ICD-10 Directory
Use Additional
• code to identify resistance to antimicrobial drugs (Z16)
Type 1 Excludes
• certain localized infections - see body system-related chapters
Type 2 Excludes
• carrier or suspected carrier of infectious disease (Z22)
• infectious and parasitic diseases complicating pregnancy, childbirth and the puerperium (O98)
• infectious and parasitic diseases specific to the perinatal period (P35-P39)
• influenza and other acute respiratory infections (J00-J22)
Includes
• diseases generally recognized as communicable or transmissible
Note:
• Functional activity
• All neoplasms are classified in this chapter, whether they are functionally active or not. An additional code from Chapter 4 may be used, to identify functional activity associated with any neoplasm.
• Morphology [Histology]
• Chapter 2 classifies neoplasms primarily by site (topography), with broad groupings for behavior, malignant, in situ, benign, etc. The Table of Neoplasms should be used to identify the correct topography code. In a few cases, such as for malignant melanoma and certain neuroendocrine tumors, the morphology (histologic type) is included in the category and codes.
• Primary malignant neoplasms overlapping site boundaries
• A primary malignant neoplasm that overlaps two or more contiguous (next to each other) sites should be classified to the subcategory/code .8 ('overlapping lesion'), unless the combination is specifically indexed elsewhere. For multiple neoplasms of the same site that are not contiguous, such as tumors in different quadrants of the same breast, codes for each site should be assigned.
• Malignant neoplasm of ectopic tissue
• Malignant neoplasms of ectopic tissue are to be coded to the site mentioned, e.g., ectopic pancreatic malignant neoplasms are coded to pancreas, unspecified (C25.9).
Type 2 Excludes
• autoimmune disease (systemic) NOS (M35.9)
• certain conditions originating in the perinatal period (P00-P96)
• complications of pregnancy, childbirth and the puerperium (O00-O9A)
• congenital malformations, deformations and chromosomal abnormalities (Q00-Q99)
• endocrine, nutritional and metabolic diseases (E00-E88)
• human immunodeficiency virus [HIV] disease (B20)
• injury, poisoning and certain other consequences of external causes (S00-T88)
• neoplasms (C00-D49)
• symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R94)
Note:
• All neoplasms, whether functionally active or not, are classified in Chapter 2. Appropriate codes in this chapter (i.e. E05.8, E07.0, E16-E31, E34.) may be used as additional codes to indicate either functional activity by neoplasms and ectopic endocrine tissue or hyperfunction and hypofunction of endocrine glands associated with neoplasms and other conditions classified elsewhere.
Type 1 Excludes
• transitory endocrine and metabolic disorders specific to newborn (P70-P74)
Type 2 Excludes
• symptoms, signs and abnormal clinical laboratory findings, not elsewhere classified (R00-R99)
Includes
• disorders of psychological development
Type 2 Excludes
• certain conditions originating in the perinatal period (P04-P96)
• certain infectious and parasitic diseases (A00-B99)
• complications of pregnancy, childbirth and the puerperium (O00-O9A)
• congenital malformations, deformations, and chromosomal abnormalities (Q00-Q99)
• endocrine, nutritional and metabolic diseases (E00-E88)
• injury, poisoning and certain other consequences of external causes (S00-T88)
• neoplasms (C00-D49)
• symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R94)
Note:
• Use an external cause code following the code for the eye condition, if applicable, to identify the cause of the eye condition
Type 2 Excludes
• certain conditions originating in the perinatal period (P04-P96)
• certain infectious and parasitic diseases (A00-B99)
• complications of pregnancy, childbirth and the puerperium (O00-O9A)
• congenital malformations, deformations, and chromosomal abnormalities (Q00-Q99)
• diabetes mellitus related eye conditions (E09.3-, E10.3-, E11.3-, E13.3-)
• endocrine, nutritional and metabolic diseases (E00-E88)
• injury (trauma) of eye and orbit (S05.-)
• injury, poisoning and certain other consequences of external causes (S00-T88)
• neoplasms (C00-D49)
• symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R94)
• syphilis related eye disorders (A50.01, A50.3-, A51.43, A52.71)
Note:
• Use an external cause code following the code for the ear condition, if applicable, to identify the cause of the ear condition
Type 2 Excludes
• certain conditions originating in the perinatal period (P04-P96)
• certain infectious and parasitic diseases (A00-B99)
• complications of pregnancy, childbirth and the puerperium (O00-O9A)
• congenital malformations, deformations and chromosomal abnormalities (Q00-Q99)
• endocrine, nutritional and metabolic diseases (E00-E88)
• injury, poisoning and certain other consequences of external causes (S00-T88)
• neoplasms (C00-D49)
• symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R94)
Type 2 Excludes
• certain conditions originating in the perinatal period (P04-P96)
• certain infectious and parasitic diseases (A00-B99)
• complications of pregnancy, childbirth and the puerperium (O00-O9A)
• congenital malformations, deformations, and chromosomal abnormalities (Q00-Q99)
• endocrine, nutritional and metabolic diseases (E00-E88)
• injury, poisoning and certain other consequences of external causes (S00-T88)
• neoplasms (C00-D49)
• symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R94)
• systemic connective tissue disorders (M30-M36)
• transient cerebral ischemic attacks and related syndromes (G45.-)
Note:
• When a respiratory condition is described as occurring in more than one site and is not specifically indexed, it should be classified to the lower anatomic site (e.g. tracheobronchitis to bronchitis in J40).
Use Additional code, where applicable, to identify:
• exposure to environmental tobacco smoke (Z77.22)
• exposure to tobacco smoke in the perinatal period (P96.81)
• history of tobacco use (Z87.891)
• occupational exposure to environmental tobacco smoke (Z57.31)
• tobacco dependence (F17.-)
• tobacco use (Z72.0)
Type 2 Excludes
• certain conditions originating in the perinatal period (P04-P96)
• certain infectious and parasitic diseases (A00-B99)
• complications of pregnancy, childbirth and the puerperium (O00-O9A)
• congenital malformations, deformations and chromosomal abnormalities (Q00-Q99)
• endocrine, nutritional and metabolic diseases (E00-E88)
• injury, poisoning and certain other consequences of external causes (S00-T88)
• neoplasms (C00-D49)
• smoke inhalation (T59.81-)
• symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R94)
Type 2 Excludes
• certain conditions originating in the perinatal period (P04-P96)
• certain infectious and parasitic diseases (A00-B99)
• complications of pregnancy, childbirth and the puerperium (O00-O9A)
• congenital malformations, deformations and chromosomal abnormalities (Q00-Q99)
• endocrine, nutritional and metabolic diseases (E00-E88)
• injury, poisoning and certain other consequences of external causes (S00-T88)
• neoplasms (C00-D49)
• symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R94)
Type 2 Excludes
• certain conditions originating in the perinatal period (P04-P96)
• certain infectious and parasitic diseases (A00-B99)
• complications of pregnancy, childbirth and the puerperium (O00-O9A)
• congenital malformations, deformations, and chromosomal abnormalities (Q00-Q99)
• endocrine, nutritional and metabolic diseases (E00-E88)
• lipomelanotic reticulosis (I89.8)
• neoplasms (C00-D49)
• symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R94)
• systemic connective tissue disorders (M30-M36)
• viral warts (B07.-)
Note:
• Use an external cause code following the code for the musculoskeletal condition, if applicable, to identify the cause of the musculoskeletal condition
Type 2 Excludes
• arthropathic psoriasis (L40.5-)
• certain conditions originating in the perinatal period (P04-P96)
• certain infectious and parasitic diseases (A00-B99)
• compartment syndrome (traumatic) (T79.A-)
• complications of pregnancy, childbirth and the puerperium (O00-O9A)
• congenital malformations, deformations, and chromosomal abnormalities (Q00-Q99)
• endocrine, nutritional and metabolic diseases (E00-E88)
• injury, poisoning and certain other consequences of external causes (S00-T88)
• neoplasms (C00-D49)
• symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R94)
Type 2 Excludes
• certain conditions originating in the perinatal period (P04-P96)
• certain infectious and parasitic diseases (A00-B99)
• complications of pregnancy, childbirth and the puerperium (O00-O9A)
• congenital malformations, deformations and chromosomal abnormalities (Q00-Q99)
• endocrine, nutritional and metabolic diseases (E00-E88)
• injury, poisoning and certain other consequences of external causes (S00-T88)
• neoplasms (C00-D49)
• symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R94)
Note:
• CODES FROM THIS CHAPTER ARE FOR USE ONLY ON MATERNAL RECORDS, NEVER ON NEWBORN RECORDS
• Codes from this chapter are for use for conditions related to or aggravated by the pregnancy, childbirth, or by the puerperium (maternal causes or obstetric causes)
• Trimesters are counted from the first day of the last menstrual period. They are defined as follows:
• 1st trimester- less than 14 weeks 0 days
• 2nd trimester- 14 weeks 0 days to less than 28 weeks 0 days
• 3rd trimester- 28 weeks 0 days until delivery
Use Additional
• code from category Z3A, Weeks of gestation, to identify the specific week of the pregnancy
Type 1 Excludes
• supervision of normal pregnancy (Z34.-)
Type 2 Excludes
• mental and behavioral disorders associated with the puerperium (F53)
• obstetrical tetanus (A34)
• postpartum necrosis of pituitary gland (E23.0)
• puerperal osteomalacia (M83.0)
Note:
• Codes from this chapter are for use on newborn records only, never on maternal records
Type 2 Excludes
• congenital malformations, deformations and chromosomal abnormalities (Q00-Q99)
• endocrine, nutritional and metabolic diseases (E00-E88)
• injury, poisoning and certain other consequences of external causes (S00-T88)
• neoplasms (C00-D49)
• tetanus neonatorum (A33)
Includes
• conditions that have their origin in the fetal or perinatal period (before birth through the first 28 days after birth) even if morbidity occurs later
Note:
• Codes from this chapter are not for use on maternal or fetal records
Type 2 Excludes
• inborn errors of metabolism (E70-E88)
Note:
• 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.
Type 2 Excludes
• 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)
Note:
• Use secondary code(s) from Chapter 20, External causes of morbidity, to indicate cause of injury. Codes within the T section that include the external cause do not require an additional external cause code
Use Additional
• code to identify any retained foreign body, if applicable (Z18.-)
Type 1 Excludes
• birth trauma (P10-P15)
• obstetric trauma (O70-O71)
Note:
• This chapter permits the classification of environmental events and circumstances as the cause of injury, and other adverse effects. Where a code from this section is applicable, it is intended that it shall be used secondary to a code from another chapter of the Classification indicating the nature of the condition. Most often, the condition will be classifiable to Chapter 19, Injury, poisoning and certain other consequences of external causes (S00-T88). Other conditions that may be stated to be due to external causes are classified in Chapters I to XVIII. For these conditions, codes from Chapter 20 should be used to provide additional information as to the cause of the condition.
Note:
• Z codes represent reasons for encounters. A corresponding procedure code must accompany a Z code if a procedure is performed. Categories Z00-Z99 are provided for occasions when circumstances other than a disease, injury or external cause classifiable to categories A00-Y89 are recorded as 'diagnoses' or 'problems'. This can arise in two main ways:
• (a) When a person who may or may not be sick encounters the health services for some specific purpose, such as to receive limited care or service for a current condition, to donate an organ or tissue, to receive prophylactic vaccination (immunization), or to discuss a problem which is in itself not a disease or injury.
• (b) When some circumstance or problem is present which influences the person's health status but is not in itself a current illness or injury.