Classification of diseases and injuries



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PERSONS ENCOUNTERING HEALTH SERVICES IN CIRCUMSTANCES RELATED TO REPRODUCTION AND DEVELOPMENT (V20-V29)

V20 Health supervision of infant or child

V20.0 Foundling

V20.1 Other healthy infant or child receiving care

Medical or nursing care supervision of healthy infant in cases of:

maternal illness, physical or psychiatric

socioeconomic adverse condition at home

too many children at home preventing or interfering with normal care

V20.2 Routine infant or child health check

Developmental testing of infant or child

Health check for child over 28 days old

Immunizations appropriate for age

Routine vision and hearing testing

Excludes: health check for child under 29 days old (V20.31-V20.32)

newborn health supervision (V20.31-V20.32)

special screening for developmental handicaps (V79.3)

Use additional code(s) to identify:

Special screening examination(s) performed (V73.0-V82.9)

V20.3 Newborn health supervision

Health check for child under 29 days old

Excludes: health check for child over 28 days old (V20.2)

V20.31 Health supervision for newborn under 8 days old

Health check for newborn under 8 days old

V20.32 Health supervision for newborn 8 to 28 days old

Health check for newborn 8 to 28 days old

Newborn weight check

V21 Constitutional states in development

V21.0 Period of rapid growth in childhood

V21.1 Puberty

V21.2 Other adolescence

V21.3 Low birth weight status

Excludes: history of perinatal problems (V13.7)

V21.30 Low birth weight status, unspecified

V21.31 Low birth weight status, less than 500 grams

V21.32 Low birth weight status, 500-999 grams

V21.33 Low birth weight status, 1000-1499 grams

V21.34 Low birth weight status, 1500-1999 grams

V21.35 Low birth weight status, 2000-2500 grams

V21.8 Other specified constitutional states in development

V21.9 Unspecified constitutional state in development

V22 Normal pregnancy

Excludes: pregnancy examination or test, pregnancy unconfirmed (V72.40)

V22.0 Supervision of normal first pregnancy

V22.1 Supervision of other normal pregnancy

V22.2 Pregnant state, incidental

Pregnant state NOS

V23 Supervision of high-risk pregnancy

V23.0 Pregnancy with history of infertility

V23.1 Pregnancy with history of trophoblastic disease

Pregnancy with history of:

hydatidiform mole

vesicular mole

Excludes: that without current pregnancy (V13.1)

V23.2 Pregnancy with history of abortion

Pregnancy with history of conditions classifiable to 634-638

Excludes: recurrent pregnancy loss:

care during pregnancy (646.3)

that without current pregnancy (629.81)

V23.3 Grand multiparity

Excludes: care in relation to labor and delivery (659.4)

that without current pregnancy (V61.5)

V23.4 Pregnancy with other poor obstetric history

Pregnancy with history of other conditions classifiable to 630-676

V23.41 Pregnancy with history of pre-term labor

V23.42 Pregnancy with history of ectopic pregnancy

V23.49 Pregnancy with other poor obstetric history

V23.5 Pregnancy with other poor reproductive history

Pregnancy with history of stillbirth or neonatal death

V23.7 Insufficient prenatal care

History of little or no prenatal care

V23.8 Other high-risk pregnancy

V23.81 Elderly primigravida

First pregnancy in a woman who will be 35 years of age or older at expected date of delivery

Excludes: elderly primigravida complicating pregnancy (659.5)

V23.82 Elderly multigravida

Second or more pregnancy in a woman who will be 35 years of age or older at expected date of delivery

Excludes: elderly multigravida complicating pregnancy (659.6)

V23.83 Young primigravida

First pregnancy in a female less than 16 years old at expected date of delivery

Excludes: young primigravida complicating pregnancy (659.8)

V23.84 Young multigravida

Second or more pregnancy in a female less than 16 years old at expected date of delivery

Excludes: young multigravida complicating pregnancy (659.8)

V23.85 Pregnancy resulting from assisted reproductive technology

Pregnancy resulting from in vitro fertilization

V23.86 Pregnancy with history of in utero procedure during previous pregnancy

Excludes: management of pregnancy affected by in utero procedure during current pregnancy (679.0-679.1)

V23.87 Pregnancy with inconclusive fetal viability

Encounter to determine fetal viability of pregnancy

V23.89 Other high-risk pregnancy

V23.9 Unspecified high-risk pregnancy

V24 Postpartum care and examination

V24.0 Immediately after delivery

Care and observation in uncomplicated cases

V24.1 Lactating mother

Supervision of lactation

V24.2 Routine postpartum follow-up

V25 Encounter for contraceptive management

V25.0 General counseling and advice

V25.01 Prescription of oral contraceptives

V25.02 Initiation of other contraceptive measures

Fitting of diaphragm

Prescription of foams, creams, or other agents

V25.03 Encounter for emergency contraceptive counseling and prescription

Encounter for postcoital contraceptive counseling and prescription

V25.04 Counseling and instruction in natural family planning to avoid pregnancy

V25.09 Other

Family planning advice

V25.1 Encounter for insertion or removal of intrauterine contraceptive device

Excludes: encounter for routine checking of intrauterine contraceptive device (V25.42)

V25.11 Encounter for insertion of intrauterine contraceptive device

V25.12 Encounter for removal of intrauterine contraceptive device

V25.13 Encounter for removal and reinsertion of intrauterine contraceptive device

Encounter for replacement of intrauterine contraceptive device

V25.2 Sterilization

Admission for interruption of fallopian tubes or vas deferens

V25.3 Menstrual extraction

Menstrual regulation

V25.4 Surveillance of previously prescribed contraceptive methods

Checking, reinsertion, or removal of contraceptive device

Repeat prescription for contraceptive method

Routine examination in connection with contraceptive maintenance

V25.40 Contraceptive surveillance, unspecified

V25.41 Contraceptive pill

V25.42 Intrauterine contraceptive device

Checking of intrauterine device

Excludes: insertion or removal of intrauterine contraceptive device (V25.11-V25.13)

presence of intrauterine contraceptive device as incidental finding (V45.5)

V25.43 Implantable subdermal contraceptive

V25.49 Other contraceptive method

V25.5 Insertion of implantable subdermal contraceptive

V25.8 Other specified contraceptive management

Postvasectomy sperm count

Excludes: sperm count following sterilization reversal (V26.22)

sperm count for fertility testing (V26.21)

V25.9 Unspecified contraceptive management

V26 Procreative management

V26.0 Tuboplasty or vasoplasty after previous sterilization

V26.1 Artificial insemination

V26.2 Investigation and testing

Excludes: postvasectomy sperm count (V25.8)

V26.21 Fertility testing

Fallopian insufflation

Sperm count for fertility testing

Excludes: genetic counseling and testing (V26.31-V26.39)

V26.22 Aftercare following sterilization reversal

Fallopian insufflation following sterilization reversal

Sperm count following sterilization reversal

V26.29 Other investigation and testing

V26.3 Genetic counseling and testing

Excludes: fertility testing (V26.21)

nonprocreative genetic screening (V82.71, V82.79)

V26.31 Testing of female genetic disease carrier status

V26.32 Other genetic testing of female

Use additional code to identify recurrent pregnancy loss (629.81, 646.3)

V26.33 Genetic counseling

V26.34 Testing of male for genetic disease carrier status

V26.35 Encounter for testing of male partner of female with recurrent pregnancy loss

V26.39 Other genetic testing of male

V26.4 General counseling and advice

V26.41 Procreative counseling and advice using natural family planning

V26.42 Encounter for fertility preservation counseling

Encounter for fertility preservation counseling prior to cancer therapy

Encounter for fertility preservation counseling prior to surgical removal of gonads

V26.49 Other procreative management counseling and advice

V26.5 Sterilization status

V26.51 Tubal ligation status

Excludes: infertility not due to previous tubal ligation (628.0-628.9)

V26.52 Vasectomy status

V26.8 Other specified procreative management

V26.81 Encounter for assisted reproductive fertility procedure cycle

Patient undergoing in vitro fertilization cycle

Use additional code to identify the type of infertility

Excludes: pre-cycle diagnosis and testing - code to reason for encounter

V26.82 Encounter for fertility preservation procedure

Encounter for fertility preservation procedure prior to cancer therapy

Encounter for fertility preservation procedure prior to surgical removal of gonads

V26.89 Other specified procreative management

V26.9 Unspecified procreative management

V27 Outcome of delivery

Note: This category is intended for the coding of the outcome of delivery on the mother's record.

V27.0 Single liveborn

V27.1 Single stillborn

V27.2 Twins, both liveborn

V27.3 Twins, one liveborn and one stillborn

V27.4 Twins, both stillborn

V27.5 Other multiple birth, all liveborn

V27.6 Other multiple birth, some liveborn

V27.7 Other multiple birth, all stillborn

V27.9 Unspecified outcome of delivery

routine prenatal care (V22.0-V23.9)

V28 Encounter for antenatal screening of mother

Excludes: abnormal findings on screening- code to findings

suspected fetal conditions affecting management of pregnancy (655.00-655.93, 656.00-656.93, 657.00-657.03, 658.00-658.93)

suspected fetal conditions not found (V89.01-V89.09)

V28.0 Screening for chromosomal anomalies by amniocentesis

V28.1 Screening for raised alpha-fetoprotein levels in amniotic fluid

V28.2 Other screening based on amniocentesis

V28.3 Encounter for routine screening for malformation using ultrasonics

Encounter for routine fetal ultrasound NOS

Excludes: encounter for fetal anatomic survey (V28.81)

genetic counseling and testing (V26.31-V26.39)

V28.4 Screening for fetal growth retardation using ultrasonics

V28.5 Screening for isoimmunization

V28.6 Screening for Streptococcus B

V28.8 Other specified antenatal screening

V28.81 Encounter for fetal anatomic survey

V28.82 Encounter for screening for risk of pre-term labor

V28.89 Other specified antenatal screening

Chorionic villus sampling

Genomic screening

Nuchal translucency testing

Proteomic screening

V28.9 Unspecified antenatal screening

V29 Observation and evaluation of newborns for suspected condition not found

Note: This category is to be used for newborns, within the neonatal period (the first 28 days of life), who are suspected of having an abnormal condition resulting from exposure from the mother or the birth process, but without signs or symptoms, and which, after examination and observation, is found not to exist.

Excludes: suspected fetal conditions not found (V89.01-V89.09)

V29.0 Observation for suspected infectious condition

V29.1 Observation for suspected neurological condition

V29.2 Observation for suspected respiratory condition

V29.3 Observation for suspected genetic or metabolic condition

V29.8 Observation for other specified suspected condition

V29.9 Observation for unspecified suspected condition

LIVEBORN INFANTS ACCORDING TO TYPE OF BIRTH (V30-V39)

Note: These categories are intended for the coding of liveborn infants who are consuming health care [e.g., crib or bassinet occupancy].

The following fourth-digit subdivisions are for use with categories V30-V39:

0 Born in hospital

1 Born before admission to hospital

2 Born outside hospital and not hospitalized

The following two fifths-digits are for use with the fourth-digit .0, Born in hospital:

0 delivered without mention of cesarean delivery

1 delivered by cesarean delivery

V30 Single liveborn

V31 Twin, mate liveborn

V32 Twin, mate stillborn

V33 Twin, unspecified

V34 Other multiple, mates all liveborn

V35 Other multiple, mates all stillborn

V36 Other multiple, mates live- and stillborn

V37 Other multiple, unspecified

V39 Unspecified



PERSONS WITH A CONDITION INFLUENCING THEIR HEALTH STATUS (V40-V49)

Note: These categories are intended for use when these conditions are recorded as "diagnoses" or "problems."

V40 Mental and behavioral problems

V40.0 Problems with learning

V40.1 Problems with communication [including speech]

V40.2 Other mental problems

V40.3 Other behavioral problems

V40.31 Wandering in diseases classified elsewhere

Code first underlying disorder such as:

Alzheimer's disease (331.0)

autism or pervasive developmental disorder (299.0-299.9)

dementia, unspecified, with behavioral disturbance (294.21)

intellectual disabilities (317-319)

V40.39 Other specified behavioral problem

V40.9 Unspecified mental or behavioral problem

V41 Problems with special senses and other special functions

V41.0 Problems with sight

V41.1 Other eye problems

V41.2 Problems with hearing

V41.3 Other ear problems

V41.4 Problems with voice production

V41.5 Problems with smell and taste

V41.6 Problems with swallowing and mastication

V41.7 Problems with sexual function

Excludes: marital problems (V61.10)

psychosexual disorders (302.0-302.9)

V41.8 Other problems with special functions

V41.9 Unspecified problem with special functions

V42 Organ or tissue replaced by transplant

Includes: homologous or heterologous (animal) (human) transplant organ status

V42.0 Kidney

V42.1 Heart

V42.2 Heart valve

V42.3 Skin

V42.4 Bone

V42.5 Cornea

V42.6 Lung

V42.7 Liver

V42.8 Other specified organ or tissue

V42.81 Bone marrow

V42.82 Peripheral stem cells

V42.83 Pancreas

V42.84 Intestines

V42.89 Other

V42.9 Unspecified organ or tissue

V43 Organ or tissue replaced by other means

Includes: organ or tissue assisted by other means

replacement of organ by:

artificial device

mechanical device

prosthesis

Excludes: cardiac pacemaker in situ (V45.01)

fitting and adjustment of prosthetic device (V52.0-V52.9)

renal dialysis status (V45.11)

V43.0 Eye globe

V43.1 Lens

Pseudophakos

V43.2 Heart

V43.21 Heart assist device

V43.22 Fully implantable artificial heart

V43.3 Heart valve

V43.4 Blood vessel

V43.5 Bladder

V43.6 Joint

V43.60 Unspecified joint

V43.61 Shoulder

V43.62 Elbow

V43.63 Wrist

V43.64 Hip

V43.65 Knee

V43.66 Ankle

V43.69 Other

V43.7 Limb

V43.8 Other organ or tissue

V43.81 Larynx

V43.82 Breast

V43.83 Artificial skin

V43.89 Other

V44 Artificial opening status

Excludes: artificial openings requiring attention or management (V55.0-V55.9)

V44.0 Tracheostomy

V44.1 Gastrostomy

V44.2 Ileostomy

V44.3 Colostomy

V44.4 Other artificial opening of gastrointestinal tract

V44.5 Cystostomy

V44.50 Cystostomy, unspecified

V44.51 Cutaneous-vesicostomy

V44.52 Appendico-vesicostomy

V44.59 Other cystostomy

V44.6 Other artificial opening of urinary tract

Nephrostomy

Ureterostomy

Urethrostomy

V44.7 Artificial vagina

V44.8 Other artificial opening status

V44.9 Unspecified artificial opening status

V45 Other postprocedural states

Excludes: aftercare management (V51-V58.9)

malfunction or other complication - code to condition

V45.0 Cardiac device in situ

Excludes: artificial heart (V43.22)

heart assist device (V43.21)

V45.00 Unspecified cardiac device

V45.01 Cardiac pacemaker

Excludes: cardiac defibrillator with synchronous cardiac pacemaker (V45.02)

V45.02 Automatic implantable cardiac defibrillator

With synchronous cardiac pacemaker

V45.09 Other specified cardiac device

Carotid sinus pacemaker in situ

V45.1 Renal dialysis status

Excludes: admission for dialysis treatment or session (V56.0)

V45.11 Renal dialysis status

Hemodialysis status

Patient requiring intermittent renal dialysis

Peritoneal dialysis status

Presence of arterial-venous shunt (for dialysis)

V45.12 Noncompliance with renal dialysis

V45.2 Presence of cerebrospinal fluid drainage device

Cerebral ventricle (communicating) shunt, valve, or device in situ

Excludes: malfunction (996.2)

V45.3 Intestinal bypass or anastomosis status

Excludes: bariatric surgery status (V45.86)

gastric bypass status (V45.86)

obesity surgery status (V45.86)

V45.4 Arthrodesis status

V45.5 Presence of contraceptive device

V45.51 Intrauterine contraceptive device

Excludes: checking of device (V25.42)

complication from device (996.32)

insertion and removal of device (V25.11-V25.13)

V45.52 Subdermal contraceptive implant

V45.59 Other

V45.6 States following surgery of eye and adnexa

Excludes: aphakia (379.31)

artificial eye globe (V43.0)

V45.61 Cataract extraction status

Use additional code for associated artifical lens status (V43.1)

V45.69 Other states following surgery of eye and adnexa

V45.7 Acquired absence of organ

V45.71 Acquired absence of breast and nipple

Excludes: congenital absence of breast and nipple (757.6)

V45.72 Acquired absence of intestine (large) (small)

V45.73 Acquired absence of kidney

V45.74 Other parts of urinary tract

Bladder

V45.75 Stomach



V45.76 Lung

V45.77 Genital organs

Excludes: acquired absence of cervix and uterus (V88.01-V88.03)

female genital mutilation status (629.20-629.29)

V45.78 Eye

V45.79 Other acquired absence of organ

Excludes: acquired absence of pancreas (V88.11-V88.12)

V45.8 Other postprocedural status

V45.81 Aortocoronary bypass status

V45.82 Percutaneous transluminal coronary angioplasty status

V45.83 Breast implant removal status

V45.84 Dental restoration status

Dental crowns status

Dental fillings status

V45.85 Insulin pump status

V45.86 Bariatric surgery status

Gastric banding status

Gastric bypass status for obesity

Obesity surgery status

Excludes: bariatric surgery status complicating pregnancy, childbirth or the puerperium (649.2)

intestinal bypass or anastomosis status (V45.3)

V45.87 Transplanted organ removal status

Transplanted organ previously removed due to complication, failure, rejection or infection

Excludes: encounter for removal of transplanted organ - code to complication of transplanted organ (996.80-996.89)

V45.88 Status post administration of tPA (rtPA) in a different facility within the last 24 hours prior to admission to the current facility

Code first condition requiring tPA administration, such as:

acute cerebral infarction (433.0-433.9 with fifth-digit 1, 434.0-434.9 with fifth digit 1)

acute myocardial infarction (410.00-410.92)

V45.89 Other

Presence of neuropacemaker or other electronic device

Excludes: artificial heart valve in situ (V43.3)

vascular prosthesis in situ (V43.4)

V46 Other dependence on machines and devices

V46.0 Aspirator

V46.1 Respirator [Ventilator]

Iron lung

V46.11 Dependence on respirator, status

V46.12 Encounter for respirator dependence during power failure

V46.13 Encounter for weaning from respirator [ventilator]

V46.14 Mechanical complication of respirator [ventilator]

Mechanical failure of respirator [ventilator]

V46.2 Supplemental oxygen

Long-term oxygen therapy

V46.3 Wheelchair dependence

Wheelchair confinement status

Code first cause of dependence, such as:

muscular dystrophy (359.1)

obesity (278.00-278.03)

V46.8 Other enabling machines

Hyperbaric chamber

Possum [Patient-Operated-Selector-Mechanism]

Excludes: cardiac pacemaker (V45.0)

kidney dialysis machine (V45.11)

V46.9 Unspecified machine dependence

V47 Other problems with internal organs

V47.0 Deficiencies of internal organs

V47.1 Mechanical and motor problems with internal organs

V47.2 Other cardiorespiratory problems

Cardiovascular exercise intolerance with pain (with):

at rest


less than ordinary activity

ordinary activity

V47.3 Other digestive problems

V47.4 Other urinary problems

V47.5 Other genital problems

V47.9 Unspecified

V48 Problems with head, neck, and trunk

V48.0 Deficiencies of head

Excludes: deficiencies of ears, eyelids, and nose (V48.8)

V48.1 Deficiencies of neck and trunk

V48.2 Mechanical and motor problems with head

V48.3 Mechanical and motor problems with neck and trunk

V48.4 Sensory problem with head

V48.5 Sensory problem with neck and trunk

V48.6 Disfigurements of head

V48.7 Disfigurements of neck and trunk

V48.8 Other problems with head, neck, and trunk

V48.9 Unspecified problem with head, neck, or trunk

V49 Other conditions influencing health status

V49.0 Deficiencies of limbs

V49.1 Mechanical problems with limbs

V49.2 Motor problems with limbs

V49.3 Sensory problems with limbs

V49.4 Disfigurements of limbs

V49.5 Other problems of limbs

V49.6 Upper limb amputation status

V49.60 Unspecified level

V49.61 Thumb

V49.62 Other finger(s)

V49.63 Hand

V49.64 Wrist

Disarticulation of wrist

V49.65 Below elbow

V49.66 Above elbow

Disarticulation of elbow

V49.67 Shoulder

Disarticulation of shoulder

V49.7 Lower limb amputation status

V49.70 Unspecified level

V49.71 Great toe

V49.72 Other toe(s)

V49.73 Foot

V49.74 Ankle

Disarticulation of ankle

V49.75 Below knee

V49.76 Above knee

Disarticulation of knee

V49.77 Hip

Disarticulation of hip

V49.8 Other specified conditions influencing health status

V49.81 Asymptomatic postmenopausal status (age-related) (natural)

Excludes: menopausal and premenopausal disorders (627.0-627.9)

postsurgical menopause (256.2)

premature menopause (256.31)

symptomatic menopause(627.0-627.9)

V49.82 Dental sealant status

V49.83 Awaiting organ transplant status

V49.84 Bed confinement status

V49.85 Dual sensory impairment

Blindness with deafness

Combined visual hearing impairment

Code first

hearing impairment (389.00-389.9)

visual impairment (369.00-369.9)

V49.86 Do not resuscitate status

V49.87 Physical restraints status

Excludes: restraint due to a procedure - omit code

V49.89 Other specified conditions influencing health status

V49.9 Unspecified

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