ICD-10-CM (2010)/CHAPTER 18

=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-R94 consist of: (a) cases for which no more specific diagnosis can be made even after all the facts bearing on the case have been investigated: (b) signs or symptoms existing at the time of initial encounter that proved to be transient and whose causes could not be determined; (c) provisional diagnosis in a patient who failed to return for further investigation or care;(d) cases referred elsewhere for investigation or treatment before the diagnosis was made; (e) cases in which a more precise diagnosis was not available for any other reason; (f) certain symptoms, for which supplementary information is provided, that represent important problems in medical care in their own right.

Excludes2: abnormal findings on antenatal screening of mother (O28.-)

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

signs and symptoms classified in the body system chapters

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

This chapter contains the following blocks:

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 behavior

R47-R49 Symptoms and signs involving speech and voice

R50R69 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

R97 Abnormal tumor markers

R99 Ill-defined and unknown cause of mortality

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

R00 Abnormalities of heart beat

Excludes1: abnormalities originating in the perinatal period (P29.1)

specified arrhythmias (I47-I49)

R00.0 Tachycardia, unspecified

Rapid heart beat

Sinoauricular tachycardia NOS

Sinus [sinusal] tachycardia NOS

Excludes1: neonatal tachycardia (P29.11)

paroxysmal tachycardia (I47.-)

R00.1 Bradycardia, unspecified

Sinoatrial bradycardia

Sinus bradycardia

Slow heart beat

Vagal bradycardia

Excludes1: neonatal bradycardia (P29.12)

R00.2 Palpitations

Awareness of heart beat

R00.8 Other abnormalities of heart beat

R00.9 Unspecified abnormalities of heart beat

R01 Cardiac murmurs and other cardiac sounds

Excludes1: cardiac murmurs and sounds originating in the perinatal period (P29.8)

R01.0 Benign and innocent cardiac murmurs

Functional cardiac murmur

R01.1 Cardiac murmur, unspecified

Cardiac bruit NOS

Heart murmur NOS

R01.2 Other cardiac sounds

Cardiac dullness, increased or decreased

Precordial friction

R03 Abnormal blood-pressure reading, without diagnosis

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

Note: This category is to be used to record an episode of elevated blood pressure in a patient in whom no formal diagnosis of hypertension has been made, or as an isolated incidental finding.

R03.1 Nonspecific low blood-pressure reading

Excludes1: hypotension (I95.-)

maternal hypotension syndrome (O26.5-)

neurogenic orthostatic hypotension (G90.3)

R04 Hemorrhage from respiratory passages

R04.0 Epistaxis

Hemorrhage from nose

Nosebleed

R04.1 Hemorrhage from throat

Excludes2: hemoptysis (R04.2)

R04.2 Hemoptysis

Blood-stained sputum

Cough with hemorrhage

R04.8 Hemorrhage from other sites in respiratory passages

Pulmonary hemorrhage NOS

Excludes1: perinatal pulmonary hemorrhage (P26.-)

R04.9 Hemorrhage from respiratory passages, unspecified

R05 Cough

Excludes1: cough with hemorrhage (R04.2)

smoker's cough (J41.0)

R06 Abnormalities of breathing

Excludes1: acute respiratory distress syndrome (J80)

respiratory arrest (R09.2)

respiratory arrest of newborn (P28.81)

respiratory distress syndrome of newborn (P22.-)

respiratory failure (J96.-)

respiratory failure of newborn (P28.5)

R06.0 Dyspnea

Excludes1: tachypnea NOS (R06.82)

transient tachypnea of newborn (P22.1)

R06.00 Dyspnea NOS

R06.01 Orthopnea

R06.02 Shortness of breath

R06.09 Other forms of dyspnea

R06.1 Stridor

Excludes1: congenital laryngeal stridor (P28.89)

laryngismus (stridulus) (J38.5)

R06.2 Wheezing

Excludes1: Asthma (J45.-)

R06. 3 Periodic breathing

Cheyne-Stokes breathing

R06.4 Hyperventilation

Excludes1: psychogenic hyperventilation (F45.8)

R06.5 Mouth breathing

Excludes2: dry mouth NOS (R68.2)

R06.6 Hiccough

Excludes1: psychogenic hiccough (F45.8)

R06.7 Sneezing

R06.8 Other abnormalities of breathing

R06.81 Apnea, not elsewhere classified

Apnea NOS

Excludes1: apnea (of) newborn (P28.4)

sleep apnea (G47.3-)

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

R06.82 Tachypnea, not elsewhere classified

Tachypnea NOS

Excludes1: transitory tachypnea of newborn (P22.1)

R06.83 Snoring

R06.89 Other abnormalities of breathing

Breath-holding (spells)

Sighing

R06.9 Unspecified abnormalities of breathing

R07 Pain in throat and chest

Excludes1: epidemic myalgia (B33.0)

Excludes2: pain in breast (N64.4)

R07.0 Pain in throat

Excludes1: chronic sore throat (J31.2)

sore throat (acute) NOS (J02.9)

Excludes2: dysphagia (R13.1-)

pain in neck (M54.2)

R07.1 Chest pain on breathing

Painful respiration

R07.2 Precordial pain

R07.8 Other chest pain

R07.81 Pleurodynia

Pleurodynia NOS

Excludes1: epidemic pleurodynia (B33.0)

R07.82 Intercostal pain

R07.89 Other chest pain

Anterior chest-wall pain NOS

R07.9 Chest pain, unspecified

R09 Other symptoms and signs involving the circulatory and respiratory system

Excludes1: acute respiratory distress syndrome (J80)

respiratory arrest of newborn (P28.81)

respiratory distress syndrome of newborn (P22.0)

respiratory failure (J96.-)

respiratory failure of newborn (P28.5)

R09.0 Asphyxia and hypoxemia

Excludes1: asphyxia due to carbon monoxide (T58.-)

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

birth (intrauterine) asphyxia (P84)

hypercapnia (R06.4)

hyperventilation (R06.4)

traumatic asphyxia (T71-)

R09.01 Asphyxia

R09.02 Hypoxemia

R09.1 Pleurisy

Excludes1: pleurisy with effusion (J90)

R09.2 Respiratory arrest

Cardiorespiratory failure

Excludes1: cardiac arrest (I46.-)

respiratory arrest of newborn (P28.81)

respiratory distress of newborn (P22.0)

respiratory failure (J96.-)

respiratory failure of newborn (P28.5)

respiratory insufficiency (R06.89)

respiratory insufficiency of newborn (P28.5)

R09.3 Abnormal sputum

Abnormal amount of sputum

Abnormal color of sputum

Abnormal odor of sputum

Excessive sputum

Excludes1: blood-stained sputum (R04.2)

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

R09.81 Nasal congestion

R09.82 Postnasal drip

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

Bruit (arterial)

Abnormal chest percussion

Feeling of foreign body in throat

Friction sounds in chest

Chest tympany

Choking sensation

Rales

Weak pulse

Excludes2: foreign body in throat (T17.2-)

wheezing (R06.2)

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

Excludes1: congenital or infantile pylorospasm (Q40.0)

gastrointestinal hemorrhage (K92.0-K92.2)

intestinal obstruction (K56.-)

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

newborn intestinal obstruction (P76.-)

pylorospasm (K31.3)

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

symptoms referable to female genital organs (N94.-)

symptoms referable to male genital organs male (N48-N50)

R10 Abdominal and pelvic pain

Excludes1: renal colic (N23)

Excludes2: dorsalgia (M54.-)

flatulence and related conditions (R14.-)

R10.0 Acute abdomen

Severe abdominal pain (generalized) (with abdominal rigidity)

Excludes1: abdominal rigidity NOS (R19.3)

generalized abdominal pain NOS (R10.84)

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

R10.1 Pain localized to upper abdomen

R10.10 Upper abdominal pain, unspecified

R10.11 Right upper quadrant pain

R10.12 Left upper quadrant pain

R10.13 Epigastric pain

R10.2 Pelvic and perineal pain

Excludes1: vulvodynia (N94.81)

R10.3 Pain localized to other parts of lower abdomen

R10.30 Lower abdominal pain, unspecified

R10.31 Right lower quadrant pain

R10.32 Left lower quadrant pain

R10.33 Periumbilical pain

R10.8 Other abdominal pain

R10.81 Abdominal tenderness

Abdominal tenderness NOS

R10.811 Right upper quadrant abdominal tenderness

R10.812 Left upper quadrant abdominal tenderness

R10.813 Right lower quadrant abdominal tenderness

R10.814 Left lower quadrant abdominal tenderness

R10.815 Periumbilic abdominal tenderness

R10.816 Epigastric abdominal tenderness

R10.817 Generalized abdominal tenderness

R10.819 Abdominal tenderness, unspecified site

R10. 82 Rebound abdominal tenderness

R10.821 Right upper quadrant rebound abdominal tenderness

R10.822 Left upper quadrant rebound abdominal tenderness

R10.823 Right lower quadrant rebound abdominal tenderness

R10.824 Left lower quadrant rebound abdominal tenderness

R10.825 Periumbilic rebound abdominal tenderness

R10.826 Epigastric rebound abdominal tenderness

R10.827 Generalized rebound abdominal tenderness

R10.829 Rebound abdominal tenderness, unspecified site

R10.83 Colic

Colic NOS

Infantile colic

Excludes1: colic in adult and child over 12 months old (R10.84)

R10.84 Generalized abdominal pain

Excludes1: generalized abdominal pain associated with acute abdomen (R10.0)

R10.9 Unspecified abdominal pain

R11 Nausea and vomiting

Excludes1: cyclical vomiting associated with migraine (G43.a-)

excessive vomiting in pregnancy (O21.-)

hematemesis (K92.0)

neonatal hematemesis (P54.0)

newborn vomiting (P92.0-)

psychogenic vomiting (F50.8)

vomiting associated with bulimia nervosa (F50.2)

vomiting following gastrointestinal surgery (K91.0)

R11.0 Nausea

Nausea NOS

Nausea without vomiting

R11.1 Vomiting

R11.10 Vomiting, unspecified

Vomiting NOS

R11.11 Vomiting without nausea

R11.12 Projectile vomiting

R11.13 Vomiting of fecal matter

R11.14 Bilious vomiting

Bilious emesis

R11.2 Nausea with vomiting, unspecified

Persistent nausea with vomiting NOS

R12 Heartburn

Excludes1: dyspepsia (K30)

R13 Aphagia and dysphagia

R13.0 Aphagia

Inability to swallow

Excludes1: psychogenic aphagia (F50.9)

R13.1 Dysphagia

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

Excludes1: psychogenic dysphagia (F45.8)

R13.10 Dysphagia, unspecified

Difficulty in swallowing NOS

R13.11 Dysphagia, oral phase

R13.12 Dysphagia, oropharyngeal phase

R13.13 Dysphagia, pharyngeal phase

R13.14 Dysphagia, pharyngoesophageal phase

R13.19 Other dysphagia

Cervical dysphagia

Neurogenic dysphagia

R14 Flatulence and related conditions

Excludes1: psychogenic aerophagy (F45.8)

R14.0 Abdominal distension (gaseous)

Bloating

Tympanites (abdominal) (intestinal)

R14.1 Gas pain

R14.2 Eructation

R14.3 Flatulence

R14.8 Other

R15 Fecal incontinence

Includes: encopresis NOS

Excludes1: fecal incontinence 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

Excludes1: neonatal jaundice (P55, P57-P59)

R18 Ascites

Includes: fluid in peritoneal cavity

Excludes1: ascites in alcoholic cirrhosis (K70.31)

ascites in alcoholic hepatitis (K70.11)

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

R18.0 Malignant ascites

Code first malignancy, such as:

malignant neoplasm of ovary (C56.-)

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

R18.8 Other ascites

Ascites NOS

Peritoneal effusion (chronic)

R19 Other symptoms and signs involving the digestive system and abdomen

Excludes1: acute abdomen (R10.0)

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

Excludes1: abdominal distension (gaseous) (R14.-)

ascites (R18.-)

R19.00 Intra-abdominal and pelvic swelling, mass and lump, unspecified site

R19.01 Right upper quadrant abdominal swelling, mass and lump

R19.02 Left upper quadrant abdominal swelling, mass and lump

R19.03 Right lower quadrant abdominal swelling, mass and lump

R19.04 Left lower quadrant abdominal swelling, mass and lump

R19.05 Periumbilic swelling, mass or lump

Diffuse or generalized umbilical swelling or mass

R19.06 Epigastric swelling, mass or lump

R19.07 Generalized intra-abdominal and pelvic swelling, mass and lump

Diffuse or generalized intra-abdominal swelling or mass NOS

Diffuse or generalized pelvic swelling or mass NOS

R19.09 Other intra-abdominal and pelvic swelling, mass and lump

R19.1 Abnormal bowel sounds

R19.11 Absent bowel sounds

R19.12 Hyperactive bowel sounds

R19.15 Other abnormal bowel sounds

Abnormal bowel sounds NOS

R19.2 Visible peristalsis

Hyperperistalsis

R19.3 Abdominal rigidity

Excludes1: abdominal rigidity with severe abdominal pain (R10.0)

R19.30 Abdominal rigidity, unspecified site

R19. 31 Right upper quadrant abdominal rigidity

R19.32 Left upper quadrant abdominal rigidity

R19.33 Right lower quadrant abdominal rigidity

R19.34 Left lower quadrant abdominal rigidity

R19.35 Periumbilic abdominal rigidity

R19.36 Epigastric abdominal rigidity

R19.37 Generalized abdominal rigidity

R19.4 Change in bowel habit

Excludes1: constipation (K59.0-)

functional diarrhea (K59.1)

R19.5 Other fecal abnormalities

Abnormal stool color

Bulky stools

Mucus in stools

Occult blood in feces

Occult blood in stools

Excludes1: melena (K92.1)

neonatal melena (P54.1)

R19.6 Halitosis

R19.7 Diarrhea, unspecified

Diarrhea NOS

Excludes1: functional diarrhea (K59.1)

neonatal diarrhea (P78.3)

psychogenic diarrhea (F45.8)

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

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

Excludes2: symptoms relating to breast (N64.4-N64.5)

R20 Disturbances of skin sensation

Excludes1: dissociative anesthesia and sensory loss (F44.6)

psychogenic disturbances (F45.8)

R20.0 Anesthesia of skin

R20.1 Hypoesthesia of skin

R20.2 Paresthesia of skin

Formication

Pins and needles

Tingling skin

Excludes1: acroparesthesia (I73.8)

R20.3 Hyperesthesia

R20.8 Other disturbances of skin sensation

R20.9 Unspecified disturbances of skin sensation

R21 Rash and other nonspecific skin eruption

Rash NOS

Excludes1: specified type of rash- code to condition

vesicular eruption (R23.8)

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

Includes: subcutaneous nodules (localized)(superficial)

Excludes1: abnormal findings on diagnostic imaging (R90-R93)

edema (R60.-)

enlarged lymph nodes (R59.-)

localized adiposity (E65)

swelling of joint (M25.4-)

R22.0 Localized swelling, mass and lump, head

R22.1 Localized swelling, mass and lump, neck

R22.2 Localized swelling, mass and lump, trunk

Excludes1: intra-abdominal or pelvic mass and lump (R19.0-)

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

Excludes2: breast mass and lump (N63)

R22.3 Localized swelling, mass and lump, upper limb

R22.30 Localized swelling, mass and lump, upper limb, unspecified side

R22.31 Localized swelling, mass and lump, right upper limb

R22.32 Localized swelling, mass and lump, left upper limb

R22.33 Localized swelling, mass and lump, upper limb, bilateral

R22.4 Localized swelling, mass and lump, lower limb

R22.40 Localized swelling, mass and lump, lower limb, unspecified side

R22.41 Localized swelling, mass and lump, right lower limb

R22.42 Localized swelling, mass and lump, left lower limb

R22.43 Localized swelling, mass and lump, lower limb, bilateral

R22.9 Localized swelling, mass and lump, unspecified

R23 Other skin changes

R23.0 Cyanosis

Excludes1: acrocyanosis (I73.8)

cyanotic attacks of newborn (P28.2)

R23.1 Pallor

Clammy skin

R23.2 Flushing

Excessive blushing

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

R23.3 Spontaneous ecchymoses

Petechiae

Excludes1: ecchymoses of newborn (P54.5)

purpura (D69.-)

R23.4 Changes in skin texture

Desquamation of skin

Induration of skin

Scaling of skin

Excludes1: epidermal thickening NOS (L85.9)

R23.8 Other skin changes

R23.9 Unspecified skin changes

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

R25 Abnormal involuntary movements

Excludes1: specific movement disorders (G20-G26)

stereotyped movement disorders (F98.4)

tic disorders (F95.-)

R25.0 Abnormal head movements

R25.1 Tremor, unspecified

Excludes1: chorea NOS (G25.5)

essential tremor (G25.0)

hysterical tremor (F44.4)

intention tremor (G25.2)

R25.2 Cramp and spasm

Excludes2: carpopedal spasm (R29.0)

charley-horse (M62.831)

infantile spasms (G40.4-)

muscle spasm of back (M62.830)

muscle spasm of calf (M62.831)

R25.3 Fasciculation

Twitching NOS

R25.8 Other abnormal involuntary movements

R25.9 Unspecified abnormal involuntary movements

R26 Abnormalities of gait and mobility

Excludes1: ataxia NOS (R27.0)

hereditary ataxia (G11.-)

locomotor (syphilitic) ataxia (A52.11)

immobility syndrome (paraplegic) (M62.3)

R26.0 Ataxic gait

Staggering gait

R26.1 Paralytic gait

Spastic gait

R26.2 Difficulty in walking, not elsewhere classified

Excludes1: falling (R29.6)

unsteadiness on feet (R26.81)

R26.8 Other abnormalities of gait and mobility

R26.81 Unsteadiness on feet

R26.89 Other abnormalities of gait and mobility

R26.9 Unspecified abnormalities of gait and mobility

R27 Other lack of coordination

Excludes1: ataxic gait (R26.0)

hereditary ataxia (G11.-)

vertigo NOS (R42)

R27.0 Ataxia, unspecified

Excludes1: ataxia following cerebrovascular disease (I69. with final characters -93)

R27.8 Other lack of coordination

R27.9 Unspecified lack of coordination

R29 Other symptoms and signs involving the nervous and musculoskeletal systems

R29.0 Tetany

Carpopedal spasm

Excludes1: hysterical tetany (F44.5)

neonatal tetany (P71.3)

parathyroid tetany (E20.9)

post-thyroidectomy tetany (E89.2)

R29.1 Meningismus

R29.2 Abnormal reflex

Excludes2: abnormal pupillary reflex (H57.0)

hyperactive gag reflex (J39.2)

vasovagal reaction or syncope (R55)

R29.3 Abnormal posture

R29.4 Clicking hip

Excludes1: congenital deformities of hip (Q65.-)

R29.5 Transient paralysis

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

Excludes1: transient ischemic attack (G45.9)

R29.6 Repeated falls

Falling

Tendency to fall

Excludes2: at risk for falling (Z91.81)

history of falling (Z91.81)

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

R29.81 Other symptoms and signs involving the nervous system

R29.810 Facial weakness

Facial droop

Excludes1: Bell's palsy (G51.0)

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

R29.818 Other symptoms and signs involving the nervous system

R29.89 Other symptoms and signs involving the musculoskeletal system

Excludes2: pain in limb (M79.6-)

R29.890 Loss of height

Excludes1: osteoporosis (M80-M82)

R29.891 Ocular torticollis

Excludes1: congenital (sternomastoid) torticollis Q68.0

psychogenic torticollis (F45.8)

spasmodic torticollis (G24.3)

torticollis due to birth injury (P15.8)

torticollis NOS M43.6

R29.898 Other symptoms and signs involving the musculoskeletal system

R29.9 Unspecified symptoms and signs involving the nervous and musculoskeletal systems

R29.90 Unspecified symptoms and signs involving the nervous system

R29.91 Unspecified symptoms and signs involving the musculoskeletal system

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

R30 Pain associated with micturition

Excludes1: psychogenic pain associated with micturition (F45.8)

R30.0 Dysuria

Strangury

R30.1 Vesical tenesmus

R30.9 Painful micturition, unspecified

Painful urination NOS

R31 Hematuria

Excludes1: hematuria included with underlying conditions, such as:

acute cystitis with hematuria (N30.01)

acute prostatitis with hematuria (N41.01)

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

R31.0 Gross hematuria

R31. 1 Benign essential microscopic hematuria

R31.2 Other microscopic hematuria

R31.9 Hematuria, unspecified

R32 Unspecified urinary incontinence

Includes: enuresis NOS

Excludes1: functional urinary incontinence (R39.81)

nonorganic enuresis (F98.0)

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

urinary incontinence associated with cognitive impairment (R39.81)

R33 Retention of urine

Excludes1: psychogenic retention of urine (F45.8)

R33.0 Drug induced retention of urine

Code first (T36-T50) to identify the drug

R33.8 Other retention of urine

Code, if applicable, any causal condition first, such as:

enlarged prostate (N40.1)

R33.9 Retention of urine, unspecified

R34 Anuria and oliguria

Excludes1: anuria and oliguria complicating abortion or ectopic or molar pregnancy (O00-O07, O08.4)

anuria and oliguria complicating pregnancy (O26.83-)

anuria and oliguria complicating the puerperium (O90.4)

R35 Polyuria

Code, if applicable, any causal condition first, such as:

enlarged prostate (N40.1)

Excludes1: psychogenic polyuria (F45.8)

R35.0 Frequency of micturition

R35.1 Nocturia

R35.8 Other polyuria

Polyuria NOS

R36 Urethral discharge

R36.0 Urethral discharge without blood

R36.1 Hematospermia

R36.9 Urethral discharge, unspecified

Penile discharge NOS

Urethrorrhea

R37 Sexual dysfunction, unspecified

R39 Other and unspecified symptoms and signs involving the genitourinary system

R39.0 Extravasation of urine

R39. 1 Other difficulties with micturition

Code, if applicable, any causal condition first, such as:

enlarged prostate (N40.1)

R39.11 Hesitancy of micturition

R39.12 Poor urinary stream

Weak urinary steam

R39.13 Splitting of urinary stream

R39.14 Feeling of incomplete bladder emptying

R39.15 Urgency of urination

Excludes1 urge incontinence (N39.41, N39.46)

R39.16 Straining to void

R39.19 Other difficulties with micturition

R39.2 Extrarenal uremia

Prerenal uremia

Excludes1: uremia NOS (N19)

R39.8 Other symptoms and signs involving the genitourinary system

R39.81 Functional urinary incontinence

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

Excludes1: stress incontinence and other specified urinary incontinence (N39.3-N39.4-)

urinary incontinence NOS (R32)

R39.89 Other symptoms and signs involving the genitourinary system

R39.9 Unspecified symptoms and signs involving the genitourinary system

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

Excludes1: symptoms and signs constituting part of a pattern of mental disorder (F01-F99)

R40 Somnolence, stupor and coma

Excludes1: neonatal coma (P91.5)

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

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

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

R40.0 Somnolence

Drowsiness

Excludes1: coma (R40.2-)

R40.1 Stupor

Catatonic stupor

Semicoma

Excludes1: catatonic schizophrenia (F20.2)

coma (R40.2-)

depressive stupor (F31-F33)

dissociative stupor (F44.2)

manic stupor (F30.2)

R40.2 Coma

Coma NOS

Unconsciousness NOS

Codes first any associated:

coma in fracture of skull (S02.-)

coma in intracranial injury (S06.-)

The appropriate 7th character is to be added to each code from subcategory R40.21-, R40.22-, R40.23-:

0 unspecified time

1 in the field [EMT or ambulance]

2 at arrival to emergency department

3 at hospital admission

4 24 hours or more after hospital admission

A code from each subcategory is required to complete the coma scale

Note: These codes are intended primarily for trauma registry and research use but may be utilized by all users of the classification who wish to collect this information

R40.20 Unspecified coma

R40.21 Coma scale, eyes open

R40.211 Coma scale, eyes open, never

R40.212 Coma scale, eyes open, to pain

R40.213 Coma scale, eyes open, to sound

R40.214 Coma scale, eyes open, spontaneous

R40.22 Coma scale, best verbal response

R40.221 Coma scale, best verbal response, none

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

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

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

R40.225 Coma scale, best verbal response, oriented

R40.23 Coma scale, best motor response

R40.231 Coma scale, best motor response, none

R40.232 Coma scale, best motor response, extension

R40.233 Coma scale, best motor response, abnormal

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

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

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

R40.3 Persistent vegetative state

R40.4 Transient alteration of awareness

R41 Other symptoms and signs involving cognitive functions and awareness

Excludes1: dissociative [conversion] disorders (F44.-)

R41.0 Disorientation, unspecified

Confusion NOS

Delirium NOS

R41.1 Anterograde amnesia

R41.2 Retrograde amnesia

R41.3 Other amnesia

Amnesia NOS

Memory loss NOS

Excludes1: amnestic disorder due to known physiologic condition (F04)

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

transient global amnesia (G45.4)

R41.4 Neurologic neglect syndrome

Asomatognosia

Hemi-akinesia

Hemi-inattention

Hemispatial neglect

Left-sided neglect

Sensory neglect

Visuospatial neglect

R41.8 Other symptoms and signs involving cognitive functions and awareness

R41.81 Age-related cognitive decline

Senility NOS

R41.82 Altered mental status, unspecified

Change in mental status NOS

Excludes1: altered level of consciousness (R40.-)

altered mental status due to known condition - code to condition

delirium NOS (R41.0)

R41.83 Borderline intellectual functioning

IQ level 71 to 84

Excludes1: mental retardation (F70-F79)

R41.89 Other symptoms and signs involving cognitive functions and awareness

Anosognosia

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

R42 Dizziness and giddiness

Includes: light-headedness

vertigo NOS

Excludes1: vertiginous syndromes (H81.-)

vertigo from infrasound (T75.23)

R43 Disturbances of smell and taste

R43.0 Anosmia

R43.1 Parosmia

R43.2 Parageusia

R43.8 Other disturbances of smell and taste

Mixed disturbance of smell and taste

R43.9 Unspecified disturbances of smell and taste

R44 Other symptoms and signs involving general sensations and perceptions

Excludes1: alcoholic hallucinations (F1.5)

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

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

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

Excludes2: disturbances of skin sensation (R20.-)

R44.0 Auditory hallucinations

R44.1 Visual hallucinations

R44.2 Other hallucinations

R44.3 Hallucinations, unspecified

R44.8 Other symptoms and signs involving general sensations and perceptions

R44.9 Unspecified symptoms and signs involving general sensations and perceptions

R45 Symptoms and signs involving emotional state

R45.0 Nervousness

Nervous tension

R45.1 Restlessness and agitation

R45.2 Unhappiness

R45.3 Demoralization and apathy

Excludes1: anhedonia (R45.84)

R45.4 Irritability and anger

R45.5 Hostility

R45.6 Violent behavior

R45.7 State of emotional shock and stress, unspecified

R45.8 Other symptoms and signs involving emotional state

R45.81 Low self-esteem

R45.82 Worries

R45.83 Excessive crying of child, adolescent or adult

Excludes1: excessive crying of infant (baby) R68.11

R45.84 Anhedonia

R45.85 Suicidal ideation

Excludes1: suicide attempt (T14.91)

R45.86 Emotional lability

R45.87 Impulsiveness

R45.89 Other symptoms and signs involving emotional state

R46 Symptoms and signs involving appearance and behavior

Excludes1: appearance and behavior in schizophrenia, schizotypal and delusional disorders (F20-F29)

mental and behavioral disorders (F01-F99)

R46.0 Very low level of personal hygiene

R46.1 Bizarre personal appearance

R46.2 Strange and inexplicable behavior

R46.3 Overactivity

R46.4 Slowness and poor responsiveness

Excludes1: stupor (R40.1)

R46.5 Suspiciousness and marked evasiveness

R46.6 Undue concern and preoccupation with stressful events

R46.7 Verbosity and circumstantial detail obscuring reason for contact

R46.8 Other symptoms and signs involving appearance and behavior

R46.81 Obsessive-compulsive behavior

Excludes1: obsessive-compulsive disorder (F42)

R46.89 Other symptoms and signs involving appearance and behavior

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

R47 Speech disturbances, not elsewhere classified

Excludes1: autism (F84.0)

cluttering (F98.8)

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

stuttering [stammering] (F98.5)

R47.0 Dysphasia and aphasia

R47.01 Aphasia

Excludes1: aphasia following cerebrovascular disease (I69. with final characters -20)

progressive isolated aphasia (G31.01)

R47.02 Dysphasia

Excludes1: dysphasia following cerebrovascular disease (I69. with final characters -21)

R47.1 Dysarthria and anarthria

Excludes1: dyarthria following cerebrovascular disease (I69. with final characters -22)

R47.8 Other speech disturbances

Excludes1: dyarthria following cerebrovascular disease (I69. with final characters -28)

R47.81 Slurred speech

R47.89 Other speech disturbances

R47.9 Unspecified speech disturbances

R48 Dyslexia and other symbolic dysfunctions, not elsewhere classified

Excludes1: specific developmental disorders of scholastic skills (F81.-)

R48.0 Dyslexia and alexia

R48.1 Agnosia

Astereognosia (astereognosis)

Autotopagnosia

Excludes1: visual object agnosia H53.16

R48.2 Apraxia

Excludes1: apraxia following cerebrovascular disease (I69. with final characters -90)

R48.8 Other symbolic dysfunctions

Acalculia

Agraphia

R48.9 Unspecified symbolic dysfunctions

R49 Voice and resonance disorders

Excludes1: psychogenic voice and resonance disorders (F44.4)

R49.0 Dysphonia

Hoarseness

R49.1 Aphonia

Loss of voice

R49.2 Hypernasality and hyponasality

R49.21 Hypernasality

R49.22 Hyponasality

R49.8 Other voice and resonance disorders

R49.9 Unspecified voice and resonance disorder

Change in voice NOS

Resonance disorder NOS

General symptoms and signs (R50-R69)

R50 Fever of other and unknown origin

Excludes1: febrile convulsions (R56.0-)

fever of unknown origin during labor (O75.2)

fever of unknown origin in newborn (P81.9)

malignant hyperthermia due to anesthesia (T88.3)

puerperal pyrexia NOS (O86.4)

R50.2 Drug induced fever

Code first (T36-T50) to identify drug

Excludes1: postvaccination (postimmunization) fever (R50.83)

R50.8 Other specified fever

R50.81 Fever presenting with conditions classified elsewhere

Code first underlying condition when associated fever is present, such as with:

leukemia (C91-C95)

neutropenia (D70.-)

sickle cell disease (D57.-)

R50.82 Postprocedural fever

Excludes1: postprocedural infection (T81.4)

postvaccination (postimmunization) fever (R50.83)

R50.83 Postvaccination fever

Postimmunization fever

R50.9 Fever, unspecified

Fever NOS

Fever of unknown origin [FUO]

Fever with chills

Fever with rigors

Hyperpyrexia NOS

Persistent fever

Pyrexia NOS

R51 Headache

Includes: facial pain NOS

Excludes1: atypical face pain (G50.1)

migraine and other headache syndromes (G43-G44)

trigeminal neuralgia (G50.0)

R52 Pain, unspecified

Acute pain NOS

Chronic pain NOS

Generalized pain NOS

Pain NOS

Excludes1: acute and chronic pain, not elsewhere classified (G89.-)

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

abdomen pain (R10.-)

back pain (M54.9)

breast pain (N64.4)

chest pain (R07.1-R07.9)

ear pain (H92.0-)

eye pain (H57.1)

headache (R51)

joint pain (M25.5-)

limb pain (M79.6-)

lumbar region pain (M54.57)

pelvic and perineal pain (R10.2)

shoulder pain (M25.51-)

spine pain (M54.-)

throat pain (R07.0)

tongue pain (K14.6)

tooth pain (K08.8)

renal colic (N23)

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

R53 Malaise and fatigue

R53.0 Neoplastic (malignant) related fatigue

Code first associated neoplasm

R53.1 Weakness

Asthenia NOS

Excludes1: age-related weakness (R54)

muscle weakness (M62.8-)

senile asthenia (R54)

R53.2 Functional quadriplegia

Complete immobility due to severe physical disability or frailty

Excludes1: frailty NOS (R54)

hysterical paralysis (F44.4)

immobility syndrome (M62.3)

neurologic quadriplegia (G82.5-)

quadriplegia (G82.50)

R53.8 Other malaise and fatigue

Excludes1: combat exhaustion and fatigue (F43.0)

congenital debility (P96.9)

exhaustion and fatigue due to:

depressive episode (F32.-)

excessive exertion (T73.3)

exposure (T73.2)

heat (T67.-)

pregnancy (O26.8-)

recurrent depressive episode (F33)

senile debility (R54)

R53.81 Other malaise

Chronic debility

Debility NOS

General physical deterioration

Malaise NOS

Nervous debility

Excludes1: age-related physical debility (R54)

R53.82 Chronic fatigue, unspecified

Chronic fatigue syndrome NOS

Excludes1: postviral fatigue syndrome (G93.3)

R53.83 Other fatigue

Fatigue NOS

Lack of energy

Lethargy

Tiredness

R54 Age-related physical debility

Frailty

Old age

Senescence

Senile asthenia

Senile debility

Excludes1: age-related cognitive decline (R41.81)

senile psychosis (F03)

senility NOS (R41.81)

R55 Syncope and collapse

Includes: blackout

fainting

vasovagal attack

Excludes1: cardiogenic shock (R57.0)

carotid sinus syncope (G90.01)

heat syncope (T67.1)

neurocirculatory asthenia (F45.3)

neurogenic orthostatic hypotension (G90.3)

orthostatic hypotension (I95.1)

postprocedural shock (T81.1)

psychogenic syncope (F48.8)

shock NOS (R57.9)

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

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

Stokes-Adams attack (I45.9)

unconsciousness NOS (R40.2-)

R56 Convulsions, not elsewhere classified

Excludes1: dissociative convulsions and seizures (F44.5)

epileptic convulsions and seizures (G40.-)

newborn convulsions and seizures (P90)

R56.0 Febrile convulsions

R56.00 Simple febrile convulsions

Febrile convulsion NOS

Febrile seizure NOS

R56.01 Complex febrile convulsions

Atypical febrile seizure

Complex febrile seizure

Complicated febrile seizure

Excludes1: status epilepticus (G40.901)

R56.9 Unspecified convulsions

Convulsion disorder

Fit NOS

Recurrent convulsions

Seizure(s) (convulsive) NOS

R57 Shock, not elsewhere classified

Excludes1: anaphylactic shock NOS (T78.2)

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

anaphylactic shock due to serum (T80.5)

anesthetic shock (T88.3)

electric shock (T75.4)

obstetric shock (O75.1)

postprocedural shock (T81.1)

psychic shock (F43.0)

septic shock (R65.21)

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

shock due to lightning (T75.0)

traumatic shock (T79.4)

toxic shock syndrome (A48.3)

R57.0 Cardiogenic shock

R57.1 Hypovolemic shock

R57.8 Other shock

R57.9 Shock, unspecified

Failure of peripheral circulation NOS

R58 Hemorrhage, not elsewhere classified

Includes: hemorrhage NOS

Excludes1: hemorrhage included with underlying conditions, such as:

acute duodenal ulcer with hemorrhage (K26.0)

acute gastritis with bleeding (K29.01)

ulcerative enterocolitis with rectal bleeding (K51.01)

R59 Enlarged lymph nodes

Includes: swollen glands

Excludes1: lymphadenitis NOS (I88.9)

acute lymphadenitis (L04.-)

chronic lymphadenitis (I88.1)

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

R59.0 Localized enlarged lymph nodes

R59.1 Generalized enlarged lymph nodes

Lymphadenopathy NOS

R59.9 Enlarged lymph nodes, unspecified

R60 Edema, not elsewhere classified

Excludes1: angioneurotic edema (T78.3)

ascites (R18.-)

cerebral edema (G93.6)

cerebral edema due to birth injury (P11.0)

edema of larynx (J38.4)

edema of nasopharynx (J39.2)

edema of pharynx (J39.2)

gestational edema (O12.0-)

hereditary edema (Q82.0)

hydrops fetalis NOS (P83.2)

hydrothorax (J94.8)

nutritional edema (E40-E46)

hydrops fetalis NOS (P83.2)

newborn edema (P83.3)

pulmonary edema (J81.-)

R60.0 Localized edema

R60.1 Generalized edema

R60.9 Edema, unspecified

Fluid retention NOS

R61 Generalized hyperhidrosis

Excessive sweating

Night sweats

Secondary hyperhidrosis

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

Excludes1: focal (primary) (secondary) hyperhidrosis (L74.5-)

Frey's syndrome (L74.52)

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

R62 Lack of expected normal physiological development in childhood and adults

Excludes1: delayed puberty (E30.0)

gonadal dysgenesis (Q99.1)

hypopituitarism (E23.0)

R62.0 Delayed milestone in childhood

Delayed attainment of expected physiological developmental stage

Late talker

Late walker

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

Excludes1: HIV disease resulting in failure to thrive (B20)

physical retardation due to malnutrition (E45)

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

Infantilism NOS

R62. 51 Failure to thrive (child)

Failure to gain weight

Excludes1: failure to thrive in child under 28 days old (P92.6)

R62.52 Short stature (child)

Lack of growth

Physical retardation

Short stature NOS

Excludes1: short stature due to endocrine disorder (E34.3)

R62.59 Other lack of expected normal physiological development in childhood

R62.7 Adult failure to thrive

R63 Symptoms and signs concerning food and fluid intake

Excludes1: bulimia NOS (F50.2)

eating disorders of nonorganic origin (F50.-)

malnutrition (E40-E46)

R63.0 Anorexia

Loss of appetite

Excludes1: 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

Feeding problem (elderly) (infant) NOS

Excludes1: feeding problems of newborn (P92.-)

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

R63.4 Abnormal weight loss

R63.5 Abnormal weight gain

Excludes1: excessive weight gain in pregnancy (O26.0-)

obesity (E66.-)

R63.6 Underweight

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

Excludes1: abnormal weight loss (R63.4)

anorexia nervosa (F50.0-)

malnutrition (E40-E46)

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

R64 Cachexia

Includes: wasting syndrome

Code first underlying condition, if known

Excludes1: abnormal weight loss (R63.4)

nutritional marasmus (E41)

R65 Symptoms and signs specifically associated with systemic inflammation and infection

R65.1 Systemic inflammatory response syndrome (SIRS) of non-infectious origin

Code first underlying condition

Excludes1: sepsis- code to infection

severe sepsis (R65.2)

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

Systemic inflammatory response syndrome (SIRS) NOS

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

Use additional code to identify specific acute organ dysfunction, such as:

acute kidney failure (N17.-)

acute respiratory failure (J96.0)

critical illness myopathy (G72.81)

critical illness polyneuropathy (G62.81)

disseminated intravascular coagulopathy [DIC] (D65)

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

hepatic failure (K72.0-)

R65.2 Severe sepsis

Infection with associated acute organ dysfunction

Sepsis with acute organ dysfunction

Sepsis with multiple organ dysfunction

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

Code first underlying infection, such as:

Infection following a procedure (T81.4)

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

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

Sepsis following ectopic and molar pregnancy (O08.82)

Sepsis following incomplete spontaneous abortion (O03.37)

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

Sepsis NOS A41.9

Use additional code to identify specific acute organ dysfunction, such as:

acute kidney failure (N17.-)

acute respiratory failure (J96.0)

critical illness myopathy (G72.81)

critical illness polyneuropathy (G62.81)

disseminated intravascular coagulopathy [DIC] (D65)

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

hepatic failure (K72.0-)

R65.20 Severe sepsis without septic shock

Severe sepsis NOS

R65.21 Severe sepsis with septic shock

R68 Other general symptoms and signs

R68.0 Hypothermia, not associated with low environmental temperature

Excludes1: hypothermia NOS (accidental) (T68)

hypothermia due to anesthesia (T88.51)

hypothermia due to low environmental temperature (T68)

newborn hypothermia (P80.-)

R68.1 Nonspecific symptoms peculiar to infancy

Excludes1: colic, infantile (R10.43)

neonatal cerebral irritability (P91.3)

teething syndrome (K00.7)

R68.11 Excessive crying of infant (baby)

Excludes1: excessive crying of child, adolescent, or adult (R45.83)

R68.12 Fussy infant (baby)

Irritable infant

R68.13 Apparent life threatening event in infant [ALTE]

Apparent life threatening event in newborn

Use additional code(s) for associated signs and symptoms

Excludes1: signs and symptoms associated with a confirmed diagnosis - code to confirmed diagnosis

R68.19 Other nonspecific symptoms peculiar to infancy

R68.2 Dry mouth, unspecified

Excludes1: dry mouth due to dehydration (E86.0)

dry mouth due to sicca syndrome [Sj?gren] (M35.0-)

salivary gland hyposecretion (K11.7)

R68.3 Clubbing of fingers

Clubbing of nails

Excludes1: congenital clubfinger (Q68.1)

R68.8 Other general symptoms and signs

R68.81 Early satiety

R68.82 Decreased libido

Decreased sexual desire

R68.83 Chills (without fever)

Chills NOS

Excludes1: chills with fever (R50.9)

R68.89 Other general symptoms and signs

R69 Illness NOS

Includes: unknown and unspecified cases of morbidity

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

Excludes1: abnormalities (of)(on):

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

coagulation hemorrhagic disorders (D65-D68)

lipids (E78.-)

platelets and thrombocytes (D69.-)

white blood cells classified elsewhere (D70-D72)

diagnostic abnormal findings classified elsewhere - see Alphabetical Index

hemorrhagic and hematological disorders of newborn (P50-P61)

R70 Elevated erythrocyte sedimentation rate and abnormality of plasma viscosity

R70.0 Elevated erythrocyte sedimentation rate

R70.1 Abnormal plasma viscosity

R71 Abnormality of red blood cells

Excludes1: anemias (D50-D64)

anemia of premature infant (P61.2)

benign (familial) polycythemia (D75.0)

congenital anemias (P61.2-P61.4)

newborn anemia due to isoimmunization (P55.-)

polycythemia neonatorum (P61.1)

polycythemia NOS (D75.1)

polycythemia vera (D45)

secondary polycythemia (D75.1)

R71.0 Precipitous drop in hematocrit

Drop (precipitous) in hemoglobin

Drop in hematocrit

R71.8 Other abnormality of red blood cells

Abnormal red-cell morphology NOS

Abnormal red-cell volume NOS

Anisocytosis

Poikilocytosis

R73 Elevated blood glucose level

Excludes1: diabetes mellitus (E08-E13)

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

neonatal disorders (P70.0-P70.2)

postsurgical hypoinsulinemia (E89.1)

R73.0 Abnormal glucose

Excludes1: abnormal glucose in pregnancy (O99.81-)

diabetes mellitus (E08-E13)

dysmetabolic syndrome X (E88.81)

gestational diabetes (O24.4)

glycosuria (R81)

hypoglycemia (E16.2)

R73.01 Impaired fasting glucose

Elevated fasting glucose

R73.02 Impaired glucose tolerance (oral)

Elevated glucose tolerance

R73.09 Other abnormal glucose

Abnormal glucose NOS

Abnormal non-fasting glucose tolerance

Latent diabetes

Prediabetes

R73.9 Hyperglycemia, unspecified

R74 Abnormal serum enzyme levels

R74.0 Nonspecific elevation of levels of transaminase and lactic acid dehydrogenase [LDH]

R74.8 Abnormal levels of other serum enzymes

Abnormal level of acid phosphatase

Abnormal level of alkaline phosphatase

Abnormal level of amylase

Abnormal level of lipase [triacylglycerol lipase]

R74.9 Abnormal serum enzyme level, unspecified

R75 Inconclusive laboratory evidence of human immunodeficiency virus [HIV]

Includes: nonconclusive HIV-test finding in infants

Excludes1: asymptomatic human immunodeficiency virus [HIV] infection status (Z21)

human immunodeficiency virus [HIV] disease (B20)

R76 Other abnormal immunological findings in serum

R76.0 Raised antibody titer

Excludes1: isoimmunization in pregnancy (O36.0-O36.1)

isoimmunization affecting newborn (P55.-)

R76.1 Abnormal reaction to tuberculin test

Abnormal result of Mantoux test

R76.8 Other specified abnormal immunological findings in serum

Raised level of immunoglobulins NOS

R76.9 Abnormal immunological finding in serum, unspecified

R77 Other abnormalities of plasma proteins

Excludes1: disorders of plasma-protein metabolism (E88.0)

R77.0 Abnormality of albumin

R77.1 Abnormality of globulin

Hyperglobulinemia NOS

R77. 2 Abnormality of alphafetoprotein

R77.8 Other specified abnormalities of plasma proteins

R77.9 Abnormality of plasma protein, unspecified

R78 Findings of drugs and other substances, not normally found in blood

Excludes1: mental or behavioral disorders due to psychoactive substance use (F10-F19)

R78.0 Finding of alcohol in blood

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

R78.1 Finding of opiate drug in blood

R78.2 Finding of cocaine in blood

R78.3 Finding of hallucinogen in blood

R78.4 Finding of other drugs of addictive potential in blood

R78.5 Finding of other psychotropic drug in blood

R78.6 Finding of steroid agent in blood

R78.7 Finding of abnormal level of heavy metals in blood

R78.71 Abnormal lead level in blood

Excludes1: lead poisoning (T56.0-)

R78.79 Finding of abnormal level of heavy metals in blood

R78.8 Finding of other specified substances, not normally found in blood

R78.81 Bacteremia

Excludes1: sepsis-code to specified infection (A00-B99)

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

Finding of abnormal level of lithium in blood

R78.9 Finding of unspecified substance, not normally found in blood

R79 Other abnormal findings of blood chemistry

Excludes1: abnormality of fluid, electrolyte or acid-base balance (E86-E87)

asymptomatic hyperuricemia (E79.0)

hyperglycemia NOS (R73.9)

hypoglycemia NOS (E16.2)

neonatal hypoglycemia (P70.3-P70.4)

specific findings indicating disorder of:

amino-acid metabolism (E70-E72)

carbohydrate metabolism (E73-E74)

lipid metabolism (E75.-)

R79.0 Abnormal level of blood mineral

Abnormal blood level of cobalt

Abnormal blood level of copper

Abnormal blood level of iron

Abnormal blood level of magnesium

Abnormal blood level of mineral NEC

Abnormal blood level of zinc

Excludes1: abnormal level of lithium (R78.89)

disorders of mineral metabolism (E83.-)

neonatal hypomagnesemia (P71.2)

nutritional mineral deficiency (E58-E61)

R79.1 Abnormal coagulation profile

Abnormal or prolonged bleeding time

Abnormal or prolonged coagulation time

Abnormal or prolonged partial thromboplastin time [PTT]

Abnormal or prolonged prothrombin time [PT]

Excludes1: coagulation defects (D68.-)

R79.8 Other specified abnormal findings of blood chemistry

R79.81 Abnormal blood-gas level

R79.82 Elevated C-reactive protein (CRP)

R79.89 Other specified abnormal findings of blood chemistry

R79.9 Abnormal finding of blood chemistry, unspecified

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

Excludes1: abnormal findings on antenatal screening of mother (O28.-)

diagnostic abnormal findings classified elsewhere - see Alphabetical Index

specific findings indicating disorder of:

amino-acid metabolism (E70-E72)

carbohydrate metabolism (E73-E74)

R80 Proteinuria

Excludes1: gestational proteinuria (O12.1-)

R80.0 Isolated proteinuria

Idiopathic proteinuria

Excludes1: isolated proteinuria with specific morphological lesion (N06.-)

R80.1 Persistent proteinuria, unspecified

R80.2 Orthostatic proteinuria, unspecified

Postural proteinuria

R80.3 Bence Jones proteinuria

R80.8 Other proteinuria

R80.9 Proteinuria NOS

Albuminuria NOS

R81 Glycosuria

Excludes1: renal glycosuria (E74.8)

R82 Other and unspecified abnormal findings in urine

Includes: chromoabnormalities in urine

Excludes2: hematuria (R31.-)

R82.0 Chyluria

Excludes1: filarial chyluria (B74.-)

R82.1 Myoglobinuria

R82.2 Biliuria

R82.3 Hemoglobinuria

Excludes1: hemoglobinuria due to hemolysis from external causes NEC (D59.6)

hemoglobinuria due to 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

Elevated urine levels of indoleacetic acid

Elevated urine levels of 17-ketosteroids

Elevated urine levels of steroids

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

Abnormal urine level of heavy metals

R82.7 Abnormal findings on microbiological examination of urine

Positive culture findings of urine

Excludes1: colonization status (Z22.-)

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

R82.9 Other and unspecified abnormal findings in urine

R82.90 Unspecified abnormal findings in urine

R82.91 Other chromoabnormalities of urine

Chromoconversion (dipstick)

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

Excludes1: hemoglobinuria (R82.3)

myoglobinuria (R82.1)

R82.99 Other abnormal findings in urine

Cells and casts in urine

Crystalluria

Melanuria

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

Excludes1: abnormal findings on antenatal screening of mother (O28.-)

diagnostic abnormal findings classified elsewhere - see Alphabetical Index

Excludes2: abnormal findings on examination of blood, without diagnosis (R70-R79)

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

abnormal tumor markers (R97.-)

R83 Abnormal findings in cerebrospinal fluid

R83.0 Abnormal level of enzymes in cerebrospinal fluid

R83.1 Abnormal level of hormones in cerebrospinal fluid

R83.2 Abnormal level of other drugs, medicaments and biological substances in cerebrospinal fluid

R83.3 Abnormal level of substances chiefly nonmedicinal as to source in cerebrospinal fluid

R83.4 Abnormal immunological findings in cerebrospinal fluid

R83.5 Abnormal microbiological findings in cerebrospinal fluid

Positive culture findings in cerebrospinal fluid

Excludes1: colonization status (Z22.-)

R83.6 Abnormal cytological findings in cerebrospinal fluid

R83.8 Other abnormal findings in cerebrospinal fluid

Abnormal chromosomal findings in cerebrospinal fluid

R83.9 Unspecified abnormal finding in cerebrospinal fluid

R84 Abnormal findings in specimens from respiratory organs and thorax

Includes: abnormal findings in bronchial washings

abnormal findings in nasal secretions

abnormal findings in pleural fluid

abnormal findings in sputum

abnormal findings in throat scrapings

Excludes1: blood-stained sputum (R04.2)

R84.0 Abnormal level of enzymes in specimens from respiratory organs and thorax

R84.1 Abnormal level of hormones in specimens from respiratory organs and thorax

R84.2 Abnormal level of other drugs, medicaments and biological substances in specimens from respiratory organs and thorax

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

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

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

Positive culture findings in specimens from respiratory organs and thorax

Excludes1: colonization status (Z22.-)

R84.6 Abnormal cytological findings in specimens from respiratory organs and thorax

R84.7 Abnormal histological findings in specimens from respiratory organs and thorax

R84.8 Other abnormal findings in specimens from respiratory organs and thorax

Abnormal chromosomal findings in specimens from respiratory organs and thorax

R84. 9 Unspecified abnormal finding in specimens from respiratory organs and thorax

R85 Abnormal findings in specimens from digestive organs and abdominal cavity

Includes: abnormal findings in peritoneal fluid

abnormal findings in saliva

Excludes1: cloudy peritoneal dialysis effluent (R88.0)

fecal abnormalities (R19.5)

R85.0 Abnormal level of enzymes in specimens from digestive organs and abdominal cavity

R85.1 Abnormal level of hormones in specimens from digestive organs and abdominal cavity

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

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

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

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

Positive culture findings in specimens from digestive organs and abdominal cavity

Excludes1: colonization status (Z22.-)

R85.6 Abnormal cytological findings in specimens from digestive organs and abdominal cavity

R85.61 Abnormal cytologic smear of anus

Excludes1: abnormal cytological findings in specimens from other digestive organs and abdominal cavity (R85.69)

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

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

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

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

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

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

Excludes2: anal high risk human papillomavirus (HPV) DNA test positive (R85.81)

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

R85. 610 Atypical squamous cells of undetermined significance on cytologic smear of anus (ASC-US)

R85.611 Atypical squamous cells cannot exclude high grade squamous intraepithelial lesion on cytologic smear of anus (ASC-H)

R85.612 Low grade squamous intraepithelial lesion on cytologic smear of anus (LGSIL)

R85.613 High grade squamous intraepithelial lesion on cytologic smear of anus (HGSIL)

R85.614 Cytologic evidence of malignancy on smear of anus

R85.615 Unsatisfactory cytologic smear of anus

Inadequate sample of cytologic smear of anus

R85.616 Satisfactory anal smear but lacking transformation zone

R85.618 Other abnormal cytological findings on specimens from anus

R85.619 Unspecified abnormal cytological findings in specimens from anus

Abnormal anal cytology NOS

Atypical glandular cells of anus NOS

R85.69 Abnormal cytological findings in specimens from other digestive organs and abdominal cavity

R85.7 Abnormal histological findings in specimens from digestive organs and abdominal cavity

R85.8 Other abnormal findings in specimens from digestive organs and abdominal cavity

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

Excludes1: anogenital warts due to human papillomavirus (HPV) (A63.0)

condyloma acuminatum (A63.0)

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

Use additional code for associated human papillomavirus (B97.7)

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

Abnormal chromosomal findings in specimens from digestive organs and abdominal cavity

R85.9 Unspecified abnormal finding in specimens from digestive organs and abdominal cavity

R86 Abnormal findings in specimens from male genital organs

Includes: abnormal findings in prostatic secretions

abnormal findings in semen, seminal fluid

abnormal spermatozoa

Excludes1: azoospermia (N46.0-)

oligospermia (N46.1-)

R86.0 Abnormal level of enzymes in specimens from male genital organs

R86.1 Abnormal level of hormones in specimens from male genital organs

R86.2 Abnormal level of other drugs, medicaments and biological substances in specimens from male genital organs

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

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

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

Positive culture findings in specimens from male genital organs

Excludes1: colonization status (Z22.-)

R86.6 Abnormal cytological findings in specimens from male genital organs

R86.7 Abnormal histological findings in specimens from male genital organs

R86.8 Other abnormal findings in specimens from male genital organs

Abnormal chromosomal findings in specimens from male genital organs

R86.9 Unspecified abnormal finding in specimens from male genital organs

R87 Abnormal findings in specimens from female genital organs

Includes: abnormal findings in secretion and smears from cervix uteri

abnormal findings in secretion and smears from vagina

abnormal findings in secretion and smears from vulva

R87.0 Abnormal level of enzymes in specimens from female genital organs

R87.1 Abnormal level of hormones in specimens from female genital organs

R87.2 Abnormal level of other drugs, medicaments and biological substances in specimens from female genital organs

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

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

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

Positive culture findings in specimens from female genital organs

Excludes1: colonization status (Z22.-)

R87. 6 Abnormal cytological findings in specimens from female genital organs

R87.61 Abnormal cytological findings in specimens from cervix uteri

Excludes1: abnormal cytological findings in specimens from other female genital organs (R87.69)

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

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

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

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

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

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

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

Excludes2: cervical high risk human papillomavirus (HPV) DNA test positive (R87.810)

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

R87.610 Atypical squamous cells of undetermined significance on cytologic smear of cervix (ASC-US)

R87.611 Atypical squamous cells cannot exclude high grade squamous intraepithelial lesion on cytologic smear of cervix (ASC-H)

R87.612 Low grade squamous intraepithelial lesion on cytologic smear of cervix (LGSIL)

R87.613 High grade squamous intraepithelial lesion on cytologic smear of cervix (HGSIL)

R87.614 Cytologic evidence of malignancy on smear of cervix

R87.615 Unsatisfactory cytologic smear of cervix

Inadequate sample of cytologic smear of cervix

R87.616 Satisfactory cervical smear but lacking transformation zone

R87.618 Other abnormal cytological findings on specimens from cervix uteri

R87.619 Unspecified abnormal cytological findings in specimens from cervix uteri

Abnormal cervical cytology NOS

Abnormal Papanicolaou smear of cervix NOS

Abnormal thin preparation smear of cervix NOS

Atypical endocervial cells of cervix NOS

Atypical endometrial cells of cervix NOS

Atypical glandular cells of cervix NOS

R87.62 Abnormal cytological findings in specimens from vagina

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

Excludes1: abnormal cytological findings in specimens from cervix uteri (R87.61-)

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

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

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

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

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

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

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

Excludes2: vaginal high risk human papillomavirus (HPV) DNA test positive (R87.811)

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

R87.620 Atypical squamous cells of undetermined significance on cytologic smear of vagina (ASC-US)

R87.621 Atypical squamous cells cannot exclude high grade squamous intraepithelial lesion on cytologic smear of vagina (ASC-H)

R87.622 Low grade squamous intraepithelial lesion on cytologic smear of vagina (LGSIL)

R87.623 High grade squamous intraepithelial lesion on cytologic smear of vagina (HGSIL)

R87.624 Cytologic evidence of malignancy on smear of vagina

R87.625 Unsatisfactory cytologic smear of vagina

Inadequate sample of cytologic smear of vagina

R87.628 Other abnormal cytological findings on specimens from vagina

R87.629 Unspecified abnormal cytological findings in specimens from vagina

Abnormal Papanicolaou smear of vagina NOS

Abnormal thin preparation smear of vagina NOS

Abnormal vaginal cytology NOS

Atypical endocervical cells of vagina NOS

Atypical endometrial cells of vagina NOS

Atypical glandular cells of vagina NOS

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

Abnormal cytological findings in specimens from female genital organs NOS

Excludes1: dysplasia of vulva (histologically confirmed) (N90.0-N90.3)

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

Excludes1: carcinoma in situ (histologically confirmed) of female genital organs (D06-D07.3)

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

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

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

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

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

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

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

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

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

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

R87.8 Other abnormal findings in specimens from female genital organs

R87.81 High risk human papillomavirus (HPV) DNA test positive from female genital organs

Excludes1: anogenital warts due to human papillomavirus (HPV) (A63.0)

condyloma acuminatum (A63.0)

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

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

R87.82 Low risk human papillomavirus (HPV) DNA test positive from female genital organs

Use additional code for associated human papillomavirus (B97.7)

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

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

R87. 89 Other abnormal findings in specimens from female genital organs

Abnormal chromosomal findings in specimens from female genital organs

R87.9 Unspecified abnormal finding in specimens from female genital organs

R88 Abnormal findings in other body fluids and substances

R88.0 Cloudy (hemodialysis) (peritoneal) dialysis effluent

R88.8 Abnormal findings in other body fluids and substances

R89 Abnormal findings in specimens from other organs, systems and tissues

Includes: abnormal findings in nipple discharge

abnormal findings in synovial fluid

abnormal findings in wound secretions

R89.0 Abnormal level of enzymes in specimens from other organs, systems and tissues

R89.1 Abnormal level of hormones in specimens from other organs, systems and tissues

R89.2 Abnormal level of other drugs, medicaments and biological substances in specimens from other organs, systems and tissues

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

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

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

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

Excludes1: colonization status (Z22.-)

R89.6 Abnormal cytological findings in specimens from other organs, systems and tissues

R89.7 Abnormal histological findings in specimens from other organs, systems and tissues

R89.8 Other abnormal findings in specimens from other organs, systems and tissues

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

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

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

Includes: nonspecific abnormal findings on diagnostic imaging by:

computerized axial tomography [CAT scan]

magnetic resonance imaging [MRI][NMR]

positron emission tomography [PET scan]

thermography

ultrasound [echogram]

X-ray examination

Excludes1: abnormal findings on antenatal screening of mother (O28.-)

diagnostic abnormal findings classified elsewhere - see Alphabetical Index

R90 Abnormal findings on diagnostic imaging of central nervous system

R90.0 Intracranial space-occupying lesion found on diagnostic imaging of central nervous system

R90.8 Other abnormal findings on diagnostic imaging of central nervous system

R90.81 Abnormal echoencephalogram

R90.82 White matter disease, unspecified

R90.89 Other abnormal findings on diagnostic imaging of central nervous system

Other cerebrovascular abnormality found on diagnostic imaging of central nervous system

R91 Abnormal findings on diagnostic imaging of lung

Includes: coin lesion NOS found on diagnostic imaging of lung

lung mass NOS found on diagnostic imaging of lung

R92 Abnormal and inconclusive findings on diagnostic imaging of breast

R92.0 Mammographic microcalcification found on diagnostic imaging of breast

Excludes2: mammographic calcification (calculus) found on diagnostic imaging of breast (R92.1)

R92.1 Mammographic calcification found on diagnostic imaging of breast

Mammographic calculus found on diagnostic imaging of breast

R92.2 Inconclusive mammogram

Dense breasts NOS

Inconclusive mammogram NEC

Inconclusive mammography due to dense breasts

Inconclusive mammography NEC

R92. 8 Other abnormal and inconclusive findings on diagnostic imaging of breast

R93 Abnormal findings on diagnostic imaging of other body structures

R93.0 Abnormal findings on diagnostic imaging of skull and head, not elsewhere classified

Excludes1: intracranial space-occupying lesion found on diagnostic imaging (R90.0)

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

Abnormal echocardiogram NOS

Abnormal heart shadow

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

Nonvisualization of gallbladder

R93.3 Abnormal findings on diagnostic imaging of other parts of digestive tract

R93.4 Abnormal findings on diagnostic imaging of urinary organs

Filling defect of bladder found on diagnostic imaging

Filling defect of kidney found on diagnostic imaging

Filling defect of ureter found on diagnostic imaging

Excludes1: hypertrophy of kidney (N28.81)

R93.5 Abnormal findings on diagnostic imaging of other abdominal regions, including retroperitoneum

R93.6 Abnormal findings on diagnostic imaging of limbs

Excludes2: abnormal finding in skin and subcutaneous tissue (R93.8)

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

Excludes2: abnormal findings on diagnostic imaging of skull (R93.0)

R93.8 Abnormal findings on diagnostic imaging of other specified body structures

Abnormal finding by radioisotope localization of placenta

Abnormal radiological finding in skin and subcutaneous tissue

Mediastinal shift

R93.9 Diagnostic imaging inconclusive due to excess body fat of patient

R94 Abnormal results of function studies

Includes: abnormal results of radionuclide [radioisotope] uptake studies

abnormal results of scintigraphy

R94.0 Abnormal results of function studies of central nervous system

R94.01 Abnormal electroencephalogram [EEG]

R94.02 Abnormal brain scan

R94.09 Abnormal results of other function studies of central nervous system

R94. 1 Abnormal results of function studies of peripheral nervous system and special senses

R94.11 Abnormal results of function studies of eye

R94.110 Abnormal electro-oculogram [EOG]

R94.111 Abnormal electroretinogram [ERG]

Abnormal retinal function study

R94.112 Abnormal visually evoked potential [VEP]

R94.113 Abnormal oculomotor study

R94.118 Abnormal results of other function studies of eye

R94.12 Abnormal results of function studies of ear and other special senses

R94.120 Abnormal auditory function study

R94.121 Abnormal vestibular function study

R94.128 Abnormal results of other function studies of ear and other special senses

R94.13 Abnormal results of function studies of peripheral nervous system

R94.130 Abnormal response to nerve stimulation, unspecified

R94.131 Abnormal electromyogram [EMG]

Excludes1: electromyogram of eye (R94.113)

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

R94.2 Abnormal results of pulmonary function studies

Reduced ventilatory capacity

Reduced vital capacity

R94.3 Abnormal results of cardiovascular function studies

R94.30 Abnormal result of cardiovascular function study, unspecified

R94.31 Abnormal electrocardiogram [ECG] [EKG]

Excludes1: long QT syndrome (I45.81)

R94.39 Abnormal result of other cardiovascular function study

Abnormal electrophysiological intracardiac studies

Abnormal phonocardiogram

Abnormal vectorcardiogram

R94.4 Abnormal results of kidney function studies

Abnormal renal function test

R94.5 Abnormal results of liver function studies

R94.6 Abnormal results of thyroid function studies

R94.7 Abnormal results of other endocrine function studies

Excludes2: abnormal glucose (R73.0-)

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

Abnormal basal metabolic rate [BMR]

Abnormal bladder function test

Abnormal splenic function test

Abnormal tumor markers (R97)

R97 Abnormal tumor markers

Elevated tumor associated antigens [TAA]

Elevated tumor specific antigens [TSA]

R97.0 Elevated carcinoembryonic antigen [CEA]

R97.1 Elevated cancer antigen 125 [CA 125]

R97.2 Elevated prostate specific antigen [PSA]

R97.8 Other abnormal tumor markers

Ill-defined and unknown cause of mortality (R99)

R99 Ill-defined and unknown cause of mortality

Includes: Death (unexplained) NOS

Unspecified cause ofmortality