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Prevention
305.1 Tobacco Abuse
V03.1 Immunization, typhoid
V03.81 Immunization, HIB
V03.82 Immunization, pneumovax
V03.89 Immunization, single bacterial disease
V04.0 Immunization, polio
V04.1 Immunization, smallpox
V04.81 Immunization, influenza
V04.82 Immunization, RSV
V04.89 Immunization, other viral illness
V05.3 Immunization, hepatitis
V05.4 Immunization, varicella
V05.8 Immunization, other, specified
V06.1 Immunization, DTP
V06.3 Immunization, DTP/polio
V06.4 Immunization, MMR
V06.5 Immunization, Td
V06.8 Immunization, combination, other
V20.2 Well Child Check
WELL ADOLESCENT VISIT 11 YEARS
WELL ADOLESCENT VISIT 12 YEARS
WELL ADOLESCENT VISIT 13 YEARS
WELL ADOLESCENT VISIT 14 YEARS
WELL ADOLESCENT VISIT 15 YEARS
WELL ADOLESCENT VISIT 16 YEARS
WELL ADOLESCENT VISIT 17 YEARS
WELL ADOLESCENT VISIT 18 YEARS
WELL CHILD VISIT 1 MONTH
WELL CHILD VISIT 1 WEEK
WELL CHILD VISIT 10 YEARS
WELL CHILD VISIT 12 MONTHS
WELL CHILD VISIT 18 MONTHS
WELL CHILD VISIT 2 MONTHS
WELL CHILD VISIT 2 YEARS
WELL CHILD VISIT 3 YEARS
WELL CHILD VISIT 4 MONTHS
WELL CHILD VISIT 4 YEARS
WELL CHILD VISIT 5 YEARS
WELL CHILD VISIT 6 MONTHS
WELL CHILD VISIT 6 YEARS
WELL CHILD VISIT 7 YEARS
WELL CHILD VISIT 8 YEARS
WELL CHILD VISIT 9 MONTHS
WELL CHILD VISIT 9 YEARS
V76.9 Screening, cancer, unspec.
V77.1 Screening, diabetes
V77.91 Screening, lipoid disorders
V81.0 Screening, cardiac disease
V82.5 Screening for lead/heavy metals
Procedures
10060 I&D Abscess/ Cyst / Furuncle
10120 I&R of FB.SC Tissue, Simple
10121 I&R of FB,SC tissue, complex
10140 I&D Hematoma / Seroma
11055 Lesion, paring / cutting, one
11056 Lesion, paring / cutting, 2-4
11057 Lesion, paring / cutting. 4+
11100 Lesion, biopsy. one
11101 Lesion, biopsy, each add’l
11200 Skin Tag removal 1-15
113__ Lesion, shave site ____ size____
114__ Lesion, excision, benign; site____ size____
11730 Nail removal, partial
11740 Evacuation Subungual Hematoma
11750 Excision of nail and matrix
11900 Intralesional Injection, skin <7 lesions
11975 Contraceptive Capsules Insertion
11976 Contraceptive Capsules Removal
11977 Contraceptive Capsule Removal / Reinsertion
120__ Laceration repair, simple; site:____, size:____
120__Laceration repair, layered; site:____, size:____
17110 Wart. Flat / molluscum contagiosum 1-14
20550 Injection, tendon sheath, trigger finger
56420 I&D Bartholin’s gland abscess
56740 Excision of Bartholin’s gland or cyst
57170 Diaphragm fitting
57452 Colposcopy
57454 Colposcopy with Biopsy
58100 Endometrial Aspiration
58300 IUD Insertion
58301 IUD Removal
59025 Fetal Non-Stress Test
V58.30 Dressing change, nonsurgical
V58.32 Suture removal
Admin
Notes
Disease Classification
Cardiovascular
398.90 Rheumatic heart disease, unspec.
401.0 Hypertension, malignant
401.1 Hypertension, benign
401.9 Hypertension, unspec.
403.91 Hypertensive chronic kidney disease, w/ stage V/end stage renal disease
405.11 Hypertension, renovascular, benign
405.11 Hypertension, renovascular, malignant
410.00 MI, acute, anterolateral
410.10 MI, acute, anterior, NOS
410.20 MI, acute, inferolateral
410.30 MI, acute, inferoposterior
410.40 MI, acute, other inferior wall, NOS
410.50 MI, acute, other lateral wall
410.50 MI, acute, other lateral wall
410.60 MI, acute, true posterior
410.70 MI, acute, subendocardial
410.90 MI, acute, unspec.
411.1 Angina, unstable
412 MI, old
413.1 Prinzmetal angina
413.9 Angina pectoris, NOS
414.01 Coronary atherosclerosis, native coronary artery
414.02 CAD, autologous vein bypass graft
414.04 CAD, artery bypass graft
414.8 Chronic ischemic heart disease, other
414.9 Chronic ischemic heart disease, unspec.
415.19 Pulmonary embolism, not iatrogenic
416.9 Pulmonary heart dis., chronic, unspec.
420.91 Pericarditis, acute, nonspecific
421.0 Endocarditis, acute, bacterial
422.91 Myocarditis, idiopathic
424.0 Heart valve, mitral, not rheum.
424.1 Heart valve, aortic, not rheum.
424.2 Heart valve, tricuspid, not rheum.
424.3 Heart valve, pulmonic, not rheum.
425.1 Cardiomyopathy, hypertrophic obstr.
426.0 Atrioventricular block, third degree
426.11 Atrioventricular block, first degree
426.12 Atrioventricular block, Mobitz II
426.13 Atrioventricular block, Wenckebach’s
426.3 Bundle branch block, left
426.4 Bundle branch block, right
426.6 Sinoatrial heart block
426.7 Atrioventricular excitation, anomalous
426.82 Long QT syndrome
427.0 Tachycardia, paroxysmal SVT
427.31 Atrial fibrillation
427.32 Atrial flutter
427.41 Ventricular fibrillation
427.5 Cardiac arrest
427.60 Premature beats, unspec.
427.81 Sick sinus syndrome
427.89 Sinus bradycardia, NOS
428.0 Heart failure, congestive, unspec.
428.1 Pulmonary edema, acute
428.20 Heart failure, systolic, unspec.
428.21 Heart failure, systolic, acute
428.22 Heart failure, systolic, chronic
428.30 Heart failure, diastolic, unspec.
428.32 Heart failure, diastolic, chronic
428.40 Heart failure, combined, unspec.
435.9 Transient ischemic attack, unspec.
440.21 Intermittent claudication
440.9 Atherosclerosis, NOS (not heart/brain)
441.01 Aortic dissection, thoracic
441.3 Aortic aneurysm, abdominal, ruptured
441.4 Aortic aneurysm, abdominal, intact
441.9 Aortic aneurysm, unspec.
443.9 Peripheral vascular disease, unspec.
446.0 Polyarteritis nodosa
446.1 Kawasaki disease
451.0 Phlebitis, superficial, lower extrem.
451.19 Phlebitis, deep, lower extrem., other
451.82 Phlebitis, superficial, upper extrem.
451.9 Thrombophlebitis, unspec.
453.40 Deep vein thrombosis, unspec.
453.41 Deep vein thrombosis, proximal
453.42 Deep vein thrombosis, distal
453.9 Venous embolism, unspec. site
454.0 Varicose veins w/ ulcer
454.1 Varicose veins w/ inflammation
454.2 Varicose veins w/ulcer, inflammation
454.9 Varicose veins, asymptomatic
456.0 Esophageal varices w/ bleeding
456.1 Esophageal varices w/o bleeding
457.0 Postmastectomy lymphedema
458.0 Hypotension, orthostatic
458.21 Hypotension of hemodialysis
458.29 Hypotension, iatrogenic
459.81 Venous insufficiency, unspec.
796.2 Elevated BP w/o hypertension
861.01 Cardiac contusion
Cardiovascular EXAM
Cardiovascular ROS
Comprehensive (All)
Comprehensive Exam
Comprehensive ROS
Constitutional
Constitutional EXAM
Constitutional ROS
Dermatology
110.1 Onychomycosis
110.3 Tinea cruris
110.4 Tinea pedis
110.9 Tinea corporis, NOS
111.0 Tinea versicolor
306.3 Pruritus, psychogenic
376.01 Cellulitis, orbital
448.1 Nevus, vascular, non-neoplastic
566 Abscess, perianal
680.0 Boil, face
680.1 Boil, neck
680.2 Boil, trunk
680.5 Boil, buttock
681.01 Felon
681.02 Paronychia, finger
681.11 Paronychia, toe
681.9 Cellulitis/abscess, unspec. digit
682.0 Cellulitis/abscess, face
682.1 Cellulitis/abscess, neck
682.4 Cellulitis/abscess, hand
682.5 Cellulitis/abscess, buttock
682.6 Cellulitis/abscess, leg
682.7 Cellulitis/abscess, foot
682.9 Cellulitis/abscess, unspec.
683 Lymphadenitis, acute
684 Impetigo
685.0 Pilonidal cyst w/ abscess
685.1 Pilonidal cyst, unspec.
690.10 Seborrheic dermatitis, NOS
690.10 Seborrheic dermatitis, NOS
690.11 Cradle cap
691.0 Diaper rash
691.8 Eczema, atopic dermatitis
692.72 Solar radiation dermatitis
692.75 Disseminated actinic porokeratosis
692.81 Dermatitis, due to cosmetics
692.83 Dermatitis, due to metals
692.9 Contact dermatitis, NOS
695.3 Rosacea
696.1 Psoriasis, other
696.3 Pityriasis rosea
698.0 Pruritus ani
698.9 Pruritus, NOS
700 Corn/callus
701.4 Keloid scar
702.0 Actinic keratosis
702.19 Seborrheic keratosis, NOS
703.0 Ingrown nail
704.00 Alopecia, unspec.
704.1 Hirsutism
705.1 Prickly heat, heat rash
705.83 Hidradenitis suppurativa
706.1 Acne, other
706.2 Sebaceous cyst
707.04 Decubitus ulcer, hip
707.05 Decubitus ulcer, buttock
707.07 Decubitus ulcer, heel
707.09 Decubitus ulcer, other
707.10 Ulcer, unspec. of lower limb
707.12 Ulcer, skin, lower leg
707.13 Ulcer, skin, ankle
707.15 Ulcer, skin, chronic, other part of foot
707.9 Ulcer, skin, chronic, unspec.
708.0 Urticaria, allergic
708.1 Urticaria, idiopathic
708.9 Urticaria, unspec.
709.2 Scar
709.9 Other skin disease, unspec.
Dermatology EXAM
Dermatology ROS
Endocrine
240.9 Goiter, unspec.
241.0 Thyroid nodule
241.9 Goiter, unspec. nontoxic nodular
242.00 Goiter toxic, diffuse
242.90 Hyperthyroidism, NOS
244.0 Hypothyroidism, post-surgical
244.1 Hypothyroidism, post-ablative
244.9 Hypothyroidism, unspe
245.0 Thyroiditis, acute
245.1 Thyroiditis, subacute
245.2 Thyroiditis, chronic, Hashimoto’s
246.2 Thyroid cys
250.00 Diabetes II, uncomplicated
250.01 Diabetes I, uncomplicated
250.02 Diabetes II/unspec., w/o complications, uncontrolled
250.03 Diabetes I, uncontrolled
250.13 Diabetic ketoacidosis, uncontrolled
250.23 Diabetes I, w/ hyperosmolarity, uncontrolled
250.41 Diabetes I, w/ renal changes
250.51 Diabetic retinopathy, background
250.62 Diabetes II/unspec., w/neurological manifestations, uncontrolled
250.80 Hypoglycemia, DM, uncontrolled
250.81 Hypoglycemia, diabetes I
250.91 Diabetes I, w/ unspec. complications
251.2 Hypoglycemia, nondiabetic, unspec
252.00 Hyperparathyroidism, unspec
252.01 Hyperparathyroidism, primary
252.1 Hypoparathyroidism
253.6 SIADH
255.0 Cushing’s syndrome
255.41 Glucocorticoid deficiency
255.42 Mineralocorticoid deficiency
259.0 Puberty, delayed
259.1 Sexual precocity
260 Kwashiorkor
261 Marasmus
266.2 B12 deficiency w/o anemia
272.0 Hypercholesterolemia, pure
272.1 Hypertriglyceridemia
272.2 Hyperlipidemia, mixed
274.9 Gout, unspec.
275.0 Hemochromatosis
275.2 Magnesium disorders
275.41 Hypocalcemia
275.42 Hypercalcemia
275.49 Pseudohypoparathyroidism
276.0 Hypernatremia
276.1 Hyponatremia
276.2 Acidosis
276.3 Alkalosis
276.51 Dehydration
276.52 Hypovolemia
276.7 Hyperkalemia
276.8 Hypokalemia
277.00 Cystic fibrosis
277.1 Porphyria
277.30 Amyloidosis, unspec
277.4 Hyperbilirubinemia
277.7 Dysmetabolic syndrome
278.00 Obesity, NOS
278.01 Obesity, morbid
278.02 Overweight
588.0 Renal osteodystroph
588.81 Hyperparathyroidism, secondary, renal
Endocrine EXAM
Endocrine ROS
V85.4 BMI 40 and over, adult
V85.51 BMI < 5th percentile, pediatric
V85.54 BMI ≥ 95th percentile, pediatric
Gastroenterology
008.8 Gastroenteritis, viral
009.1 Gastroenteritis, infectious
306.4 Psychogenic GI symptoms
455.0 Hemorrhoids, internal w/o complication
455.2 Hemorrhoids, internal w/ complication
455.3 Hemorrhoids, external w/o complication
455.4 Hemorrhoids, external thrombosed
455.6 Hemorrhoids, NOS
521.00 Dental caries, unspec.
521.00 Dental caries, unspec.
523.10 Gingivitis, chronic, plaque induced
523.40 Periodontitis, chronic, unspec.
525.40 Edentulism
525.40 Edentulism
525.9 Dental, unspec.
525.9 Dental, unspec.
527.2 Parotitis
528.00 Stomatitis, mucositis, unspec., NOS
528.2 Aphthous ulcer
528.6 Leukoplakia, oral mucosa
529.0 Glossitis
530.0 Achalasia/ cardiospasm
530.10 Esophagitis, unspec
530.10 Esophagitis, unspec.
530.3 Esophageal stricture/stenosis
530.3 Esophageal stricture/stenosis
530.81 Gastroesophageal reflux, no esophagitis
531.00 Gastric ulcer, acute w/ hemorrhage
531.00 Gastric ulcer, acute w/ hemorrhage
531.30 Gastric ulcer, acute, uncomplicated
531.30 Gastric ulcer, acute, uncomplicated
531.70 Gastric ulcer, chronic, uncomplicated
531.70 Gastric ulcer, chronic, uncomplicated
532.00 Duodenal ulcer, acute w/ hemorrhage
532.00 Duodenal ulcer, acute w/ hemorrhage
532.30 Duodenal ulcer, acute w/o bleeding
532.30 Duodenal ulcer, acute w/o bleeding
532.70 Duodenal ulcer, chronic w/o hemorrhage
532.70 Duodenal ulcer, chronic w/o hemorrhage
533.00 Peptic ulcer, acute w/ hemorrhage, w/o obstruction
533.30 Peptic ulcer, acute, uncomplicated
533.70 Peptic ulcer, chronic, uncomplicated
533.90 Peptic ulcer disease, unspec. w/o obstruction
535.30 Gastritis, alcoholic, w/o hemorrhage
535.31 Gastritis
535.31 Gastritis, alcoholic, w/ hemorrhage
535.50 Gastritis, unspec. w/o hemorrhage
536.3 Gastroparesis
536.8 Dyspepsia
536.8 Dyspepsia
540.9 Appendicitis, acute w/o peritonitis
550.90 Hernia, inguinal, NOS, unilateral
553.00 Hernia, femoral, unilateral
553.1 Hernia, umbilical
553.20 Hernia, ventral, unspec.
553.21 Hernia, ventral, incisional
553.3 Hernia, hiatal, noncongenital
553.9 Hernias, other, NOS
555.0 Crohn’s, small intestine
555.0 Crohn’s, small intestine
555.1 Crohn’s, large intestine
555.1 Crohn’s, large intestine
555.9 Crohn’s disease, NOS
556.9 Ulcerative colitis, unspec.
557.0 Vascular insufficiency, acute, intestine
557.9 Ischemic bowel disease, unspec.
560.1 Ileus
560.30 Impaction of intestine
560.9 Intestinal obstruction, unspec.
562.10 Diverticulosis of colon
562.10 Diverticulosis of colon
562.11 Diverticulitis of colon, NOS
562.11 Diverticulitis of colon, NOS
562.12 Diverticulosis, colon w/ hemorrhage
562.12 Diverticulosis, colon w/ hemorrhage
564.00 Constipation, unspec.
564.1 Irritable bowel syndrome
564.2 Post-gastric-surgery syndromes
564.4 Postoperative functional disorders
564.6 Anal spasm
565.0 Anal fissure, nontraumatic
568.0 Adhesions, peritoneal
569.61 Infection, colostomy/enterostomy
569.62 Mechanical complication of ostomy
569.85 Angiodysplasia, intestine w/ hemorrhage
570 Hepatic failure, acute
571.0 Fatty liver, alcoholic
571.0 Fatty liver, alcoholic, w/ hemorrhage
571.2 Cirrhosis, liver, alcoholic
571.40 Hepatitis, chronic, unspec.
571.5 Cirrhosis, NOS
571.9 Liver disease, chronic, unspec.
572.4 Hepatorenal syndrome
573.3 Hepatitis, toxic
574.01 Cholelithiasis, GB w/ obstruction & acute cholecystitis
574.20 Cholelithiasis, NOS
574.31 Cholelithiasis, bile duct w/ obstruction & acute cholecystitis
574.61 Cholelithiasis, GB/bile duct w/ obstruction & acute cholecystitis
574.90 Cholelithiasis, GB/bile duct, uncomplicated
575.0 Cholecystitis, acute
575.9 Gallbladder disease, unspec
575.9 Gallbladder disease, unspec.
576.1 Cholangitis
577.0 Pancreatitis, acute
577.1 Pancreatitis, chronic
577.2 Pancreatic cyst, pseudocyst
578.0 Hematemesis
578.1 Melena
579.9 Malabsorption, NOS
864.01 Hematoma, liver, not open into cavity
873.63 Tooth, broken, due to trauma
935.1 Foreign body, esophagus
935.1 Foreign body, esophagus
935.2 Foreign body, stomach
935.2 Foreign body, stomach
937 Foreign body, anus/rectum
937 Foreign body, anus/rectum
Gastroenterology EXAM
Gastroenterology ROS
Genitourinary / Gynecology
112.1 Candidiasis – of vulva and vagina
218.9 Fibroid uterus (leiomyoma), unspec.
256.2 Ovarian failure, postablative
256.39 Ovarian failure, other
256.4 Ovaries, polycystic
257.2 Testicular hypofunction
302.72 Impotence, psychosexual dysfunction
456.4 Varicocele
580.9 Glomerulonephritis, acute, unspec.
581.9 Nephrotic syndrome, unspec.
582.9 Glomerulonephritis, chronic, unspec.
584.5 Renal failure, acute w/ tubular necrosis
584.9 Renal failure, acute, unspec.
585.6 Renal disease, end stage
585.9 Renal failure/insuffic., chronic, unspec.
590.10 Pyelonephritis, acute, w/o necrosis
591 Hydronephrosis
592.0 Calculus, kidney
592.1 Calculus, ureter
592.9 Calculus, urinary, unspec.
593.2 Cyst, kidney, acquired
593.6 Proteinuria, benign postural
593.70 Vesicoureteral reflux, unspec.
593.9 Renal insufficiency, acute
595.0 Cystitis, acute
595.1 Cystitis, interstitial, chronic
595.82 Cystitis, irradiation
596.0 Bladder neck obstruction
596.4 Atony of bladder
596.51 Bladder hypertonicity
596.54 Bladder, neurogenic, NOS
597.81 Urethral syndrome, non-VD, NOS
598.00 Stricture, urethral, unspec. infection
598.1 Stricture, urethral, traumatic
599.0 Urinary tract infection, unspec./pyuria
599.60 Urinary obstruction, unspec.
599.7 Hematuria
600.00 BPH/LUTS w/o obstruction
600.01 BPH/LUTS w/ obstruction
601.0 Prostatitis, acute
601.1 Prostatitis, chronic
601.9 Prostatitis, NOS
603.9 Hydrocele, unspec.
604.90 Orchitis/epididymitis, unspec.
605 Phimosis
606.9 Infertility, male, unspec.
607.1 Balanitis
607.3 Priapism
607.84 Impotence, organic
608.1 Spermatocele
608.20 Torsion of testis, unspec.
608.3 Atrophy of testis
608.82 Hematospermia
610.1 Fibrocystic disease
610.2 Fibroadenosis
611.0 Mastitis, NOS
611.1 Gynecomastia
611.6 Galactorrhea
611.71 Mastodynia
611.72 Breast lump
611.9 Breast disease, unspec.
614.0 Salpingitis, oophoritis, acute
614.6 Adhesions, pelvic peritoneal
614.9 Pelvic inflammatory disease, unspec.
616.0 Cervicitis
616.10 Vaginitis/vulvitis, unspec
616.2 Bartholin cyst
616.3 Bartholin abscess
617.9 Endometriosis, unspec.
618.01 Cystocele, midline
618.03 Urethrocele
618.04 Rectocele
618.04 Rectocele
618.9 Cystocele/rectocele/prolapse, unspec.
620.0 Cyst of ovary, follicular
620.1 Corpus luteum cyst
621.2 Uterus, hypertrophy
621.30 Endometrial hyperplasia, unspec.
622.10 Dysplasia, cervix, unspec.
622.4 Stenosis, cervix
622.7 Cervical polyp, NOS
623.5 Leukorrhea, NOS
624.1 Atrophy, vulva
625.0 Dyspareunia
625.1 Vaginismus
625.2 Mittelschmerz
625.3 Menstruation, painful
625.4 Premenstrual tension syndrome
625.6 Incontinence, stress, female
625.9 Pelvic pain, unspec. female disease
626.0 Amenorrhea
626.2 Menstruation, excessive/frequent, Menorrhagia
626.6 Metrorrhagia
627.1 Bleeding, postmenopausal
627.2 Menopausal state, symptomatic
627.3 Vaginitis, postmenopausal atrophic
627.9 Menopausal disorders, unspec.
628.9 Infertility, female, unspec.
675.94 Mastitis, postpartum, unspec.
790.93 PSA, elevated
791.0 Proteinuria, nonpostural, nonobstetric
Genitourinary EXAM
Genitourinary ROS
V07.4 Hormone replacement therapy
V49.81 Menopausal state, asymptomatic
Hematology
238.4 Polycythemia vera
280.0 Anemia, low iron, chronic blood loss
280.1 Anemia, iron def., decreased intake
280.9 Anemia, iron deficiency, unspec.
281.0 Anemia, pernicious
281.2 Anemia, folate deficiency
282.5 Sickle-cell trait
282.61 Sickle cell w/o crisis
282.62 Sickle cell w/ crisis
283.0 Anemia, autoimmune hemolytic
285.1 Anemia, acute blood loss
285.21 Anemia, chronic kidney disease
285.22 Anemia, neoplastic disease
285.29 Anemia, chronic disease, other
285.9 Anemia, other, unspec.
286.0 Hemophilia
286.9 Coagulation defects, other
287.30 Thrombocytopenia, primary
287.31 Idiopathic thrombocytopenic purpura
287.4 Thrombocytopenia, secondary
287.9 Hemorrhagic conditions, unspec.
288.00 Neutropenia, unspec.
288.3 Eosinophilia
288.50 Leukocytopenia, unspec.
288.60 Leukocytosis, unspec.
288.9 Abnormal white blood cells, unspec.
289.1 Lymphadenitis, chronic
289.81 Primary hypercoagulable state
Hematology EXAM
Hematology ROS
Infectious Disease
003.0 Salmonella gastroenteritis
004.9 Shigellosis, unspec.
005.0 Staphylococcal food poisoning
007.1 Giardiasis
007.9 Intestinal protozoa, NOS
008.61 Rotavirus
011.90 Tuberculosis, pulmonary, NOS
034.0 Strep throat
034.1 Scarlet Fever
035 Erysipelas
038.2 Pneumococcal septicemia
038.40 Septicemia, gram-negative, unspec.
038.9 Septicemia, NOS
042 HIV disease
052.9 Chickenpox, NOS
053.9 Herpes zoster, NOS
054.11 Herpetic vulvovaginitis
054.13 Herpetic infection, penis
054.2 Herpetic gingivostomatitis
054.9 Herpetic disease, uncomplicated
055.9 Measles, uncomplicated
056.9 Rubella, uncomplicated
057.0 Fifth disease
057.9 Exanthems, viral, unspec.
058.10 Roseola infantum, unspec.
062.9 Encephalitis, mosquito, unspec.
066.40 West Nile Virus, unspec.
070.1 Hepatitis A w/o coma
070.30 Hepatitis B w/o coma, acute
070.32 Hepatitis B w/o coma, chronic
070.51 Hepatitis C w/o coma, acute
070.54 Hepatitis C w/o coma, chronic
070.9 Hepatitis, viral, NOS
072.9 Mumps, uncomplicated
074.0 Herpangina
074.3 Hand, foot, mouth disease
075 Infectious mononucleosis
078.0 Molluscum contagiosum
078.10 Warts, all sites
078.11 Condyloma acuminata
078.5 CMV disease
079.3 Rhinovirus
079.4 HPV
079.4 HPV
079.6 Respiratory syncytial virus
079.99 Viral infection, unspec.
082.0 Rocky mountain spotted fever
088.81 Lyme disease
091.0 Syphilis, primary, genital
098.0 Gonorrhea, acute, lower GU tract
099.40 Urethritis, nongonococcal
099.8 Venereal disease, other spec.
110.0 Dermatophytosis of scalp/beard
110.2 Dermatophytosis of hand
111.9 Dermatomycosis, unspec.
112.0 Moniliasis, oral
112.1 Moniliasis, vulva/vagina
112.2 Monilial balanitis
112.3 Moniliasis, skin/nails
115.00 Histoplasmosis, unspec.
127.0 Ascariasis
127.4 Pinworms
130.9 Toxoplasmosis, unspec.
131.01 Trichomonal vaginitis
131.02 Trichomoniasis, urethritis
132.0 Pediculosis, head lice
132.1 Pediculosis, body lice
132.2 Pediculosis, pubic lice
133.0 Scabies
133.8 Chiggers
136.9 Infectious/parasitic diseases, unspec.
137.0 Tuberculosis, respiratory, late effects
138 Polio, late effects
323.9 Encephalitis, myelitis, unspec.
790.7 Bacteremia
795.5 Positive PPD
99.53 Chlamydia
V08 HIV positive, asymptomatic
Neurology
036.0 Meningococcal meningitis
077.0 Conjunctivitis, chlamydia
077.99 Conjunctivitis, viral, NOS
098.40 Conjunctivitis, gonococcal
250.61 Neuropathy, diabetic
29.2 Neuralgia, radiculitis
307.20 Tic disorder, unspec.
307.23 Tourette’s
307.81 Headache, tension
310.2 Post-concussion syndrome
320.0 Meningitis, hemophilus
320.9 Meningitis, bacterial, NOS
322.9 Meningitis, unspec. cause
325 Venous sinus thrombosis, intracranial
327.23 Sleep apnea, obstructive
327.24 Hypoventilation, idiopathic, sleep related
327.52 Leg cramps, nocturnal
331.4 Hydrocephalus, obstructive
331.5 Hydrocephalus, normal pressure
331.81 Reye’s syndrome
331.83 Cognitive impairment, mild
332.0 Parkinsonism, primary
333.1 Tremor, essential/familial
333.4 Huntington’s chorea
333.81 Blepharospasm
333.94 Restless legs syndrome
337.21 Reflex sympathetic dyst., upper limb
337.22 Reflex sympathetic dyst., lower limb
340 Multiple sclerosis
342.00 Hemiplegia, flaccid
342.10 Hemiplegia, spastic
343.0 Cerebral palsy, paraplegic, congenital
343.1 Cerebral palsy, hemiplegic, congenital
343.2 Cerebral palsy, quadriplegic
345.00 Epilepsy, absence, w/o statu
345.10 Epilepsy, tonic-clonic, w/o status
345.3 Epilepsy, status
345.40 Epilepsy, partial complex, w/o statu
345.90 Epilepsy, unspec., not intractable
346.00 Migraine, classical, not intractable
346.10 Migraine, common, not intractable
346.20 Headaches, cluster, not intractable
346.90 Migraine, unspec., not intractable
347.00 Narcolepsy, w/o cataplexy
348.2 Pseudotumor cerebri
348.30 Encephalopathy, unspec
348.31 Encephalopathy, metabolic
348.5 Cerebral edema
349.0 Headache, post spinal puncture
350.1 Trigeminal neuralgia
351.0 Bell’s palsy
353.0 Thoracic outlet syndrome
353.6 Phantom limb
354.0 Carpal tunnel
355.1 Neuropathy, lateral femoral cutaneous
355.6 Morton’s neuroma
357.0 Guillain-Barré
357.5 Neuropathy, poly-, alcoholic
357.9 Neuropathy, poly-, unspec
358.00 Myasthenia gravis w/o exacerbation
358.01 Myasthenia gravis w/ exacerbation
359.1 Muscular dyst., hereditary
361.01 Retinal detachment, partial, single defect
362.01 Retinopathy, diabetic, background
362.02 Retinopathy, diabetic, proliferative
362.11 Retinopathy, hypertensive
362.51 Macular degeneration, nonexudative
364.01 Iritis/cyclitis, acute, primary
364.41 Hyphema
365.11 Glaucoma, primary open angle
365.22 Glaucoma, acute angle closure
365.23 Glaucoma, chronic angle closure
365.9 Glaucoma, unspec.
366.15 Cataract, cortical, senile
366.9 Cataract, unspec.
367.0 Farsightedness
367.1 Nearsightedness
367.9 Refractive errors, unspec.
368.10 Visual disturbance, unspec.
368.12 Visual loss, transient
368.2 Diplopia
368.40 Visual field defect, unspec.
368.41 Scotoma, central
370.00 Corneal ulcer, unspec
371.24 Corneal edema, contact lenses
372.03 Conjunctivitis, mucopurulent
372.05 Conjunctivitis, acute atopic
372.30 Conjunctivitis, unspec.
372.42 Pterygium, peripheral, progressive
372.72 Subconjunctival hemorrhage
373.00 Blepharitis, unspec.
373.11 Stye (hordeolum)
373.2 Chalazion
374.41 Lid lag
375.15 Dry eye syndrome
377.01 Papilledema, increased intracranial pressure
378.01 Esotropia, monocular
378.9 Eye movement disorder, unspec.
379.41 Anisocoria
379.54 Nystagmus, inner ear disease
380.10 Otitis Externa, unspec.
380.12 Swimmers’ ear, acute
380.4 Cerumen impaction
381.01 Otitis media, acute serous
381.10 Otitis media, chronic serous
381.81 Eustachian tube dysfunction
382.00 Otitis media, acute
382.01 Otitis media, acute w/ rupture of TM
384.21 Perforation, central, tympanic mem.
386.00 Ménière’s disease, unspec.
386.11 Vertigo, benign paroxysmal positional
386.2 Vertigo, central
386.35 Labyrinthitis, viral
388.01 Presbyacusis
388.12 Hearing loss, noise-induced
388.2 Hearing loss, sudden, unspec.
388.71 Otalgia, otogenic
388.72 Otalgia, referred
389.01 Hearing loss, conductive, external ear
389.03 Hearing loss, conductive, middle ear
389.05 Hearing loss, conductive, unilateral
389.05 Hearing loss, conductive, unilateral
389.10 Hearing loss, sensorineural
389.15 Hearing loss, sensorineural, unilateral
389.20 Hearing loss, mixed, unspec.
389.9 Hearing loss, unspec.
430 Subarachnoid hemorrhage
432.9 Hemorrhage, intracranial, NOS
434.91 Cerebral art. occl., w/ infarction, unspec.
437.3 Cerebral aneurysm, nonruptured
438.9 CVA, late effect, unspec
572.2 Coma, hepatic
724.3 Sciatica
781.0 Tremor/spasms, NOS
850.0 Concussion, no loss of consciousness
850.11 Concussion w/ LOC ≤ 30 minutes
850.12 Concussion w/ LOC 31 to 59 minutes
850.2 Concussion, moderate loss
850.9 Concussion, unspec.
852.20 Subdural hemorrhage w/o open wound
918.1 Corneal abrasion
930.9 Foreign body, eye, external, unspec.
931 Foreign body, ear
940.9 Eye burn, unspec.
993.0 Barotrauma, otitic
Neurology EXAM
Neurology ROS
V50.3 Ear piercing
Obstetrics / Childbirth
630 Hydatidiform mole
632 Abortion, missed
633.10 Ectopic preg., tubal, no IUP
633.90 Ectopic preg., no IUP, unspec.
634.91 Abortion, spontaneous, incomplete, uncomplicated
634.92 Abortion, spontaneous, complete, uncomplicated
635.92 Abortion, induced, w/o comp, complete
641.00 Placenta previa, w/o bleeding, unspec.
641.10 Placenta previa, w/ bleeding, unspec.
641.20 Abruptio placentae, unspec.
641.90 Hemorrhage in preg., unspec.
642.33 Gestational hypertension, antepartum
642.40 Pre-eclampsia, unspec.
642.60 Eclampsia, unspec.
643.03 Hyperemesis gravidarum, mild
643.13 Hyperemesis gravidarum, w/ metabolic disturbance, antepartum
643.90 Vomiting of preg., unspec.
644.03 Premature labor, threat., undelivered
644.21 Premature labor, delivered
645.10 Post-term preg., unspec.
645.13 Post-term preg., antepartum
646.63 Urinary tract infection, antepartum
646.90 Preg., other complications, unspec.
647.93 Infections, complicating pregnancy
648.83 Gestational diabetes, antepartum
649.50 Spotting during pregnancy, unspec.
649.60 Uterine size/date discrepancy
650 Normal delivery
651.00 Twins, unspec.
655.73 Fetal movement, decreased, antepart.
656.11 Rh incompatibility, delivered
656.31 Fetal distress, delivered
656.53 Small-for-dates, antepartum
656.61 Large-for-dates, delivered
657.03 Polyhydramnios, antepartum
658.03 Oligohydramnios, antepartum
658.10 Premature rupture of mem., unspec.
659.10 Induction of labor, failed
659.70 Abnormality in fetal heart tracing
660.01 Obstruction, malposition, delivered
660.11 Obstruction, bony pelvis, delivered
660.41 Shoulder dystocia, delivered
660.61 Trial of labor, failed, delivered
661.00 Uterine inertia, primary, unspec.
661.10 Uterine inertia, secondary, unspec.
661.30 Labor, precipitate, unspec.
662.10 Labor, prolonged, unspec.
663.10 Cord around neck, unspec.
663.30 Cord entanglement, other and unspec.
664.04 Laceration, perineal, 1st deg., PP
664.14 Laceration, perineal, 2nd deg., PP
664.24 Laceration, perineal, 3rd deg., PP
664.34 Laceration, perineal, 4th deg., PP
665.30 Laceration of cervix, unspec.
666.04 Hemorrhage, 3rd stage, postpartum
666.14 Hemorrhage, immediate PP, other
669.51 Forceps/vacuum delivery, delivered
669.90 Complicated delivery/labor, unspec.
670.04 Endometritis, postpartum
671.44 Thrombophlebitis, postpartum
674.90 Peripartum, complications, unspec.
675.14 Abscess of breast, postpartum
676.24 Engorgement of breasts, postpartum
Obstetric ROS
V22.0 Prenatal care, normal, first pregnancy
V22.1 Prenatal care, normal, other pregnancy
V22.2 Pregnant state, incidental
V23.41 Preg., h/o pre-term labor
V23.9 Prenatal care, high risk, unspec.
V24.2 Postpartum follow-up, routine
Oncology
153.9 Colon, unspec.
159.9 Gastrointestinal tract, NOS
162.9 Lung, unspec.
165.9 Respiratory tract, NOS
173.9 Skin, unspec.
174.9 Breast, female, unspec.
184.9 Female genital, unspec., CIS excluded
185 Prostate
187.9 Male genital, unspec.
188.9 Bladder, unspec.
189.9 Urinary, unspec
199.1 Malignant lesion, unspec.
201.90 Hodgkin’s, NOS
201.90 Hodgkin’s, NOS
211.3 Colon
214.0 Lipoma, facial
214.1 Lipoma, other skin, subcutaneous
214.9 Lipoma, any site
216.4 Skin neoplasm, scalp/neck
216.5 Skin neoplasm, skin of trunk
216.6 Skin neoplasm, upper limb
216.7 Skin neoplasm, lower limb
216.9 Skin, unspec.
229.9 Benign lesion, unspec.
233.1 Cervix uteri (CIS)
239.2 Skin, soft tissue neoplasm, unspec.
782.8 Change in skin texture
782.9 Other symptoms involving skin
Ophthalmology
Ophthalmology EXAM
Ophthalmology ROS
Orthopedics
524.62 Temporomandibular arthralgia
710.5 Eosinophilia myalgia syndrome
715.09 Osteoarthrosis, gen., multiple sites
715.11 Osteoarthrosis, shoulder
715.14 Osteoarthrosis, hand
715.15 Osteoarthrosis, hip
715.16 Osteoarthrosis, knee
715.17 Osteoarthrosis, ankle/foot
715.90 Osteoarthrosis, unspec.
716.10 Arthropathy, traumatic, unspec.
717.1 Derangement, ant, med meniscus, knee
717.42 Derangement, lat meniscus, knee
717.7 Chondromalacia of patella
717.9 Derangement, internal, knee, unspec.
719.06 Knee effusion
719.46 Patellofemoral Pain Syndrome
719.7 Difficulty in walking
721.0 Cervical spondylosis w/o myelopathy
721.1 Cervical spondylosis, w/myelopathy
721.2 Thoracic spondylosis w/o myelopathy
721.3 Lumbosacral spondylosis w/o myelopathy
721.42 Lumbar spondylosis w/ myelopathy
721.90 Osteoarthritis of spine, NOS
722.0 Cervical disc displacement
722.10 Lumbar disc displacement w/o myelopathy
722.4 Degenerative disc disease, cervical
722.51 Degenerative disc disease, thoracic
722.52 Degenerative disc disease, lumbar
722.71 Cervical disc disorder w/myelopathy
722.73 Lumbar disc disorder w/myelopathy
722.81 Postlaminectomy syndrome, cervical
722.83 Postlaminectomy syndrome, lumbar
723.5 Torticollis, unspec.
723.9 Cervical disorder, NOS
724.02 Spinal stenosis, lumbar region
724.4 Back pain w/ radiation, unspec.
724.79 Coccygodynia
725 Polymyalgia rheumatica
726.0 Adhesive capsulitis, shoulder
726.10 Rotator cuff/shoulder synd., unspec.
726.12 Bicipital tenosynovitis
726.31 Medial epicondylitis
726.32 Lateral epicondylitis
726.33 Olecranon bursitis
726.61 Pes anserinus tendinitis
726.64 Tendinitis, patellar
726.65 Prepatellar bursitis
726.71 Tendinitis, achilles
726.72 Tendinitis, tibialis
726.73 Calcaneal spur
727.03 Trigger finger, acquired
727.04 de Quervain’s disease
727.05 Tenosynovitis, hand/wrist
727.06 Tenosynovitis, foot/ankle
727.1 Bunion
727.42 Ganglion, tendon sheath
727.43 Ganglion, unspec.
727.51 Baker’s cyst
727.62 Rupture, biceps tendon
727.67 Rupture, achilles tendon
727.89 Abscess, bursa
728.12 Myositis ossificans, traumatic
728.2 Muscular wasting, atrophy
728.6 Dupuytren’s contracture
728.84 Diastasis recti
728.85 Muscle spasm
728.87 Muscle weakness, generalized
728.88 Rhabdomyolysis
728.89 Iliotibial band syndrome
729.1 Fibromyalgia/myositis, unspec.
729.5 Pain in limb
729.6 Foreign body in soft tissue
730.00 Osteomyelitis, acute, unspec.
730.04 Osteomyelitis, hand, acute
730.06 Osteomyelitis, leg, acute
730.07 Osteomyelitis, foot, acute
730.10 Osteomyelitis, chronic, unspec.
732.7 Osteochondritis dissecans
733.00 Osteoporosis, unspec.
733.01 Osteoporosis, senile
733.21 Bone cyst, solitary
733.42 Aseptic necrosis, head/neck of femur
733.6 Costochondritis
733.82 Nonunion of Fracture
733.93 Stress Fracture: tibia or fibula
733.94 Stress Fracture: metatarsals
733.95 Stress Fracture: other bone
734 Flat foot
735.0 Hallux valgus
735.2 Hallux rigidus
735.4 Hammer toe, other
736.1 Mallet finger
736.21 Boutonniere deformity
736.22 Swan-neck deformity
736.72 Equinus deformity, foot
736.79 Acquired deformity, ankle/foot, other, foot drop
736.9 Acquired deformity, limb, unspec.
737.10 Kyphosis (acquired)
737.30 Scoliosis
737.9 Kyphosis/scoliosis, unspec.
738.4 Spondylolisthesis, spondylolysis
739.1 Somatic dysfunction, cervical region
739.2 Somatic dysfunction, thoracic region
739.3 Somatic dysfunction, lumbar region
739.5 Somatic dysfunction, pelvic region
739.8 Somatic dysfunction, rib cage
802.0 Nose, closed Fracture
802.20 Mandible, closed, unspec. Fracture
802.6 Orbital floor, closed Fracture
803.00 Skull, closed, unspec. Fracture
805.2 Dorsal, thoracic, closed Fracture
805.4 Lumbar, closed Fracture
805.8 Vertebral, closed, unspec. Fracture
807.00 Ribs, closed, unspec. Fracture
807.01 Ribs, closed, one rib Fracture
807.02 Ribs, closed, two ribs Fracture
808.8 Pelvic, closed, unspec. Fracture
810.00 Clavicle, closed, unspec. Fracture
810.02 Clavicle, closed, shaft Fracture
810.03 Clavicle, closed, acromial Fracture
812.02 Humerus, closed, anatomical neck Fracture
812.09 Humerus, closed, upper end, unspec. Fracture
812.20 Humerus, closed, unspec. Fracture
813.21 Radius, shaft, closed Fracture
813.22 Ulna, shaft, closed Fracture
813.41 Colles’ Fracture
813.80 Forearm, closed, unspec. Fracture
814.00 Carpal, closed, unspec. Fracture
814.01 Carpal, closed, scaphoid Fracture
815.00 Metacarpal, closed, unspec. Fracture
815.03 Metacarpal, closed, shaft Fracture
815.04 Metacarpal, closed, neck Fracture
816.00 Phalanges, hand, closed, unspec. Fracture
816.01 Phalanges, hand, mid./prox., closed Fracture
816.02 Phalanges, hand, distal, closed Fracture
820.02 Femur, midcervical, closed Fracture
820.21 Femur, intertrochanteric section Fracture
820.8 Femur/hip, closed, unspec. Fracture
823.01 Fibula, upper end, closed Fracture
823.80 Tibia, closed, unspec. Fracture
823.81 Fibula, closed, unspec. Fracture
823.82 Tibia/fibula, closed, unspec. Fracture
824.2 Ankle, closed, lateral malleolus Fracture
824.8 Ankle, closed, unspec. Fracture
825.0 Calcaneus, closed Fracture
825.20 Foot, closed, unspec. Fracture
825.25 Metatarsal bone, closed Fracture
826.0 Toe, closed Fracture
829.0 Other sites, closed, unspec. Fracture
831.01 Dislocation: shoulder, closed, anterior
836.0 Knee meniscus injury, medial
836.1 Knee meniscus injury, lateral
840.4 Sprain/strain: shoulder, rotator cuff
840.6 Sprain/strain: supraspinatus
840.9 Sprain/strain: shoulder/upper arm, unspec.
842.00 Sprain/strain: wrist, unspec.
842.10 Sprain/strain: hand, unspec.
844.0 Sprain/strain: knee, lateral collat. lig.
844.1 Sprain/strain: knee, medial collat. lig.
844.2 Sprain/strain: knee, cruciate lig.
844.9 Sprain/strain: knee/leg, unspec.
845.00 Sprain/strain: ankle, unspec.
845.01 Sprain/strain: ankle, deltoid lig.
845.10 Sprain/strain: foot, unspec.
846.1 Sprain/strain: sacroiliac lig.
847.0 Sprain/strain: neck, unspec.
847.2 Sprain: lumbar
847.9 Sprain/strain: vertebral, unspec.
848.3 Sprain/strain: ribs
953.0 Cervical root injury
Orthopedics EXAM
Orthopedics ROS
Otolaryngology
Otolaryngology EXAM
Otolaryngology ROS
Pediatrics
Congenital Anomalies
741.93 Spina bifida, lumbar, uncomplicated
742.1 Microcephalus
743.65 Tear duct , blocked
744.02 Atresia, auditory canal (external)
744.41 Branchial cleft sinus/fistula
745.4 Ventricular septal defect
745.5 Atrial septal defect
746.9 Heart anomaly, NOS
747.60 Arteriovenous malformation, unspec.
747.81 Arteriovenous malformation of brain
749.00 Cleft palate, unspec.
749.20 Cleft palate w/ cleft lip
750.0 Tongue tie
750.5 Pyloric stenosis
751.0 Meckel’s diverticulum
751.2 Imperforate anus
751.3 Hirschsprung’s disease
752.42 Imperforate hymen
752.51 Undescended testis
752.61 Hypospadias
753.12 Polycystic kidney, unspec.
754.1 Torticollis, sternomastoid
754.30 Dislocation of hip, unilateral
754.51 Talipes equinovarus
754.81 Pectus excavatum
755.01 Polydactyly, fingers
755.9 Limb anomaly, unspec.
756.17 Spina bifida occulta
756.51 Osteogenesis imperfecta
757.32 Birthmarks
757.6 Supernumerary nipple
758.0 Down’s syndrome
759.82 Marfan syndrome
Perinatal (Infant)
760.71 Fetal alcohol syndrome
760.72 Exposure to narcotics, perinatal
760.75 Exposure to cocaine, perinatal
760.77 Exposure to anticonvulsants
761.1 Newborn affected by PROM
763.84 Meconium passage during delivery
764.00 Newborn, SGA, weight unspec.
765.10 Preterm infant, weight unspec.
766.0 Exceptionally large baby, 4,500g +
766.21 Post-term infant
766.22 Prolonged gestation of infant
767.2 Birth trauma, fracture of clavicle
767.9 Birth trauma, unspec.
768.3 Fetal distress, during labor, in infant
768.5 Birth asphyxia, severe
768.9 Birth asphyxia, unspec.
769 Respiratory distress syndrome
770.10 Aspiration, neonatal/fetal, unspec.
770.88 Hypoxemia, newborn, NOS
771.6 Ophthalmia neonatorum, NOS
771.81 Sepsis, neonatal
773.0 Hemolysis, RH isoimmunization
773.1 Hemolysis, ABO isoimmunization
774.2 Jaundice, newborn, prematurity
774.30 Jaundice, newborn, unspec.
774.39 Jaundice, newborn, breast milk
775.0 Infant of diabetic mother syndrome
775.4 Hypocalcemia
775.6 Hypoglycemia, neonatal
777.3 Swallowed maternal blood
777.5 Necrotizing enterocolitis
778.7 Breast engorgement in newborn
778.9 Skin/temperature problem
779.3 Feeding problem, newborn
779.5 Drug withdrawal in newborn
798.0 Sudden infant death syndrome
V30.00 Well newborn, hospital birth, vaginal
V30.01 Well newborn, hospital birth, c-section
V50.2 Circumcision, routine
Psychiatry
00.23 Social phobia
290.0 Dementia, senile, NOS
290.40 Dementia, vascular, uncomplicated
291.0 Delirium tremens
291.81 Alcohol withdrawal
292.0 Drug withdrawal
292.11 Drug-induced paranoia
293.0 Delirium, conditions classified elsewhere
295.02 Schizophrenia, simple, chronic
295.12 Schizophrenia, disorganized, chronic
295.32 Schizophrenia, paranoid, chronic
295.72 Schizoaffective, chronic
295.90 Schizophrenia, unspec
296.22 Depression, major, single episode
296.42 Bipolar I, recently manic, mod.
296.52 Bipolar I, recently depressed, mod.
296.80 Bipolar disorder, unspec.
298.0 Depressive psychosis
298.1 Hysterical psychosis, acute
298.3 Paranoid reaction, acute
298.9 Psychosis, unspec.
299.00 Autism, current or active
300.00 Anxiety state, unspec.
300.01 Panic disorder, no agoraphobia
300.02 Generalized anxiety disorder
300.10 Hysteria, unspec.
300.11 Conversion disorder
300.21 Agoraphobia w/ panic
300.23 Social phobia
300.3 Obsessive-compulsive disorder
300.4 Neurotic depression
300.81 Somatization disorde
300.9 Neurosis, NOS
301.3 Explosive personality disorder
301.7 Antisocial personality disorder
301.83 Borderline personality disorder
301.9 Personality disorder, unspec.
302.70 Psychosexual dysf., unspec.
302.71 Psychosexual dysf., inhibited desire
302.75 Premature ejaculation
302.76 Dyspareunia, psychogenic
303.00 Alcohol intoxication, acute, unspec.
303.91 Alcoholism, chronic, continuous
304.01 Opioid dependence, continuous
304.11 Barbiturate dependence, continuous
304.21 Cocaine dependence, continuous
304.31 Cannabis dependence, continuous
304.41 Amphetamine dependence, continuous
304.90 Drug dependence, unspec.
305.00 Alcohol abuse, unspec.
305.1 Tobacco abuse
305.22 Cannabis abuse, episodic
305.52 Opioid abuse, episodic
305.62 Cocaine abuse, episodic
305.90 Drug abuse, unspec.
306.8 Bruxism
307.0 Stuttering
307.1 Anorexia nervosa
307.40 Insomnia, sleep disorder, unspec.
307.41 Insomnia, transient
307.46 Somnambulism
307.51 Bulimia nervosa
307.52 Pica
307.6 Enuresis
307.7 Encopresis
307.80 Pain, psychogenic
308.3 Stress, acute situational disturbance
309.0 Adjustment disorder, depressive
309.24 Adjustment reaction, anxious mood
309.81 Post-traumatic stress disorder
311 Depressive disorder, NOS
312.9 Conduct disorder, unspec.
314.00 Attention deficit, w/o hyperactivity
314.01 Attention deficit, w/ hyperactivity
315.9 Learning disability/develop. delay, NOS
317 Mental retardation, mild
319 Mental retardation, unspec.
327.30 Circadian rhythm sleep disorder, unspec.
331.0 Alzheimer’s
Psychiatry EXAM
Psychiatry ROS
V61.10 Counseling, marital/partner, unspec.
V61.20 Counseling, parent/child, unspec
V62.82 Bereavement
V62.84 Suicidal ideation
V65.42 Counseling, substance use/abuse
Pulmonology
460 Common cold
461.0 Sinusitis, acute, maxillary
461.1 Sinusitis, acute, frontal
461.9 Sinusitis, acute, NOS
462 Pharyngitis, acute
463 Tonsillitis, acute
464.00 Laryngitis, acute, no obstruction
464.30 Epiglottitis, acute
464.4 Croup
465.9 Upper respiratory infection, acute, NOS
466.0 Bronchitis, acute
466.11 Bronchiolitis, acute, due to RSV
470 Deviated nasal septum
471.0 Polyp, nasal cavity
472.0 Rhinitis, chronic
473.0 Sinusitis, chronic, maxillary
473.1 Sinusitis, chronic, frontal
473.9 Sinusitis, chronic, NOS
474.11 Tonsillar hypertrophy alone
474.9 Tonsil/adenoid disease, chronic, unspec.
475 Peritonsillar abscess
476.0 Laryngitis, chronic
477.0 Rhinitis, allergic, due to pollen
477.2 Rhinitis, allergic, due to animal dander
477.9 Rhinitis, allergic, cause unspec.
478.19 Disease nasal cavity/sinuses, other
480.3 Pneumonia, SARS-associated coronavirus
480.9 Pneumonia, viral, unspec.
481 Pneumococcal pneumonia
482.9 Pneumonia, bacterial, unspec.
483.0 Mycoplasma pneumoniae
486 Pneumonia, unspec.
487.0 Influenza w/ pneumonia
487.1 Influenza w/ URI symptoms
491.20 Bronchitis, chronic, w/o exacerbation
491.21 Bronchitis, chronic, w/ exacerbation
491.9 Bronchitis, chronic, unspec.
492.8 Emphysema
493.00 Asthma, extrinsic w/o status
493.01 Asthma, extrinsic, w/ status asthmaticus
493.02 Asthma, extrinsic, acute exacerbation
493.10 Asthma, intrinsic w/o status
493.11 Asthma, intrinsic w/ status asthmaticus
493.12 Asthma, intrinsic w/ acute exacerbation
493.81 Exercise-induced bronchospasm
493.82 Cough variant asthma
493.90 Asthma, unspec.
493.92 Asthma, unspec. w/ acute exacerbation
496 COPD, NOS
501 Asbestosis
506.0 Bronchitis/pneumonitis due to fumes
507.0 Pneumonia, aspiration
511.0 Pleurisy, NOS
511.9 Pleural effusion, NOS
512.8 Pneumothorax, spontaneous
515 Pulmonary fibrosis, postinflammatory
518.0 Atelectasis
518.5 ARDS
518.81 Respiratory failure, acute
519.11 Bronchospasm, acute
860.0 Pneumothorax, traumatic, closed
861.21 Contusion, lung
861.21 Pulmonary contusion, closed
932 Foreign body, nose
Pulmonology EXAM
Pulmonology ROS
Rheumatology
135 Sarcoidosis
274.0 Gouty arthropathy
443.0 Raynaud’s syndrome
446.4 Wegener’s granulomatosis
446.5 Arteritis, giant cell, temporal
695.1 Erythema multiforme
695.2 Erythema nodosum
710.0 Systemic lupus erythematosus
710.2 Sjögren’s disease
710.3 Dermatomyositis
710.4 Polymyositis
710.9 Connective tissue disease, unspec.
711.59 Arthropathy, other viral, multiple
713.0 Arthropathy, endocrine disorders
713.1 Arthropathy, GI conditions
714.0 Rheumatoid arthritis (not JRA)
714.30 Polyarticular juvenile rheumatoid arthritis
716.90 Arthropathy, unspec.
720.0 Ankylosing spondylitis
720.2 Sacroiliitis
727.00 Synovitis/tenosynovitis, unspec.
780.71 Chronic fatigue syndrome
Rheumatology EXAM
Rheumatology ROS
Signs & Symptoms
271.9 Glucose intolerance
300.5 Fatigue, psychogenic
306.1 Hyperventilation
338.0 Pain syndrome, central
338.11 Pain, acute, due to trauma
338.21 Pain, chronic, due to trauma
338.29 Pain, chronic, other
338.3 Pain, neoplasm related
338.4 Pain syndrome, chronic
569.3 Bleeding, rectal
578.0 Hematemesis
578.1 Blood in stool, melena
719.00 Effusion/swelling of joint, unspec.
719.40 Arthralgia, unspec.
719.41 Pain, shoulder
719.45 Pain, hip
719.46 Pain, knee
723.1 Pain, neck
724.2 Pain, low back
780.01 Coma, nondiabetic, nonhepatic
780.02 Mental status changes
780.09 Semicoma, stupor
780.1 Hallucinations
780.2 Syncope
780.31 Seizures, simple, febrile, unspec.
780.39 Seizures, convulsions, other
780.4 Dizziness/vertigo, NOS
780.50 Sleep disturbance, unspec.
780.58 Movement disorder, sleep related
780.6 Fever, nonperinatal
780.79 Fatigue and malaise, other
780.8 Sweating, excessive
780.92 Crying, infant, excessive
780.93 Memory loss
780.94 Early satiety
780.94 Early satiety
780.96 Pain, generalized
780.97 Altered Mental Status
781.0 Movement disorder
781.0 Tremor
781.1 Disturbances, smell and taste
781.2 Gait disturbance
781.5 Clubbing of fingers
781.8 Neurologic neglect syndrome
781.91 Loss of height
781.92 Abnormal posture
781.94 Facial weakness
782.0 Sensory disturbance skin
782.1 Rash, nonvesicular, unspec.
782.2 Localized swelling/mass, superficial
782.3 Edema, localized, NOS
782.4 Jaundice
782.5 Cyanosis
782.7 Petechiae
783.0 Anorexia
783.1 Abnormal weight gain
783.21 Abnormal loss of weight
783.22 Underweight
783.3 Feeding problem, infant/elderly
783.40 Lack of norm. physiolog. dev., unspec.
783.41 Failure to thrive, child
783.42 Delayed milestones
783.42 Delayed milestones
783.43 Short stature
783.5 Polydipsia
783.6 Polyphagia
783.7 Failure to thrive, adult
784.0 Headache, unspec.
784.3 Aphasia
784.49 Hoarseness
784.5 Dysarthria
784.61 Dyslexia
784.7 Epistaxis
784.91 Postnasal drip
785.0 Tachycardia
785.1 Palpitations
785.2 Murmur of heart, undiagnosed
785.50 Shock, unspec.
785.52 Septic shock
785.6 Lymph nodes, enlarged
785.9 Bruit
786.05 Shortness of breath
786.06 Tachypnea
786.07 Wheezing
786.1 Stridor
786.2 Cough
786.3 Hemoptysis
786.50 Chest pain, unspec.
786.51 Precordial pain
786.52 Pleuritic pain
786.8 Hiccoughs
787.01 Nausea w/vomiting
787.02 Nausea, alone
787.03 Vomiting, alone
787.1 Heartburn
787.20 Dysphagia, unspec.
787.3 Gas/bloating
787.6 Encopresis, NOS, fecal incontinence
788.1 Dysuria
788.30 Incontinence/enuresis, NOS
788.31 Incontinence, urge
788.36 Enuresis, nocturnal
788.41 Urinary frequency
788.42 Polyuria
788.43 Nocturia
788.63 Urgency of urination
788.64 Urinary hesitancy
789.00 Abdominal pain, unspec.
789.01 Abdominal pain, RUQ
789.03 Abdominal pain, RLQ
789.04 Abdominal pain, LLQ
789.06 Abdominal pain, epigastric
789.09 Colic, infantile
789.1 Hepatomegaly
789.2 Splenomegaly
789.30 Abdominal/pelvic mass, unspec.
789.33 Abdominal/pelvic mass, RLQ
789.34 Abdominal/pelvic mass, LLQ
789.51 Ascites, malignant
789.59 Ascites, other
790.0 Abnormal red blood cell
790.1 Elevated sedimentation rate
790.21 Abnormal fasting glucose
790.22 Abnormal glucose tolerance test
790.29 Abnormal glucose, other
790.4 Abnormal transaminase/LDH
790.6 Abnormal blood chemistry, other
790.92 Abnormal coagulation profile
791.0 Proteinuria
791.5 Glycosuria
792.1 Blood in stool, occult
793.1 Abnormal X-ray, lung
793.80 Abnormal mammogram, unspec.
794.31 Abnormal electrocardiogram
795.00 Abnormal Pap, unspec.
795.01 Abnormal Pap, ASC-US
795.02 Abnormal Pap, ASC, possible HGSIL
795.03 Abnormal Pap, LGSIL
795.04 Abnormal Pap, HGSIL
795.05 HPV positive test
795.08 Unsatisfactory Pap smear
795.09 Abnormal Pap, other and HPV
799.02 Hypoxemia
799.1 Respiratory arrest
799.4 Cachexia
799.81 Decreased libido
873.0 Open wound, scalp, w/o complication
873.40 Open wound, face, w/o complication
873.41 Open wound, cheek, w/o complication
873.42 Open wound, forehead, w/o comp.
873.43 Open wound, lip, w/o complication
873.64 Open wound, tongue, w/o complication
879.8 Open wound, head/neck/trunk, unspec., w/o complication
881.00 Open wound, forearm, w/o complication
882.0 Open wound, hand, w/o complication
883.0 Open wound, fingers, w/o complication
884.0 Open wound, upper limb, unspec.
892.0 Open wound, foot, w/o complication
894.0 Open wound, lower limb, unspec.
908.9 Late effects of injury, unspec.
919.0 Abrasion, unspec.
919.4 Insect bite
919.6 Foreign body, skin, superficial, unspec.
921.0 Contusion, black eye
923.11 Contusion, upper limb, elbow
924.11 Contusion, knee
924.4 Contusion, multiple sites, lower limb
924.8 Contusion, multiple sites, no classified
924.9 Contusion, unspec.
927.3 Crushing injury, fingers
928.3 Crushing injury, toe
948.00 Burns, <10% body surface
949.0 Burn, degree unspec.
958.91 Compartment syndrome, traumatic (UE)
958.92 Compartment syndrome, traumatic (LE) 958.92 Compartment syndrome, traumatic (LE)
959.01 Head injury, NOS
959.9 Other trauma, unspec.
965.01 Poisoning, heroin
965.09 Poisoning, other opiates
965.1 Poisoning, salicylates
977.9 Poisoning, medicine overdose, unspec.
986 Poisoning, carbon monoxide
989.9 Poisoning, nonmedicinal substance
991.3 Frostbite, unspec./other
991.6 Hypothermia
992.0 Heat stroke
992.3 Heat exhaustion
994.1 Drowning, nonfatal submersion
994.4 Exhaustion due to exposure
994.6 Motion sickness
995.0 Anaphylaxis
995.1 Angioneurotic edema
995.20 Medication, adverse effects, unspec.
995.3 Allergy, unspec.
995.50 Child abuse, unspec.
995.55 Shaken infant syndrome
995.81 Adult physical abuse
996.41 Prosthetic joint, loosened
996.57 Complication, due to insulin pump
998.32 Operative wound dehiscence
E922.9 Gunshot wound, NOS
V71.5 Rape
Supplemental Classification
V01.6 Exposure to venereal disease
V01.71 Exposure to varicella
V01.79 Exposure to other viruses
V01.9 Exposure to infectious disease, unspec.
V13.22 Cervical dysplasia, past history
V15.02 Allergy to milk products
V15.07 Allergy to latex
V15.88 Falls, risk for, history of
V18.9 Genetic disease carrier
V25.01 Contraception, oral
V25.02 Contraception, other (diaphragm, etc.)
V25.03 Emergency contraception visit
V25.09 Contraception advice
V25.2 Contraception, sterilization
V25.40 Contraception surveillance, unspec.
V25.9 Contraception management, depo.
V45.86 Bariatric surgery status
V54.12 Fracture lower arm, healing, aftercare
V54.17 Fracture vertebrae, healing, aftercare
V58.61 Anticoagulant therapy, long term
V58.63 Chronic use antiplatelet/thrombotic
V60.0 Housing problem/homeless
V61.0 Family disruption
V61.3 Problem w/ aged parents or in-laws
V61.49 Caring for family/household member
V61.9 Family problem, other, unspec.
V62.3 Educational problem
V62.4 Social maladjustment
V62.5 Legal problem
V62.89 Phase-of-life problem
V65.11 Pre-birth visit, expectant mother
V65.19 Visit on behalf of another person
V65.2 Malingering
V65.40 Advice/health instruction, NOS
V65.5 Worried well
V66.7 Palliative care
V68.09 Form, other
V68.9 Administrative, other, unspec.
V72.32 Confirm norm Pap after initial abn
V84.89 Genetic susceptibility to disease, other
V86.0 Estrogen receptor positive status
Example
787.91 Diarrhea, NOS
Generic NOTE Parts
Allergies
Assessment
Diagnostics
Family History
V16.0 Family history of GI tract cancer
V16.1 Family history of lung cancer
V16.3 Family history of breast cancer
V17.3 Family history of cardiac disease
V17.5 Family history of asthma
V17.81 Family history of osteoporosis
V18.0 Family history of diabetes mellitus
Generic Notes Parts Template
Laboratory Findings
Medications
V58.64 Long-term use of NSAIDs
V58.65 Long-term use of steroids
V58.66 Long-term use of aspirin
V58.69 Long term use of high-risk meds.
V58.83 Therapeutic drug monitoring
Past Medical History
Past Surgical History
Patient Education
Physical Exam
Cardiovascular EXAM
Comprehensive Exam
Constitutional EXAM
Dermatologic EXAM
Gastroenterology EXAM
Genitourinary EXAM
Neurologic EXAM
Ophthalmologic EXAM
Orthopedic EXAM
Otolaryngologic EXAM
Psychiatric EXAM
Pulmonology EXAM
Plan
Review of Systems
Cardiovascular ROS
Comprehensive ROS
Constitutional ROS
Dermatology ROS
Endocrine ROS
Gastroenterology ROS
Genitourinary ROS
Hematology ROS
Neurology ROS
Obstetric ROS
Ophthalmology ROS
Orthopedics ROS
Otolaryngology ROS
Psychiatry ROS
Pulmonology ROS
Rheumatology ROS
SOAP Notes
Social History
Subjective
Members
Notecuts
113__ Lesion, shave site ____ size____
NOTE
Brief
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Expanded
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