ICD-10-CM (2010)/CHAPTER 18

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ICD-10-CM TABULAR LIST of DISEASES and INJURIES  (2010) 
CHAPTER 18 - Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99)

Contents

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

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
R50-R69 General symptoms and signs
R70-R79 Abnormal findings on examination of blood, without diagnosis
R80-R82 Abnormal findings on examination of urine, without diagnosis
R83-R89 Abnormal findings on examination of other body fluids, substances and tissues, without diagnosis
R90-R94 Abnormal findings on diagnostic imaging and in function studies, without diagnosis
R97 Abnormal tumor markers
R99 Ill-defined and unknown cause of mortality

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

R00 Abnormalities of heart beat[edit]

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[edit]

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[edit]

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[edit]

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[edit]

Excludes1: cough with hemorrhage (R04.2)
smoker's cough (J41.0)

R06 Abnormalities of breathing[edit]

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[edit]

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[edit]

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)[edit]

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[edit]

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[edit]

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[edit]

Excludes1: dyspepsia (K30)

R13 Aphagia and dysphagia[edit]

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[edit]

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[edit]

Includes: encopresis NOS
Excludes1: fecal incontinence of nonorganic origin (F98.1)

R16 Hepatomegaly and splenomegaly, not elsewhere classified[edit]

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[edit]

Excludes1: neonatal jaundice (P55, P57-P59)

R18 Ascites[edit]

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[edit]

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)[edit]

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

R20 Disturbances of skin sensation[edit]

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[edit]

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[edit]

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[edit]

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)[edit]

R25 Abnormal involuntary movements[edit]

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[edit]

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[edit]

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[edit]

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)[edit]

R30 Pain associated with micturition[edit]

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[edit]

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[edit]

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[edit]

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[edit]

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[edit]

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[edit]

R36.0 Urethral discharge without blood
R36.1 Hematospermia
R36.9 Urethral discharge, unspecified
Penile discharge NOS
Urethrorrhea

R37 Sexual dysfunction, unspecified[edit]

R39 Other and unspecified symptoms and signs involving the genitourinary system[edit]

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)[edit]

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

R40 Somnolence, stupor and coma[edit]

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[edit]

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[edit]

Includes: light-headedness
vertigo NOS
Excludes1: vertiginous syndromes (H81.-)
vertigo from infrasound (T75.23)

R43 Disturbances of smell and taste[edit]

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[edit]

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[edit]

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[edit]

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[edit]

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[edit]

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[edit]

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)[edit]

R50 Fever of other and unknown origin[edit]

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[edit]

Includes: facial pain NOS
Excludes1: atypical face pain (G50.1)
migraine and other headache syndromes (G43-G44)
trigeminal neuralgia (G50.0)

R52 Pain, unspecified[edit]

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[edit]

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[edit]

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[edit]

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[edit]

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[edit]

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[edit]

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[edit]

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[edit]

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[edit]

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[edit]

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[edit]

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[edit]

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[edit]

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[edit]

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[edit]

Includes: unknown and unspecified cases of morbidity

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

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[edit]

R70.0 Elevated erythrocyte sedimentation rate
R70.1 Abnormal plasma viscosity

R71 Abnormality of red blood cells[edit]

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[edit]

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[edit]

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][edit]

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[edit]

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[edit]

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[edit]

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[edit]

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)[edit]

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[edit]

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[edit]

Excludes1: renal glycosuria (E74.8)

R82 Other and unspecified abnormal findings in urine[edit]

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)[edit]

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[edit]

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[edit]

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[edit]

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[edit]

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[edit]

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[edit]

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[edit]

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)[edit]

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[edit]

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[edit]

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[edit]

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[edit]

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[edit]

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)[edit]

R97 Abnormal tumor markers[edit]

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)[edit]

R99 Ill-defined and unknown cause of mortality[edit]

Includes: Death (unexplained) NOS
Unspecified cause of mortality