsils S460.0

vulva S770.1

with water SO35.1

wrist S955.5

Swimmer’s ear S350.3

Syncope S030.0

Syndrome

carpal tunnel D370.O

irritabIe boweI D665.O

organic brain D3 00.0

Synovitis D905.O

Syphilis D020.O

Tachycardia S260.1

paroxysmal D520.O

Tall, too S075.2

Tap, spinaI X370.0

57
Taste

]0SS of S220.4

unusual S220.0

Tattoo, remove T520.O

Tearing

excessive S31 0.2

eye S31O.2

Temper problems S130.5

Temperature, high SO10.0

Tenderness

breast S800.0

penis S700.1

scrotum S715.1

skin S870.0

Tendinitis D905.O

Tennis, elbow S950.0

Tenosynovitis D905.O

Tension S1 00.0

nervous S1OO.O

premenstrual S745.1

sexual S160.0

Termination, pregnancy X515.0

Test

allergy X300.O

blood, premarital A135.1

blood cuIture X3 15.0

blood pressure X320.O

blood sugar X310.0

blood, for V.D. X315.1

blood, NOS X315.O

blood, required A135.O

cholesterol X315.0

clotting X31 5.0

diabetes X310.0

estriol (blood) X315.0

estriol (urine) X325.O

eye X230.O

for diabetes X31O.O

glaucoma X370.1

glucose X310.0

glucose tolerance X31 0.0

hearing X360.O

lab, NOS X370.O

PKU X315.O

PPB X305.O

pregnancy X200.O

prothrombin time X315.0

pulmonary function X370.O

sensitization X300.O

sickle cell X31 5.0

skin (allergy) X300.O

Test–Con.

skin (immunity) X305.O

stress X350.O

sugar X325.0

sugar (blood) X3 10.0

tuberculin x305.o

urine X325.O

urine, for sugar X325.0

V.D. X315.1

vision X230.O

Testes, pain S715.1

Testing, psychological X130.O

Texture, skin, change in S880.0

Therapy

grOUp T41O.O

heat T400.O

inhalation T405.0

occupatiomd T400.O

physical T400.O

radiation T4 15.0

recreational T400.O

respiratory T405.O

speech T400.O

ultraviolet T5 60.0

Thermography (breast) X340.O

Thin bIood D250.O

Thirst, thirsty

excessive S035.3

Thrombophlebitis D535.O

Thrombosis D535.O

Throwing up S530.0

feel like S525.0

Thrush D025.O

Thumbsucking S165.2

Thyrotoxicosis D200.O

Tickle, throat S455.4

Tics S200.0

Tightness, chest S050.2

Time, prothrombin X3 15.0

Time-zone syndrome S135.0

Tingling S220.3

Tinnitus S345.3

Tired, tiredness S015,0

blood S015.0

TonsiIIitis D605.O

streptococcal DO1O.O

Too

large, breasts S81O.3

little hair S890.1

small, breasts S81O.3

Toothache S500.1
Touch, loss of sense of S220.1

Toxemia D735.O

Treadmill X350.O

Treatment

allergy TIOO.O

asthma T405.O

Tremors S200.0

Trichomonas D035.O

Trip, bad J91 0.0

Trouble (see also Problem)

breathing S420.0

bladder S665.0

contact lens S335.1

ear S365.0

eating S615.0

eye S335,0

female S795.0

hearing S345.1

job T725.O

kidney S670.0

learning S165.0

marital T705.O

prostate S71O.O

seeing S305.2

sleepingS135.1

waIIiing S095.0

Truancy T720.O

Tuberculosis D035.0

Tumor (see also Mass)

brain D130.O

Turn in, feet S965.3

Turned

ankleJ120.O

wristJ565.O

Twisted ankle J120.O

Twitch, NOS S200.0

eyelid S340.4

Ulcer, NOS S865.0

duodenal D650.O

eye D400.O

mouth S510.4

nose S405.2

penis S700.0

peptic D650.O

perineum S770.3

skin S865.0

stomach D650.O

tongue S515.0

vulva S770.3

Ultrasonography X3 70.0

Umbilicus, problems of S895.0

Unable to

breathe S420.0

communicate S240.0

put weight on (leg) S920.4

sleep S135.1

stop drinkingS145.0

urinate (void) S660.1

Unbalanced S225.0*

emotionally S165.0

Uncodable U990.O

Unconscious J840.O

Uncooperative S165.0

Uncoordinated S095.0

Underweight S045.2

Undescended testicle(s) D955.O

Unemployment T725.O

Unequal pupils S325.3

Unhappy S110.0

Unresponsive J840.0

Unwanted hair S890.2

Upset

emotional S1OO.O

stomach S525.0

Urethritis D705.O

Urgency S645.0

Uric acid, high R1OO.O

Urinalysis X325.O

Urination, urinate

burning S650.0

difficulty in, NOS S660.0

difficulty starting S660.2

discomfort S650.0

frequent S645.0

frequent, at night S645.1

hesitancy S660.2

inability to S660.1

involuntary S655.1

large volume S660.3

painful S650.0

urgent S645.0

Urine

blood in S640.1

dark S640.3

pus in S640.2

retention of S600.1

unusual color S640.3

unusual odor S640.3

Urticaria D825.O

59
V.D. D020.O

exposed to X405.O

Vaccination X400.O

Vaginitis, NOS D725.O

Trichomonas D035.O

Varicose veins D540.O

Vasectomy

advice regarding X500.O

performed X525.O

VDRL, positive R1 10.0

Venogram X345.O

Vertigo S225.0

Vestibulitis D455.O

Violence J81 5.0

Virus, NOS S085.1

intestinal S540.0

stomach s540.0

throat S455.3

Vision

blurred S305.2

cloudy S305.3

diminished S305.2

disturbance S305.0

double S305.4

dull S305.2

dysfunction S305.0

extraneous S305.3

floaters S305.3

half S305.1

hazy S305.3

poor S305.2

tunnel S305.0

Visit

followup T800.O

postoperative, NOS T205.O

preoperative T200.0

progress T800.O

referraI U998.O

testing X370.O

Voice

disorder S480.0

10SS of S480.1

Vomiting S530.0

blood S580.1

Vulvitis D730.O

Walking, difficulty S095.0

Wart, NOS S850.0

Plantar’s DO15.0

vulva S770.3

Wart, NOS S850.O–Con.

penis S700.3

scrotum S715.3

Wasting extremities S980.0

Water broke S790.3

Watering, watery

eye S31O.2

Wax, waxy

ear S360.0

skin S880.0

Weak

blood S020.0

eyes S305.2

heart S270.0

Weakness, NOS S020.0

arm S945.4

extremities S230.0

general S020.0

hip S915.4

left-sided S230.0

leg S920.4

muscle S965.4

necrologic S230.0

right-sided S230.0

Weight, NOS T600.0

failure to gain S075.1

gain S040.0

loss S045.O

loss, recent S045.1

Well baby exam X105.O

Welts S875.0

Wheals S875.0

Wheezing S425.0

WheIps S875.0

Whiplash J105.0

Whiteheads S830.0

Widowhood T730.O

Wife (see ProbIem, marital T705,0)

Windburn J750.0

Withdrawal S130.1

woozy S225.0

Working mother T71O.O

Worms D030.O

worn out S015.O

Worried S100.0

Wound

gunshot J815.O

knife J815.O

skin J575.O

Wrinkles S880.3

60
Wrist drop S955.2

Writing, disturbances in S240.0

X-rays X345.O

Xerography (breast) X340.O

Yellow

eyes S61O.2

skin S61O.2

000

61
APPENDIX Ill

CODING RULES AND INSTRUCTIONS

Coding guidelines for the use of the RVC are

presented below. In addition to general coding

instructions, rules for coding within each module and clarifications of the content of selected

categories of the tabular list are also presented.

These guidelines have been implemented in the

NAMCS medical coding operation; however,

other users of the RVC may find it necessary to

restructure these rules to meet their specific

needs.

1.

2.

3.

4.

5.

The reason for visit should be coded

exactly as recorded, that is, no inferences regarding what the patient really

meant to say should be made.

The alphabetical index should be consulted first in assigning codes, and the

code should then be verified with the

designated category in the tabular list.

If a term cannot be found in the alphabetical index, synonymous terms should

be consulted. A Iist shouId be maintained of these nonindexed terms so that

they may be added periodically to the

index to make it as complete as possible.

Unspecified problems of a body part or

system should be coded to the body part

or system using the upper hierarchy

code, that is, the .0 code, of the appropriate category. For example, “Check

my nose” is coded S405.0, and “Problem with my ears” to S365.0.

Data should be coded as specifically as

possible. For example, “Nightmares”

(S135.3) is a specific code under the

broader code of “Disturbances of sleep”

(S135.0). The code for “Nightmares”

is, therefore, S135.3. However, if the

data simply stated “Sleep problem,” it

should be assigned to category S135.0,

since the type of sleep disturbance is

not specified. In cases where the information is specific, but there is no lower

hierarchy code to fit it, the coder should

code to the broad category. For example,. “Sore on the tongue” would be

coded to “Symptoms of the tongue”

(S515.0), since it does not fit under

“Pain” (S515.1), “Bleeding” (S515.2),

or the other specified tongue symptoms.

Upper hierarchy codes (.0) should be

used for not elsewhere classifiable (NEC)

and not otherwise specified (NOS) entries, unless specific codes are given for

these entries.

6. For terms with multiple interpretations,

for example, the term “Hurt” could

refer to “Pain” as “My arm hurts” or to

“Injury” as “I hurt my arm,” the coder

should first determine whether the entry

refers to a symptom or injury before

assigning a code from the appropriate

module.

Symptomatic data should be coded into the

Symptom Module regardless of whether the description is given in lay or medicz-d terrninology,

for example, “Hematuria” and “Blood in urine”

are both coded to category S640. 1. An attempt

has been made to include both lay terminology

and medical jargon in the alphabetical index.

Xloo.o, “General medical examination,”

should be used to code visits for examinations of

62
a comprehensive nature, that is, an examination

of all or most body systems. “Family planning”

requests should be coded as specifically as possible according to the type of service requested.

Reasons for visit, such as “For birth control” or

“For contraception” should be coded X500.0,

“Family planning, NOS .“

Visits indicating only that the visit was a folIowup for a previously performed surgery, that

is, a postoperative visit, should be coded T205.O.

When additional information about the reason

for visit is known, as “Postoperative visit, suture

removal,” both data items should be coded with

the suture removal being coded first and the

postoperative visit second. This rule also applies

to posttraumatic visits, that is, “Suture removal,

lacerated arm,” should be coded T555.0,

J225.O. The exclusions under T800.0, “Progress

visit, NOS, ” should be noted.

Fractures, sprains, lacerations, contusions, ~

burns, foreign bodies, and bites are always coded

into the Injuries and Adverse Effects Module.

The injury should be coded by type and location. If this information is not available, refer to

“Injury, NOS.” The codes for adverse effects

of drugs and alcohol, J9 10.0 and J9 15.0, respectively, refer to acute conditions of intoxication.

U9 90.0 should be used when the entry is not

codable elsewhere in the scheme. U997.0 should

be used to code entries of “None” or “No complaint.” U998.O should be used to code inadequate entries, that is, entries whose meaning cannot be determined from the available data.

U999.O should be used to code illegible entries.

000

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

Series 1, Programs and Collection Procedures. –Reports which describe the general programs of the National

Center for Health Statistics and its offices and divisions and data collection methods used and include

definitions and other material necessary for understanding the data.

Series 2. Data Evaluation and Methods Research. –Studies of new statistical methodology including experimental tests of new survey methods, studies of vital statistics collection methods, new analytical

techniques, objective evaluations of reliability of collected data, and contributions to statistical theory.

Series 3. Analytical Studies. –Reports presenting analytical or interpretive studies based on vital and health

statistics, cwrying the analysis further than the expository types of reports in the other series.

Series 4. Documents and Committee Reports. – Final reports of major committees concerned with vital and

health statistics and documents such as recommended model vital registration Iaws and revised birth

and death certificates.

Series 10. Data From the Health Interview Survey. –Statistics on illness, accidental injuries, disability, use of

hospital, medical, dental, and other services, and other heaIth-reIated topics, all based on data collected

in a continuing national household interview survey.

Sericx 11. Data From the Health Examination Survey and the Health and Nutrition Examination Survey .–Data

from direct examination, testing, and measurement of national samples of the civilian noninstitutionalized population provide the basis for two types of reports: (1) estimates of the medically defined

prevalence of specific diseases in the United States and the distributions of the population with respect

to physical, physiological, and psychological characteristics and (2) analysis of relationships among the

various measurements without reference to an explicit fhite universe of persons.

Series 12. Data From the Institutionalized Population Survey s.–Discontinued effective 1975. Future reports from

these surveys will be in Series 13.

Series 13. Data on Health Resources Utilization. –Statistics on the utilization of health manpower and facilities

providing long-term care, ambulatory care, hospitaI care, and family planning services.

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

occupations, hospitals, nursing homes, and outpatient facilities.

Series 20. Data on Mortality. –Various statistics on mortality other than as included in regular annual or monthly

reports. Special analyses by cause of death, age, and other demographic variables; geographic and time

series analyses; asrd statistics on characteristics of deaths not available from the vital records based on

sample surveys of those records.

Series 21. Data on Natality, Marriage, and Divorce. –Various statistics on natality, marriage, and divorce other

than as included in regular annual or monthly reports. Special analyses by demographic variables;

geographic and time series analyses; studies of fertility; and statistics on characteristics of births not

available from the vital records based on sample surveys of those records.

Series 22. Data From the National .kfortatity and Natality Survey s.–Discontinued effective 1975. Future reports

from these sample surveys based on vital records will be included in Series 20 and 21, respectively.

Series 23. Data From the National Survey of Family Gro wth. –Statistics on fertility, family formation and dissolution, family planning, and related maternal and infant health topics derived from a biennial survey

of a nationwide probability sample of ever-married women 15-44 years of age.

For a list of titles of reports published in these series, write to: Scientific and Technical Information Branch

National Center for Health Statistics

Public Health Service

Hyattsville, Md, 20782
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US DEPARTMENT OF HEALTH EDUCATION, ANO WELFARE us L) EPA RTMt W1 (>F HFW

P.blm Health Semce HEW 396

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