SCCA REFERENCE MANUAL ICD-10

SCCA REFERENCE MANUAL ICD-10 PART 1: ONCOLOGY 1

TABLE OF CONTENTS HEMATOLOGY ONCOLOGY LEUKEMIA/MDS..................................... 5 LYMPHOMA & MYELOMA............................. 6 GI/PANCREAS MALIGNANT NEOPLASMS OF DIGESTIVE ORGANS......... 9 THORACIC, HEAD, & NECK MALIGNANT NEOPLASMS OF HEAD, NECK, LIP, ORAL CAVITY & PHARYNX............................. 12 MALIGNANT NEOPLASMS OF LUNG - RESPIRATORY & INTRATHORACIC ORGANS.............................13 WOMEN S CENTER MALIGNANT NEOPLASMS OF THE BREAST................ 15 MALIGNANT NEOPLASMS OF FEMALE GENITAL ORGANS.... 15 GU/PROSTATE MALIGNANT NEOPLASMS OF URINARY TRACT............. 17 MALIGNANT NEOPLASMS OF MALE GENITAL ORGANS...... 17 SARCOMA AND ORTHOPEDICS MALIGNANT NEOPLASMS OF MESOTHELIOMA & SOFT TISSUE....................................... 19 MALIGNANT NEOPLASMS OF PERIPHERAL NERVES & AUTONOMIC NERVOUS SYSTEM....................... 19 MALIGNANT NEOPLASMS OF BONE & ARTICULAR CARTILAGE.............................. 20 MELANOMA/SKIN MELANOMA & OTHER MALIGNANT NEOPLASM OF SKIN... 22 NEURO-ONCOLOGY MALIGNANT NEOPLASMS OF EYE, BRAIN & OTHER PARTS OF CENTRAL NERVOUS SYSTEM.................. 24 2

TABLE OF CONTENTS ENDOCRINE MALIGNANT NEOPLASMS OF THYROID & OTHER ENDOCRINE GLANDS................................ 26 METASTATIC SECONDARY SITES MALIGNANT NEOPLASMS OF OTHER & ILL-DEFINED SITES.. 28 MALIGNANT NEOPLASMS OF OTHER SECONDARY & UNCERTAIN OR UNSPECIFIED NEOPLASMS............... 29 MALIGNANT NEUROENDOCRINE TUMORS............... 29 HEMATOLOGY MYELOPROLIF/MGUs................................ 31 NUTRITIONAL ANEMIAS...............................31 HEMOLYTIC ANEMIAS.................................32 THALASSEMIA......................................32 SICKLE CELL.........................................32 APLASTIC ANEMIA & BONE MARROW FAILURE........... 33 SECONDARY & OTHER ANEMIAS........................ 34 COAGULATION DEFECTS & OTHER EMORRHAGIC.......... 34 IMMUNE THROMBOCYTOPENIC & OTHERS............... 34 THROMBOTIC CONDITIONS............................ 35 NEUTROPENIA & OTHER WBC DISORDERS............... 36 MYELOFIBROSIS, FAMILIAL ERTHROCYTOSIS & SECONDARY POLYCYTHEMIA........................... 36 COMBINED IMMUNODEFICIENCIES..................... 37 SARCOIDOSIS...................................... 37 GVHD & CRYOGLOBULINEMIA......................... 38 PORPHYRIA........................................ 38 3

HEMATOLOGY ONCOLOGY 4

LEUKEMIA/MDS Leukemia, LYMPHOID 0 - Acute lymphoblastic leukemia 1- Chronic lymphocytic leukemia of B-cell type 3 - Prolymphocytic leukemia of B-cell type 4 - Hairy cell leukemia 5 - Adult T-cell lymphoma/leukemia (HTLV-1-associated) 6 - Prolymphocytic leukemia of T-cell type A - Mature B-cell leukemia Burkitt-type Z - Other lymphoid leukemia Leukemia, MYELOID 0 - Acute myeloblastic leukemia 1 - Chronic myeloid leukemia, BCR/ABLpositive 2 - Atypical chronic myeloid leukemia, BCR/ABL-negative 3 - Myeloid sarcoma 4 - Acute promyelocytic leukemia 5 - Acute myelomonocytic leukemia 6 -Acute myeloid leukemia with 11q23- abnormality A - Acute myeloid leukemia with multilineage dysplasia Z - Other myeloid leukemia C91. 0 - Not having achieved remission 1 - In remission 2 - In relapse C92. 0 -Not having achieved remission 1 - In remission 2 - In relapse Leukemia, MONOCYTIC C93. 0 - Acute monoblastic/monocytic leukemia 1 - Chronic myelomonocytic leukemia 3 - Juvenile myelomonocytic leukemia Z - Other monocytic leukemia Poisoning by Adverse Effect of & Underdosing of, 0 - Not having achieved remission 1- In remission 2 In relapse ANTINEOPLASTIC & IMMUNOSUPPRESSIVE DRUGS 1- Poisoning by antineoplastic and immunosuppressive drugs, accidental (unintentional) 5- Adverse effect of antineoplastic & immunosuppressive drugs T45.1X A - initial encounter D - subsequent encounter S - sequela Other Leukemias of SPECIFIED CELL TYPE 0 - Acute erythroid leukemia 2 - Acute megakaryoblastic leukemia 3 - Mast cell leukemia 4 - Acute panmyelosis with myelofibrosis 8 - Other specified leukemias 6 - Myelodysplastic disease, not classified Leukemia of UNSPECIFIED CELL TYPE 0 - Acute 1 - Chronic Unspecified Malignant Neoplasms of LYMPHOID, HEMATO POIETIC & RELATED TISSUE 0 - Multifocal and multisystemic (disseminated) Langerhans-cell histiocytosis 2 - Malignant mast cell tumor 4 - Sarcoma of dendritic cells (accessory cells) 5 - Multifocal and unisystemic Langerhans-cell histiocytosis 6 - Unifocal Langerhans-cell histiocytosis A - Histiocytic sarcoma Z - Other specified MYELODYSPLASTIC SYNDROME (MDS) 2 - Refractory anemia with excess of blasts C94. 0 - Not having achieved remission 1 - In remission 2 - In relapse C95. 0 - Not having achieved remission 1- In remission 2 In relapse C96. 0 - Not having achieved remission 1-1 2 2 Use T45.1X code for adverse effect, if applicable D46. 0 - Refractory anemia without ring sideroblasts, so stated 1 - Refractory anemia with ring sideroblasts A - Refractory cytopenia with multilineage dysplasia B - Refractory cytopenia with multilineage dysplasia and ring sideroblasts C - Myelodysplastic syndrome with isolated del(5q) chromosomal abnormality 4 - Refractory anemia, unspecified Z - Other myelodysplastic syndromes 5

B-CELL LYMPHOMA Lymphoma, HODGKIN 0 - Nodular lymphocyte predominant 1 - Nodular sclerosis classical 2 - Mixed cellularity classical 3 - Lymphocyte-depleted classical 4 - Lymphocyte-rich classical 7 - Other classical C81. site 1 - Head, neck, face 2 - Intrathoracic 3 - Intra-abdominal 4 - Axilla and upper limb 5 - Inguinal region and lower limb 6 -Intrapelvic 7 -Spleen 8 - Multiple-sites 9 - Extranodal and solid organ site Lymphoma, OTHER NON-HODGKIN 1 - Unspecified B-cell lymphoma 2 - Mediastinal (thymic) large B-cell 8 - Other specified types of non-hodgkin s C85. site 1 - Head, neck, face 2 - Intrathoracic 3 - Intra-abdominal 4 - Axilla and upper limb 5 - Inguinal region and lower limb 6 -Intrapelvic 7 -Spleen 8 - Multiple-sites 9 - Extranodal and solid organ site Lymphoma, FOLLICULAR 0 - Grade I 1 - Grade II 2 - Grade III unspecified 3 - Grade IIIa 4 - Grade IIIb 5 - Diffuse follicle center lymphoma 6 - Cutaneous follicle center lymphoma 8 - Other types lymphoma C82. Lymphomas, MALIGNANT site 1 - Head, neck, face 2 - Intrathoracic 3 - Intra-abdominal 4 - Axilla and upper limb 5 - Inguinal region and lower limb 6 -Intrapelvic 7 -Spleen 8 - Multiple-sites 9 - Extranodal and solid organ site IMMUNOPROLIFERATIVE & OTHER B-CELLS 0 - Waldenstrom macroglobulinemia 2 - Heavy chain disease 3 - Immunoproliferative small intestinal disease 4 - Extranodal marginal zone B-cell lymphoma of mucosaassociated lymphoid tissue [MALT-lymphoma] 8 - Other malignant immunoproliferative diseases. C88. Lymphoma, NON-FOLLICULAR 0 - Small cell B-cell Lymphoma 1 - Mantle cell Lymphoma 3 - Diffuse Large B-cell lymphoma 5 - Lymphoblastic (diffuse lymphoma) 7 - Burkitt lymphoma 8 - Other non-follicular Lymphoma (includes PEL/ intravascular) C83. site 1 - Head, neck, face 2 - Intrathoracic 3 - Intra-abdominal 4 - Axilla and upper limb 5 - Inguinal region and lower limb 6 -Intrapelvic 7 -Spleen 8 - Multiple-sites 9 - Extranodal and solid organ site 6

T-CELL LYMPHOMA LYMPHOMA, MATURE T/NK CELL 0 - Mycosis Fungoides 1 - Sezary Disease 4 - Peripheral T-cell, not classified 6 - Anaplastic Large cell AKL-positive 7 - Anaplastic Large cell AKL-negative A - Cutaneous T-cell, unspecified Z- Other C84. site 1 - Head, neck, face 2 - Intrathoracic 3 - Intra-abdominal 4 - Axilla and upper limb 5 - Inguinal region and lower limb 6 -Intrapelvic 7 -Spleen 8 - Multiple-sites 9 - Extranodal and solid organ site Lymphoma, Other SPECIFIED T/NK-CELL 0 - Extranodal NK/T-cell lymphoma, nasal type 1 - Hepatosplenic T-cell lymphoma 2 - Enteropathy-type (intestinal) T-cell lymphoma 3 - Subcutaneous panniculitis-like-t-cell lymphoma 4 - Blastic NK-cell lymphoma 5 - Angiommunoblastic T-cell lymphoma 6 - Primary cutaneous CD-30-positive T-cell proliferations C86. MYELOMA Multiple Myeloma & Malignant PLASMA CELL NEOPLASM 0 - Multiple Myeloma 1 - Plasma cell leukemia 2 - Extramedullary plasmacytoma 3 - Solitary plasmacytoma C90. 0 - Not having achieved remission 1 - In remission 2 In relapse HEME NEOPLASMS UNCERTAIN D47. Neoplasms of Uncertain Behavior of LYMPHOID, HEMA- TOPOIETIC & RELATED TISSUE 0 - Histiocytic and mast cell tumors of uncertain behavior 1 - Chronic myeloproliferative disease 2 - Monoclonal gammopathy 3 - Essential (hemorrhagic) thrombocythemia 4 - Osteomyelofibrosis MYELOFIBROSIS D75.81 Z - Other specified neoplasms 1- Post-transplant lymphoproliferative disorder (PTLD) 9 - Other specified neoplasms For MYELOFIBROSIS, use D75.81 7

GI/PANCREAS 8

MALIGNANT NEOPLASMS OF DIGESTIVE ORGANS ESOPHAGUS 3 - Upper third of esophagus 4 - Middle third of esophagus 5 - Lower third of esophagus 8 - Overlapping sites of esophagus STOMACH 0 - Cardia 1 - Fundus of stomach 2 - Body of stomach 3 - Pyloric antrum 4 - Pylorus 5 - Lesser curvature of stomach, unspecified 6 - Greater curvature of stomach, unspecified 8 - Overlapping sites of stomach SMALL INTESTINE 0 - Duodenum 1 - Jejunum 2 - Ileum 3 - Meckel's diverticulum, malignant 8 - Overlapping sites of small intestine Excludes Carcinoid C15. C16. C17. RECTUM Excludes Carcinoid ANUS & ANAL CANAL 0 - Anus, unspecified 1 - Anal canal 2 -Cloacogenic zone 8 - Overlapping sites of rectum, anus and anal canal LIVER & INTRAHEPATIC BILE DUCTS 0 - Liver cell carcinoma 1 - Intrahepatic bile duct carcinoma 2 - Hepatoblastoma 3 - Angiosarcoma of liver 4 - Other sarcomas of liver 7 - Other specified carcinomas of liver 8 - Malignant neoplasm of liver, primary, unspecified as to type 9 - Malignant neoplasm of liver, not specified as primary or secondary GALL BLADDER C20 C21. C22. Use additional code to identify alcohol abuse / dependence and Hepatitis C or B. C23 COLON 0 - Cecum 1 - Appendix 2 - Ascending colon 3 - Hepatic flexure 4 - Transverse colon 5 - Splenic flexure 6 - Descending colon 7 - Sigmoid colon 8 - Overlapping sites of colon C18. Excludes Carcinoid OTHER & UNSPECIFIED PARTS OF BILIARY 0 - Extrahepatic bile duct 1 - Ampulla of Vater 8 - Overlapping sites of biliary tract 9 - Biliary tract, unspecified C24. RECTOSIGMOID JUNCTION Excludes Carcinoid C19 CARCINOID SYNDROME E34.0 9

MALIGNANT NEOPLASMS OF DIGESTIVE ORGANS (continued) PANCREAS 0 - Head of pancreas 1 - Body of pancreas 2 - Tail of pancreas 3 - Pancreatic duct 4 - Endocrine pancreas (Use additional code to identify any functional activity) 7 - Other parts of pancreas 8 - Overlapping sites of pancreas Use additional code to identify alcohol abuse and dependence OTHER & ILL-DEFINED DIGESTIVE ORGANS 0 - Intestinal tract, part unspecified 1 - Spleen 9 - Ill-defined sites within the digestive system C25. C26. Malignant NEUROENDOCRINE TUMORS 0- Malignant Carcinoid Tumors 0- Unspecified site 1- Small intestine 2- Appendix, large intestine, and rectum 9- Other sites C7A. 0 Duodenum 1- Jejunum 2- Ileum 9 Unspecified 0- Appendix 1- Cecum 2- Ascending colon 3- Transverse colon 0- Bronchus/Lung 1- Thymus 2- Stomach 3- Kidney 4- Descending colon 5- Sigmoid colon 6- Rectum 9- Large intestine, unspecified 4- Foregut NOS 5- Midgut NOS 6- Hindgut NOS 8- Other sites 1 - Malignant poorly differentiated neuroendocrine tumors 8 - Other malignant neuroendocrine tumors SECONDARY NEUROENDOCRINE TUMORS 0 - Secondary carcinoid tumors 1- Secondary Merkel cell carcinoma 8- Other secondary neuroendocrine tumors 1 - Distant lymph nodes 2 - Liver 3 - Bone 4 - Peritoneum 9 - Other sites C7B. 10

THORACIC, HEAD, & NECK 11

MALIGNANT NEOPLASMS OF HEAD, NECK, LIP, ORAL CAVITY & PHARYNX DOCUMENTING ALCOHOL/TOBACCO USE If applicable, use additional code to identify - alcohol abuse and dependence - Exposure to environmental tobacco smoke - Exposure to tobacco smoke in perinatal period - History of tobacco - Occupational exposure to environmental tobacco smoke - Tobacco dependence - Tobacco use LIP 0 - External upper lip 1 - External lower lip 2 - External lip, unspecified 3 - Upper lip, inner aspect 4 - Lower lip, inner aspect 5 - Lip, unspecified, inner aspect 6 - Commissure of lip, unspecified 8 - Overlapping sites of lip BASE OF TONGUE * Document alcohol/tobacco use * Document alcohol/ tobacco use OTHER & UNSPECIFIED PARTS OF TONGUE 0 - Dorsal surface 1 - Border 2 - Ventral surface 3 - Anterior two-thirds of tongue, part unspecified 4 - Lingual tonsil 8 - Overlapping sites of tongue * Document alcohol/tobacco use GUM 0 - Upper gum 1 - Lower gum * Document alcohol/tobacco use FLOOR OF MOUTH 0 - Anterior 1 - Lateral 8 - Overlapping sites * Document alcohol/ tobacco use C00. C01 C02. C03. C04. PALATE 0 - Hard palate 1 - Soft palate 2 - Uvula 8 - Overlapping sites PAROTID GLAND * Document alcohol/tobacco use C05. * Document alcohol/tobacco use OTHER & UNSPECIFIED MAJOR SALIVARY GLANDS 0 - Submandibular gland 1 - Sublingual gland TONSIL 0 - Fossa 1 - Pillar (anterior & posterior) 8 - Overlapping sites OROPHARYNX 0 - Vallecula 1 - Anterior surface of epiglottis 2 - Lateral wall of oropharynx 3 - Posterior wall of oropharynx 4 - Branchial cleft 8 - Overlapping sites C07 C08. * Document alcohol/tobacco use C09. * Document alcohol/tobacco use C10. * Document alcohol/tobacco use 12

MALIGNANT NEOPLASMS OF LUNG - RESPIRATORY & INTRATHORACIC ORGANS DOCUMENTING ALCOHOL/TOBACCO USE If applicable, use additional code to identify - alcohol abuse and dependence - Exposure to environmental tobacco smoke - Exposure to tobacco smoke in perinatal period - History of tobacco - Occupational exposure to environmental tobacco smoke - Tobacco dependence - Tobacco use NASOPHARYNX 0 - Superior wall 1 - Posterior wall 2 - Lateral wall 3 - Anterior wall 8 - Overlapping sites C11. * Document tobacco use LARYNX 0 - Glottis 1 - Supraglottis 2 - Subglottis 3 - Laryngeal cartilage 8 - Overlapping sites C32. * Document alcohol/tobacco use PYRIFORM SINUS * Document tobacco use C12 TRACHEA * Document alcohol/tobacco use C33 HYPOPHARYNX 0 - Postcricoid region 1 - Aryepiglottic fold, hypopharyngeal aspect 2 - Posterior wall 8 - Overlapping sites NASAL CAVITY & MIDDLE EAR 0 - Nasal cavity 1 - Middle ear C13. * Document tobacco use C30. BRONCHUS & LUNG 0 - Main bronchus 1 Upper lobe, bronchus or lung 3 Lower lobe, bronchus or lung 8 - Overlapping sites of bronchus & lung 9 Unspecified part of bronchus or lung 2 - Middle lobe, bronchus or lung Excludes Carcinoid & Kaposi s * Document tobacco use THYMUS C34. 1 - Right 2 - Left C37 ACCESSORY SINUSES 0 - Maxillary sinus 1 - Ethmoidal sinus 2 - Frontal sinus 3 - Sphenoid sinus 8 - Overlapping sites C31. HEART, MEDIASTINUM & PLEURA 0 - Heart 1 - Anterior mediastinum 2 - Posterior mediastinum 3 - Mediastinum, part unspecified 4 - Pleura 8 - Overlapping sites of heart, mediastinum and pleura C38. 13

WOMEN S CENTER 14

MALIGNANT NEOPLASMS OF THE BREAST BREAST (INCLUDES PAGET S DISEASE) 0 - Nipple and areola 1 - Central portion 2 - Upper-inner quadrant 3 - Lower-inner quadrant 4 - Upper-outer quadrant 5 - Lower-outer quadrant 6 - Axillary tail 8 - Overlapping sites site 1 - Female 2 - Male C50. Use additional code to identify estrogen receptor status 1 - Right 2 - Left ESTROGEN RECEPTOR STATUS 0 - Positive status [ER+] 1 - Negative status [ER-] Cancer In Situ of BREAST 0 - Lobular carcinoma (LCIS) 1 - Intraductal carcinoma (DCIS) 8 - Other specified type of carcinoma type of carcinoma Z17. D05. 1- Unspecified 2 - Right 3 - Left MALIGNANT NEOPLASMS OF FEMALE GENITAL ORGANS VULVA 0 - Labium majus 1 - Labium minus 2 - Clitoris 8 - Overlapping sites VAGINA UTERUS, PART UNSPECIFIED OVARY 1 - Right ovary 2 - Left ovary ovary CORPUS UTERI 0 - Isthmus uteri 1 - Endometrium 2 - Myometrium 3 - Fundus uteri 8 - Overlapping sites C51. C52 C55 C56. C54. CERVIX UTERI 0 - Endocervix 1 - Exocervix 8 - Overlapping sites Carcinoma In Situ CERVIX UTERI (CIN III) 0 - Endocervix 1 - Exocervix 7 - Other parts of cervix Dysplasia of CERVIX UTERI 0 - Mild (CIN I) 1 - Moderate (CIN II) OTHER & UNSPECIFIED FEMALE GENITAL ORGANS 0 - Fallopian tube 1 - Broad ligament 2 - Round ligament 1- Unspecified 2 - Right 3 - Left 3 - Parametrium 4 - Uterine adnexa, unspecified 7 -Other specified female genital organs 8 -Overlapping sites of female genital organs C53. D06. C56. N87. 15

GU/PROSTATE 16

MALIGNANT NEOPLASMS OF URINARY TRACT KIDNEY, EXCEPT RENAL PELVIS 1 - Right kidney 2 - Left kidney RENAL PELVIS C64. C65. BLADDER 0 - Trigone 1 - Dome 2 - Lateral wall 3 - Anterior wall 4 - Posterior wall 5 - Bladder neck 6 - Ureteric orifice 7 - Urachus 8 - Overlapping C67. 1 - Right renal pelvis 2 - Left renal pelvis URETER 1 - Right ureter 2 - Left ureter C66. Other & UNSPECIFIED URINARY ORGANS 0 - Urethra 1 - Paraurethral glands 8 - Overlapping sites C68. MALIGNANT NEOPLASMS OF MALE GENITAL ORGANS PENIS 0 - Prepuce 1 - Glans 2 - Body 8 - Overlapping C60. OTHER & UNSPECIFIED MALE GENITAL ORGANS 0 - Epididymis 1 - Spermatic cord 1 - Right 2 - Left C63. PROSTATE C61 2 - Scrotum 7 -Other specified 8 - Overlapping sites TESTIS C62. 0 - Undescended 1 - Descended 1 - Right 2 - Left 17

SARCOMA AND ORTHOPEDICS 18

MALIGNANT NEOPLASMS OF MESOTHELIOMA & SOFT TISSUE MESOTHELIOMA 0 - Pleura 1 - Peritoneum 2 - Pericardium 7 - Other sites C45. KAPOSIS SARCOMA 0 - Skin 1- Soft tissue 2 - Palate 3 - Lymph nodes 4 - Gastrointestinal sites 7 - Other 5 - Lung Code first any HIV disease 1 - Right 2 - Left C46. MALIGNANT NEOPLASMS OF PERIPHERAL NERVES & AUTONOMIC NERVOUS SYSTEM PERIPHERAL NERVES 0 - Head, face & neck 3 - Thorax 4 - Abdomen 5 - Pelvis 6 - Trunk, unspecified 8 - Overlapping sites 1 - Upper limb, including shoulder 2 - Lower limb, including hip RETROPERITONEUM & PERITONEUM 1 - Right 2 - Left C47. 0 - Retroperitoneum 1 - Specified parts of peritoneum 2 - Unspecified peritoneum 8 - Overlapping sites of retroperitoneum & peritoneum C48. Other CONNECTIVE & SOFT TISSUE 0 - Head, face & neck 3 - Thorax 4 - Abdomen 5 - Pelvis 6 - Trunk, unspecified 8 - Overlapping sites 1 - Upper limb, including shoulder 2 - Lower limb, including hip 1 - Right 2 - Left C49. 19

MALIGNANT NEOPLASMS OF BONE & ARTICULAR CARTILAGE BONE & CARTILAGE OF LIMBS 0 - Scapula & long bones of upper limb 1- Short bones of upper limb 2 - Long bones of lower limb 3 - Short bones of lower limb 8 - Overlapping Use additional code to identify major osseous defect, if applicable (M89.7) C40. 1 - Right 2 - Left BONE & ARTICULAR CARTILAGE OF OTHER & UNSPECIFIED SITES 0 - Bones of skull and face 1 - Mandible 2 - Vertebral column 3 - Ribs, sternum and clavicle 4 - Pelvic bones, sacrum and coccyx C41. 20

MELANOMA/SKIN 21

MELANOMA & OTHER MALIGNANT NEOPLASM OF SKIN Malignant Melanoma of SKIN 1- Eyelid including canthus 2 - Ear and external auricular canal 6 - Upper limb, including shoulder 7 - Lower limb, including hip 3 - Other and unspecified parts of face 5 - Trunk 0 - Lip 4 - Scalp & neck 8 - Overlapping sites of skin MERKEL CELL CARCINOMA 1- Eyelid including canthus 2 - Ear and external auricular canal 6 -Upper limb, including shoulder 7 -Lower limb, including hip 3 - Other and unspecified parts of face C43. 1 - Right 2 - Left 1 - Nose 9 Other parts of face 1 - Anal skin 2 - Skin of breast 9 Other part of trunk C4A. 1 - Right 2 - Left 1 - Nose 9 Other parts of face Other & Unspecified Malignant Neoplasm of SKIN 0 - Lip 4 - Skin of scalp & neck 8 - Overlapping sites of skin 1- Eyelid including canthus 6 - Upper limb, Including shoulder 7 - Lower limb, including hip 2 - Ear and external auricular canal 3 - Other and unspecified parts of face 1 - Basal cell carcinoma 2 - Squamous cell carcinoma 9 Other 1 - Basal cell carcinoma 2 - Squamous cell carcinoma 9 Other 1 - Basal cell carcinoma 2 - Squamous cell carcinoma 9 Other C44. 1 - Basal cell carcinoma 2 - Squamous cell carcinoma 9 Other specified 1 - Unspecified 2 - Right 9 - Left 1 - Unspecified 2 - Right 9 - Left 1 - Unspecified 1 - Nose 9 - Other parts of face 5 - Trunk 0 - Lip 4- Scalp & neck 8 - Overlapping sites of skin 1 - Anal skin 2 - Skin of breast 9 Other part of trunk 5 - Trunk 1 - Basal cell carcinoma 2 - Squamous cell carcinoma 9 Other 0 - Anal skin 1 - Skin of breast 9 - Other part of trunk SECONDARY NEUROENDOCRINE TUMORS 0 - Secondary carcinoid tumors 1- Secondary Merkel cell carcinoma 8- Other secondary neuroendocrine tumors 1 - Distant lymph nodes 2 - Liver 3 - Bone 4 - Peritoneum 9 - Other sites C7B. 22

NEURO-ONCOLOGY 23

MALIGNANT NEOPLASMS OF EYE, BRAIN & OTHER PARTS OF CENTRAL NERVOUS SYSTEM EYE & ADNEXA 0 - Conjuntiva 1 - Cornea 2 - Retina 3 - Choroid 4 - Ciliary body 5 - Lacrimal gland and duct 6 - Orbit 8 - Overlapping sites of eye and adnexa site of eye C69. 1 - Right 2 - Left BRAIN 0 - Cerebrum, except lobes and ventricles 1- Frontal lobe 2 - Temporal lobe 3 - Parietal lobe 4 - Occipital lobe 5 - Cerebral ventricle 6 - Cerebellum 7 - Brain stem 8 - Overlapping sites of brain C71. MENINGES 0 - Cerebral meninges 1 - Spinal meninges C70. SPINAL CORD, CRANIAL NERVES & OTHER PARTS OF CENTRAL NERVOUS SYSTEM 0 - Spinal cord 1 - Cauda equina C72. 2 - Olfactory nerve 3 - Optic nerve 4 - Acoustic nerve 5 - Other and unspecified cranial nerves 1 - Right 2 - Left 9 - Other 24

ENDOCRINE 25

MALIGNANT NEOPLASMS OF THYROID & OTHER ENDOCRINE GLANDS THYROID GLAND ADRENAL GLAND 0 - Cortex 1- Medulla 9 -Unspecified 1 - Right 2 - Left C74. C73 OTHER ENDOCRINE GLANDS & RELATED STRUCTURES 0 - Parathyroid gland 1- Pituitary gland 2 - Craniopharyngeal duct 3 - Pineal gland 4 - Carotid body 5 - Aortic body and other paraganglia 8 - Pluriglandular involvement, unspecified 9 - Endocrine gland, unspecified C75. 26

METASTATIC SECONDARY SITES 27

SECONDARY MALIGNANCIES Secondary & Unspecified Malignant Neoplasm of LYMPH NODES 0 - Head, face, & neck 1- Intrathoracic 2 - Intra-abdominal 3 - Axilla and upper limb 4 - Inguinal and lower limb 5 - Intrapelvic 8 - Lymph nodes of multiple regions Secondary RESPIRATORY & DIGESTIVE ORGANS 0 - Lung 1- Mediastinum 2 - Pluera 4 - Small intestine 5 - Large Intestine & rectum 6 - Retroperitoneum and peritoneum 7 -Liver and intrahepatic bile duct 3 - Other/unspecified respiratory organs 8 - Other/unspecified digestive organs C77. C78. 1 - Right 2 - Left 9 - Other Secondary OTHER & UNSPECIFIED SITES 0 - Kidney & Renal Pelvis 6 - Ovary 7 - Adrenal gland 1- Bladder and other and unspecified urinary organs 2 - Skin 3 Brain and cerebral meninges 4 Other & unspecified parts of nervous system SECONDARY NEUROENDOCRINE TUMORS 0 - Secondary carcinoid tumors 1- Secondary Merkel cell carcinoma 8- Other secondary neuroendocrine tumors 1 - Right 2 - Left urinary organs 1 - Bladder 9 - Other urinary organs 9 - Other 5 Bone and bone marrow 1 - Bone 2 -Bone marrow 8 Other specified sites 1 - Breast 2 - Genital organs 9 - Other 1 - Distant lymph nodes 2 - Liver 3 - Bone 4 - Peritoneum 9 - Other sites C79. 1 Brain 2 Cerebral meninges C7B. 28

UNSPECIFIED NEOPLASM OTHER & ILL-DEFINED SITES 0 - Head, face & neck 1- Thorax 2 - Abdomen 3 - Pelvis 8 -Other specified ill-defined sites 4 - Upper limb 5- Lower limb C76. 1 - Right 2 - Left Neoplasm of UNSPECIFIED BEHAVIOR D49. 0 - Digestive system 1 - Respiratory system 2 - Bone, soft tissue and skin 3 - Breast 4 - Bladder 5 - Genitourinary organs 6 - Brain 7 - Endocrine glands and other parts of nervous system site Neoplasm of Uncertain Behavior of OTHER & UNSPECIFIED SITES 0 - Bone and articular cartilage 1 - Connective and other soft tissue 2 - Peripheral nerves and autonomic nervous system 3 - Retroperitoneum 4 - Peritoneum 5 - Skin 7 - Other specified sites D48. 8 - Other specified sites 1 - Retina and choroid 9 - Other specified sites Malignant neoplasm W/O SPECIFICATION OF SITE 0 - Disseminated malignant neoplasm, unspecified 1 - Malignant (primary) neoplasm, unspecified 2 - Malignant neoplasm associated with transplanted organ C80. 6 - Breast 1 - Right 2 - Left MALIGNANT NEUROENDOCRINE TUMORS Malignant NEUROENDOCRINE TUMORS 0- Unspecified site C7A. 0- Malignant Carcinoid Tumors 1- Small intestine 2- Appendix, large intestine, and rectum 0 Duodenum 1- Jejunum 2- Ileum 9 Unspecified 0- Appendix 1- Cecum 2- Ascending colon 3- Transverse colon 4- Descending colon 5- Sigmoid colon 6- Rectum 9- Large intestine, unspecified 9- Other sites 0- Bronchus/Lung 1- Thymus 2- Stomach 3- Kidney 4- Foregut NOS 5- Midgut NOS 6- Hindgut NOS 8- Other sites 1 - Malignant poorly differentiated neuroendocrine tumors 8 - Other malignant neuroendocrine tumors 29

HEMATOLOGY 30

MYELOPROLIF/MGUS Neoplasms of Uncertain Behavior of LYMPHOID, HEMA- TOPOIETIC & RELATED TISSUE 0 - Histiocytic and mast cell tumors of uncertain behavior 1 - Chronic myeloproliferative disease 2 - Monoclonal gammopathy 3 - Essential (hemorrhagic) thrombocythemia 4 - Osteomyelofibrosis Z - Other specified neoplasms For MYELOFIBROSIS, use D75.81 D47. 1- Post-transplant lymphoproliferative disorder (PTLD) 9 - Other specified neoplasms POLYCYTHEMIA VERA MONOCLONAL GAMMOPATHY ESSENTIAL (HEMORRHAGIC) THROMBOCYTHEMIA D45 D47.2 D47.3 Other & Unspecified Diseases of BLOOD & BLOOD- FORMING ORGANS (MYELOFIBROSIS) 0 - Familial erythrocytosis 1 - Secondary polycythemia D75. MYELOFIBROSIS D75.81 8 - Other specified diseases of blood and bloodforming organs 1- MYELOFIBROSIS (Code first underlying disorder such as neoplasm. If applicable, code for associated therapy-related MDS and for adverse effects to identify drug) 2 - Heparin induced thrombocytopenia (HIT) 9 - Other specified diseases of blood and blood-forming organs NUTRITIONAL ANEMIAS Anemia, IRON DEFICIENCY D50. 0 - Secondary to blood loss (chronic) 1 - Sideropenic dysphagia 8 - Other iron deficiency anemias Anemia, VITAMIN B12 DEFICIENCY 0 - Intrinsic factor deficiency 1 - Selective vitamin B12 malabsorption with proteinuria 2 - Transcobalamin II deficiency 3 - Other dietary Vitamin B12 deficiency 8 - Other D51. Anemia, FOLATE DEFICIENCY 0 Dietary 1 - Drug-induced (Use additional code for adverse effects, if applicable, to identify drug) 8 - Other Anemias, OTHER NUTRITIONAL 0 - Protein deficiency anemia 1 - Other megaloblastic anemias, not elsewhere classified 2 - Scorbutic anemia 8 - Other D52. D53. 31

HEMOLYTIC ANEMIAS Anemia due to ENZYME DISORDERS D55. 0 - Due to glucose-6-phosphate dehydrogenase [G6PD] deficiency 1 - Other disorders of glutathione metabolism 2 - Disorders of glycolytic enzymes 3 - Disorders of nucleotide metabolism 8 - Other anemias Other Hemolytic Anemias HEREDITARY 0 - Hereditary spherocytosis 1 - Hereditary elliptocytosis 2 - Other hemoglobinopathies 8 - Other specified D58. Hemolytic Anemia, ACQUIRED D59. 0 -Drug-induced autoimmune (Use additional code for adverse effects, if applicable, to identify drug) 1 - Other autoimmune 2 - Drug-induced non-autoimmune (Use additional code for adverse effects, if applicable, to identify drug) 3 - Hemolytic-uremic syndrome (Use additional code to identify associated: E. coli, Pneumoncoccal pneumonia, or Shigella dysenteriae) 4 - Other non-autoimmune 5 - Paroxysmal nocturnal hemoglobinuria (Marchiafava-Micheli) 6 - Hemoglobinuria due to hemolysis from other external causes 8 - Other acquired hemolytic anemias THALASSEMIA THALASSEMIA D56. 0 Alpha 1 - Beta 2 - Delta-beta 3 - Minor 4 - HPFH (Hereditary persistence of fetal hemoglobin) 5 - Hemoglobin E-beta 8 - Other SICKLE CELL SICKLE CELL DISORDERS D57. 0 - Hb-SS with crisis 1 - Acute chest syndrome 2 - Splenic sequestration 1 - Sickle cell without crisis 3 - Sickle-cell trait 2 - Hb-C disease 4 - Thalassemia 8 - Other Sickle-Cell 0 - Without crisis 1 - With crisis Use additional code for any associated fever 1 - Acute chest syndrome 2 - Splenic sequestration 32

IRON IRON OVERLOAD & OTHERS 0 - Disorder of Iron Metabolism, unspecified E83.1 1 - Hemochromatosis 0 - Hereditary 1 - Due to repeated red blood cell transfusions 8 - Other APLASTIC ANEMIA & BONE MARROW FAILURE ACQUIRED PURE RED D60. CELL APLASIA (ERYTHROBLAENIA) 0 Chronic 1 - Transient 8 - Other ACUTE POST- HEMORRHAGIC ANEMIA D62 Other Aplastic Anemias & Other BONE MARROW FAILURE SYNDROMES 0 Constitutional aplastic anemia 8 - Other specified aplastic anemias & other bone marrow failure syndromes 1 - Constitutional (pure) red blood cell aplasia 9 - Other constitutional aplastic anemia 1- Pancytopenia 2 - Myelophthisis 9- Other specified aplastic anemias & other bone marrow failure syndrome D61. 0 - Antineoplastic chemotherapy induced pancytopenia 1 - Other drug-induced pancytopenia 8 - Other pancytopenia 1 - Drug-induced aplastic anemia (If applicable, use additional code for adverse effects to identify drug) 2 - Aplastic anemia due to other external agents (If applicable, code first toxic effects of substance chiefly non-medicinal as to source (T51-T65) 3 - Idiopathic aplastic anemia 33

SECONDARY & OTHER ANEMIAS OTHER ANEMIAS Anemia in CHRONIC DISEASES CLASSIFIED ELSEWHERE 0 - Anemia in neoplastic disease (Code first neoplasm) 1 - Anemia in chronic kidney disease (Code first underlying CKD) 8 - Anemia in other chronic diseases classified elsewhere (Code first underlying disease such as: - Hypothyroidism - Tuberculosis) D63. 0 - Hereditary sideroblastic anemia 1 - Secondary sideroblastic anemia due to disease 2 - Secondary sideroblastic anemia due to drugs and toxins 3 - Other sideroblastic anemias 4 - Congenital dyserythropoietic anemia 8 Other specified anemias D64. 1- Anemia due to anti-neoplastic chemotherapy 9 -Other specified anemias HEMORRHAGIC CONDITIONS DISSEMINATED D65 INTRAVASCULAR COAGULATION HEREDITARY FACTOR IX DEFICIENCY D67 HEREDITARY FACTOR VIII DEFICIENCY D66 HEREDITARY HEMORRHAGIC TELANGIECTASIA I78.0 IMMUNE THROMBOCYTOPENIC & PLATELET OTHER PURPURA & OTHER HEMORRHAGIC CONDITION D69. HEPARIN INDUCED THROMBOCYTOPENIA D75.82 0 - Allergic purpura 1 - Qualitative platelet defects 2 - Other non-thrombocytopenic purpura 3 - Immune thrombocytopenic purpura 6 - Thrombocytopenia, unspecified 8 - Other specified hemorrhagic conditions 4 - Other primary thrombocytopenia 5 - Secondary thrombocytopenia 1 - Evans syndrome 2 - Congenital and hereditary thrombocytopenia purpura 9 - Other primary thrombocytopenia 1 - Post-transfusion purpura 9 - Other secondary thrombocytopenia 34

THROMBOTIC CONDITIONS ACUTE EMBOLISM & THROMBOSIS OF DEEP VEINS OF LOWER EXTREMITY deep veins/ lower extremity 1 - Femoral vein 2 - Iliac vein 3 - Popliteal vein 4 - Tibial vein 9 - Other specified Y - Proximal lower extremity Z - Distal lower extremity POSTTHROMBOTIC SYNDROME 0 - Without complications 1 - With ulcer 2 - With inflammation 3 - With ulcer & inflammation 9 - With other complications 1 - Right 2 - Left 3 - Bilateral NONPYOGENIC THROMBOSIS OF INTRACRANIAL VENOUS SYSTEM I82.4 I87.0 1 - Right lower extremity 2 - Left lower extremity 3 - Bilateral lower extremity lower extremity PULMONARY EMBOLISM W/O ACUTE COR PULMONALE 0 - Septic pulmonary embolism 2 - Saddle embolus of pulmonary artery 9 - Other HEPARIN INDUCED THROMBOCYTOPENIA I26.9 I67.6 D75.82 HEPATIC THROMBOSIS I81: PORTAL VEIN THROMBOSIS I82.0: BUDD-CHIARI SYNDROME Other COAGULATION DEFECTS 0 - Von Willebrand's disease 1- Hereditary factor XI deficiency 2 -Hereditary deficiency of other clotting factors 4 - Acquired coagulation factor deficiency 8 - Other specified coagulation defects Hemorrhagic Disorders due to CIRCULATING ANTI-COAGULANTS 3 - Hemorrhagic disorder due to circulating anticoagulants 1- Hemorrhagic disorder due to intrinsic circulating anticoagulants, antibodies, or inhibitors 2 - Hemorrhagic disorder due to extrinsic circulating anticoagulants Other Coagulation Defects, THROMBOPHILIA 5 - Primary thrombophilia 6 - Other thrombophilia D68. D68. 1 - Acquired hemophilia 2 - Antiphospholipid antibody with hemorrhagic disorder 8 - Other Hemorrhagic disorder due to intrinsic circulating anticoagulants, antibodies, or inhibitors D68. 1- Activated protein C resistance 2 - Prothrombin gene mutation 9 - Other primary thrombophilia 1- Antiphospholipid syndrome 2 - Lupus anticoagulant syndrome 9 - Other thrombophilia 35

NEUTROPENIA & OTHER WBC DISORDERS NEUTROPENIA 0 Congenital agranulocytosis 1 - Agranulocytosis secondary to cancer chemotherapy (Code also underlying neoplasm. Use additional code for adverse effect, if applicable, to identify drug.) 2 - Other drug-induced agranulocytosis (Use additional code for adverse effect, if applicable, to identify drug) 3 - Neutropenia due to infection 4 - Cyclic neutropenia 8 - Other Use additional code for any associated fever & mucositis Functional Disorders of POLYMORPHONUCLEAR NEUTROPHILS D70. D71 Other Disorders of WHITE BLOOD CELLS 0 - Genetic anomalies of leukocytes 1 - Eosinophilia 8 - Other specified disorders of white blood cells 1 - Decreased white blood cell count 2 - Elevated white blood cell count 9 - Other specified disorders D72. 0 - Lymphocytopenia 8 - Other 9 - unspecified 0 - Lymphocytosis (symptomatic) 1 - Monocytosis (symptomatic) 2 - Plasmacytosis 3 - Leukemoid reaction 4 - Basophilia 5 - Bandemia 8 - Other MYELOFIBROSIS, HLH, HIT, 2 POLYCYTHEMIA Other & Unspecified Diseases of BLOOD & BLOOD- FORMING ORGANS (MYELOFIBROSIS) 0 - Familial erythrocytosis 1 - Secondary polycythemia 8 - Other specified diseases of blood and bloodforming organs D75. 1- MYELOFIBROSIS (Code first underlying disorder such as neoplasm. If applicable, code for associated therapy-related MDS and for adverse effects to identify drug) 2 - Heparin induced thrombocytopenia (HIT) 9 - Other specified diseases of blood and blood-forming organs Other Specified Diseases W/Participation of D76. LYMPHORETICULAR & RETICULOHISTIOCYTIC TISSUE 1 - Hemophagocytic lymphohistiocytosis 2 - Hemophagocytic syndrome, infection-associated (Use additional code to identify infectious agent or disease) 3 - Other histiocytosis syndromes 36

COMBINED IMMUNODEFICIENCIES COMBINED IMMUNODEFICIENCIES 8 - Other combined immunodeficiencies 1 - Biotindependent carboxylase deficiency 9 - Other combined immunodeficiencies D81. 0 - Severe combined immunodeficiency [SCID] with reticular dysgenesis 1 - SCID with low T- and B-cell numbers 2 - SCID with low or normal B-cell numbers 3 - Adenosine deaminase [ADA] deficiency 4 - Nezelof's syndrome 5 - Purine nucleoside phosphorylase [PNP] deficiency 6 - Major histocompatibility complex class I deficiency 7 - Major histocompatibility complex class II deficiency 0 - Biotinidase deficiency 8 - Other biotindependent carboxylase Deficiency Immunodeficiency associated with OTHER MAJOR DEFECTS 0 - Wiskott-Aldrich syndrome 1 - Di George's syndrome 2 -Immunodeficiency with short-limbed stature 3 -Immunodeficiency following hereditary defective response to Epstein-Barr virus 4 -Hyperimmunoglobulin E [IgE] syndrome 8 - Other specified major defects COMMON VARIABLE IMMUNODEFICIENCY 0 - With predominant abnormalities of B-cell numbers and function 1 - With predominant immunoregulatory T-cell disorders 2 -With autoantibodies to B- or T-cells 8 - Other common variable immunodeficiency 9 -Unspecified D82. D83. SARCOIDOSIS SARCOIDOSIS 0 - Lung 1 - Lymph nodes 2 - Lung with sarcoidosis of lymph nodes 3 - Skin 9 -Unspecified D86. 8 - Other sites 1 - Sarcoid meningitis 2 - Multiple cranial nerve palsies in sarcoidosis 3 - Iridocyclitis 4 - pyelonephritis 5 - myocarditis 6 - arthropathy 7 - myositis 9 - Other sites 37

GVHD & CRYOGLOBULINEMIA Other Disorders Involving the IMMUNE MECHANISM, NOT ELSEWHERE CLASSIFIED 0 - Polyclonal hypergammaglobulinemia 1 - Cryoglobulinemia 2 - Hypergammaglobulinemia, unspecified 3 - Immune reconstitution syndrome 8 - Other specified disorders involving the immune mechanism, not elsewhere classified 1 - Graftversushost disease D89. 2 - Autoimmune lymphoproliferative syndrome [ALPS] 9 - Other specified disorders 0 - Acute 1 - Chronic 2 -Acute on chronic graftversus-host disease 3 - Unspecified GRAFT-VERSUS-HOST DISEASE 0 - Acute 1 - Chronic 2 - Acute on chronic 3 - Unspecified 1 - Right lacrimal gland 2 Left lacrimal gland 3 - Bilateral lacrimal glands lacrimal gland HEREDITARY HEMORRHAGIC TELANGIECTASIA D89.81 DRY EYE SYNDROME HO4.12 I78.0 PORPHYRIA Disorders of PORPHYRIN & BILIRUBIN METABOLISM 0 - Hereditary erythropoietic porphyria 1 - Porphyria cutanea tarda E80. 2 - Other and unspecified porphyria 1 - Acute intermittent (hepatic) 9 - Other 38

Actor Ix, 34 Acute Chest Syndrome, 32 Acute Panmyelosis With Myelofibrosis, 5 ADA Deficiency, 37 Adenosine Deaminase [ADA] Deficiency, 37 Adrenal Gland, 26 Agranulocytosis, 36 AKL, 7 Alcohol, 12, 13 Alps, 38 AML, 5 Ampulla Of Vater, 9 Anaplastic Large Cell, 7 Anemia, 31, 32, 34 Aplastic, 33 Congenital Dyserythropoietic, 34 Drug Induced, 32 Due To Anti Neoplastic Chemotherapy, 34 Hemolytic, 32 Hemorrhagic, 33 Hereditary Sideroblastic, 34 In Chronic Kidney Disease, 34 In Neoplastic Disease, 34 Megaloblastic, 31 Protein Deficiency Anemia, 31 Refractory, 5 Scorbutic, 31 ANEMIA Due To ENZYME DISORDERS, 32 Angiommunoblastic T Cell Lymphoma, 7 Angiosarcoma Of Liver, 9 Anticoagulants, 35 Antineoplastic, 33 Antiphospholipid Antibody, 35 Anus & Anal Canal, 9 Aortic Body And Other Paraganglia, 26 Aplastic Anemia, 33 Drug Induced, 33 Idiopathic, 33 Appendix, 9, 10, 29 Arthropathy, 37 Articular Cartilage, 20 Aryepiglottic Fold, 13 Autoimmune Lymphoproliferative Syndrome [ALPS], 38 Axillary Tail, 15 Bandemia, 36 Basal Cell Carcinoma, 22 Basophilia, 36 B Cell Lymphoma, 6 Biliary, 9 Biotin Dependent Carboxylase, 37 Biotinidase Deficiency, 37 Bladder, 9, 17 Blastic NK Cell Lymphoma, 7 Bone, 20 Bone Marrow, 33 Failure, 33 A B Brain, 24 Stem, 24 Branchial Cleft, 12 Breast, 15 Broad Ligament, 15 Bronchus/Lung, 10, 13, 29 Budd Chiari Syndrome, 35 Burkitt Lymphoma, 6 Canthus, 22 Carcinoid Syndrome, 9 Carcinoid Tumors, 10, 29 Secondary, 10, 22, 28 Carcinoma Basal Cell, 22 In Situ of Cervix, 15 Intraductal, 15 Intrahepatic Bile Duct, 9 Liver Cell, 9 Lobular, 15 Merkel Cell, 22 Squamous Cell, 22 Carotid Body, 26 Cartilage, 20 Cauda Equina, 24 Cecum, 9, 10, 29 Cerebellum, 24 Cerebral Ventricle, 24 Cerebrum, 24 Cervix Uteri, 15 Carcinoma In Situ (CIN III), 15 Chemo Induced Pancytopenia:, 33 Chronic Kidney Disease, 34 CIN I,II, III, 15 Circulating Anti Coagulants, 35 CKD, 34 Clitoris, 15 Cloacogenic Zone, 9 Coagulation, 34, 35 Colon, 9 Common Variable Immunodeficiency, 37 Congenital Agranulocytosis, 36 Congenital Dyserythropoietic Anemia, 34 Corpus Uteri, 15 Cortex, 26 Cranial Nerves, 24 Craniopharyngeal Duct, 26 Cryoglobulinemia, 38 Cutaneous T Cell, 7 Cyclic Neutropenia, 36 Cytopenia Refractory, 5 DCIS, 15 Di George's Syndrome, 37 Digestive Organs, 9, 10, 28 Drug Induced Aplastic Anemia, 33 Dry Eye Syndrome, 38 C D 39

E. Coli, 32 Ear And External Auricular Canal, 22 Elliptocytosis, 32 Embolism, 35 Endocervix, 15 Endocrine, 25, 26 Endometrium, 15 Enteropathy, 7 Enzyme Disorders, 32 Eosinophilia, 36 Epididymis, 17 Epiglottis, 12 Epstein Barr Virus, 37 Erythroblastopenia, 33 Erythrocytosis, 31, 36 Esophagus, 9 Estrogen Receptor Status, 15 Evans Syndrome, 34 Exocervix, 15 Extrahepatic Bile Duct, 9 Extrinsic Circulating, 35 Eye & Adnexa, 24 Eye, Brain & Other Parts Of Central Nervous System, 24 Eyelid, 22 Face, 20 Factor Viii Deficiency, 34 Factor XI, 35 Fallopian Tube, 15 Familial Erythrocytosis, 31, 36 Female Genital Organs, 15 Fetal Hemoglobin, 32 Floor Of Mouth, 12 Folate Deficiency, 31 Fossa, 12 Fundus Uteri, 15 G6pd, 32 Gall Bladder, 9 Gammopathy, 7, 31 Genetic Anomalies Of Leukocytes, 36 Glottis, 13 Glutathione Metabolism, 32 Glycolytic Enzymes, 32 Graft Versus Host Disease, 38 Gum, 12 GVHD, 38 Hb C Disease, 32 Heart, 13 Heavy Chain Disease, 6 Hematology, 30 Hemochromatosis, 33 Hemoglobin E Beta, 32 Hemoglobinopathies, 32 E F G H Hemoglobinuria, 32 Hemolytic Anemias, 32 Hemolytic Uremic Syndrome, 32 Hemophagocytic Lymphohistiocytosis, 36 Hemophagocytic Syndrome, Infection Associated, 36 Hemophilia, 35 Hemorrhagic, 31, 33, 34, 38 Anemia, 33 Conditions, 34 Due To Circulating Anti Coagulants, 35 Hemorrhagic Telangiectasia, 34, 38 Heparin Induced Thrombocytopenia, 31, 34, 35, 36 Hepatic Flexure, 9 Hepatoblastoma, 9 Hepatosplenic, 7 Hereditary Factor IX, 34 Hemorrhagic Telangiectasia, 34, 38 Sideroblastic Anemia, 34 Histiocytic Tumors, 7, 31 Histocompatibility Complex, 37 Hodgkin Lymphoma, 6 HPFH, 32 Hypergammaglobulinemia, 38 Hyperimmunoglobulin E [IgE] Syndrome, 37 Hypopharyngeal Aspect, 13 Hypopharynx, 13 Hypothyroidism, 34 Idiopathic Aplastic Anemia, 33 IgE, 37 Ill Defined Sites, 29 Immune Reconstitution Syndrome, 38 Immune Thrombocytopenic, 34 Immunodeficiency, 37 Immunoproliferative Diseases, 6 In Situ Cancer of Breast, 15 Carcinoma, of Cervix, 15 Intestinal Tract, 10 Intraductal carcinoma, 15 Intrahepatic Bile Duct Carcinoma, 9 Intrathoracic, 13 Intrinsic Factor Deficiency, 31 Iridocyclitis, 37 Iron Deficiency, 31 Iron Overload, 33 Isthmus Uteri, 15 Kaposi's Sarcoma, 19 Kidney, 10, 28, 29 Labium, 15 Lacrimal Gland, 38 Langerhans Cell Histiocytosis, 5 Laryngeal Cartilage, 13 Larynx, 13 I K L 40

LCIS, 15 Leukemia, 5 Acute Erythroid, 5 Acute Lymphoblastic, 5 Acute Megakaryoblastic, 5 Acute Myeloblastic, 5 Acute Myelomonocytic, 5 Acute Promyelocytic, 5 Adult T Cell, 5 ALL, 5 Hairy Cell, 5 Mast Cell, 5 MONOCYTIC, 5 Prolymphocytic, Of B Cell Type, 5 Prolymphocytic, Of T Cell Type, 5 Leukemoid Reaction, 36 Leukocytes Genetic Anomalies Of, 36 Limb, 6, 7, 19, 20, 22, 28, 29 Lip, 12 Liver & Intrahepatic Bile Ducts, 9 Liver Cell Carcinoma, 9 Lobular carcinoma, 15 Lung, 13 Lymphocytopenia, 36 Lymphocytosis, 36 Lymphohistiocytosis Hemophagocytic, 36 Lymphoid, 5, 7, 31 Lymphoma, 6, 7 B Cell, 6 Burkitt, 6 Hodgkin, 6 Non Hodgkin, 6 Lymphoreticular, 36 Myelodysplastic Disease, 5 Myelodysplastic Syndrome (MDS), 5 Myelofibrosis, 7, 31, 36 Myeloid Sarcoma, 5 Myeloma, 7 Myelomonocytic Leukemia, 5 Myelophthisis, 33 Myeloproliferative, 7, 31 Myeloproliferative Disease, 7, 31 Myocarditis, 37 Myometrium, 15 Myositis, 37 Nasal Cavity, 13 Nasopharynx, 13 Neck, 6, 7, 17, 19, 22, 28, 29 Neoplastic Disease, 34 Nerve, 24, 37 Nerve Palsies, 37 Nerves, 19 Neuroendocrine Tumors, 10, 22, 28, 29 Secondary, 10, 22, 28, 29 Neutropenia, 36 Cyclic, 36 Due To Infection, 36 Neutrophils, Polymorphonuclear, 36 Nipple And Areola, 15 NK/T Cell, 7 Non Hodgkin Lymphoma, 6 Nonpyogenic Thrombosis, 35 Nose, 22 Nucleotide Metabolism, 32 Nutritional Anemias, 31 N M Major Salivary Glands, 12 Male Genital Organs, 17 Mandible, 20 Marchiafava Micheli, 32 Mast Cell Tumor, 5, 7, 31 Mast Cell Tumors, 7, 31 Mature B Cell Leukemia Burkitt Type, 5 Mature T/Nk Cell, 7 MDS, 5, 31, 36 Mediastinum & Pleura, 13 Medulla, 26 Megaloblastic Anemias, 31 Meninges, 24 Merkel Cell Carcinoma, 22 Secondary, 10, 22, 28 Mesothelioma, 19 Middle Ear, 13 Monoclonal, 31 Monoclonal Gammopathy, 7, 31 Monocytic Leukemia, 5 Monocytosis, 36 Mucositis, 36 Multiple Cranial Nerve Palsies, 37 Multiple Myeloma, 7 Mycosis Fungoides, 7 Oropharynx, 12 Orthopedics, 19 Osseous Defect, 20 Osteomyelofibrosis, 7, 31 Ovary, 15 Palate, 12 Pancreas, 10 Pancytopenia, 33 Panmyelosis, 5 Panniculitis, 7 Parametrium, 15 Parathyroid Gland, 26 Paraurethral Glands, 17 Parotid Gland, 12 Paroxysmal Nocturnal Hemoglobinuria (Marchiafava Micheli), 32 Pelvic Bones, Sacrum And Coccyx, 20 Penis, 17 Pericardium, 19 Peritoneum, 10, 19, 22, 28, 29 Pillar (Anterior & Posterior), 12 Pineal Gland, 26 Pituitary Gland, 26 O P 41

Plasma Cell Leukemia, 7 Plasmacytoma, 7 Plasmacytosis, 36 Platelet, 34 Pleura, 13, 19 Pluriglandular Involvement, Unspecified, 26 Pneumoncoccal Pneumonia, 32 PNP Deficiency, 37 Poietic & Related Tissue, 5 Polycythemia, 31, 36 2, 36 Secondary, 31, 36 Vera, 31, 36 Polymorphonuclear Neutrophils, 36 Porphyria, 38 Porphyrin, 38 Postcricoid Region, 13 Postthrombotic Syndrome, 35 Post Transplant Lymphoproliferative Disorder, 7, 31 Prostate, 17 Protein Deficiency Anemia, 31 PTLD, 7, 31 Pulmonale, 35 Pulmonary Embolism, 35 Septic, 35 Purine Nucleoside Phosphorylase [PNP] Deficiency, 37 Purpura, 34 Pyelonephritis, 37 Pyriform Sinus, 13 Rectosigmoid Junction, 9 Rectum, 9 Refractory Cytopenia, 5 Renal Pelvis, 17 Respiratory, 13 Reticulohistiocytic Tissue, 36 Retroperitoneum, 19, 28, 29 Ribs, Sternum And Clavicle, 20 Ring Sideroblasts, 5 Round Ligament, 15 Saddle Embolus Pulmonary Artery, 35 Sarcoid Meningitis, 37 Sarcoidosis, 37 Sarcoma, 19 Histiocytic, 5 Of Dendritic Cells (Accessory Cells), 5 Scalp, 22 Scid, 37 Scorbutic Anemia, 31 Scrotum, 17 Secondary Malignancies, 28 Septic Pulmonary Embolism, 35 Severe Combined Immunodeficiency [SCID], 37 Sezary Disease, 7 Shigella Dysenteriae, 32 Sickle Cell, 32 Sideroblasts, 5 Sideropenic Dysphagia, 31 R S Skin, 22 Skull, 20 Small Intestine, 9 Spermatic Cord, 17 Spherocytosis, 32 Spinal Cord, 24 Spleen, 6, 7, 10 Splenic Flexure, 9 Splenic Sequestration, 32 Squamous Cell Carcinoma, 22 Stomach, 10, 29 Subglottis, 13 Sublingual Gland, 12 Submandibular Gland, 12 Supraglottis, 13 T/NK Cell, 7 T Cell Lymphoma, 7 Telangiectasia, 34, 38 Testis, 17 Thrombocytopenia, 34 Heparin Induced, 34, 35 Thrombophilia, 35 Thrombosis, 35 Nonpyogenic, Of Intracranial Venous System, 35 Thymus, 13 Thyroid Gland, 26 Tobacco, 12, 13 Tongue, 12 Tonsil, 12 Topoietic, 7, 31 Trachea, 13 Transcobalamin II Deficiency, 31 Tuberculosis, 34 Undefined SITES, 29 Ureter, 17 Urethra, 17 Urinary Organs, 17 Urinary Tract, 17 Uterine Adnexa, 15 Uterus, 15 Uvula, 12 Vagina, 15 Vallecula, 12 Vertebral Column, 20 Vitamin B12 Deficiency, 31 Von Willebrand's Disease, 35 Vulva, 15 Waldenstrom Macroglobulinemia, 6 WBC Disorders, 36 WHITE BLOOD CELLS, Disorders Of, 36 Wiskott Aldrich Syndrome, 37 T U V W 42

SCCA REFERENCE MANUAL ICD-10 PART 2: COMPLICATIONS AND COMORBIDITIES 1

TABLE OF CONTENTS DRUG-INDUCED PHENOMENON....................... 4 METABOLISM METABOLISM........................................ 6 FLUID & ELECTROLYTES................................ 6 DIABETES MELLITUS.................................. 7 SLEEP DISORDERS.................................... 7 PAIN............................................ 9 GI.............................................. 12 BLOOD.......................................... 14 CONSTITUTIONAL................................. 16 RENAL/GU....................................... 18 LUNG/RESPIRATORY................................ 21 INFECTIOUS DISEASES.............................. 23 PSYCHIATRIC...................................... 26 NEUROLOGY...................................... 28 CARDIOLOGY.................................... 30 MISCELLANEOUS.................................. 32 2

DRUG-INDUCED PHENOMENON 3

DRUG-INDUCED PHENOMENON AGRANULOCYTOSIS SECONDARY TO CANCER CHEMOTHERAPY DRUG INDUCED DM E09.00: W/O NONKETOTIC HYPER- GLYCEMIC-HYPEROSMOLAR COMA (NKHHC) E09.42: W/DIABETIC POLYNEUROPATHY E09.65: W/HYPERGLYCEMIA D70.1 AGRANULOCYTOSIS D70.2 DUE TO NON-CHEMOTHERAPY DRUG ANEMIA DUE TO ANTINEOPLASTIC CHEMOTHERAPY OTHER SECONDARY THROMBOCYTOPENIA D69.59 * Due to drugs, EtOH, alloimmunization; NOT ITP DRUG (OPIATE) INDUCED CONSTIPATION DRUG-INDUCED ADRENOCORTICAL INSUFFICIENCY D64.81 K59.09 E27.3 HYPOTENSION DUE TO DRUGS TOXIC LIVER DISEASE 0 - With cholestasis 2 - With acute hepatitis 1 - With hepatic necrosis OTOTOXIC HEARING LOSS: DRUG INDUCED DRUG-INDUCED CUSHING'S SYNDROME This is for toxic effects due to drug; Does Not include ETOH 0 - Without coma 1 -With coma Other & Unspecified POLYNEUROPATHIES 0 - Drug-induced 1 - Alcoholic 2 - Due to other toxic agents (as used for AIDS) 8 - Other specified 1 -Critical illness 2 - Radiation-induced 9 - Other I95.2 K71. POLYNEUROPATHY IN DISEASES CLASSIFIED ELSEWHERE (Includes myeloma induced neuropathy) ORAL MUCOSITIS, ULCERATIVE 0 -Unspecified 1 - Due to antineoplastic therapy 2 - Due to other drugs 3 - Due to radiation 9 - Other G62. G63 K12.3 H91.09 E24.2 4

METABOLISM 5

METABOLISM Disorders of ADRENAL GLAND 1 - Primary adrenocortical insufficiency 2 - Addisonian crisis 3 - Drug-induced adrenocortical insufficiency OBESITY E27. E66.01: MORBID (SEVERE) OBESITY DUE TO EXCESS CALORIES VIT. D DEFICIENCY E55. 0 - Rickets, active BONE HEALTH: OSTEOPOROSIS W/O CURRENT FRACTURE 0 - Age-Related 8 - Other (includes drug induced/steroids) M81. E66.3: OVERWEIGHT HYPERLIPEDMIA 0 - Pure hypercholesterolemia 1 - Pure hyperglyceridemia 2 - Mixed hyperlipidemia 5 - Unspecified E78. FLUIDS & ELECTROLYTES Disorders of MAGNESIUM & CALCIUM METABOLISM E83.42: HYPO-MAGNESEMIA E83.51: HYPO-CALCEMIA E83.52: HYPER-CALCEMIA Disorders of FLUID, ELECTROLYTE & ACID/BASE BALANCE 0 - Hyperosmolality & Hypernatremia 1 - Hypoosmolality and hyponatremia 2 - Acidosis 3 - Alkalosis 4 - Mixed disorder of acid-base balance 5 - Hyperkalemia 6 - Hypokalemia 8 - Other electrolyte & acid/base disorder E87. 7 - Fluid Overload 1- Transfusion associated circulatory overload 9 - Other 6

DIABETES MELLITUS Diabetic complications are complex and can be added electronically by using the following key words: kidney, ophthalmic, or neurologic complications DM DUE TO UNDERLYING CONDITION E08.42: W/DIABETIC POLYNEUROPATHY E08.65: W/ HYPERGLYCEMIA TYPE 2 DM E11.42: W/ DIABETIC POLYNEUROPATHY E11.65: W/ HYPERGLYCEMIA E11.9: W/O COMPLICATIONS TYPE 2 DIABETES MELLITUS E08: DUE TO UNDERLYING CONDITION E09: DRUG OR CHEMICAL INDUCED E10: TYPE 1 E11: TYPE 2 E13: OTHER SPECIFIED *Diabetes codes are complex; Need to look up; Key words: kidney, ophthalmic, neurological, circulatory, skin SLEEP DISORDERS SLEEP DISORDERS G47.33: OBSTRUCTIVE SLEEP APNEA (ADULT) (PEDIATRIC) G25.81: RESTLESS LEGS SYNDROME INSOMNIA 1 Due to medical condition 9 - Other G47.0 7

PAIN 8

DORSALGIA 3 - Sciatica 4- Lumbago with sciatica 5- Low back pain LIMB PAIN 0 - Pain in limb, unspecified 2 - Upper arm 3 - Forearm 5 - Thigh 6 - Lower leg 4 - Hand & fingers 7 - Foot & toes side 1 Right side 2 - Left side 1 - Right arm 2 - Left arm 3 - Arm unspecified 4 - Right leg 5 - Left leg 6 - Leg unspecified limb 1 - Right 2 - Left limb M54. M79.6 1 - Right hand or foot 2 - Left hand or foot 3 - Unspecified hand or foot 4 - Right finger or toe 5 - Left finger or toes 6 - Unspecified finger or toe MIGRAINE G43.009: W/O AURA, NOT INTRACTABLE W/O STATUS MIGRAINOSUS G43.109: W/AURA, NOT INTRACTABLE W/O STATUS MIGRAINOSUS G43.709: CHRONIC MIGRAINE W/O AURA, NOT INTRACTABLE W/O STATUS MIGRAINOSUS G43.829: MENSTRUAL MIGRAINE, NOT INTRACTABLE W/O STATUS MIGRAINOSUS ABDOMINAL & PELVIC PAIN 0 - Acute abdomen 2 - Pelvic and Perineal pain R10. JOINT PAIN M25.5 1 - Pain localized to Upper Abdomen 0 - Upper abdomen unspecified 1 Right upper quadrant 2 - Left upper quadrant 3 - Epigastric pain joint 1 - Shoulder 2 - Elbow 3 - Wrist 5 - Hip 6 - Knee 7 - Ankle & foot joints 1 - Right 2 - Left 3 - Pain localized to lower abdomen 0 - Lower abdomen unspecified 1 Right lower quadrant 2 - Left lower quadrant 3 - Periumbilical pain FIBROMYALGIA M79.7 PAIN IN THROAT R07.0 PAIN G89.29: OTHER CHRONIC PAIN G89.3: NEOPLASM RELATED PAIN (ACUTE) (CHRONIC) 9

Other Disorders of BREAST 0 - Fissure and fistula of nipple 1 - Fat necrosis of breast 2 - Atrophy of breast 3 - Galactorrhea not associated with childbirth 4 - Mastodynia N64. HEADACHE R51 This code excludes atypical face pain, migraine and other headache syndromes, trigeminal neuralgia. 5 - Other signs and symptoms in breast 8 - Other specified disorders of breast 1 - Induration of breast 2- Nipple discharge 3 - Retraction of nipple 9 - Other 1 - Ptosis of breast 2- Hypoplasia of breast 9 - Other 10

GI 11

ALCOHOLIC LIVER DISEASE 3 - Alcoholic cirrhosis of liver 4 - Alcoholic hepatic failure 0 - Without ascites 1 With ascites 0 - Without coma 1 With coma K70. Other non-infective GASTROENTERITIS & COLITIS 0 - Gastroenteritis and colitis due to radiation 1 - Toxic gastroenteritis and colitis 2 - Allergic and dietetic gastroenteritis and colitis K52. TOXIC LIVER DISEASE 0 - With cholestasis 2 - With acute hepatitis 1 - With hepatic necrosis 0 - Without coma 1 -With coma * This code is for toxic effects due to drug; Does Not include ETOH Other Diseases of LIVER 0 - Fatty (change of) liver, not elsewhere classified 1 - Chronic passive congestion of liver 2 - Central hemorrhagic necrosis of liver 3 - Infarction of liver 4 - Peliosis hepatis 5 - Hepatic veno-occlusive disease 6 - Portal hypertension 7 - Hepatorenal syndrome K71. K76. RADIATION PROCTITIS K62.7 GASTRO-ESOPHAGEAL REFLUX DISEASE 0 - With esophagitis 9 - Without esophagitis NAUSEA & VOMITING 0 - Nausea 2 - Nausea with vomiting, unspecified 1 - Vomiting 1 -Without nausea 2 - Projectile vomiting K21. R11. ANOREXIA R63.0 DYSPHAGIA 1 Oral phase 2 - Oropharyngeal phase 3 - Pharyngeal phase 4 - Pharyngoesophageal phase 9 - Other R13.1 ANAL FISSURE K60. 0 - Acute 1 - Chronic HEMORRHOIDS K64. 0 - First degree 1 - Second degree 2 - Third degree 3 - Fourth degree CONSTIPATION 1 Slow transit 9 - Other (including Opiate-induced constipation in therapeutic use) K59.0 ASCITES R18. 0 - Malignant 8 - Other 12

BLOOD 13

ANEMIA DUE TO ANTINEOPLASTIC CHEMOTHERAPY D64.81 LEUKEMOID REACTION D72.823 ANEMIA IN CHRONIC DISEASES 0 - In neoplastic disease 1 - In chronic kidney disease 8 - In other chronic diseases D63. OTHER SECONDARY THROMBOCYTOPENIA D69.59 * Due to drugs, EtOH, alloimmunization; NOT ITP WHITE BLOOD CELL DISORDERS D70.1: AGRANULOCYTOSIS SECONDARY TO CANCER CHEMOTHERAPY D70.2: AGRANULOCYTOSIS DUE TO NON- CHEMOTHERAPY DRUG D70.9: NEUTROPENIA,UNSPECIFIED D72.810: LYMPHOCYTOPENIA D72.823: LEUKEMOID REACTION LYMPHO- CYTOPENIA HEREDITARY HEMORRHAGIC TELANGIECTASIA D72.810 I78.0 14

CONSTITUTIONAL 15

ESSENTIAL (PRIMARY) HYPERTENSION I10 NON VERERTIGINOUS DIZZINESS R42 HYPOTENSION I95. 0 - Idiopathic 1 - Orthostatic 2 - Due to drugs FEVER OF UNKNOWN ORIGIN 2 - Drug Induced R50. EDEMA R60. 0 - Localized 1 - Generalized 8 - Other specified fever 1 - Fever presenting with conditions classified elsewhere 2 - Post procedural fever 3 - Post vaccination fever 4 - Febrile nonhemolytic transfusion reaction ENLARGED LYMPH NODES 0 - Localized 1 - Generalized R59. CHILLS W/O FEVER R68.83 ABNORMALITIES OF GAIT & MOBILITY 0 - Ataxic gait 1 - Paralytic gait 2 - Difficulty in walking 8 - Other abnormalities of gait & mobility 1 - Unsteadiness on feet R26. DEHYDRATION E86.0 UNSPECIFIED PROTEIN- CALORIE MALNUTRITION E46 CACHEXIA R64 16

RENAL/GU 17

ESSENTIAL (PRIMARY) HYPERTENSION ACUTE KIDNEY FAILURE 0 - With tubular necrosis 1 - With acute cortical necrosis 2 - With medullary necrosis 8 - Other CHRONIC KIDNEY DISEASE (CKD) 1 - Stage 1 2 - Stage 2 (mild) 3 - Stage 3 (moderate) 4 - Stage 4 (severe) 5 - Stage 5 6 - End stage renal disease Disorders of FLUID, ELECTROLYTE & ACID/BASE BALANCE 0 - Hyperosmolality & Hypernatremia 1 - Hypoosmolality and hyponatremia 2 - Acidosis 3 - Alkalosis 4 - Mixed disorder of acid-base balance 5 - Hyperkalemia 6 - Hypokalemia 8 - Other electrolyte & acid/base disorder 7 - Fluid Overload 1- Transfusion associated circulatory overload 9 - Other I10 N17. N18. E87. DIABETES INSIPIDUS E23.2 HEMATURIA 0 - Gross hematuria 1 - Benign essential microscopic hematuria *Use code forcystitis/ glomerunephritis if present) R31. DYSURIA R30.0 OBSTRUCTIVE & REFLUX UROPATHY 1 - Hydronephrosis with ureteral stricture, 2 - Hydronephrosis with renal and ureteral calculous obstruction 8 - Other obstructive and reflux uropathy (includes Obstructive nephropathy due to prostate/mass) 0 - Without lower urinary tract symptoms 1 - With lower urinary tract symptoms N13. ENLARGED PROSTATE N40. INCONTINENCE/ UTI 0 - Urinary tract infection, site not specified 3 - Stress incontinence (female/male) 4 - Other specified urinary incontinence 1 - Urge incontinence 2 - Incontinence without sensory awareness 3 - Post-void dribbling 4 - Nocturnal enuresis 5 - Continuous leakage 6 - Mixed incontinence 9 - Other incontinence N39. 1 - Overflow incontinence 8 - Other specified urinary incontinence POLYURIA R35. 0 - Frequency of micturition 1 - Nocturia 18

CYSTITIS 0 - Acute 1 - Interstitial cystitis (chronic) 2 - Other chronic cystitis 3 - Trigonitis 4 - Irradiation cystitis N30. 0 - Without hematuria 1 - With hematuria EDEMA R60. 0 - Localized 1 - Generalized CALCULUS OF KIDNEY & URETER 0 - Calculus of kidney 1 - Calculus of ureter 2 - Calculus of kidney with calculus of ureter N20. 19

LUNG/RESPIRATORY 20

COUGH RO5 BREATHING ABNORMALITIES RO6.01: ORTHOPNEA RO6.02: SHORTNESS OF BREATH R06.2: WHEEZING R06.4: HYPERVENTILATION R06.6: HICCOUGH R06.81: APNEA (Sleep apnea) OBSTRUCTIVE SLEEP APNEA (ADULT & PEDIATRIC) MALIGNANT PLEURAL EFFUSION ASPERGILLOSIS 0 - Invasive pulmonary 1 - Other pulmonary 2 - Tonsillar 7 - Disseminated 8 - Other 1- Allergic bronchopulmonary 9 - Other forms G47.33 J91.0 B44. ASTHMA 2 - Mild intermittent 3 - Mild persistent 4 - Moderate persistent 5 - Severe persistent J45. 0 Uncomplicated 1 - With acute exacerbation 2 - With status asthmaticus PULMONARY EMBOLISM W/O ACUTE COR PULMONALE I26.9 EMPHYSEMA J43. 0 - Unilateral pulmonary emphysema [MacLeod's syndrome] 1 - Panlobular 2 - Centrilobular 8 - Other 0 - Septic pulmonary embolism 2 Saddle embolus of pulmonary artery 9 - Other NICOTINE DEPENDENCE - CIGARETTES F17.21 Other COPD 0 - With acute lower respiratory infection 1 - With (acute) exacerbation J44. 0 - Uncomplicated 1 - In Remission 3 - With withdrawal 8 - With other nicotine-induced disorders nicotine-induced disorders Abnormal Findings on DIAGNOSTIC IMAGING OF LUNG R91. 1 - Solitary pulmonary nodule 8 - Other nonspecific abnormal finding of lung field Including multiple pulmonary nodules 21

INFECTIOUS DISEASES 22

CYTOMEGALOVIRAL DISEASE 0 - CMV pneumonitis 1 - CMV hepatitis 2 - CMV pancreatitis 8 - Other CMV (includes CMV colitis, CMV enteritis, CMV gastritis & CMV viremia) CMV BACTERIAL INTESTINAL INFECTIONS 0 - Enteropathogenic Escherichia coli infection 1 - Enterotoxigenic Escherichia coli infection 2 - Enteroinvasive Escherichia coli infection 3 - Enterohemorrhagic Escherichia coli infection 4 - Other intestinal Escherichia coli infections 5 - Campylobacter enteritis 6 - Enteritis due to Yersinia enterocolitica 7 - Enterocolitis due to Clostridium difficile 8 - Other specified bacterial intestinal infections B25. A04. ZOSTER (HERPES) 0 - Zoster encephalitis 1 - Zoster meningitis 7 - Disseminated 8 - With other complications 9 - Without complications 2 - With other nervous system involvement 3 - Ocular disease HIV DISEASE B02. 1- Postherpetic geniculate ganglionitis 2 - Postherpetic trigeminal neuralgia 3 - Postherpetic polyneuropathy 4 - Postherpetic myelitis 9 - Other postherpetic nervous system involvement 1 Conjunctivitis 2 - Iridocyclitis 3 - Keratitis 4 - Scleritis 9 - Other herpes zoster eye B20 CANDIDIASIS 0 - Candidal stomatitis 1 - Pulmonary candidiasis 2 - Candidiasis of skin and nail 3 - Candidiasis of vulva and vagina 5 - Candidal meningitis 6 - Candidal endocarditis 7 - Candidal sepsis 4 - Other urogenital sites 8 - Other sites B37. 1- Candidal cystitis and urethritis 2 - Candidal balanitis 9 - Other urogenital candidiasis 1- Candidal esophagitis 2 - Candidal enteritis 3 - Candidal cheilitis 4 - Candidal otitis externa 9 - Other sites CELLULITIS & ACUTE LYMPHANGITIS 0 - Finger & toe 1 - Other parts of limb 2 - Face & Neck 1 - Cellulitis of finger 2 - Acute lymphangitis of finger 3 - Cellulitis of toe 4 - Acute lymphangitis of finger 1 - Cellulitis 2 - Acute lymphangitis 1 - Face 2 - Neck L03. L03. 1 - Right 12 - Right Left 29 - Left Unspecified 1 - Right axilla 2 - Left axilla 3 - Right upper limb 4 - Left upper limb 5 - Right lower limb 6 - Left lower limb part 1 - Cellulitis 2 - Acute lymphangitis PNEUMOCYSTOSIS B59 3 - Trunk 1 - Cellulitis 2 - Acute lymphangitis 1 - Abdominal wall 2 - Back (except buttock) 3 - Chest wall 4 - Groin 5 - Perineum 6 - Umbilicus 7 - Buttock part 8 - Other sites 1 - Cellulitis 2 - Acute lymphangitis 1 - Head (except face) 8 - Other sites 0 - Cellulitis 1 - Acute lymphangitis 23

TOXOPLASMOSIS 0 - Oculopathy 1 - Hepatitis 2 - Meningoencephalitis 3 - Pulmonary toxoplasmosis 8 - With other organ involvement RESPIRATORY SYNCYTIAL VIRUS PNEUMONIA B58. 1 - Chorioretinitis 9 - Other 1 - Myocarditis 2 - Myositis 3 - Tubulo-interstitial nephropathy 9 - Other organ involvement J12.1 FEVER OF UNKNOWN ORIGIN 2 - Drug Induced 8 - Other specified fever ASPERGILLOSIS 0 - Invasive pulmonary 1 - Other pulmonary 2 - Tonsillar 7 - Disseminated 8 - Other R50. 1 - Fever presenting with conditions classified elsewhere 2 - Post procedural fever 3 - Post vaccination fever 4 - Febrile nonhemolytic transfusion reaction 1- Allergic bronchopulmonary 9 - Other forms B44. 24

PSYCHIATRIC 25

MAJOR DEPRESSIVE DISORDER, SINGLE EPISODE 0 - Mild 1 - Moderate 2 - Severe without psychotic features 3 - Severe with psychotic features 4 - In partial remission 5 - In full remission F32. ANXIETY DISORDERS F41. 0 - Panic disorder [episodic paroxysmal anxiety] without agoraphobia 1 - Generalized anxiety disorder REACTION TO SEVERE STRESS 1 - PTSD 1 -Acute 2 - Chronic F43. 2 - Adjustment disorders 1 -With depressed mood 2 - With anxiety 3 - With anxiety & depressed mood 4 - With disturbance of conduct 5 - With disturbance of emotions & conduct 9 - With other symptoms 26

NEUROLOGY 27

Other & Unspecified POLYNEUROPATHIES G62. RESTLESS LEGS SYNDROME G25.81 0 - Drug-induced 1 - Alcoholic 2 - Due to other toxic agents (Myeloma/Amyloid) POLYNEUROPATHY IN DISEASES CLASSIFIED ELSEWHERE G63 POSTERIOR REVERSIBLE ENCEPHALOPATHY SYNDROME I67.83 *Code malignancy elsewhere OTOTOXIC HEARING LOSS H91.0 1 -Right ear 2 - Left ear 3 - Bilateral (drug-induced) TINNITUS 1 -Right ear 2 - Left ear 3 - Bilateral H93.1 TYPE 1 DM WITH DIABETIC POLYNEUROPATHY E10.42 TYPE 2 DM WITH DIABETIC POLYNEUROPATHY E11.42 28

CARDIOLOGY 29

ATRIAL FIBRILLATION & FLUTTER 0 - Paroxysmal atrial fibrillation 1 - Persistent atrial fibrillation 2 - Chronic atrial fibrillation I48. HYPOTENSION I95. 0 - Idiopathic 1 - Orthostatic 2 - Due to drugs ABNORMALITIES OF HEART BEAT 0 - Tachycardia, unspecified 1 - Bradycardia, unspecified 2 - Palpitations R00. HEART FAILURE I50. 1 - Left ventricular failure 2 - Systolic CHF 3 - Diastolic CHF 4 - Combined systolic & diastolic CHF 1 -Acute 2 - Chronic 3 - Acute on chronic 30

MISCELLANEOUS 31

GRAFT-VERSUS- HOST DISEASE 0 - Acute 1 - Chronic 2 - Acute on chronic 3 - Unspecified D89.81 DRY EYE SYNDROME H04.12 ENLARGED LYMPH NODES 0 - Localized 1 - Generalized R59. EPISTAXIS R04.0 1 - Right lacrimal gland 2 Left lacrimal gland 3 - Bilateral lacrimal glands lacrimal gland ORAL MUCOSITIS, ULCERATIVE 0 -Unspecified 1 - Due to antineoplastic therapy 2 - Due to other drugs 3 - Due to radiation 9 - Other SICCA SYNDROME 0 -Unspecified 1 - With keratoconjunctivitis 2 - With lung involvement 3 - With myopathy 4 - With tubulo-interstitial nephropathy 9 - With other organ involvement K12.3 M35.0 NICOTINE DEPENDENCE - CIGARETTES 0 - Uncomplicated 1 - In Remission 3 - With withdrawal 8 - With other nicotine-induced disorders nicotine-induced disorders F17.21 D80.1 NONFAMILIAL HYPOGAMMAGLOBULINEMIA SHINE DIAGNOSIS CODES POSTMASTECTOMY LYMPHEDEMA SYNDROME LYMPHEDEMA, NOT ELSEWHERE CLASSIFIED I97.2 I89.0 ABNORMALITIES OF GAIT & MOBILITY 0 - Ataxic gait 1 - Paralytic gait 2 - Difficulty in walking 8 - Other abnormalities of gait & mobility 1 - Unsteadiness on feet R26. 32

Abdominal & Pelvic Pain, 9 Abnormal Findings On Diagnostic Imaging Of Lung, 21 Acid/Base Balance, 18 Acid/Base Balance, Disorder Of, 18 Acidosis, 6, 18 Addisonian Crisis, 6 Adjustment Disorders, 26 Adrenocortical Insufficiency, 6 Agranulocytosis, 4, 14 Alcoholic Cirrhosis Of Liver, 12 Alcoholic Hepatic Failure, 12 Alcoholic Liver Disease, 12 Alkalosis, 6, 18 Allergic And Dietetic Gastroenteritis And Colitis, 12 Anal Fissure, 12 Anemia Chronic Kidney Disease, 14 Due To Antineoplastic Chemotherapy, 4, 14 In Chronic Diseases, 14 Neoplastic Disease, 14 Anorexia, 12 Anxiety, 26 Apnea (Sleep Apnea), 21 Ascites, 12 Aspergillosis, 21, 24 Asthma, 21 Asthmaticus, 21 Ataxic Gait, 16, 32 Atrial Fibrillation, 30 Atrophy Of Breast, 10 A B Bacterial Intestinal Infections, 23 Balanitis, 23 Bradycardia, 30 Breast, Other Disorders Of, 10 Breathing Abnormalities, 21 Bronchopulmonary, 21, 24 Cachexia, 16 Calculus Of Kidney & Ureter, 19 Campylobacter Enteritis, 23 Candidal, 23 Candidiasis, 23 Cellulitis, 23 CHF, 30 Chills, 16 C Cholestasis, 4, 12 Chorioretinitis, 24 Chronic Kidney Disease (CKD), 18 Chronic Passive Congestion Of Liver, 12 Cigarettes, 21, 32 Circulatory Overload, 18 Cirrhosis Of Liver, 12 CKD, 18 Clostridium Difficile Enterocolitis Due To, 23 CMV, 23 Colitis, 12 Allergic And Dietetic, 12 Due To Radiation, 12 Toxic, 12 Congestive Heart Failure, 30 Conjunctivitis, 23 Constipation, 4, 12 COPD, 21 Cough, 21 Cystitis, 19 Cytomegaloviral Disease, 23 Dehydration, 16 Depression, 26 Diabetes Insipidus, 18 Diabetes Mellitus, 7 Drug Induced, 4 Diabetic Polyneuropathy, 4, 7, 28 Diastolic CHF, 30 Dietetic And Dietetic Gastroenteritis And Colitis, 12 Disturbance, 26 Dizziness, 16 DM, 7 Type II, 28 Dribbling, 18 Drug Induced Fever, 16, 24 Drug Induced Adrenocortical Insufficiency, 4, 6 Cushing's Syndrome, 4 Ototoxic Hearing Loss, 4, 28 Dry Eye Syndrome, 32 Dysphagia, 12 Dysuria, 18 E. coli, 23 Edema, 16, 19 Electrolyte, 6, 18 D E 33

Electrolytes, 6 Embolism, 21 Embolus, Saddle Of Pulmonary Artery, 21 Emphysema, 21 Unilateral Pulmonary, 21 Encephalitis, Zoster, 23 Enlarged Lymph Nodes, 16, 32 Enlarged Prostate, 18 Enteritis Campylobacter, 23 Due To Yersinia Enterocolitica, 23 Enterocolitis Due To Clostridium Difficile, 23 Enuresis Nocturnal, 18 Epistaxis, 32 Escherichia Coli Infection, 23 Esophagitis, 12 Essential (Primary) Hypertension, 16, 18 Exacerbation, 21 Fat Necrosis Of Breast, 10 Fatty (Change Of) Liver, 12 Febrile Nonhemolytic Transfusion Reaction, 16, 24 Fever, 16, 24 Post Procedural, 16, 24 Post Vaccination, 16, 24 Fissure And Fistula Of Nipple, 10 Fluid, 6, 18 Fluid Overload, 18 Flutter, 30 F G Gait, 16 Gait And Mobility, Abnormalities Of, 32 Galactorrhea, 10 Ganglionitis, 23 Gastroenteritis, 12 Allergic And Dietetic, 12 Due To Radiation, 12 Toxic, 12 Gastro Esophageal Reflux Disease, 12 Geniculate Ganglionitis, 23 Graft Versus Host Disease, 32 GVHD, 32 Hematuria, 18, 19 Hemorrhagic Necrosis Of Liver, 12 Hemorrhoids, 12 Hepatic Failure, 12 Hepatic Veno Occlusive Disease, 12 Hepatitis, 4, 12, 23, 24 Hepatorenal Syndrome, 12 Hereditary Hemorrhagic Telangiectasia, 14 Herpes, 23 Hiccough, 21 HIV, 23 Human Immunodeficiency Virus (HIV), 23 Hydronephrosis, 18 Hyper Calcemia, 6 Hypercholesterolemia, 6 Hyperglycemia, 4, 7 Hyperglyceridemia, 6 Hyperkalemia, 6, 18 Hyperlipidemia, 6 Hypernatremia, 6, 18 Hyperosmolality, 6, 18 Hypertension, 16, 18 Portal, 12 Hyperventilation, 21 Hypo Calcemia, 6 Hypogammaglobulinemia, 32 Hypokalemia, 6, 18 Hypo Magnesemia, 6 Hyponatremia, 6, 18 Hypoosmolality, 6, 18 Hypoplasia Of Breast, 10 Hypotension, 4, 16, 30 Due To Drugs, 4 Incontinence, 18 Overflow, 18 Stress, 18 Urge, 18 Induration Of Breast, 10 Infarction Of Liver, 12 Insomnia, 7 Interstitial Cystitis (Chronic), 19 Intestinal Infections, Bacterial, 23 Iridocyclitis, 23 Irradiation Cystitis, 19 I H Headache, 10 Heart Beat, Abnormalities Of, 30 Heart Failure, 30 Joint Pain, 9 J 34

Keratitis, 23 Kidney Failure, 18 Lacrimal Gland, 32 Leakage, 18 Left Ventricular Failure, 30 Leukemoid Reaction, 14 Liver, 12 Central Hemorrhagic Necrosis Of, 12 Infarction Of, 12 Necrosis Of, 12 Lumbago With Sciatica, 9 Lung Abnormal Findings On Diagnostic Imaging Of, 21 Lymph Nodes Enlarged, 16, 32 Lymph Nodes, Enlarged, 16, 32 Lymphangitlis, 23 Lymphedema Syndrome, 32 Lymphocytopenia, 14 K L M Magnesium, 6 Malignant Pleural Effusion, 21 Malnutrition, 16 Mastodynia, 10 Medullary Necrosis, 18 Meningitis, Zoster, 23 Meningoencephalitis, 24 Metabolism, 6 Micturition, 18 Migraine, 9 Chronic Migraine, 9 Menstrual Migraine, 9 Mobility, 16 Mobility, Abnormalities Of, 32 Mucositis, 4, 32 Mucositis, Oral, Ulcerative, 4, 32 Myelitis, 23 Myeloma Induced Neuropathy, 4 Myocarditis, 24 Myositis, 24 Nausea, 12 Necrosis, 4, 12 Acute Cortical, 18 N Medullary, 18 Tubular, 18 Necrosis Of Liver, 12 Nephropathy, 24 Obstructive, 18 Neuralgia, 23 Neuropathy Myeloma Induced, 4 Neutropenia, 14 Nicotine, 21, 32 Nicotine Dependence, 32 Nipple Discharge, 10 NKHHC, 4 Nocturia, 18 Nocturnal Enuresis, 18 Nonfamilial Hypogammaglobulinemia, 32 O Obesity, 6 Obstructive Nephropathy, 18 Obstructive Sleep Apnea, 21 Obstructive Uropathy, 18 Ocular Disease, 23 Oculopathy, 24 Oral Mucositis, Ulcerative, 4, 32 Orthopnea, 21 Osteoporosis, 6 Ototoxic Hearing Loss, 4, 28 Overflow Incontinence, 18 Overweight, 6 Pain, 9 Abdominal & Pelvic, 9 Joint, 9 Neoplasm Related, 9 Perineal, 9 Palpitations, 30 Panic, 26 Paralytic Gait, 16, 32 Peliosis Hepatis, 12 Perineal Pain, 9 Pleural Effusion Malignant, 21 Pneumocystosis, 23 Pneumonia, 24 Polyneuropathy, 4, 23, 28 Polyuria, 18 Portal Hypertension, 12 Post Procedural Fever, 16, 24 Post Vaccination Fever, 16, 24 P 35

Posterior Reversible Encephalopathy Syndrome, 28 Postherpetic Geniculate Ganglionitis, 23 Myelitis, 23 Polyneuropathy, 23 Trigeminal Neuralgia, 23 Postmastectomy Lymphedema Syndrome, 32 Post Traumatic Stress Disorder, 26 PRES, 28 Primary Hypertension, 16, 18 Proctitis Radiation, 12 Prostate Enlarged, 18 Protein Calorie Malnutrition, 16 Psychotic, 26 Ptosis Of Breast, 10 PTSD, 26 Pulmonary, 24 Pulmonary Nodules, 21 Radiation Proctitis, 12 Reflux Uropathy, 18 Renal Disease, 18 Respiratory Syncytial Virus Pneumonia, 24 Restless Legs Syndrome, 28 Retraction Of Nipple, 10 Rickets, 6 Saddle Embolus Of Pulmonary Artery, 21 Sciatica, 9 Scleritis, 23 Shortness Of Breath, 21 Sicca Syndrome, 32 Solitary Pulmonary Nodule, 21 Stress, 26 Syncytial Virus Pneumonia, 24 Systolic CHF, 30 R S Tachycardia, 30 Telangiectasia Hereditary Hemorrhagic, 14 Thrombocytopenia, 4, 14 Tinnitus, 28 Toxic Gastroenteritis And Colitis, 12 Toxic Liver Disease, 4, 12 Toxoplasmosis, 24 Transfusion Reaction, Febrile Nonhemolytic, 16, 24 Trigeminal Neuralgia, 23 Trigonitis, 19 Tubulo Interstitial, 24 T U Unilateral Pulmonary Emphysema, 21 Unsteadiness, 16, 32 Unsteadiness On Feet, 16 Urinary Tract Infection, 18 Uropathy, 18 UTI, 18 Vomiting, 12 Walking, Difficulty In, 16 WBC Disorders, 14 Wheezing, 21 White Blood Cell Disorders, 14 Yersinia Enterocolitica Enteritis Due To, 23 Zoster, 23 V W Y Z 36