ICD 10 || Tabular list of inclusions and four-character subcategories || CHAPTER XV Pregnancy, childbirth and the puerperium (O00–O99) - CHAPTER XVIII Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00–R99)
CHAPTER XVII
Congenital malformations,
deformations and chromosomal abnormalities (Q00–Q99)
Excl.: inborn errors of metabolism (E70–E90)
This chapter contains the following blocks:
Q00–Q07 Congenital malformations of the
nervous system Q10–Q18 Congenital malformations of eye, ear, face and neck
Q20–Q28 Congenital malformations of the circulatory system Q30–Q34 Congenital
malformations of the respiratory system Q35–Q37 Cleft lip and cleft palate
Q38–Q45 Other congenital malformations of the
digestive system Q50–Q56 Congenital malformations of genital organs
Q60–Q64 Congenital
malformations of the urinary system
Q65–Q79 Congenital malformations and
deformations of the musculoskeletal system Q80–Q89 Other congenital
malformations
Q90–Q99 Chromosomal abnormalities, not
elsewhere classified
Congenital malformations of the nervous system (Q00–Q07)
Q00 Anencephaly and
similar malformations
Q00.0 Anencephaly
Acephaly Acrania Amyelencephaly Hemianencephaly Hemicephaly
Q00.1 Craniorachischisis Q00.2 Iniencephaly
Q01 Encephalocele
Incl.: encephalomyelocele hydroencephalocele hydromeningocele,
cranial meningocele, cerebral meningoencephalocele
Excl.: Meckel–Gruber
syndrome (Q61.9)
Q01.0 Frontal encephalocele Q01.1 Nasofrontal encephalocele Q01.2 Occipital
encephalocele Q01.8 Encephalocele
of other sites Q01.9 Encephalocele, unspecified
Q02 Microcephaly
Incl.: hydromicrocephaly micrencephalon
Excl.: Meckel–Gruber
syndrome (Q61.9)
Q03 Congenital hydrocephalus
Incl.: hydrocephalus
in newborn
Excl.: Arnold–Chiari syndrome (Q07.0) hydrocephalus:
•
acquired NOS (G91.-)
•
acquired, of newborn (P91.7)
•
due to congenital toxoplasmosis
(P37.1)
•
with spina bifida (Q05.0-Q05.4)
Q03.0 Malformations
of aqueduct of Sylvius
Aqueduct of Sylvius:
• anomaly
• obstruction,
congenital
• stenosis
Q03.1 Atresia
of foramina of Magendie and Luschka
Dandy–Walker syndrome
Q03.8 Other
congenital hydrocephalus
Q03.9 Congenital hydrocephalus, unspecified
Q04 Other congenital malformations of brain
Excl.: cyclopia (Q87.0)
macrocephaly (Q75.3)
Q04.0 Congenital
malformations of corpus callosum
Agenesis of corpus callosum
Q04.1 Arhinencephaly
Q04.2 Holoprosencephaly
Q04.3 Other
reduction deformities of brain
|
Absence Agenesis
Aplasia Hypoplasia |
of
part of brain |
Agyria Hydranencephaly Lissencephaly
Microgyria Pachygyria
Excl.: congenital
malformations of corpus callosum (Q04.0)
Q04.4 Septo-optic
dysplasia Q04.5 Megalencephaly
Q04.6 Congenital
cerebral cysts
Porencephaly Schizencephaly
Excl.: acquired
porencephalic cyst (G93.0)
Q04.8 Other
specified congenital malformations of brain
Macrogyria
Q04.9 Congenital
malformation of brain, unspecified
|
Congenital: •
anomaly •
deformity •
disease or lesion •
multiple anomalies |
NOS
of brain |
Q05 Spina bifida
Incl.: hydromeningocele (spinal) meningocele (spinal)
meningomyelocele myelocele myelomeningocele rachischisis
spina bifida (aperta)(cystica)
syringomyelocele
Excl.: Arnold–Chiari syndrome (Q07.0) spina bifida occulta
(Q76.0)
|
Q05.0 Cervical spina bifida with hydrocephalus
Q05.1 Thoracic spina bifida with hydrocephalus
Q05.2 Lumbar spina bifida with hydrocephalus
Lumbosacral spina bifida with
hydrocephalus Q05.3 Sacral
spina bifida with hydrocephalus Q05.4 Unspecified
spina bifida with hydrocephalus Q05.5 Cervical
spina bifida without hydrocephalus
Q05.6 Thoracic spina bifida without hydrocephalus
Spina bifida:
•
dorsal NOS
•
thoracolumbar NOS
Q05.7 Lumbar
spina bifida without hydrocephalus
Lumbosacral spina bifida NOS
Q05.8 Sacral
spina bifida without hydrocephalus Q05.9 Spina
bifida, unspecified
Q06 Other congenital malformations of spinal cord
Q06.0 Amyelia
Q06.1 Hypoplasia and dysplasia of spinal cord
Atelomyelia Myelatelia
Myelodysplasia of spinal cord
Q06.2 Diastematomyelia
Q06.3 Other congenital cauda equina
malformations Q06.4 Hydromyelia
Hydrorachis
|
Q06.8 Other specified congenital malformations
of spinal cord Q06.9 Congenital malformation of spinal
cord, unspecified
Q07 Other congenital malformations of nervous system
Excl.: familial dysautonomia [Riley–Day] (G90.1)
neurofibromatosis (nonmalignant) (Q85.0)
Q07.0 Arnold–Chiari syndrome
Q07.8 Other specified congenital malformations
of nervous system
Agenesis of nerve Displacement of brachial
plexus Jaw-winking syndrome
Marcus Gunn syndrome
Q07.9 Congenital
malformation of nervous system, unspecified
|
Congenital: •
anomaly •
deformity •
disease or lesion |
NOS
of nervous system |
Congenital
malformations of eye, ear, face and neck (Q10–Q18)
Excl.: cleft lip and cleft palate (Q35–Q37) congenital
malformation of:
• cervical
spine (Q05.0, Q05.5, Q67.5, Q76.0–Q76.4)
• larynx
(Q31.-)
• lip
NEC (Q38.0)
• nose
(Q30.-)
• parathyroid
gland (Q89.2)
• thyroid
gland (Q89.2)
Q10 Congenital malformations of eyelid, lacrimal apparatus and orbit
Excl.: cryptophthalmos:
• NOS (Q11.2)
• syndrome
(Q87.0) Q10.0 Congenital ptosis Q10.1 Congenital ectropion Q10.2 Congenital entropion
Q10.3 Other congenital malformations of eyelid
Ablepharon
Absence or agenesis of:
• cilia
•
eyelid Accessory:
• eyelid
•
eye muscle
Blepharophimosis, congenital Coloboma of eyelid
Congenital malformation of
eyelid NOS
Q10.4 Absence
and agenesis of lacrimal apparatus
Absence of punctum lacrimale
Q10.5 Congenital stenosis and stricture of
lacrimal duct Q10.6 Other
congenital malformations of lacrimal apparatus
Congenital malformation of
lacrimal apparatus NOS
Q10.7 Congenital
malformation of orbit
Q11 Anophthalmos, microphthalmos and macrophthalmos
Q11.0 Cystic eyeball
Q11.1 Other anophthalmos
|
Agenesis Aplasia |
of
eye |
Q11.2 Microphthalmos
Cryptophthalmos NOS Dysplasia of eye
Hypoplasia of eye Rudimentary eye
Excl.: cryptophthalmos
syndrome (Q87.0)
Q11.3 Macrophthalmos
Excl.: macrophthalmos
in congenital glaucoma (Q15.0)
Q12 Congenital lens malformations
Q12.0 Congenital cataract
Q12.1 Congenital
displaced lens Q12.2 Coloboma of lens
Q12.3 Congenital
aphakia Q12.4 Spherophakia
Q12.8 Other
congenital lens malformations Q12.9 Congenital
lens malformation, unspecified
Q13 Congenital malformations of anterior segment of eye
Q13.0 Coloboma of iris
Coloboma NOS
Q13.1 Absence
of iris
Aniridia
Q13.2 Other
congenital malformations of iris
Anisocoria, congenital Atresia of pupil
Congenital malformation of iris NOS Corectopia
Q13.3 Congenital
corneal opacity
Q13.4 Other
congenital corneal malformations Congenital malformation of
cornea NOS Microcornea
Peter anomaly
Q13.5 Blue sclera
Q13.8 Other congenital malformations of
anterior segment of eye
Rieger anomaly
Q13.9 Congenital malformation of anterior
segment of eye, unspecified
Q14 Congenital malformations of posterior segment of eye
Q14.0 Congenital malformation of vitreous humour
Congenital vitreous opacity
Q14.1 Congenital
malformation of retina
Congenital retinal aneurysm
Q14.2 Congenital
malformation of optic disc
Coloboma of optic disc
Q14.3 Congenital
malformation of choroid
Q14.8 Other congenital malformations of
posterior segment of eye
Coloboma of the fundus
Q14.9 Congenital malformation of posterior
segment of eye, unspecified
Q15 Other congenital malformations of eye
Excl.: congenital nystagmus (H55) ocular albinism (E70.3)
retinitis pigmentosa (H35.5)
Q15.0 Congenital glaucoma
Buphthalmos Glaucoma of newborn Hydrophthalmos
Keratoglobus, congenital, with glaucoma
Macrocornea with glaucoma Macrophthalmos in congenital glaucoma Megalocornea
with glaucoma
|
Q15.8 Other specified congenital malformations
of eye Q15.9 Congenital
malformation of eye, unspecified
Q16 Congenital
malformations of ear causing impairment
of hearing
Excl.: congenital
deafness (H90.-)
Q16.0 Congenital
absence of (ear) auricle
Q16.1 Congenital absence,
atresia and stricture of auditory canal (external)
Atresia or stricture of osseous
meatus
Q16.2 Absence
of eustachian tube
Q16.3 Congenital malformation of ear ossicles
Fusion of ear ossicles
Q16.4 Other
congenital malformations of middle ear
Congenital malformation of middle ear NOS
Q16.5 Congenital
malformation of inner ear
Anomaly:
• membranous
labyrinth
• organ
of Corti
Q16.9 Congenital malformation of ear causing
impairment of hearing, unspecified
Congenital absence of ear NOS
Q17 Other congenital malformations of ear
Excl.: preauricular
sinus (Q18.1)
Q17.0 Accessory auricle
Accessory tragus Polyotia
Preauricular appendage or tag Supernumerary:
• ear
• lobule
Q17.1 Macrotia
Q17.2 Microtia
Q17.3 Other misshapen ear
Pointed ear
Q17.4 Misplaced ear
Low-set ears
Excl.: cervical
auricle (Q18.2)
Q17.5 Prominent ear
Bat ear
Q17.8 Other
specified congenital malformations of ear
Congenital absence of lobe of ear
Q17.9 Congenital
malformation of ear, unspecified
Congenital anomaly of ear NOS
Q18 Other congenital malformations of face and neck
Excl.: cleft lip and cleft palate (Q35–Q37) conditions
classified to Q67.0–Q67.4
congenital malformations of skull and face
bones (Q75.-) cyclopia (Q87.0)
dentofacial anomalies [including malocclusion]
(K07.-) malformation syndromes affecting facial appearance (Q87.0) persistent
thyroglossal duct (Q89.2)
Q18.0 Sinus,
fistula and cyst of branchial cleft
Branchial vestige
Q18.1 Preauricular
sinus and cyst
Fistula (of):
• auricle,
congenital
• cervicoaural Pretragal sinus and cyst
Q18.2 Other
branchial cleft malformations Branchial cleft malformation
NOS Cervical auricle
Otocephaly
Q18.3 Webbing
of neck
Pterygium colli
Q18.4 Macrostomia
Q18.5 Microstomia
Q18.6 Macrocheilia
Hypertrophy of lip, congenital
Q18.7 Microcheilia
Q18.8 Other specified congenital malformations
of face and neck
|
Medial: •
cyst •
fistula •
sinus |
of
face and neck |
Q18.9 Congenital malformation of face and
neck, unspecified
Congenital anomaly NOS of face and neck
Congenital malformations of the circulatory system
(Q20–Q28)
Q20 Congenital malformations of cardiac chambers and connections
Excl.: dextrocardia with situs inversus (Q89.3)
mirror-image atrial arrangement
with situs inversus (Q89.3)
Q20.0 Common
arterial trunk
Persistent truncus arteriosus
Q20.1 Double
outlet right ventricle
Taussig–Bing syndrome
Q20.2 Double
outlet left ventricle
Q20.3 Discordant ventriculoarterial connection
Dextrotransposition of aorta Transposition of
great vessels (complete)
Q20.4 Double
inlet ventricle
Common ventricle
Cor triloculare biatriatum Single ventricle
Q20.5 Discordant
atrioventricular connection
Corrected transposition Laevotransposition
Ventricular inversion
Q20.6 Isomerism
of atrial appendages
Isomerism of atrial appendages with asplenia or
polysplenia
Q20.8 Other congenital malformations of
cardiac chambers and connections
Q20.9 Congenital malformation of cardiac
chambers and connections, unspecified
Q21 Congenital malformations of cardiac septa
Excl.: acquired
cardiac septal defect (I51.0)
Q21.0 Ventricular septal defect Q21.1 Atrial septal defect
Coronary sinus defect Patent or persistent:
• foramen
ovale
• ostium secundum defect (type II) Sinus venosus defect
Q21.2 Atrioventricular
septal defect Common
atrioventricular canal Endocardial cushion defect
Ostium primum atrial septal
defect (type I)
Q21.3 Tetralogy of Fallot
Ventricular septal defect with pulmonary
stenosis or atresia, dextroposition of aorta and hypertrophy of right
ventricle.
Q21.4 Aortopulmonary
septal defect Aortic septal defect Aortopulmonary window
Q21.8 Other
congenital malformations of cardiac septa
Eisenmenger defect Pentalogy of Fallot
Excl.: Eisenmenger
• complex
(I27.8)
• syndrome (I27.8)
Q21.9 Congenital
malformation of cardiac septum, unspecified
Septal (heart) defect NOS
Q22 Congenital malformations of pulmonary and tricuspid
valves
Q22.0 Pulmonary
valve atresia
Q22.1 Congenital
pulmonary valve stenosis Q22.2 Congenital
pulmonary valve insufficiency
Congenital pulmonary valve regurgitation
Q22.3 Other
congenital malformations of pulmonary valve
Congenital malformation of pulmonary valve NOS
Q22.4 Congenital
tricuspid stenosis
Tricuspid atresia
Q22.5 Ebstein’s anomaly
Q22.6 Hypoplastic right heart syndrome
Q22.8 Other
congenital malformations of tricuspid valve Q22.9 Congenital malformation of tricuspid valve, unspecified
Q23 Congenital malformations of aortic and mitral valves
Q23.0 Congenital stenosis of aortic valve
Congenital aortic:
• atresia
• stenosis
Excl.: congenital subaortic stenosis (Q24.4)
that in
hypoplastic left heart syndrome (Q23.4)
Q23.1 Congenital
insufficiency of aortic valve
Bicuspid aortic valve Congenital aortic insufficiency
Q23.2 Congenital
mitral stenosis
Congenital mitral atresia
Q23.3 Congenital
mitral insufficiency Q23.4 Hypoplastic
left heart syndrome
Atresia, or marked hypoplasia of aortic orifice or valve, with
hypoplasia of
ascending aorta and defective development of left ventricle
(with mitral valve stenosis or atresia)
Q23.8 Other congenital malformations of aortic and mitral valves Q23.9 Congenital malformation of aortic and mitral valves,
unspecified
Q24 Other congenital malformations of heart
Excl.: endocardial
fibroelastosis (I42.4)
Q24.0 Dextrocardia
Excl.: dextrocardia with situs inversus (Q89.3)
isomerism of atrial appendages (with asplenia
or polysplenia) (Q20.6)
mirror-image
atrial arrangement with situs inversus (Q89.3)
Q24.1 Laevocardia
Location of heart in left hemithorax with apex
pointing to the left, but with situs inversus
of other viscera
and defects of the heart,
or corrected transposition of great vessels.
Q24.2 Cor triatriatum
Q24.3 Pulmonary
infundibular stenosis Q24.4 Congenital
subaortic stenosis Q24.5 Malformation
of coronary vessels
Congenital coronary (artery) aneurysm
Q24.6 Congenital
heart block
Q24.8 Other specified congenital malformations
of heart
Congenital:
• diverticulum
of left ventricle
• malformation
of:
–
myocardium
–
pericardium
Malposition of heart Uhl disease
Q24.9 Congenital
malformation of heart, unspecified
|
Congenital: •
anomaly •
disease |
NOS
of heart |
Q25 Congenital malformations of great arteries
Q25.0 Patent ductus arteriosus
Patent ductus Botalli Persistent ductus
arteriosus
Q25.1 Coarctation
of aorta
Coarctation of aorta (preductal)(postductal)
Q25.2 Atresia of aorta Q25.3 Stenosis of
aorta
Supravalvular aortic stenosis
Excl.: congenital
stenosis of aortic valve (Q23.0)
Q25.4 Other
congenital malformations of aorta
|
Absence Aplasia Congenital: •
aneurysm •
dilatation |
of
aorta |
Aneurysm of sinus of Valsalva (ruptured)
Double aortic arch [vascular ring of aorta] Hypoplasia of aorta
Persistent:
• convolutions
of aortic arch
• right
aortic arch
Excl.: hypoplasia
of aorta in hypoplastic left heart syndrome (Q23.4)
Q25.5 Atresia of pulmonary artery Q25.6 Stenosis of pulmonary artery
Supravalvular pulmonary
stenosis
Q25.7 Other
congenital malformations of pulmonary artery
Aberrant pulmonary artery Agenesis
Aneurysm, congenital Anomaly
Hypoplasia
of pulmonary artery
Pulmonary arteriovenous aneurysm
Q25.8 Other
congenital malformations of great arteries Q25.9 Congenital malformation of great arteries, unspecified
Q26 Congenital malformations of great veins
Q26.0 Congenital stenosis of vena cava
Congenital stenosis of vena cava (inferior)(superior)
Q26.1 Persistent
left superior vena cava
Q26.2 Total anomalous pulmonary venous
connection Q26.3 Partial
anomalous pulmonary venous connection
Q26.4 Anomalous
pulmonary venous connection, unspecified
Q26.5 Anomalous portal venous connection
Q26.6 Portal vein–hepatic artery fistula
Q26.8 Other congenital malformations of great veins
Absence of vena cava (inferior)(superior)
Azygos continuation of inferior vena cava Persistent left posterior cardinal
vein Scimitar syndrome
Q26.9 Congenital
malformation of great vein, unspecified
Anomaly of vena cava (inferior)(superior) NOS
Q27 Other congenital malformations of peripheral vascular system
Excl.: anomalies
of:
• cerebral
and precerebral vessels (Q28.0–Q28.3)
• coronary
vessels (Q24.5)
•
pulmonary artery
(Q25.5–Q25.7) congenital retinal aneurysm (Q14.1) haemangioma and lymphangioma (D18.-)
Q27.0 Congenital
absence and hypoplasia of umbilical artery
Single umbilical artery
Q27.1 Congenital
renal artery stenosis
Q27.2 Other congenital malformations of renal artery
Congenital malformation of renal artery NOS
Multiple renal arteries
Q27.3 Peripheral
arteriovenous malformation
Arteriovenous aneurysm
Excl.: acquired
arteriovenous aneurysm (I77.0)
Q27.4 Congenital phlebectasia
Q27.8 Other specified congenital malformations
of peripheral vascular system
Aberrant subclavian artery
|
Absence Atresia |
of
artery or vein NEC |
Congenital:
• aneurysm
(peripheral)
• stricture, artery
• varix
Q27.9 Congenital malformation of peripheral
vascular system, unspecified
Anomaly of artery or vein NOS
Q28 Other congenital malformations of circulatory system
Excl.: congenital
aneurysm:
• NOS (Q27.8)
• coronary
(Q24.5)
• peripheral
(Q27.8)
• pulmonary
(Q25.7)
•
retinal (Q14.1) ruptured:
• cerebral
arteriovenous malformation (I60.8)
• malformation
of precerebral vessels (I72.-)
Q28.0 Arteriovenous
malformation of precerebral vessels
Congenital arteriovenous precerebral aneurysm
(nonruptured)
Q28.1 Other
malformations of precerebral vessels
Congenital:
• malformation
of precerebral vessels NOS
• precerebral
aneurysm (nonruptured)
Q28.2 Arteriovenous
malformation of cerebral vessels
Arteriovenous malformation of
brain NOS
Congenital arteriovenous
cerebral aneurysm (nonruptured)
Q28.3 Other
malformations of cerebral vessels
Congenital:
• cerebral
aneurysm (nonruptured)
• malformation
of cerebral vessels NOS
Q28.8 Other specified congenital malformations
of circulatory system
Congenital aneurysm, specified
site NEC
Q28.9 Congenital
malformation of circulatory system, unspecified
Congenital malformations of the respiratory system (Q30–Q34)
Q30 Congenital malformations of nose
Excl.: congenital
deviation of nasal septum (Q67.4)
Q30.0 Choanal atresia
|
Atresia Congenital stenosis |
of
nares (anterior)(posterior) |
Q30.1 Agenesis and underdevelopment of nose
Congenital absence of nose
Q30.2 Fissured,
notched and cleft nose Q30.3 Congenital
perforated nasal septum
Q30.8 Other
congenital malformations of nose
Accessory nose
Congenital anomaly of nasal
sinus wall
Q30.9 Congenital
malformation of nose, unspecified
Q31 Congenital malformations of larynx
Excl.: congenital
(laryngeal) stridor NOS (P28.8)
Q31.0 Web
of larynx
Web of larynx:
•
NOS
•
glottic
•
subglottic
Q31.1 Congenital
subglottic stenosis Q31.2 Laryngeal hypoplasia
Q31.3 Laryngocele
Q31.5 Congenital laryngomalacia
Q31.8 Other congenital malformations of larynx
|
Absence Agenesis
Atresia |
of cricoid cartilage, epiglottis, glottis, larynx or
thyroid cartilage |
Cleft thyroid cartilage
Congenital stenosis of larynx NEC Fissure of
epiglottis
Posterior cleft of cricoid
cartilage
Q31.9 Congenital
malformation of larynx, unspecified
Q32 Congenital malformations of trachea and bronchus
Excl.: congenital
bronchiectasis (Q33.4)
Q32.0 Congenital tracheomalacia
Q32.1 Other congenital malformations of trachea
Anomaly of tracheal cartilage Atresia of
trachea
|
Congenital: •
dilatation •
malformation •
stenosis |
of
trachea |
Congenital tracheocele
Q32.2 Congenital
bronchomalacia Q32.3 Congenital
stenosis of bronchus
Q32.4 Other
congenital malformations of bronchus
|
Absence Agenesis Atresia Congenital
malformation NOS Diverticulum |
of
bronchus |
Q33 Congenital malformations of lung
Q33.0 Congenital cystic lung
Congenital:
• honeycomb
lung
• lung
disease:
–
cystic
–
polycystic
Excl.: cystic
lung disease, acquired or unspecified (J98.4)
Q33.1 Accessory lobe of lung Q33.2 Sequestration of lung Q33.3 Agenesis of
lung
Absence of lung (lobe)
Q33.4 Congenital bronchiectasis
Q33.5 Ectopic tissue in lung
Q33.6 Hypoplasia and dysplasia of lung
Excl.: pulmonary
hypoplasia associated with short gestation (P28.0)
Q33.8 Other
congenital malformations of lung Q33.9 Congenital
malformation of lung, unspecified
Q34 Other congenital malformations of respiratory system
Q34.0 Anomaly of pleura
Q34.1 Congenital cyst of mediastinum
Q34.8 Other
specified congenital malformations of respiratory
system
Atresia of nasopharynx
Q34.9 Congenital
malformation of respiratory system, unspecified
|
Congenital: •
absence •
anomaly NOS |
of
respiratory organ |
Cleft lip and cleft palate (Q35–Q37)
Use additional code (Q30.2), if desired, to identify
associated malformations of the nose.
Excl.: Robin syndrome (Q87.0)
Q35 Cleft palate
Incl.: fissure of palate
palatoschisis
Excl.: cleft
palate with cleft lip (Q37.-)
Q35.1 Cleft
hard palate Q35.3 Cleft soft palate
Q35.5 Cleft hard
palate with cleft soft palate Q35.7 Cleft uvula
Q35.9 Cleft palate, unspecified
Q36 Cleft lip
Incl.: cheiloschisis
congenital fissure of lip harelip
labium leporinum
Excl.: cleft
lip with cleft palate (Q37.-)
Q36.0 Cleft lip, bilateral Q36.1 Cleft
lip, median Q36.9 Cleft lip, unilateral
Cleft lip NOS
Q37 Cleft palate with cleft
lip
Q37.0 Cleft hard palate with bilateral cleft
lip Q37.1 Cleft hard palate with
unilateral cleft lip
Cleft hard palate with cleft
lip NOS
Q37.2 Cleft soft palate with bilateral cleft
lip Q37.3 Cleft soft palate with
unilateral cleft lip
Cleft soft palate with cleft
lip NOS
Q37.4 Cleft hard and soft palate with
bilateral cleft lip Q37.5 Cleft hard and
soft palate with unilateral cleft lip
Cleft hard and soft palate with
cleft lip NOS
Q37.8 Unspecified cleft palate with bilateral
cleft lip Q37.9 Unspecified cleft
palate with unilateral cleft lip
Cleft palate with cleft lip NOS
Other congenital malformations of the digestive system
(Q38–Q45)
Q38 Other congenital malformations of tongue, mouth and pharynx
Excl.: macrostomia (Q18.4) microstomia (Q18.5)
Q38.0 Congenital
malformations of lips, not elsewhere classified
Congenital:
• fistula
of lip
• malformation of lip NOS Van der Woude syndrome
Excl.: cleft lip (Q36.-) cleft lip:
•
with cleft palate
(Q37.-) macrocheilia (Q18.6) microcheilia (Q18.7)
Q38.1 Ankyloglossia
Tongue tie
Q38.2 Macroglossia
Q38.3 Other congenital malformations of tongue
Aglossia Bifid tongue
|
Congenital: •
adhesion •
fissure •
malformation NOS |
of
tongue |
Hypoglossia Hypoplasia of tongue Microglossia
Q38.4 Congenital
malformations of salivary glands and ducts
|
Absence Accessory
Atresia |
(of)
salivary gland or duct |
Congenital fistula of salivary gland
Q38.5 Congenital
malformations of palate, not elsewhere classified
Absence of uvula
Congenital malformation of palate NOS High arched palate
Excl.: cleft palate (Q35.-) cleft
palate:
•
with cleft lip (Q37.-)
Q38.6 Other
congenital malformations of mouth
Congenital malformation of mouth NOS
Q38.7 Pharyngeal
pouch
Diverticulum of pharynx
Excl.: pharyngeal
pouch syndrome (D82.1)
Q38.8 Other
congenital malformations of pharynx
Congenital malformation of pharynx NOS
Q39 Congenital malformations of oesophagus
Q39.0 Atresia
of oesophagus without fistula
Atresia of oesophagus NOS
Q39.1 Atresia
of oesophagus with tracheo-oesophageal fistula
Atresia of oesophagus with broncho-oesophageal fistula
Q39.2 Congenital
tracheo-oesophageal fistula without atresia
Congenital tracheo-oesophageal fistula NOS
Q39.3 Congenital
stenosis and stricture of oesophagus
Q39.4 Oesophageal web
Q39.5 Congenital
dilatation of oesophagus Q39.6 Diverticulum
of oesophagus
Oesophageal pouch
Q39.8 Other
congenital malformations of oesophagus
|
Absent Congenital
displacement Duplication |
(of)
oesophagus |
Q39.9 Congenital malformation of oesophagus, unspecified
Q40 Other
congenital malformations of upper alimentary
tract
Q40.0 Congenital hypertrophic pyloric stenosis
|
Congenital or infantile: •
constriction •
hypertrophy •
spasm •
stenosis •
stricture |
of
pylorus |
Q40.1 Congenital hiatus hernia
Displacement of cardia through oesophageal hiatus
Excl.: congenital
diaphragmatic hernia (Q79.0)
Q40.2 Other
specified congenital malformations of stomach
Congenital:
• displacement
of stomach
• diverticulum
of stomach
• hourglass stomach Duplication of stomach Megalogastria
Microgastria
Q40.3 Congenital malformation of stomach, unspecified Q40.8 Other specified congenital
malformations of upper
alimentary tract
Q40.9 Congenital malformation of upper
alimentary tract, unspecified
|
Congenital: •
anomaly •
deformity |
NOS
of upper alimentary tract |
Q41 Congenital absence, atresia and stenosis of small intestine
Incl.: congenital obstruction, occlusion and stricture of small
intestine or intestine NOS
Excl.: meconium
ileus (E84.1)
Q41.0 Congenital absence, atresia and stenosis
of duodenum Q41.1 Congenital absence, atresia and
stenosis of jejunum
Apple peel syndrome Imperforate jejunum
Q41.2 Congenital
absence, atresia and stenosis of ileum
Q41.8 Congenital absence,
atresia and stenosis
of other specified parts of small intestine
Q41.9 Congenital
absence, atresia and stenosis of small intestine,
part unspecified
Congenital absence, atresia and
stenosis of intestine NOS
Q42 Congenital absence, atresia and stenosis of large intestine
Incl.: congenital obstruction, occlusion and
stricture of large intestine
Q42.0 Congenital
absence, atresia and stenosis of rectum with fistula Q42.1 Congenital absence, atresia and stenosis of
rectum without
fistula
Imperforate rectum
Q42.2 Congenital absence, atresia and stenosis
of anus with fistula Q42.3 Congenital absence, atresia and stenosis
of anus without fistula
Imperforate anus
Q42.8 Congenital absence, atresia and stenosis
of other parts of large intestine
Q42.9 Congenital
absence, atresia and stenosis of large intestine, part unspecified
Q43 Other congenital malformations of intestine
Q43.0 Meckel’s diverticulum
Persistent:
•
omphalomesenteric duct
•
vitelline duct
Q43.1 Hirschsprung disease
Aganglionosis
Congenital (aganglionic)
megacolon
Q43.2 Other
congenital functional disorders of colon
Congenital dilatation of colon
Q43.3 Congenital
malformations of intestinal fixation
Congenital adhesions [bands]:
• omental,
anomalous
• peritoneal Jackson membrane
Malrotation of colon
|
Rotation: •
failure of •
incomplete •
insufficient |
of
caecum and colon |
Universal mesentery Q43.4 Duplication of
intestine Q43.5 Ectopic anus
Q43.6 Congenital fistula of rectum and anus
Excl.: congenital
fistula:
• rectovaginal
(Q52.2)
•
urethrorectal (Q64.7)
pilonidal fistula or sinus (L05.-)
with absence, atresia and
stenosis (Q42.0, Q42.2)
Q43.7 Persistent cloaca
Cloaca NOS
Q43.8 Other
specified congenital malformations of intestine
Congenital:
• blind
loop syndrome
• diverticulitis,
colon
• diverticulum, intestine Dolichocolon Megaloappendix Megaloduodenum
Microcolon Transposition of:
• appendix
• colon
• intestine
Q43.9 Congenital
malformation of intestine, unspecified
Q44 Congenital
malformations of gallbladder, bile ducts and
liver
Q44.0 Agenesis, aplasia and hypoplasia of gallbladder
Congenital absence of gallbladder
Q44.1 Other
congenital malformations of gallbladder Congenital
malformation of gallbladder NOS Intrahepatic gallbladder
Q44.2 Atresia
of bile ducts
Q44.3 Congenital
stenosis and stricture of bile ducts Q44.4 Choledochal cyst
Q44.5 Other
congenital malformations of bile ducts
Accessory hepatic duct
Congenital malformation of bile duct NOS
Duplication:
•
biliary duct
•
cystic duct
Q44.6 Cystic
disease of liver
Fibrocystic disease of liver
Q44.7 Other
congenital malformations of liver
Accessory liver Alagille’s syndrome
Congenital:
•
absence of liver
•
hepatomegaly
•
malformation of liver NOS
Q45 Other
congenital malformations of digestive system
Excl.: congenital:
•
diaphragmatic hernia (Q79.0)
•
hiatus hernia (Q40.1)
Q45.0 Agenesis,
aplasia and hypoplasia of pancreas
Congenital absence of pancreas
Q45.1 Annular pancreas
Q45.2 Congenital pancreatic cyst
Q45.3 Other
congenital malformations of pancreas and pancreatic duct
Accessory pancreas
Congenital malformation of
pancreas or pancreatic duct NOS
Excl.: diabetes
mellitus:
•
congenital (E10.-)
• neonatal
(P70.2)
fibrocystic disease of pancreas
(E84.-)
Q45.8 Other
specified congenital malformations of digestive system
Absence (complete)(partial) of alimentary tract NOS
|
Duplication Malposition, congenital |
of
digestive organs NOS |
Q45.9 Congenital
malformation of digestive system, unspecified
|
Congenital: •
anomaly •
deformity |
NOS
of digestive system |
Congenital malformations of genital organs (Q50–Q56)
Excl.: androgen-resistance syndrome (E34.5)
syndromes associated with anomalies in the
number and form of chromosomes (Q90–Q99)
testicular feminization
syndrome (E34.5)
Q50
Congenital malformations of
ovaries, fallopian tubes and broad ligaments
Q50.0 Congenital absence of ovary
Excl.: Turner syndrome (Q96.-) Q50.1 Developmental
ovarian cyst Q50.2 Congenital torsion of ovary
Q50.3
Other congenital malformations of ovary
Accessory ovary
Congenital malformation of ovary NOS Ovarian
streak
Q50.4 Embryonic cyst of fallopian tube
Fimbrial cyst
Q50.5 Embryonic
cyst of broad ligament
Cyst:
• epoophoron
• Gartner duct
• parovarian
Q50.6 Other
congenital malformations of fallopian tube and broad ligament
|
Absence Accessory Atresia |
(of)
fallopian tube or broad ligament |
Congenital malformation of fallopian tube or broad
ligament NOS
Q51 Congenital malformations of uterus and cervix
Q51.0 Agenesis
and aplasia of uterus
Congenital absence of uterus
Q51.1 Doubling of uterus with doubling of
cervix and vagina Q51.2 Other doubling
of uterus
Doubling of uterus NOS
Q51.3 Bicornate uterus Q51.4 Unicornate uterus
Q51.5 Agenesis and aplasia of cervix
Congenital absence of cervix
Q51.6 Embryonic
cyst of cervix
Q51.7 Congenital
fistulae between uterus and digestive and urinary tracts
Q51.8 Other congenital malformations of uterus
and cervix
Hypoplasia of uterus and cervix
Q51.9 Congenital
malformation of uterus and cervix, unspecified
Q52 Other congenital malformations of female genitalia
Q52.0 Congenital
absence of vagina Q52.1 Doubling of vagina
Septate vagina
Excl.: doubling
of vagina with doubling of uterus and cervix (Q51.1)
Q52.2 Congenital
rectovaginal fistula
Excl.:
cloaca (Q43.7)
Q52.3 Imperforate
hymen
Q52.4 Other congenital malformations of vagina
Congenital malformation of vagina NOS Cyst:
•
canal of Nuck, congenital
•
embryonic vaginal
Q52.5 Fusion
of labia
|
Q52.6 Congenital
malformation of clitoris Q52.7 Other
congenital malformations of vulva
Q52.8 Other
specified congenital malformations of female genitalia Q52.9 Congenital malformation of female genitalia, unspecified
Q53 Undescended testicle
Q53.0 Ectopic testis
Unilateral or bilateral ectopic testes Q53.1 Undescended
testicle, unilateral Q53.2 Undescended
testicle, bilateral
Q53.9 Undescended testicle, unspecified
Cryptorchism NOS
Q54 Hypospadias
Excl.: epispadias
(Q64.0)
Q54.0 Hypospadias, balanic
Hypospadias:
• coronal
• glandular
Q54.1 Hypospadias,
penile Q54.2 Hypospadias,
penoscrotal Q54.3 Hypospadias, perineal
Q54.4 Congenital chordee
Q54.8 Other
hypospadias
Q54.9 Hypospadias, unspecified
Q55 Other congenital malformations of male genital organs
Excl.: congenital hydrocele (P83.5) hypospadias (Q54.-)
Q55.0 Absence
and aplasia of testis
Monorchism
Q55.1 Hypoplasia
of testis and scrotum
Fusion of testes
Q55.2 Other
congenital malformations of testis and scrotum Congenital
malformation of testis or scrotum NOS Polyorchism
Retractile testis Testis migrans
Q55.3 Atresia
of vas deferens
Q55.4 Other congenital malformations of vas
deferens, epididymis, seminal vesicles and prostate
Absence or aplasia of:
• prostate
• spermatic cord
Congenital malformation of vas deferens,
epididymis, seminal vesicles or prostate NOS
Q55.5 Congenital absence and aplasia of penis Q55.6 Other
congenital malformations of penis
Congenital malformation of penis NOS Curvature
of penis (lateral)
Hypoplasia of penis
|
Q55.8 Other
specified congenital malformations of
male genital organs Q55.9 Congenital malformation of male
genital organ, unspecified
Q56 Indeterminate sex and pseudohermaphroditism
Excl.: pseudohermaphroditism:
• female,
with adrenocortical disorder (E25.-)
• male,
with androgen resistance (E34.5)
• with
specified chromosomal anomaly (Q96–Q99)
Q56.0 Hermaphroditism,
not elsewhere classified
Ovotestis
Q56.1 Male
pseudohermaphroditism, not elsewhere classified
Male pseudohermaphroditism NOS
Q56.2 Female
pseudohermaphroditism, not elsewhere classified
Female pseudohermaphroditism NOS
Q56.3 Pseudohermaphroditism, unspecified Q56.4 Indeterminate sex, unspecified
Ambiguous genitalia
Congenital malformations of the urinary system (Q60–Q64)
Q60 Renal agenesis
and other reduction defects of kidney
Incl.: atrophy
of kidney:
• congenital
•
infantile
congenital absence of kidney Q60.0 Renal
agenesis, unilateral Q60.1 Renal
agenesis, bilateral Q60.2 Renal
agenesis, unspecified Q60.3 Renal
hypoplasia, unilateral Q60.4 Renal
hypoplasia, bilateral Q60.5 Renal
hypoplasia, unspecified Q60.6 Potter syndrome
Q61 Cystic kidney disease
Excl.: cyst of kidney (acquired) (N28.1) Potter syndrome (Q60.6)
Q61.0 Congenital
single renal cyst
Congenital cyst of kidney (single)
Q61.1 Polycystic
kidney, autosomal recessive
Congenital cyst of kidney (single)
Q61.2 Polycystic
kidney, autosomal dominant
Polycystic kidney, adult type
Q61.3 Polycystic kidney, unspecified Q61.4 Renal dysplasia
Multicystic:
• dyplastic
kidney
• kidney
(developmental)
• kidney
disease
• renal
dysplasia
Excl.: polycystic
kidney disease (Q61.1–Q61.3)
Q61.5 Medullary
cystic kidney
Sponge kidney NOS
Q61.8 Other
cystic kidney diseases
Fibrocystic:
• kidney
• renal
degeneration or disease
Q61.9 Cystic
kidney disease, unspecified
Meckel–Gruber syndrome
Q62 Congenital obstructive defects of renal pelvis and
congenital malformations of ureter
Q62.0 Congenital hydronephrosis Q62.1 Atresia and stenosis of ureter
Congenital occlusion of:
• ureter
• ureteropelvic
junction
• ureterovesical orifice Impervious
ureter
Q62.2 Congenital megaloureter
Congenital dilatation of ureter
Q62.3 Other
obstructive defects of renal pelvis and ureter
Congenital ureterocele
Q62.4 Agenesis
of ureter
Absent ureter
|
Q62.5
Q62.6 Malposition of ureter
|
Deviation Displacement Ectopic Implantation, anomalous |
(of)
ureter or ureteric orifice |
Q62.7 Congenital vesico-uretero-renal reflux
Q62.8 Other congenital malformations of ureter
Anomaly of ureter NOS
Q63 Other congenital malformations of kidney
Excl.: congenital
nephrotic syndrome (N04.-)
Q63.0 Accessory kidney
Q63.1 Lobulated, fused and horseshoe kidney
Q63.2 Ectopic kidney
Congenital displaced kidney Malrotation of
kidney
Q63.3 Hyperplastic
and giant kidney
Q63.8 Other specified congenital malformations
of kidney
Congenital renal calculi
Q63.9 Congenital
malformation of kidney, unspecified
Q64 Other congenital malformations of urinary system
Q64.0 Epispadias
Excl.: hypospadias
(Q54.-)
Q64.1 Exstrophy
of urinary bladder
Ectopia vesicae Extroversion of bladder
Q64.2 Congenital
posterior urethral valves
Q64.3 Other atresia and stenosis of urethra
and bladder neck
Congenital:
•
bladder neck obstruction
•
stricture of:
–
urethra
–
urinary meatus
–
vesicourethral orifice Impervious urethra
Q64.4 Malformation
of urachus
Cyst of urachus Patent urachus Prolapse of
urachus
Q64.5 Congenital
absence of bladder and urethra Q64.6 Congenital
diverticulum of bladder
Q64.7 Other
congenital malformations of bladder and urethra
Accessory:
• bladder
• urethra Congenital:
• hernia
of bladder
• malformation
of bladder or urethra NOS
• prolapse
of:
–
bladder (mucosa)
–
urethra
–
urinary meatus
• urethrorectal fistula
Double:
• urethra
• urinary
meatus
|
Q64.8 Other specified congenital malformations
of urinary system Q64.9 Congenital malformation of urinary system, unspecified
Congenital malformations
and deformations of the musculoskeletal system
(Q65–Q79)
Q65 Congenital deformities of hip
Excl.: clicking
hip (R29.4)
Q65.0 Congenital dislocation of hip,
unilateral Q65.1 Congenital dislocation
of hip, bilateral Q65.2 Congenital
dislocation of hip, unspecified Q65.3 Congenital
subluxation of hip, unilateral Q65.4 Congenital
subluxation of hip, bilateral Q65.5 Congenital
subluxation of hip, unspecified Q65.6 Unstable hip
Dislocatable hip Subluxatable hip
Q65.8 Other
congenital deformities of hip
Anteversion of femoral neck Congenital
acetabular dysplasia Congenital coxa:
•
valga
•
vara
Q65.9 Congenital
deformity of hip, unspecified
Q66 Congenital deformities of feet
Excl.: reduction defects of feet (Q72.-) valgus deformities
(acquired) (M21.0) varus deformities
(acquired) (M21.1)
Q66.0 Talipes equinovarus Q66.1 Talipes
calcaneovarus Q66.2 Metatarsus varus
Q66.3 Other
congenital varus deformities of feet
Hallux varus, congenital
Q66.4 Talipes
calcaneovalgus Q66.5 Congenital
pes planus
Flat foot:
•
congenital
•
rigid
•
spastic (everted)
Q66.6 Other
congenital valgus deformities of feet
Metatarsus valgus
Q66.7 Pes cavus
Q66.8 Other congenital deformities of feet
Clubfoot NOS
Hammer toe, congenital Talipes:
•
NOS
•
asymmetric Tarsal coalition Vertical talus
Q66.9 Congenital
deformity of feet, unspecified
Q67 Congenital
musculoskeletal deformities of head, face, spine and chest
Excl.: congenital malformation syndromes classified to Q87.-
Potter syndrome (Q60.6)
Q67.0 Facial
asymmetry Q67.1 Compression
facies Q67.2 Dolichocephaly
Q67.3 Plagiocephaly
Q67.4 Other congenital
deformities of skull, face and jaw
Depressions in skull
Deviation of nasal septum, congenital
Hemifacial atrophy or hypertrophy Squashed or bent nose, congenital
Excl.: dentofacial anomalies [including malocclusion] (K07.-)
syphilitic saddle nose (A50.5)
Q67.5 Congenital
deformity of spine
Congenital scoliosis:
• NOS
• postural
Excl.: infantile idiopathic scoliosis (M41.0)
scoliosis due to congenital
bony malformation (Q76.3)
Q67.6 Pectus excavatum
Congenital funnel chest
Q67.7 Pectus carinatum
Congenital pigeon chest
Q67.8 Other
congenital deformities of chest
Congenital deformity of chest wall NOS
Q68 Other congenital musculoskeletal deformities
Excl.: reduction
defects of limb(s) (Q71–Q73)
Q68.0 Congenital
deformity of sternocleidomastoid muscle
Congenital (sternomastoid) torticollis
Contracture of sternocleidomastoid (muscle)
Sternomastoid tumour (congenital)
Q68.1 Congenital
deformity of hand
Congenital clubfinger
Spade-like hand (congenital)
Q68.2 Congenital
deformity of knee
Congenital:
• dislocation
of knee
• genu
recurvatum
Q68.3 Congenital bowing of femur
Excl.: anteversion of femur (neck) (Q65.8)
Q68.4
Congenital bowing of tibia and fibula
Q68.5 Congenital bowing
of long bones of leg, unspecified Q68.8 Other specified congenital
musculoskeletal deformities
Congenital:
•
deformity of:
–
clavicle
–
elbow
–
forearm
–
scapula
•
dislocation of:
–
elbow
–
shoulder
Q69 Polydactyly
Q69.0
Accessory finger(s) Q69.1 Accessory thumb(s) Q69.2 Accessory toe(s)
Accessory hallux
Q69.9
Polydactyly, unspecified
Supernumerary digit(s)
NOS
Q70 Syndactyly
Q70.0 Fused fingers
Complex syndactyly of fingers with synostosis
Q70.1 Webbed fingers
Simple syndactyly of fingers without synostosis
Q70.2 Fused toes
Complex syndactyly of toes with synostosis
Q70.3 Webbed toes
Simple syndactyly of toes without synostosis
Q70.4 Polysyndactyly
Q70.9
Syndactyly, unspecified
Symphalangy NOS
Q71 Reduction defects of upper limb
Q71.0 Congenital
complete absence of upper limb(s)
Q71.1 Congenital absence of upper arm and forearm with hand
present Q71.2 Congenital absence of both forearm and hand
Q71.3 Congenital
absence of hand and finger(s)
Q71.4 Longitudinal reduction defect of radius
Clubhand (congenital) Radial clubhand
Q71.5 Longitudinal reduction defect of ulna Q71.6 Lobster-claw hand
Q71.8 Other
reduction defects of upper limb(s)
Congenital shortening of upper limb(s)
Q71.9 Reduction
defect of upper limb, unspecified
Q72 Reduction defects of lower limb
Q72.0 Congenital complete absence of lower limb(s)
Q72.1 Congenital
absence of thigh and lower leg with foot present Q72.2 Congenital absence of both lower leg and foot
Q72.3 Congenital
absence of foot and toe(s)
Q72.4 Longitudinal reduction defect of femur
Proximal femoral focal deficiency
Q72.5 Longitudinal reduction defect of tibia Q72.6 Longitudinal reduction defect of fibula
Q72.7 Split foot
Q72.8 Other
reduction defects of lower limb(s)
Congenital shortening of lower limb(s)
Q72.9 Reduction
defect of lower limb, unspecified
Q73 Reduction defects of unspecified limb
Q73.0 Congenital absence of unspecified limb(s)
Amelia NOS
Q73.1 Phocomelia,
unspecified limb(s)
Phocomelia NOS
Q73.8 Other
reduction defects of unspecified limb(s)
Longitudinal reduction deformity of unspecified limb(s)
|
Ectromelia NOS Hemimelia
NOS Reduction defect |
of
limb(s) NOS |
Q74 Other congenital malformations of limb(s)
Excl.: polydactyly (Q69.-)
reduction defect of limb (Q71–Q73) syndactyly
(Q70.-)
Q74.0 Other congenital malformations of upper
limb(s), including shoulder girdle
Accessory carpal bones Cleidocranial dysostosis
Congenital pseudarthrosis of clavicle Macrodactylia (fingers)
Madelung deformity Radioulnar synostosis
Sprengel deformity Triphalangeal thumb
Q74.1 Congenital
malformation of knee
Congenital:
•
absence of patella
•
dislocation of patella
•
genu:
–
valgum
–
varum Rudimentary patella
Excl.: congenital:
•
dislocation of knee (Q68.2)
• genu recurvatum (Q68.2) nail patella syndrome (Q87.2)
Q74.2 Other congenital malformations of lower
limb(s), including pelvic girdle
Congenital:
•
fusion of sacroiliac joint
•
malformation (of):
–
ankle (joint)
–
sacroiliac (joint)
Excl.: anteversion of femur (neck) (Q65.8)
Q74.3 Arthrogryposis
multiplex congenita
Q74.8 Other specified congenital malformations
of limb(s) Q74.9 Unspecified
congenital malformation of limb(s)
Congenital anomaly of limb(s) NOS
Q75 Other congenital malformations of skull and face bones
Excl.: congenital malformation of face NOS (Q18.-) congenital
malformation syndromes classified to Q87.- dentofacial anomalies [including
malocclusion] (K07.-)
musculoskeletal deformities of
head and face (Q67.0–Q67.4)
skull defects associated with
congenital anomalies of brain such as:
•
anencephaly (Q00.0)
•
encephalocele (Q01.-)
•
hydrocephalus (Q03.-)
•
microcephaly (Q02)
Q75.0 Craniosynostosis
Acrocephaly
Imperfect fusion of skull Oxycephaly
Trigonocephaly
Q75.1 Craniofacial dysostosis
Crouzon disease
Q75.2 Hypertelorism
Q75.3 Macrocephaly
Q75.4 Mandibulofacial dysostosis
Syndrome:
• Franceschetti
• Treacher–Collins
Q75.5 Oculomandibular
dysostosis
Q75.8 Other
specified congenital malformations of skull and face bones
Absence of skull bone, congenital
Congenital deformity of forehead Platybasia
Q75.9 Congenital
malformation of skull and face bones, unspecified
Congenital anomaly of:
• face
bones NOS
• skull NOS
Q76 Congenital malformations of spine and bony thorax
Excl.: congenital musculoskeletal deformities of spine and chest
(Q67.5–Q67.8)
Q76.0 Spina
bifida occulta
Excl.: meningocele (spinal) (Q05.-)
spina bifida (aperta)(cystica)
(Q05.-)
Q76.1 Klippel–Feil syndrome
Cervical fusion syndrome
Q76.2 Congenital spondylolisthesis
Congenital spondylolysis
Excl.: spondylolisthesis (acquired) (M43.1) spondylolysis
(acquired) (M43.0)
Q76.3 Congenital
scoliosis due to congenital bony malformation
Hemivertebra fusion or failure of segmentation with
scoliosis
Q76.4 Other congenital malformations of spine,
not associated with scoliosis
|
Congenital: •
absence of vertebra •
fusion of spine •
kyphosis •
lordosis •
malformation of
lumbosacral (joint) (region) Hemivertebra Malformation of spine Platyspondylisis
Supernumerary vertebra |
unspecified or not associated with scoliosis |
Q76.5 Cervical rib
Supernumerary rib in cervical region
Q76.6 Other
congenital malformations of ribs
Accessory rib Congenital:
•
absence of rib
•
fusion of ribs
•
malformation of ribs NOS
Excl.: short
rib syndrome (Q77.2)
Q76.7 Congenital
malformation of sternum
Congenital absence of sternum Sternum bifidum
Q76.8 Other
congenital malformations of bony thorax Q76.9 Congenital
malformation of bony thorax, unspecified
Q77 Osteochondrodysplasia
with defects of growth of tubular
bones and spine
Excl.: mucopolysaccharidosis
(E76.0–E76.3)
Q77.0 Achondrogenesis
Hypochondrogenesis
Q77.1 Thanatophoric
short stature
Q77.2 Short rib syndrome
Asphyxiating thoracic dysplasia [Jeune]
Q77.3 Chondrodysplasia punctata Q77.4 Achondroplasia
Hypochondroplasia Osteosclerosis congenita
Q77.5 Dystrophic dysplasia
Q77.6 Chondroectodermal dysplasia
Ellis–van Creveld syndrome
Q77.7 Spondyloepiphyseal
dysplasia
Q77.8 Other osteochondrodysplasia with defects
of growth of tubular bones and spine
Q77.9 Osteochondrodysplasia with defects of
growth of tubular bones and spine, unspecified
Q78 Other osteochondrodysplasias
Q78.0 Osteogenesis
imperfecta Fragilitas ossium Osteopsathyrosis
Q78.1 Polyostotic
fibrous dysplasia
Albright(–McCune)(–Sternberg) syndrome
Q78.2 Osteopetrosis
Albers–Schönberg syndrome
Q78.3 Progressive
diaphyseal dysplasia
Camurati–Engelmann syndrome
Q78.4 Enchondromatosis
Maffucci’s syndrome Ollier’s disease
Q78.5 Metaphyseal
dysplasia
Pyle’s syndrome
Q78.6 Multiple
congenital exostoses
Diaphyseal aclasis
Q78.8 Other
specified osteochondrodysplasias
Osteopoikilosis
Q78.9 Osteochondrodysplasia,
unspecified
Chondrodystrophy NOS Osteodystrophy NOS
Q79 Congenital malformations of the musculoskeletal system, not elsewhere classified
Excl.: congenital
(sternomastoid) torticollis (Q68.0)
Q79.0 Congenital
diaphragmatic hernia
Excl.: congenital
hiatus hernia (Q40.1)
Q79.1 Other
congenital malformations of diaphragm
Absence of diaphragm
Congenital malformation of diaphragm NOS
Eventration of diaphragm
Q79.2 Exomphalos
Omphalocele
Excl.: umbilical
hernia (K42.-)
Q79.3 Gastroschisis
Q79.4 Prune belly syndrome
Q79.5 Other congenital malformations of
abdominal wall
Excl.: umbilical
hernia (K42.-)
Q79.6 Ehlers–Danlos syndrome
Q79.8 Other congenital malformations of
musculoskeletal system
Absence of:
•
muscle
•
tendon Accessory muscle
Amyotrophia congenita Congenital:
•
constricting bands
•
shortening of tendon Poland’s
syndrome
Q79.9 Congenital malformation of
musculoskeletal system, unspecified
|
Congenital: •
anomaly NOS •
deformity NOS |
of
musculoskeletal system NOS |
Other congenital malformations (Q80–Q89)
Q80 Congenital ichthyosis
Excl.: Refsum
disease (G60.1)
Q80.0
Ichthyosis vulgaris Q80.1 X-linked ichthyosis Q80.2 Lamellar ichthyosis
Collodion baby
Q80.3 Congenital bullous ichthyosiform erythroderma Q80.4 Harlequin fetus
Q80.8 Other
congenital ichthyosis
Q80.9 Congenital ichthyosis, unspecified
Q81 Epidermolysis bullosa
Q81.0 Epidermolysis bullosa simplex
Excl.:
Cockayne syndrome (Q87.1)
Q81.1 Epidermolysis
bullosa letalis
Herlitz’ syndrome
Q81.2 Epidermolysis
bullosa dystrophica Q81.8 Other
epidermolysis bullosa
Q81.9 Epidermolysis
bullosa, unspecified
Q82 Other congenital malformations of skin
Excl.: acrodermatitis enteropathica (E83.2) congenital
erythropoietic porphyria (E80.0) pilonidal
cyst or sinus (L05.-) Sturge–Weber(–Dimitri) syndrome (Q85.8)
Q82.0
Hereditary lymphoedema Q82.1 Xeroderma pigmentosum Q82.2 Mastocytosis
Urticaria pigmentosa
Excl.: malignant
mastocytosis (C96.2)
Q82.3 Incontinentia
pigmenti
Q82.4 Ectodermal dysplasia (anhidrotic)
Excl.: Ellis–van
Creveld syndrome (Q77.6)
Q82.5 Congenital
non-neoplastic naevus
Birthmark NOS Naevus:
•
flammeus
•
portwine
•
sanguineous
•
strawberry
•
vascular NOS
•
verrucous
Excl.: café au lait spots (L81.3) lentigo (L81.4)
naevus:
•
NOS
(D22.-)
•
araneus (I78.1)
•
melanocytic (D22.-)
•
pigmented (D22.-)
•
spider (I78.1)
•
stellar (I78.1)
Q82.8 Other
specified congenital malformations of skin
Abnormal palmar creases Accessory skin tags
Benign familial pemphigus [Hailey–Hailey]
Cutis laxa (hyperelastica)
Dermatoglyphic anomalies
Inherited keratosis palmaris et plantaris
Keratosis follicularis [Darier–White]
Excl.: Ehlers–Danlos
syndrome (Q79.6)
Q82.9 Congenital
malformation of skin, unspecified
Q83 Congenital malformations of breast
Excl.: absence
of pectoral muscle (Q79.8)
Q83.0 Congenital absence of breast with absent
nipple Q83.1 Accessory breast
Supernumerary breast
Q83.2 Absent nipple Q83.3 Accessory
nipple
Supernumerary nipple
Q83.8 Other
congenital malformations of breast
Hypoplasia of breast
Q83.9 Congenital
malformation of breast, unspecified
Q84 Other congenital malformations of integument
Q84.0 Congenital alopecia
Congenital atrichosis
Q84.1 Congenital morphological disturbances of
hair, not elsewhere classified
Beaded hair Monilethrix Pili
annulati
Excl.: Menkes kinky hair syndrome (E83.0)
Q84.2 Other
congenital malformations of hair
Congenital:
• hypertrichosis
• malformation of hair NOS Persistent lanugo
Q84.3 Anonychia
Excl.: nail patella syndrome (Q87.2)
Q84.4 Congenital leukonychia
Q84.5 Enlarged and hypertrophic nails
Congenital onychauxis Pachyonychia
Q84.6 Other
congenital malformations of nails
Congenital:
• clubnail
• koilonychia
• malformation
of nail NOS
Q84.8 Other
specified congenital malformations of integument
Aplasia cutis congenita
Q84.9 Congenital
malformation of integument, unspecified
|
Congenital: •
anomaly NOS •
deformity NOS |
of
integument NOS |
Q85 Phakomatoses, not elsewhere classified
Excl.: ataxia telangiectasia [Louis–Bar] (G11.3) familial
dysautonomia [Riley–Day] (G90.1)
Q85.0 Neurofibromatosis (nonmalignant)
Von Recklinghausen disease
Q85.1 Tuberous sclerosis
Bourneville’s disease Epiloia
Q85.8 Other
phakomatoses, not elsewhere classified
Syndrome:
•
Peutz–Jeghers
•
Sturge–Weber(–Dimitri)
•
von
Hippel–Lindau
Excl.: Meckel–Gruber
syndrome (Q61.9)
Q85.9 Phakomatosis,
unspecified
Hamartosis NOS
Q86 Congenital malformation syndromes due to known exogenous causes, not elsewhere classified
Excl.: iodine-deficiency-related hypothyroidism (E00–E02)
nonteratogenic effects of substances transmitted via placenta or breast milk
(P04.-)
Q86.0 Fetal alcohol syndrome (dysmorphic)
Q86.1 Fetal hydantoin syndrome
Meadow’s syndrome
Q86.2 Dysmorphism
due to warfarin
Q86.8 Other
congenital malformation syndromes due to known
exogenous causes
Q87 Other
specified congenital malformation syndromes
affecting multiple systems
Q87.0 Congenital
malformation syndromes predominantly affecting facial appearance
Acrocephalopolysyndactyly
Acrocephalosyndactyly [Apert] Cryptophthalmos syndrome Cyclopia
Syndrome:
•
Goldenhar
•
Moebius
•
oro-facial-digital
•
Robin Whistling face
Q87.1 Congenital malformation syndromes
predominantly associated with short stature
Syndrome:
• Aarskog
• Cockayne
• De Lange
• Dubowitz
• Noonan
• Prader–Willi
• Robinow–Silverman–Smith
• Russell–Silver
• Seckel
• Smith–Lemli–Opitz
Excl.: Ellis–van
Creveld syndrome (Q77.6)
Q87.2 Congenital malformation syndromes
predominantly involving limbs
Syndrome:
• Holt–Oram
• Klippel–Trénaunay–Weber
• nail
patella
• Rubinstein–Taybi
• sirenomelia
• thrombocytopenia
with absent radius [TAR]
• VATER
Q87.3 Congenital malformation syndromes
involving early overgrowth
Syndrome:
• Beckwith–Wiedemann
• Sotos
• Weaver
Q87.4 Marfan syndrome
Q87.5 Other congenital malformation syndromes
with other skeletal changes
Q87.8 Other specified congenital malformation
syndromes, not elsewhere classified
Syndrome:
• Alport
• Laurence–Moon(–Bardet)–Biedl
• Zellweger
Q89 Other congenital malformations, not elsewhere classified
Q89.0 Congenital
malformations of spleen
Asplenia (congenital) Congenital splenomegaly
Excl.: isomerism of atrial appendages (with asplenia or
polysplenia) (Q20.6)
Q89.1 Congenital
malformations of adrenal gland
Excl.: congenital
adrenal hyperplasia (E25.0)
Q89.2 Congenital
malformations of other endocrine glands
Congenital malformation of parathyroid or thyroid gland
Persistent thyroglossal duct
Thyroglossal cyst
Q89.3 Situs
inversus
Dextrocardia with situs
inversus
Mirror-image atrial arrangement with situs
inversus Situs inversus or transversus:
•
abdominalis
•
thoracis
Transposition of viscera:
•
abdominal
•
thoracic
Excl.: dextrocardia NOS (Q24.0) laevocardia (Q24.1)
Q89.4 Conjoined twins
Craniopagus Dicephaly Double monster Pygopagus
Thoracopagus
Q89.7 Multiple
congenital malformations, not elsewhere classified
Monster NOS Multiple congenital:
•
anomalies NOS
•
deformities NOS
Excl.: congenital malformation syndromes affecting multiple
systems (Q87.-)
Q89.8 Other
specified congenital malformations Q89.9 Congenital
malformation, unspecified
Congenital:
•
anomaly NOS
•
deformity NOS
Chromosomal abnormalities, not elsewhere classified
(Q90–Q99)
Q90 Down syndrome
Q90.0 Trisomy 21, meiotic nondisjunction
Q90.1 Trisomy 21, mosaicism (mitotic
nondisjunction) Q90.2 Trisomy 21, translocation
Q90.9 Down syndrome, unspecified
Trisomy 21 NOS
Q91 Edwards syndrome and Patau syndrome
Q91.0 Trisomy 18, meiotic nondisjunction
Q91.1 Trisomy 18, mosaicism (mitotic
nondisjunction) Q91.2 Trisomy 18, translocation
Q91.3 Edwards
syndrome, unspecified Q91.4 Trisomy 13, meiotic nondisjunction
Q91.5 Trisomy 13, mosaicism (mitotic
nondisjunction) Q91.6 Trisomy 13, translocation
Q91.7 Patau
syndrome, unspecified
Q92 Other
trisomies and partial trisomies of the autosomes, not elsewhere classified
Incl.: unbalanced
translocations and insertions
Excl.: trisomies
of chromosomes 13, 18, 21 (Q90–Q91) Q92.0 Whole chromosome trisomy, meiotic nondisjunction Q92.1 Whole chromosome trisomy, mosaicism (mitotic
nondisjunction)
Q92.2 Major partial trisomy
Whole arm or more duplicated.
Q92.3 Minor
partial trisomy
Less than whole arm duplicated.
Q92.4 Duplications
seen only at prometaphase
Q92.5 Duplications
with other complex rearrangements Q92.6 Extra
marker chromosomes
Q92.7 Triploidy and polyploidy
Q92.8 Other
specified trisomies and partial trisomies of autosomes Q92.9 Trisomy and
partial trisomy of autosomes, unspecified
Q93 Monosomies
and deletions from the autosomes, not elsewhere classified
Q93.0 Whole
chromosome monosomy, meiotic
nondisjunction Q93.1 Whole
chromosome monosomy, mosaicism (mitotic
nondisjunction)
Q93.2 Chromosome replaced with ring or
dicentric Q93.3 Deletion of short arm
of chromosome 4
Wolff–Hirschorn syndrome
Q93.4 Deletion
of short arm of chromosome 5
Cri-du-chat syndrome
Q93.5 Other
deletions of part of a chromosome
Angelman syndrome
Q93.6 Deletions
seen only at prometaphase
Q93.7 Deletions with
other complex rearrangements Q93.8 Other
deletions from the autosomes
Q93.9 Deletion from
autosomes, unspecified
Q95 Balanced
rearrangements and structural markers, not
elsewhere classified
Incl.: Robertsonian and balanced reciprocal translocations and
insertions Q95.0 Balanced
translocation and insertion in normal individual Q95.1 Chromosome inversion in normal
individual
Q95.2 Balanced
autosomal rearrangement in abnormal individual Q95.3 Balanced sex/autosomal
rearrangement in abnormal individual
Q95.4 Individuals with marker heterochromatin
Q95.5 Individuals
with autosomal fragile site
Q95.8 Other balanced
rearrangements and structural markers Q95.9 Balanced
rearrangement and structural marker, unspecified
Q96 Turner syndrome
Excl.: Noonan
syndrome (Q87.1)
Q96.0 Karyotype 45,X
Q96.1 Karyotype 46,X iso (Xq)
Q96.2 Karyotype 46,X
with abnormal sex chromosome,
except iso (Xq) Q96.3 Mosaicism, 45,X/46,XX or XY
Q96.4 Mosaicism, 45,X/other cell line(s) with
abnormal sex chromosome
Q96.8 Other variants
of Turner syndrome Q96.9 Turner
syndrome, unspecified
Q97 Other
sex chromosome abnormalities, female
phenotype, not elsewhere classified
Excl.: Turner
syndrome (Q96.-)
Q97.0 Karyotype 47,XXX
Q97.1 Female with more than three X chromosomes
Q97.2 Mosaicism,
lines with various numbers of X chromosomes Q97.3 Female with 46,XY karyotype
Q97.8 Other specified sex chromosome
abnormalities, female phenotype
Q97.9 Sex chromosome abnormality, female phenotype,
unspecified
Q98 Other
sex chromosome abnormalities, male phenotype,
not elsewhere classified
Q98.0 Klinefelter syndrome karyotype 47,XXY
Q98.1 Klinefelter syndrome, male with more
than two X chromosomes
Q98.2 Klinefelter
syndrome, male with 46,XX karyotype
Q98.3 Other male with 46,XX karyotype
Q98.4 Klinefelter
syndrome, unspecified Q98.5 Karyotype 47,XYY
Q98.6 Male with
structurally abnormal sex chromosome
Q98.7 Male with sex chromosome mosaicism
Q98.8 Other specified sex chromosome abnormalities, male
phenotype Q98.9 Sex chromosome abnormality, male phenotype, unspecified
Q99 Other
chromosome abnormalities, not elsewhere
classified
Q99.0 Chimera
46,XX/46,XY
Chimera 46,XX/46,XY true hermaphrodite
Q99.1 46,XX
true hermaphrodite 46,XX with streak
gonads 46,XY with streak gonads Pure gonadal
dysgenesis
Q99.2 Fragile
X chromosome
Fragile X syndrome
Q99.8 Other
specified chromosome abnormalities Q99.9 Chromosomal
abnormality, unspecified
CHAPTER XVIII
Symptoms, signs and abnormal clinical and laboratory findings,
not elsewhere classified
(R00–R99)
This chapter includes symptoms, signs, abnormal results
of clinical or other investigative procedures, and ill-defined
conditions regarding which no diagnosis classifiable elsewhere is recorded.
Signs and symptoms that point rather
definitely to a given diagnosis have been assigned to a category in other chapters
of the classification. In general,
categories in this chapter
include the less well-defined conditions and symptoms that, without the
necessary study of the case to establish a final diagnosis, point perhaps
equally to two or more diseases or to two or more systems of the body. Practically all categories in the
chapter could be designated ‘not otherwise specified’, ‘unknown etiology’ or
‘transient’. The Alphabetical index should be consulted to determine which
symptoms and signs are to be allocated here and which to other chapters. The residual subcategories, numbered .8, are
generally provided for other relevant symptoms that cannot be allocated
elsewhere in the classification.
The conditions and signs or symptoms included in
categories R00–R99 consist of:
a) cases for which no more specific diagnosis can be made even
after all the facts bearing on the case have been investigated;
b) signs or symptoms
existing at the time of initial encounter
that proved to be transient and whose causes could not be determined;
c)
provisional diagnoses in a patient who failed to return for further investigation or care;
d)
cases
referred elsewhere for investigation or treatment before
the diagnosis was made;
e)
cases in which a more precise
diagnosis was not available for any other reason;
f) certain symptoms, for which supplementary information is
provided, that represent important problems in medical care in their own right.
Excl.: abnormal findings on antenatal screening of mother
(O28.-) certain conditions originating in the perinatal period (P00–P96)
This chapter contains the following blocks:
R00–R09 Symptoms and signs involving the
circulatory and respiratory systems R10–R19 Symptoms and signs involving the
digestive system and abdomen R20–R23
Symptoms and signs involving the skin and subcutaneous tissue R25–R29
Symptoms and signs involving the nervous and musculoskeletal systems R30–R39
Symptoms and signs involving the urinary system
R40–R46 Symptoms and signs
involving cognition, perception, emotional state and behaviour
R47–R49 Symptoms and signs involving speech and voice
R50–R69 General symptoms and signs
R70–R79 Abnormal findings on examination of blood,
without diagnosis R80–R82 Abnormal
findings on examination of urine, without diagnosis R83–R89 Abnormal findings
on examination of other body fluids, substances and
tissues, without diagnosis
R90–R94 Abnormal findings on
diagnostic imaging and in function studies, without diagnosis
R95–R99 Ill-defined and unknown
causes of mortality
Symptoms and signs involving the circulatory and
respiratory systems
(R00–R09)
R00 Abnormalities of heart
beat
Excl.: abnormalities originating in the perinatal period (P29.1)
specified arrhythmias (I47–I49)
R00.0 Tachycardia, unspecified Rapid
heart beat Tachycardia:
• sinoauricular NOS
• sinus
[sinusal] NOS
R00.1 Bradycardia, unspecified
Bradycardia:
• sinoatrial
• sinus
• vagal
Slow heart beat
Use additional external cause code (Chapter
XX), if desired, to identify drug, if drug-induced.
R00.2 Palpitations
Awareness of heart beat
R00.8 Other
and unspecified abnormalities of heart beat
R01 Cardiac murmurs and other cardiac sounds
Excl.: those
originating in the perinatal period (P29.8)
R01.0 Benign
and innocent cardiac murmurs
Functional cardiac murmur
R01.1 Cardiac
murmur, unspecified
Cardiac bruit NOS Systolic murmur NOS
R01.2 Other
cardiac sounds
Cardiac dullness, increased or decreased
Precordial friction
R02 Gangrene, not elsewhere
classified
Excl.: gangrene
in:
•
atherosclerosis (I70.2)
•
diabetes mellitus (E10–E14 with common
fourth character .5)
• other
peripheral vascular diseases (I73.-)
gangrene of certain specified sites – see Alphabetical
index gas gangrene (A48.0)
pyoderma gangrenosum (L88)
R03 Abnormal blood-pressure reading, without diagnosis
R03.0 Elevated blood-pressure reading,
without diagnosis of hypertension
Note:
This category is to be
used to record an episode of elevated blood pressure in a patient in whom no
formal diagnosis of hypertension has been made, or as an isolated incidental
finding.
R03.1 Nonspecific
low blood-pressure reading
Excl.: hypotension (I95.-)
maternal hypotension syndrome (O26.5)
neurogenic orthostatic hypotension (G23.8)
R04 Haemorrhage
from respiratory passages
R04.0 Epistaxis Haemorrhage
from nose Nosebleed
R04.1 Haemorrhage
from throat
Excl.: haemoptysis
(R04.2)
R04.2 Haemoptysis
Blood-stained sputum Cough with haemorrhage
R04.8 Haemorrhage
from other sites in respiratory passages
Pulmonary haemorrhage NOS
Excl.: perinatal
pulmonary haemorrhage (P26.-)
R04.9 Haemorrhage
from respiratory passages, unspecified
R05 Cough
Excl.: cough with haemorrhage (R04.2) psychogenic cough (F45.3)
R06 Abnormalities
of breathing
Excl.: respiratory:
•
arrest (R09.2)
•
distress:
–
syndrome of adult (J80)
–
in newborn (P22.-)
•
failure (J96.-)
•
failure
–
of newborn (P28.5)
R06.0 Dyspnoea Orthopnoea
Shortness of breath
Excl.: transient
tachypnoea of newborn (P22.1)
R06.1 Stridor
Excl.: congenital laryngeal stridor (P28.8) laryngismus
(stridulus) (J38.5)
R06.2 Wheezing
R06.3 Periodic breathing
Cheyne–Stokes breathing
R06.4 Hyperventilation
Excl.: psychogenic
hyperventilation (F45.3)
R06.5 Mouth
breathing
Snoring
Excl.: dry
mouth NOS (R68.2)
R06.6 Hiccough
Excl.: psychogenic
hiccough (F45.3)
R06.7 Sneezing
R06.8 Other and unspecified abnormalities of breathing
Apnoea NOS
Breath-holding (spells) Choking sensation
Sighing
Excl.: apnoea
(of):
•
newborn (P28.4)
•
sleep
(G47.3)
•
sleep:
– newborn (primary) (P28.3)
R07 Pain in throat and chest
Excl.: dysphagia (R13)
epidemic myalgia (B33.0) pain in:
•
breast (N64.4)
• neck
(M54.2)
sore throat (acute) NOS (J02.9)
R07.0 Pain
in throat
R07.1 Chest pain on breathing
Painful respiration
R07.2 Precordial
pain R07.3 Other chest pain
Anterior chest-wall pain NOS
R07.4 Chest
pain, unspecified
R09 Other
symptoms and signs involving the circulatory and respiratory systems
Excl.: respiratory:
•
distress (syndrome)(of):
–
adult (J80)
–
newborn (P22.-)
•
failure (J96.-)
•
failure:
–
newborn (P28.5)
R09.0 Asphyxia
Excl.: asphyxia
(due to):
•
birth (P21.-)
•
carbon monoxide (T58)
•
foreign body in respiratory tract
(T17.-)
•
intrauterine (P20.-)
•
traumatic (T71)
R09.1 Pleurisy
Excl.: pleurisy
with effusion (J90)
R09.2 Respiratory arrest
Cardiorespiratory failure
R09.3 Abnormal sputum
|
Abnormal: •
amount •
colour •
odour Excessive |
(of)
sputum |
Excl.: blood-stained
sputum (R04.2)
R09.8 Other specified symptoms and signs
involving the circulatory and respiratory systems
Bruit (arterial) Chest:
• abnormal
percussion
• friction sounds
•
tympany Rales Weak pulse
Symptoms and signs involving the digestive system and
abdomen
(R10–R19)
Excl.: gastrointestinal haemorrhage (K92.0–K92.2) gastrointestinal haemorrhage:
•
newborn (P54.0–P54.3)
intestinal obstruction (K56.-) intestinal
obstruction:
•
newborn (P76.-)
pylorospasm (K31.3) pylorospasm:
• congenital
or infantile (Q40.0)
symptoms and signs involving the urinary
system (R30–R39) symptoms referable to genital organs:
•
female (N94.-)
•
male (N48–N50)
R10 Abdominal and pelvic pain
Excl.: dorsalgia (M54.-)
flatulence and related conditions (R14) renal
colic (N23)
R10.0 Acute abdomen
Severe abdominal pain (generalized)(localized)(with
abdominal rigidity)
R10.1 Pain
localized to upper abdomen
Dyspepsia NOS Epigastric pain
Excl.: functional
dysp epsia (K30)
R10.2 Pelvic
and perineal pain
R10.3 Pain
localized to other parts of lower abdomen R10.4 Other
and unspecified abdominal pain
Abdominal tenderness NOS Colic:
•
NOS
•
infantile
R11 Nausea and vomiting
Excl.: haematemesis (K92.0) haematemesis
•
neonatal (P54.0) vomiting (of):
•
excessive, in pregnancy (O21.-)
•
following gastrointestinal surgery (K91.0)
•
newborn (P92.0)
•
psychogenic (F50.5)
763
R12 Heartburn
Excl.: dyspepsia
•
NOS
(R10.1)
•
functional (K30)
R13 Dysphagia
Incl.: difficulty
in swallowing
R14 Flatulence and
related conditions
Incl.: abdominal distension (gaseous) bloating
eructation gas pain
tympanites
(abdominal)(intestinal)
Excl.: psychogenic
aerophagy (F45.3)
R15 Faecal
incontinence
Incl.: encopresis
NOS
Excl.: that
of nonorganic origin (F98.1)
R16 Hepatomegaly and splenomegaly,
not elsewhere classified
R16.0 Hepatomegaly,
not elsewhere classified
Hepatomegaly NOS
R16.1 Splenomegaly,
not elsewhere classified
Splenomegaly NOS
R16.2 Hepatomegaly
with splenomegaly, not elsewhere classified
Hepatosplenomegaly NOS
R17 Unspecified jaundice
Excl.: neonatal
jaundice (P55.-, P57–P59)
R18 Ascites
Incl.: fluid
in peritoneal cavity
R19 Other symptoms and signs involving the digestive system
and abdomen
Excl.: acute
abdomen (R10.0)
R19.0 Intra-abdominal
and pelvic swelling, mass and lump
Diffuse or generalized swelling
or mass:
• intra-abdominal NOS
• pelvic NOS
• umbilical
Excl.: abdominal distension (gaseous) (R14) ascites (R18)
R19.1 Abnormal
bowel sounds
Absent bowel sounds Hyperactive bowel sounds
R19.2 Visible peristalsis
Hyperperistalsis
R19.3 Abdominal rigidity
Excl.: that
with severe abdominal pain (R10.0)
R19.4 Change
in bowel habit
Excl.: constipation (K59.0) functional diarrhoea (K59.1)
R19.5 Other
faecal abnormalities
Abnormal stool colour Bulky stools
Mucus in stools Occult blood in stools
Excl.: melaena (K92.1)
melaena:
•
neonatal (P54.1)
R19.6 Halitosis
R19.8 Other specified symptoms and signs
involving the digestive system and abdomen
Symptoms and signs
involving the skin and subcutaneous tissue
(R20–R23)
R20 Disturbances of skin sensation
Excl.: dissociative anaesthesia and sensory loss (F44.6)
psychogenic disturbances (F45.8)
R20.0 Anaesthesia of skin R20.1 Hypoaesthesia
of skin R20.2 Paraesthesia of skin
Formication Pins and needles Tingling skin
Excl.: acroparaesthesia
(I73.8)
R20.3 Hyperaesthesia
R20.8 Other and unspecified disturbances of
skin sensation
R21 Rash and other nonspecific skin
eruption
R22 Localized
swelling, mass and lump of skin and subcutaneous tissue
Incl.: subcutaneous
nodules (localized)(superficial)
Excl.: abnormal findings on diagnostic imaging (R90–R93)
enlarged lymph nodes (R59.-)
localized adiposity (E65) mass and lump:
•
breast (N63)
• intra-abdominal or pelvic (R19.0)
oedema (R60.-)
swelling (of):
•
intra-abdominal or pelvic (R19.0)
•
joint (M25.4)
R22.0 Localized
swelling, mass and lump, head R22.1 Localized
swelling, mass and lump, neck R22.2 Localized
swelling, mass and lump, trunk R22.3 Localized
swelling, mass and lump, upper limb R22.4 Localized
swelling, mass and lump, lower limb
R22.7 Localized
swelling, mass and lump, multiple sites R22.9 Localized
swelling, mass and lump, unspecified
R23 Other skin changes
R23.0 Cyanosis
Excl.: acrocyanosis (I73.8)
cyanotic attacks of newborn
(P28.2)
R23.1 Pallor
Clammy skin
R23.2 Flushing
Excessive blushing
Excl.: menopausal
and female climacteric states (N95.1)
R23.3 Spontaneous ecchymoses
Petechiae
Excl.: ecchymoses in fetus and newborn (P54.5) purpura (D69.-)
R23.4 Changes
in skin texture
|
Desquamation Induration
Scaling |
of
skin |
Excl.: epidermal
thickening NOS (L85.9)
R23.8 Other
and unspecified skin changes
Symptoms and signs
involving the nervous and musculoskeletal systems
(R25–R29)
R25 Abnormal involuntary movements
Excl.:
specific movement
disorders (G20–G26) stereotyped movement disorders (F98.4) tic disorders
(F95.-)
R25.0 Abnormal head movements R25.1 Tremor,
unspecified
Excl.: chorea NOS (G25.5)
tremor:
•
essential (G25.0)
•
hysterical (F44.4)
•
intention (G25.2)
R25.2 Cramp
and spasm
Excl.: carpopedal spasm (R29.0) infantile spasms (G40.4)
R25.3 Fasciculation
Twitching NOS
R25.8 Other
and unspecified abnormal involuntary movements
R26 Abnormalities of gait and mobility
Excl.: ataxia:
•
NOS
(R27.0)
•
hereditary (G11.-)
•
locomotor (syphilitic)
(A52.1) immobility syndrome (paraplegic) (M62.3)
R26.0 Ataxic gait
Staggering gait
R26.1 Paralytic
gait
Spastic gait
R26.2 Difficulty
in walking, not elsewhere classified
R26.3 Immobility Bedfast
Chairfast
R26.8 Other
and unspecified abnormalities of gait and mobility
Unsteadiness on feet NOS
R27 Other lack of coordination
Excl.: ataxic gait (R26.0) hereditary ataxia (G11.-) vertigo NOS
(R42)
R27.0 Ataxia, unspecified
R27.8 Other and unspecified lack of coordination
R29 Other
symptoms and signs involving the nervous and musculoskeletal systems
R29.0 Tetany
Carpopedal spasm
Excl.: tetany:
•
hysterical (F44.5)
•
neonatal (P71.3)
•
parathyroid (E20.9)
•
post-thyroidectomy (E89.2)
R29.1 Meningismus R29.2 Abnormal
reflex
Excl.: abnormal pupillary reflex (H57.0) hyperactive gag reflex
(J39.2) vasovagal reaction or syncope (R55)
R29.3 Abnormal posture R29.4 Clicking hip
Excl.: congenital deformities of hip (Q65.-)
R29.6 Tendency to fall, not elsewhere classified
Tendency to fall because of old age or other unclear
health problems
Excl.: accidents (X59.-)
difficulty in walking (R26.2) dizziness and
giddiness (R42) falls causing injury (W00–W19)
falls due to diseases classified elsewhere
syncope and collapse (R55)
R29.8 Other and unspecified symptoms and
signs involving the nervous and musculoskeletal systems
Symptoms and signs involving the urinary system (R30–R39)
R30 Pain associated with micturition
Excl.: psychogenic
pain (F45.3)
R30.0 Dysuria
Strangury
R30.1 Vesical
tenesmus
R30.9 Painful micturition, unspecified
Painful urination NOS
R31 Unspecified haematuria
Excl.: recurrent
or persistent haematuria (N02.-)
R32 Unspecified urinary incontinence
Incl.: enuresis
NOS
Excl.: nonorganic enuresis (F98.0)
stress incontinence and other specified
urinary incontinence (N39.3–N39.4)
R33 Retention of urine
R34 Anuria and oliguria
Excl.:
that complicating:
•
abortion or ectopic or molar pregnancy
(O00–O07, O08.4)
•
pregnancy, childbirth and the
puerperium (O26.8, O90.4)
R35 Polyuria
Incl.: frequency of micturition nocturia
Excl.: psychogenic
polyuria (F45.3)
R36 Urethral discharge
Incl.: penile discharge
urethrorrhoea
R39 Other symptoms and signs involving the urinary system
R39.0 Extravasation
of urine
R39.1 Other difficulties with micturition
Hesitancy of micturition Poor urinary stream
Splitting of urinary stream
R39.2 Extrarenal
uraemia
Prerenal uraemia
R39.8 Other and unspecified symptoms and
signs involving the urinary system
Symptoms and signs
involving cognition, perception, emotional state and behaviour
(R40–R46)
Excl.: those constituting part of a pattern of mental
disorder (F00–F99)
R40 Somnolence, stupor and
coma
Excl.: coma:
•
diabetic (E10–E14 with common fourth
character .0)
•
hepatic (K72.-)
•
hypoglycaemic (nondiabetic) (E15)
•
neonatal (P91.5)
•
uraemic (N19)
R40.0 Somnolence
Drowsiness
R40.1 Stupor
Semicoma
Excl.: stupor:
•
catatonic (F20.2)
•
depressive (F31–F33)
•
dissociative (F44.2)
•
manic (F30.2)
R40.2 Coma, unspecified
Unconsciousness NOS
R41 Other symptoms and signs involving cognitive functions
and awareness
Excl.: dissociative
[conversion] disorders (F44.-)
R41.0 Disorientation, unspecified
Confusion NOS
Excl.: psychogenic
disorientation (F44.8)
R41.1 Anterograde amnesia R41.2 Retrograde amnesia
R41.3 Other
amnesia
Amnesia NOS
Excl.: amnesic
syndrome:
•
due to psychoactive
substance use (F10–F19 with common fourth character .6)
• organic (F04)
transient global amnesia
(G45.4)
R41.8 Other and unspecified symptoms and
signs involving cognitive functions and awareness
R42 Dizziness and giddiness
Incl.: light-headedness
vertigo NOS
Excl.: vertiginous
syndromes (H81.-)
R43 Disturbances of smell and taste
R43.0 Anosmia
R43.1 Parosmia
R43.2 Parageusia
R43.8 Other and unspecified disturbances of
smell and taste
Mixed disturbance of smell and taste
R44 Other symptoms and signs involving general sensations and perceptions
Excl.: disturbances
of skin sensation (R20.-)
R44.0 Auditory hallucinations R44.1 Visual hallucinations R44.2 Other
hallucinations
R44.3 Hallucinations, unspecified
R44.8 Other and unspecified symptoms and
signs involving general sensations and perceptions
R45 Symptoms and signs involving emotional state
R45.0 Nervousness
Nervous tension
R45.1 Restlessness and agitation R45.2 Unhappiness
Worries NOS
R45.3 Demoralization
and apathy
R45.4 Irritability
and anger R45.5 Hostility
R45.6 Physical violence
R45.7 State of emotional shock and stress,
unspecified R45.8 Other symptoms
and signs involving emotional state
Suicidal ideation (tendencies)
Excl.: signs and symptoms constituting part of a mental disorder
(F00-F99)
R46 Symptoms and signs involving appearance and behaviour
R46.0 Very low level of personal hygiene R46.1 Bizarre personal appearance
R46.2 Strange and
inexplicable behaviour R46.3 Overactivity
R46.4 Slowness and
poor responsiveness
Excl.: stupor
(R40.1)
R46.5 Suspiciousness
and marked evasiveness
R46.6 Undue concern and preoccupation with
stressful events R46.7 Verbosity and circumstantial detail
obscuring reason for
contact
R46.8 Other
symptoms and signs involving appearance and behaviour
Self neglect NOS
Excl.: insufficient
intake of food and water due to self-neglect (R63.6)
Symptoms and signs involving speech and voice (R47–R49)
R47 Speech
disturbances, not elsewhere classified
Excl.: autism (F84.0–F84.1) cluttering (F98.6)
specific developmental disorders of speech and
language (F80.-) stuttering [stammering] (F98.5)
R47.0 Dysphasia
and aphasia
Excl.: progressive
isolated aphasia (G31.0)
R47.1 Dysarthria
and anarthria
R47.8 Other and unspecified speech disturbances
R48 Dyslexia
and other symbolic dysfunctions, not elsewhere
classified
Excl.: specific
developmental disorders of scholastic skills (F81.-)
R48.0 Dyslexia
and alexia R48.1 Agnosia
R48.2 Apraxia
R48.8 Other and unspecified symbolic dysfunctions
Acalculia Agraphia
R49 Voice disturbances
Excl.: psychogenic
voice disturbance (F44.4)
R49.0 Dysphonia
Hoarseness
R49.1 Aphonia
Loss of voice
R49.2 Hypernasality
and hyponasality
R49.8 Other and unspecified voice disturbances
Change in voice NOS
General symptoms and signs (R50–R69)
R50 Fever of other and unknown origin
Excl.: fever of unknown origin (during)(in):
•
labour (O75.2)
• newborn
(P81.9)
puerperal pyrexia NOS (O86.4)
R50.2 Drug-induced fever
Use additional external cause code (Chapter XX), if
desired, to identify drug.
R50.8 Other
specified fever
Fever with chills Fever with rigors
Persistent fever
R50.9 Fever, unspecified
Hyperpyrexia NOS Pyrexia NOS
Excl.: malignant
hyperthermia due to anaesthesia (T88.3)
R51 Headache
Incl.: Facial
pain NOS
Excl.: atypical facial pain (G50.1)
migraine and other headache syndromes
(G43–G44) trigeminal neuralgia (G50.0)
R52 Pain, not
elsewhere classified
Incl.: pain
not referable to any one organ or body region
Excl.: chronic pain personality syndrome (F62.8) headache (R51)
pain (in):
•
abdomen (R10.-)
•
back (M54.9)
•
breast (N64.4)
•
chest (R07.1-R07.4)
•
ear (H92.0)
•
eye (H57.1)
•
joint (M25.5)
•
limb (M79.6)
•
lumbar region (M54.5)
•
pelvic and perineal (R10.2)
•
psychogenic (F45.4)
•
shoulder (M25.5)
•
spine
(M54.-)
•
throat (R07.0)
•
tongue (K14.6)
• tooth (K08.8) renal colic (N23)
R52.0 Acute pain
R52.1 Chronic intractable pain R52.2 Other chronic pain R52.9 Pain, unspecified
Generalized pain NOS
R53 Malaise and fatigue
Incl.: asthenia NOS debility:
•
NOS
• chronic
general physical deterioration lethargy
tiredness
Excl.: debility:
•
congenital (P96.9)
• senile (R54)
exhaustion and fatigue (due
to)(in):
•
combat (F43.0)
•
excessive exertion (T73.3)
•
exposure (T73.2)
•
heat (T67.-)
•
neurasthenia (F48.0)
•
pregnancy (O26.8)
•
senile asthenia (R54)
fatigue syndrome (F48.0) fatigue syndrome:
•
postviral (G93.3)
R54 Senility
|
Incl.: old age senescence |
without
mention of psychosis |
senile:
•
asthenia
•
debility
Excl.: senile
psychosis (F03)
R55 Syncope and collapse
Incl.: blackout
fainting
Excl.: neurocirculatory asthenia (F45.3) orthostatic hypotension
(I95.1)
neurogenic orthostatic hypotension (G23.8)
shock:
•
NOS
(R57.9)
•
cardiogenic (R57.0)
•
complicating or following:
–
abortion or ectopic or molar pregnancy
(O00–O07, O08.3)
–
labour and delivery (O75.1)
•
postoperative (T81.1)
Stokes–Adams attack (I45.9) syncope:
•
carotid sinus (G90.0)
•
heat (T67.1)
•
psychogenic (F48.8)
unconsciousness NOS (R40.2)
R56 Convulsions, not elsewhere classified
Excl.: convulsions
and seizures (in):
•
dissociative (F44.5)
•
epilepsy (G40–G41)
•
newborn (P90)
R56.0 Febrile convulsions
R56.8 Other and unspecified convulsions
Fit NOS
Seizure (convulsive) NOS
R57 Shock, not
elsewhere classified
Excl.: shock
(due to):
•
anaesthesia (T88.2)
•
anaphylactic (due to):
– NOS (T78.2)
–
adverse food reaction (T78.0)
–
serum
(T80.5)
• complicating or following abortion or ectopic or molar pregnancy (O00–O07, O08.3)
•
electric (T75.4)
•
lightning (T75.0)
•
obstetric (O75.1)
•
postoperative (T81.1)
•
psychic (F43.0)
• traumatic
(T79.4)
toxic shock syndrome (A48.3)
R57.0 Cardiogenic
shock R57.1 Hypovolaemic shock
R57.2 Septic shock
R57.8 Other shock
Endotoxic shock
R57.9 Shock,
unspecified
Failure of peripheral circulation NOS
R58 Haemorrhage,
not elsewhere classified
Incl.: haemorrhage
NOS
R59 Enlarged lymph nodes
Incl.: swollen glands
Excl.: lymphadenitis:
•
NOS
(I88.9)
•
acute (L04.-)
•
chronic (I88.1)
•
mesenteric (acute)(chronic) (I88.0)
R59.0 Localized enlarged lymph nodes R59.1 Generalized enlarged lymph nodes
Lymphadenopathy NOS
Excl.: HIV disease resulting in (persistent) generalized
lymphadenopathy (B23.1)
R59.9 Enlarged
lymph nodes, unspecified
R60 Oedema, not elsewhere classified
Excl.: ascites (R18)
hydrops fetalis NOS (P83.2) hydrothorax
(J94.8)
oedema (of):
•
angioneurotic (T78.3)
•
cerebral (G93.6)
•
cerebral:
– due to birth injury (P11.0)
•
gestational (O12.0)
•
hereditary (Q82.0)
•
larynx (J38.4)
•
malnutrition (E40-E46)
•
nasopharynx (J39.2)
•
newborn (P83.3)
•
pharynx (J39.2)
•
pulmonary (J81) R60.0 Localized
oedema R60.1 Generalized oedema
R60.9 Oedema, unspecified
Fluid retention NOS
R61 Hyperhidrosis
R61.0 Localized
hyperhidrosis R61.1 Generalized hyperhidrosis
R61.9 Hyperhidrosis, unspecified
Excessive sweating Night sweats
R62 Lack of
expected normal physiological development
Excl.: delayed
puberty (E30.0)
R62.0 Delayed milestone
Delayed attainment of expected physiological
developmental stage Late:
• talker
• walker
R62.8 Other
lack of expected normal physiological development
Failure to:
• gain weight
•
thrive Infantilism NOS Lack of growth
Physical retardation
Excl.: HIV disease resulting in failure to thrive (B22.2)
physical retardation due to malnutrition (E45)
R62.9 Lack of expected normal physiological
development, unspecified
R63 Symptoms and signs concerning food and fluid intake
Excl.: bulimia NOS (F50.2)
eating disorders of nonorganic origin (F50.-)
malnutrition (E40–E46)
R63.0 Anorexia
Loss of appetite
Excl.: anorexia nervosa (F50.0)
loss of appetite of nonorganic
origin (F50.8)
R63.1 Polydipsia
Excessive thirst
R63.2 Polyphagia
Excessive eating Hyperalimentation NOS
R63.3 Feeding
difficulties and mismanagement
Feeding problem NOS
Excl.: feeding problems of newborn (P92.-)
infant feeding disorder of
nonorganic origin (F98.2)
R63.4 Abnormal
weight loss
R63.5 Abnormal weight gain
Excl.: excessive weight gain in pregnancy (O26.0) obesity
(E66.-)
R63.6 Insufficient
intake of food and water due to self neglect
Excl.: starvation due to anorexia (R63.0) starvation due to
privation of food (X53) thirst due to privation of water (X54) self neglect NOS (R46.8)
R63.8 Other
symptoms and signs concerning food and fluid
intake
R64 Cachexia
Excl.: HIV disease resulting in wasting syndrome (B22.2)
malignant cachexia (C80.-)
nutritional marasmus (E41)
R65 Systemic inflammatory response syndrome [SIRS]
Note: This category should
never be used in primary
coding. The category is for use in multiple coding, to
identify this condition resulting from any cause. A code from another
chapter should be assigned first, to indicate the cause or underlying disease.
R65.0 Systemic inflammatory response syndrome
of infectious origin without organ failure
R65.1 Systemic inflammatory response syndrome
of infectious origin with organ failure
Severe sepsis
R65.2 Systemic inflammatory response syndrome
of non-infectious origin without organ failure
R65.3 Systemic inflammatory response syndrome
of non-infectious origin with organ failure
R65.9 Systemic inflammatory response
syndrome, unspecified
R68 Other general symptoms and signs
R68.0 Hypothermia, not associated with low
environmental temperature
Excl.: hypothermia
(due to)(of):
•
NOS (accidental) (T68)
•
anaesthesia (T88.5)
•
low environmental temperature (T68)
•
newborn (P80.-)
R68.1 Nonspecific
symptoms peculiar to infancy
Excessive crying of infant Irritable infant
Excl.: neonatal cerebral irritability (P91.3) teething syndrome
(K00.7)
R68.2 Dry
mouth, unspecified
Excl.: dry
mouth due to:
•
dehydration (E86)
• sicca syndrome [Sjögren] (M35.0) salivary gland hyposecretion (K11.7)
R68.3 Clubbing
of fingers
Clubbing of nails
Excl.: congenital clubfinger (Q68.1) congenital clubnail (Q84.6)
R68.8 Other
specified general symptoms and signs
R69 Unknown and unspecified causes of morbidity
Incl.: illness NOS
undiagnosed disease, not
specified as to the site or system involved
Abnormal findings on examination of blood, without
diagnosis
(R70–R79)
Excl.: abnormalities
(of)(on):
• antenatal
screening of mother (O28.-)
• coagulation
(D65–D68)
• lipids
(E78.-)
• platelets
and thrombocytes (D69.-)
• white
blood cells classified elsewhere (D70–D72)
diagnostic abnormal
findings classified elsewhere - see Alphabetical
Index haemorrhagic and
haematological disorders of fetus and newborn (P50–P61)
R70 Elevated erythrocyte sedimentation rate and abnormality of plasma viscosity
R70.0 Elevated
erythrocyte sedimentation rate
R70.1 Abnormal plasma viscosity
R71 Abnormality of red blood cells
Incl.: abnormal
red-cell:
•
morphology NOS
•
volume NOS anisocytosis poikilocytosis
Excl.: anaemias (D50–D64) polycythaemia:
•
NOS
(D75.1)
•
benign (familial) (D75.0)
•
neonatorum (P61.1)
•
secondary (D75.1)
•
vera (D45)
R72 Abnormality of white blood cells, not elsewhere
classified
Incl.: abnormal
leukocyte differential NOS
Excl.: leukocytosis
(D72.8)
R73 Elevated blood glucose level
Excl.: diabetes mellitus (E10–E14) diabetes mellitus:
•
in pregnancy,
childbirth and the puerperium (O24.-) neonatal
disorders (P70.0–P70.2)
postsurgical hypoinsulinaemia
(E89.1)
R73.0 Abnormal
glucose tolerance test
Diabetes:
•
chemical
•
latent
Impaired glucose tolerance Prediabetes
R73.9 Hyperglycaemia, unspecified
R74 Abnormal serum enzyme levels
R74.0 Elevation of levels of transaminase and
lactic acid dehydrogenase [LDH]
R74.8 Abnormal levels of other serum enzymes
Abnormal level of:
•
acid phosphatase
•
alkaline phosphatase
•
amylase
•
lipase [triacylglycerol lipase]
R74.9 Abnormal
level of unspecified serum enzyme
R75 Laboratory evidence of human immunodeficiency virus [HIV]
Incl.: nonconclusive
HIV-test finding in infants
Excl.: asymptomatic human immunodeficiency virus [HIV] infection
status (Z21)
human immunodeficiency virus [HIV] disease
(B20–B24) human immunodeficiency virus [HIV] disease complicating pregnancy,
childbirth and the puerperium (O98.7)
R76 Other abnormal immunological findings in serum
R76.0 Raised
antibody titre
Excl.: isoimmunization, in pregnancy (O36.0–O36.1)
isoimmunization, in pregnancy:
•
affecting fetus or newborn (P55.-)
R76.1 Abnormal
reaction to tuberculin test
Abnormal result of Mantoux test
R76.2 False-positive
serological test for syphilis
False-positive Wassermann reaction
R76.8 Other
specified abnormal immunological findings in
serum
Raised level of immunoglobulins NOS
R76.9 Abnormal
immunological finding in serum, unspecified
R77 Other abnormalities of plasma
proteins
Excl.: disorders
of plasma-protein metabolism (E88.0)
R77.0 Abnormality of albumin R77.1 Abnormality of
globulin
Hyperglobulinaemia NOS
R77.2 Abnormality
of alphafetoprotein
R77.8 Other
specified abnormalities of plasma proteins R77.9 Abnormality of plasma protein, unspecified
R78 Findings
of drugs and other substances, not normally found in blood
Excl.: mental and behavioural disorders due to psychoactive
substance use (F10–F19)
R78.0 Finding
of alcohol in blood
Use additional external cause code (Y90), if
desired, for detail regarding alcohol level.
R78.1 Finding
of opiate drug in blood
R78.2 Finding of
cocaine in blood R78.3 Finding of
hallucinogen in blood
R78.4 Finding of
other drugs of addictive potential in blood R78.5 Finding of psychotropic drug in blood
R78.6 Finding of
steroid agent in blood
R78.7 Finding of
abnormal level of heavy metals in blood R78.8 Finding
of other specified substances, not normally
found in blood
Finding of abnormal level of lithium in blood
R78.9 Finding
of unspecified substance, not normally found in blood
R79 Other abnormal findings of blood chemistry
Excl.: abnormality of fluid, electrolyte or acid–base balance
(E86–E87) asymptomatic hyperuricaemia (E79.0)
hyperglycaemia NOS (R73.9) hypoglycaemia NOS
(E16.2) hypoglycaemia NOS:
• neonatal
(P70.3–P70.4)
specific findings indicating
disorder of:
•
amino-acid metabolism (E70–E72)
•
carbohydrate metabolism (E73–E74)
•
lipid metabolism (E75.-)
R79.0 Abnormal
level of blood mineral
Abnormal blood level of:
•
cobalt
•
copper
•
iron
•
magnesium
•
mineral NEC
•
zinc
Excl.: abnormal level of lithium (R78.8) disorders of mineral
metabolism (E83.-) neonatal hypomagnesaemia (P71.2) nutritional mineral
deficiency (E58–E61)
R79.8 Other
specified abnormal findings of blood chemistry
Abnormal blood-gas level
R79.9 Abnormal
finding of blood chemistry, unspecified
Abnormal findings on
examination of urine, without diagnosis
(R80–R82)
Excl.: abnormal findings on antenatal screening of mother (O28.-)
diagnostic abnormal findings classified elsewhere – see
Alphabetical index specific findings indicating disorder of:
• amino-acid metabolism (E70–E72)
• carbohydrate metabolism (E73–E74)
R80 Isolated proteinuria
Incl.: albuminuria NOS Bence–Jones proteinuria proteinuria NOS
Excl.: proteinuria:
• gestational (O12.1)
• isolated, with specified morphological lesion (N06.-)
• orthostatic (N39.2)
• persistent (N39.1)
R81 Glycosuria
Excl.: renal
glycosuria (E74.8)
R82 Other abnormal
findings in urine
Excl.: haematuria
(R31)
R82.0 Chyluria
Excl.: filarial
chyluria (B74.-)
R82.1 Myoglobinuria
R82.2 Biliuria
R82.3 Haemoglobinuria
Excl.: haemoglobinuria:
• due to haemolysis from external causes NEC (D59.6)
• paroxysmal nocturnal [Marchiafava–Micheli] (D59.5)
R82.4 Acetonuria
Ketonuria
R82.5 Elevated urine levels of drugs,
medicaments and biological substances
Elevated urine levels of:
• catecholamines
• indoleacetic acid
• 17-ketosteroids
• steroids
R82.6 Abnormal urine levels of substances
chiefly nonmedicinal as to source
Abnormal urine level of heavy
metals
R82.7 Abnormal
findings on microbiological examination of urine
Positive culture findings
R82.8 Abnormal findings on cytological and
histological examination of urine
R82.9 Other and unspecified abnormal findings
in urine
Cells and casts in urine Crystalluria
Melanuria
Abnormal findings on examination of other body fluids,
substances and tissues, without diagnosis
(R83–R89)
Excl.: abnormal
findings on:
•
antenatal screening of mother (O28.-)
•
examination of:
– blood,
without diagnosis (R70–R79)
– urine,
without diagnosis (R80–R82)
diagnostic abnormal findings
classified elsewhere – see Alphabetical index The following fourth-character
subdivisions are for use with categories R83–R89:
.0
Abnormal
level of enzymes
.1
Abnormal
level of hormones
.2
Abnormal
level of other drugs, medicaments and biological substances
.3
Abnormal
level of substances chiefly nonmedicinal as to
source
.4
Abnormal
immunological findings
.5 Abnormal microbiological findings
Positive culture findings
.6
Abnormal
cytological findings
Abnormal Papanicolaou smear
.7
Abnormal
histological findings
.8 Other abnormal findings
Abnormal chromosomal findings
.9
Unspecified
abnormal finding
R83 Abnormal findings in cerebrospinal fluid
[See before R83 for subdivisions]
R84 Abnormal
findings in specimens from respiratory organs and thorax
[See before R83 for subdivisions]
Incl.: abnormal
findings in:
•
bronchial washings
•
nasal
secretions
•
pleural fluid
•
sputum
•
throat scrapings
Excl.: blood-stained
sputum (R04.2)
R85 Abnormal findings in specimens from digestive organs and
abdominal cavity
[See before R83 for subdivisions]
Incl.: abnormal
findings in:
•
peritoneal fluid
•
saliva
Excl.: faecal
abnormalities (R19.5)
R86 Abnormal findings in specimens from male genital organs
[See before R83 for subdivisions]
Incl.: abnormal
findings in:
•
prostatic secretions
• semen, seminal fluid abnormal
spermatozoa
Excl.: azoospermia (N46) oligospermia (N46)
R87 Abnormal findings in specimens from female genital organs
[See before R83 for subdivisions]
Incl.: abnormal
findings in secretions and smears from:
•
cervix uteri
•
vagina
•
vulva
Excl.: carcinoma in situ (D05–D07.3) dysplasia of:
•
cervix uteri (N87.-)
•
vagina (N89.0–N89.3)
•
vulva (N90.0–N90.3)
R89 Abnormal findings in specimens from other organs, systems
and tissues
[See before R83 for subdivisions]
Incl.: abnormal
findings in:
•
nipple discharge
•
synovial fluid
•
wound
secretions
Abnormal findings on diagnostic imaging and in function
studies, without diagnosis
(R90–R94)
Incl.: nonspecific abnormal findings on diagnostic
imaging by:
• computerized
axial tomography [CAT scan]
• magnetic
resonance imaging [MRI][NMR]
• positron
emission tomography [PET scan]
• thermography
• ultrasound
[echogram]
• X-ray examination
Excl.: abnormal findings on antenatal screening of mother (O28.-)
diagnostic abnormal findings
classified elsewhere – see Alphabetical index
R90 Abnormal findings on diagnostic imaging of central
nervous system
R90.0 Intracranial
space-occupying lesion
R90.8 Other abnormal findings on diagnostic
imaging of central nervous system
Abnormal echoencephalogram White matter
disease NOS
R91 Abnormal findings on diagnostic imaging of lung
Incl.: coin
lesion NOS
lung mass NOS
R92 Abnormal findings on diagnostic imaging of breast
R93 Abnormal
findings on diagnostic imaging of other body structures
R93.0 Abnormal findings on diagnostic imaging
of skull and head, not elsewhere classified
Excl.: intracranial
space-occupying lesion (R90.0)
R93.1 Abnormal findings on diagnostic imaging
of heart and coronary circulation
Abnormal:
• echocardiogram NOS
• heart shadow
R93.2 Abnormal findings
on diagnostic imaging of liver
and biliary tract
Nonvisualization of gallbladder
R93.3 Abnormal findings on diagnostic imaging
of other parts of digestive tract
R93.4 Abnormal findings on diagnostic imaging
of urinary organs
Filling defect of:
• bladder
• kidney
• ureter
Excl.: hypertrophy
of kidney (N28.8)
R93.5 Abnormal findings on diagnostic imaging
of other abdominal regions, including retroperitoneum
R93.6 Abnormal findings on diagnostic imaging
of limbs
Excl.: abnormal
finding in skin and subcutaneous tissue (R93.8)
R93.7 Abnormal findings on diagnostic imaging
of other parts of musculoskeletal system
Excl.: abnormal
findings on diagnostic imaging of skull (R93.0)
R93.8 Abnormal findings on diagnostic imaging
of other specified body structures
Abnormal radiological finding in skin and
subcutaneous tissue Mediastinal shift
R94 Abnormal results of function studies
Incl.: abnormal
results of:
•
radionuclide [radioisotope] uptake studies
•
scintigraphy
R94.0 Abnormal results of function studies of
central nervous system
Abnormal electroencephalogram
[EEG]
R94.1 Abnormal results of function studies of
peripheral nervous system and special senses
Abnormal:
• electromyogram
[EMG]
• electro-oculogram
[EOG]
• electroretinogram
[ERG]
• response
to nerve stimulation
• visually
evoked potential [VEP]
R94.2 Abnormal
results of pulmonary function studies
Reduced:
• ventilatory
capacity
• vital
capacity
R94.3 Abnormal
results of cardiovascular function studies
Abnormal:
• electrocardiogram
[ECG][EKG]
• electrophysiological
intracardiac studies
• phonocardiogram
• vectorcardiogram
R94.4 Abnormal
results of kidney function studies
Abnormal renal function test
R94.5 Abnormal results of liver function studies R94.6 Abnormal results of thyroid function studies
R94.7 Abnormal
results of other endocrine function studies
Excl.: abnormal
glucose tolerance test (R73.0)
R94.8 Abnormal results of function studies of
other organs and systems
Abnormal:
• basal
metabolic rate [BMR]
• bladder
function test
• splenic
function test
Ill-defined and unknown causes of mortality (R95–R99)
Excl.: fetal death of unspecified cause (P95) obstetric death NOS (O95)
R95 Sudden infant
death syndrome
R95.0 Sudden infant death syndrome with
mention of autopsy R95.9 Sudden
infant death syndrome without mention of autopsy
Sudden infant death syndrome, unspecified
R96 Other sudden
death, cause unknown
Excl.: sudden:
•
cardiac death, so described (I46.1)
•
infant death syndrome (R95.-)
R96.0 Instantaneous
death
Sudden unexplained death in adult
Excl.: sudden death of known aetiology (A00.0–Q99.9, U04.9,
V01.0–Y89.9)
R96.1 Death occurring less than 24 hours from
onset of symptoms, not otherwise explained
Death known not to be violent or instantaneous
for which no cause can be discovered
Death without sign of disease
R98 Unattended death
Incl.: death in circumstances where the body of the deceased was
found and no cause could be discovered
found dead
R99 Other
ill-defined and unspecified causes of mortality
Incl.: death NOS
unknown cause of mortality
Posting Komentar untuk "ICD 10 || Tabular list of inclusions and four-character subcategories || CHAPTER XV Pregnancy, childbirth and the puerperium (O00–O99) - CHAPTER XVIII Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00–R99)"
You are welcome to share your ideas with us in comments!