Classification of diseases and injuries



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PERSONS WITHOUT REPORTED DIAGNOSIS ENCOUNTERED DURING EXAMINATION AND INVESTIGATION OF INDIVIDUALS AND POPULATIONS (V70-V82)

Note: Nonspecific abnormal findings disclosed at the time of these examinations are classifiable to categories 790-796.

V70 General medical examination

Use additional code(s) to identify any special screening examination(s) performed (V73.0-V82.9)

V70.0 Routine general medical examination at a health care facility

Health checkup

Excludes: health checkup of infant or child over 28 days old (V20.2)

health supervision of newborn 8 to 28 days old (V20.32)

health supervision of newborn under 8 days old (V20.31)

pre-procedural general physical examination (V72.83)

V70.1 General psychiatric examination, requested by the authority

V70.2 General psychiatric examination, other and unspecified

V70.3 Other medical examination for administrative purposes

General medical examination for:

admission to old age home

adoption

camp


driving license

immigration and naturalization

insurance certification

marriage


prison

school admission

sports competition

Excludes: attendance for issue of medical certificates (V68.0)

pre-employment screening (V70.5)

V70.4 Examination for medicolegal reasons

Blood-alcohol tests

Blood-drug tests

Paternity testing

Excludes: examination and observation following:

accidents (V71.3, V71.4)

assault (V71.6)

rape (V71.5)

V70.5 Health examination of defined subpopulations

Armed forces personnel

Inhabitants of institutions

Occupational health examinations

Pre-employment screening

Preschool children

Prisoners

Prostitutes

Refugees


School children

Students


V70.6 Health examination in population surveys

Excludes: special screening (V73.0-V82.9)

V70.7 Examination of participant in clinical trial

Examination of participant or control in clinical research

V70.8 Other specified general medical examinations

Examination of potential donor of organ or tissue

V70.9 Unspecified general medical examination

V71 Observation and evaluation for suspected conditions not found

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

Note: This category is to be used when persons without a diagnosis are suspected of having an abnormal condition, without signs or symptoms, which requires study, but after examination and observation, is found not to exist. This category is also for use for administrative and legal observation status.

V71.0 Observation for suspected mental condition

V71.01 Adult antisocial behavior

Dyssocial behavior or gang activity in adult without manifest psychiatric disorder

V71.02 Childhood or adolescent antisocial behavior

Dyssocial behavior or gang activity in child or adolescent without manifest psychiatric disorder

V71.09 Other suspected mental condition

V71.1 Observation for suspected malignant neoplasm

V71.2 Observation for suspected tuberculosis

V71.3 Observation following accident at work

V71.4 Observation following other accident

Examination of individual involved in motor vehicle traffic accident

V71.5 Observation following alleged rape or seduction

Examination of victim or culprit

V71.6 Observation following other inflicted injury

Examination of victim or culprit

V71.7 Observation for suspected cardiovascular disease

V71.8 Observation and evaluation for other specified suspected conditions

Excludes: contact with and (suspected) exposure to (potentially) hazardous substances (V15.84-V15.86, V87.0-V87.31)

V71.81 Abuse and neglect

Excludes: adult abuse and neglect (995.80-995.85)

child abuse and neglect (995.50-995.59)

V71.82 Observation and evaluation for suspected exposure to anthrax

V71.83 Observation and evaluation for suspected exposure to other biological agent

V71.89 Other specified suspected conditions

V71.9 Observation for unspecified suspected condition

V72 Special investigations and examinations

Includes: routine examination of specific system

Excludes: general medical examination (V70.0-70.4)

general screening examination of defined populaiton groups (V70.5, V70.6, V70.7)

health supervision of newborn 8 to 28 days old (V20.32)

health supervision of newborn under 8 days old (V20.31)

routine examination of infant or child over 28 days old (V20.2)

Use additional code(s) to identify any special screening examination(s) performed (V73.0-V82.9)

V72.0 Examination of eyes and vision

V72.1 Examination of ears and hearing

V72.11 Encounter for hearing examination following failed hearing screening

V72.12 Encounter for hearing conservation and treatment

V72.19 Other examination of ears and hearing

V72.2 Dental examination

V72.3 Gynecological examination

Excludes: cervical Papanicolaou smear without general gynecological examination (V76.2)

routine examination in contraceptive management (V25.40-V25.49)

V72.31 Routine gynecological examination

General gynecological examination with or without Papanicolaou cervical smear

Pelvic examination (annual) (periodic)

Use additional code to identify:

human papillomavirus (HPV) screening (V73.81)

routine vaginal Papanicolaou smear (V76.47)

V72.32 Encounter for Papanicolaou cervical smear to confirm findings of recent normal smear following initial abnormal smear

V72.4 Pregnancy examination or test

V72.40 Pregnancy examination or test, pregnancy unconfirmed

Possible pregnancy, not (yet) confirmed

V72.41 Pregnancy examination or test, negative result

V72.42 Pregnancy examination or test, positive result

V72.5 Radiological examination, not elsewhere classified

Routine chest x-ray

Excludes: radiologic examinations as part of pre-procedural testing (V72.81-V72.84)

V72.6 Laboratory examination

Encounters for blood and urine testing

V72.60 Laboratory examination, unspecified

V72.61 Antibody response examination

Immunity status testing

Excludes: encounter for allergy testing (V72.7)

V72.62 Laboratory examination ordered as part of a routine general medical examination

Blood tests for routine general physical examination

V72.63 Pre-procedural laboratory examination

Blood tests prior to treatment or procedure

Pre-operative laboratory examination

V72.69 Other laboratory examination

V72.7 Diagnostic skin and sensitization tests

Allergy tests

Skin tests for hypersensitivity

Excludes: diagnostic skin tests for bacterial diseases (V74.0-V74.9)

V72.8 Other specified examinations

Excludes: pre-procedural laboratory examinations (V72.63)

V72.81 Preoperative cardiovascular examination

Pre-procedural cardiovascular examination

V72.82 Preoperative respiratory examination

Pre-procedural respiratory examination

V72.83 Other specified preoperative examination

Examination prior to chemotherapy

Other pre-procedural examination

Pre-procedural general physical examination

Excludes: routine general medical examination (V70.0)

V72.84 Preoperative examination, unspecified

Pre-procedural examination, unspecified

V72.85 Other specified examination

V72.86 Encounter for blood typing

V72.9 Unspecified examination

V73 Special screening examination for viral and chlamydial diseases

V73.0 Poliomyelitis

V73.1 Smallpox

V73.2 Measles

V73.3 Rubella

V73.4 Yellow fever

V73.5 Other arthropod-borne viral diseases

Dengue fever

Hemorrhagic fever

Viral encephalitis:

mosquito-borne

tick-borne

V73.6 Trachoma

V73.8 Other specified viral and chlamydial diseases

V73.81 Human papillomavirus (HPV)

V73.88 Other specified chlamydial diseases

V73.89 Other specified viral diseases

V73.9 Unspecified viral and chlamydial disease

V73.98 Unspecified chlamydial disease

V73.99 Unspecified viral disease

V74 Special screening examination for bacterial and spirochetal diseases

Includes: diagnostic skin tests for these diseases

V74.0 Cholera

V74.1 Pulmonary tuberculosis

V74.2 Leprosy [Hansen's disease]

V74.3 Diphtheria

V74.4 Bacterial conjunctivitis

V74.5 Venereal disease

Screening for bacterial and spirochetal sexually transmitted diseases

Screening for sexually transmitted diseases NOS

Excludes: special screening for nonbacterial sexually transmitted diseases (V73.81-V73.89, V75.4, V75.8)

V74.6 Yaws

V74.8 Other specified bacterial and spirochetal diseases

Brucellosis

Leptospirosis

Plague

Tetanus


Whooping cough

V74.9 Unspecified bacterial and spirochetal disease

V75 Special screening examination for other infectious diseases

V75.0 Rickettsial diseases

V75.1 Malaria

V75.2 Leishmaniasis

V75.3 Trypanosomiasis

Chagas' disease

Sleeping sickness

V75.4 Mycotic infections

V75.5 Schistosomiasis

V75.6 Filariasis

V75.7 Intestinal helminthiasis

V75.8 Other specified parasitic infections

V75.9 Unspecified infectious disease

V76 Special screening for malignant neoplasms

V76.0 Respiratory organs

V76.1 Breast

V76.10 Breast screening, unspecified

V76.11 Screening mammogram for high-risk patient

V76.12 Other screening mammogram

V76.19 Other screening breast examination

V76.2 Cervix

Routine cervical Papanicolaou smear

Excludes: special screening for human papillomavirus (V73.81)

that as part of a general gynecological examination (V72.31)

V76.3 Bladder

V76.4 Other sites

V76.41 Rectum

V76.42 Oral cavity

V76.43 Skin

V76.44 Prostate

V76.45 Testis

V76.46 Ovary

V76.47 Vagina

Vaginal pap smear status-post hysterectomy for non-malignant condition

Use additional code to identify acquired absence of uterus (V88.01-V88.03)

Excludes: vaginal pap smear status-post hysterectomy for malignant condition (V67.01)

V76.49 Other sites

V76.5 Intestine

V76.50 Intestine, unspecified

V76.51 Colon

Screening colonoscopy NOS

Excludes: rectum (V76.41)

V76.52 Small intestine

V76.8 Other neoplasm

V76.81 Nervous system

V76.89 Other neoplasm

V76.9 Unspecified

V77 Special screening for endocrine, nutritional, metabolic, and immunity disorders

V77.0 Thyroid disorders

V77.1 Diabetes mellitus

V77.2 Malnutrition

V77.3 Phenylketonuria [PKU]

V77.4 Galactosemia

V77.5 Gout

V77.6 Cystic fibrosis

Screening for mucoviscidosis

V77.7 Other inborn errors of metabolism

V77.8 Obesity

V77.9 Other and unspecified endocrine, nutritional, metabolic, and immunity disorders

V77.91 Screening for lipoid disorders

Screening cholesterol level

Screening for hypercholesterolemia

Screening for hyperlipidemia

V77.99 Other and unspecified endocrine, nutritional, metabolic, and immunity disorders

V78 Special screening for disorders of blood and blood-forming organs

V78.0 Iron deficiency anemia

V78.1 Other and unspecified deficiency anemia

V78.2 Sickle-cell disease or trait

V78.3 Other hemoglobinopathies

V78.8 Other disorders of blood and blood-forming organs

V78.9 Unspecified disorder of blood and blood-forming organs

V79 Special screening for mental disorders and developmental handicaps

V79.0 Depression

V79.1 Alcoholism

V79.2 Intellectual disabilities

V79.3 Developmental handicaps in early childhood

V79.8 Other specified mental disorders and developmental handicaps

V79.9 Unspecified mental disorder and developmental handicap

V80 Special screening for neurological, eye, and ear diseases

V80.0 Neurological conditions

V80.01 Traumatic brain injury

V80.09 Other neurological conditions

V80.1 Glaucoma

V80.2 Other eye conditions

Screening for:

cataract


congenital anomaly of eye

senile macular lesions

Excludes: general vision examination (V72.0)

V80.3 Ear diseases

Excludes: general hearing examination (V72.11-V72.19)

V81 Special screening for cardiovascular, respiratory, and genitourinary diseases

V81.0 Ischemic heart disease

V81.1 Hypertension

V81.2 Other and unspecified cardiovascular conditions

V81.3 Chronic bronchitis and emphysema

V81.4 Other and unspecified respiratory conditions

Excludes: screening for:

lung neoplasm (V76.0)

pulmonary tuberculosis (V74.1)

V81.5 Nephropathy

Screening for asymptomatic bacteriuria

V81.6 Other and unspecified genitourinary conditions

V82 Special screening for other conditions

V82.0 Skin conditions

V82.1 Rheumatoid arthritis

V82.2 Other rheumatic disorders

V82.3 Congenital dislocation of hip

V82.4 Maternal postnatal screening for chromosomal anomalies

Excludes: antenatal screening by amniocentesis (V28.0)

V82.5 Chemical poisoning and other contamination

Screening for:

heavy metal poisoning

ingestion of radioactive substance

poisoning from contaminated water supply

radiation exposure

V82.6 Multiphasic screening

V82.7 Genetic screening

Excludes: genetic testing for procreative management (V26.31-V26.39)

V82.71 Screening for genetic disease carrier status

V82.79 Other genetic screening

V82.8 Other specified conditions

V82.81 Osteoporosis

Use additional code to identify:

hormone replacement therapy (postmenopausal) status (V07.4)

postmenopausal (natural) status (V49.81)

V82.89 Other specified conditions

V82.9 Unspecified condition



GENETICS (V83-V84)

V83 Genetic carrier status

V83.0 Hemophilia A carrier

V83.01 Asymptomatic hemophilia A carrier

V83.02 Symptomatic hemophilia A carrier

V83.8 Other genetic carrier status

V83.81 Cystic fibrosis gene carrier

V83.89 Other genetic carrier status

V84 Genetic susceptibility to disease

Includes: Confirmed abnormal gene

Use additional code, if applicable, for any associated family history of the disease (V16-V19)

Excludes: chromosomal anomalies (758.0-758.9)

V84.0 Genetic susceptibility to malignant neoplasm

Code first, if applicable, any current malignant neoplasms (140.0-195.8, 200.0-208.9, 230.0-234.9)

Use additional code, if applicable, for any personal history of malignant neoplasm (V10.0-V10.9)

V84.01 Genetic susceptibility to malignant neoplasm of breast

V84.02 Genetic susceptibility to malignant neoplasm of ovary

V84.03 Genetic susceptibility to malignant neoplasm of prostate

V84.04 Genetic susceptibility to malignant neoplasm of endometrium

V84.09 Genetic susceptibility to other malignant neoplasm

V84.8 Genetic susceptibility to other disease

V84.81 Genetic susceptibility to multiple endocrine neoplasia [MEN]

Excludes: multiple endocrine neoplasia [MEN] syndromes (258.01-258.03)

V84.89 Genetic susceptibility to other disease



BODY MASS INDEX (V85)

V85 Body mass index (BMI)

Kilograms per meters squared

Note: BMI adult codes are for use for persons over 20 years old

V85.0 Body Mass Index less than 19, adult

V85.1 Body Mass Index between 19-24, adult

V85.2 Body Mass Index between 25-29, adult

V85.21 Body Mass Index 25.0-25.9, adult

V85.22 Body Mass Index 26.0-26.9, adult

V85.23 Body Mass Index 27.0-27.9, adult

V85.24 Body Mass Index 28.0-28.9, adult

V85.25 Body Mass Index 29.0-29.9, adult

V85.3 Body Mass Index between 30-39, adult

V85.30 Body Mass Index 30.0-30.9, adult

V85.31 Body Mass Index 31.0-31.9, adult

V85.32 Body Mass Index 32.0-32.9, adult

V85.33 Body Mass Index 33.0-33.9, adult

V85.34 Body Mass Index 34.0-34.9, adult

V85.35 Body Mass Index 35.0-35.9, adult

V85.36 Body Mass Index 36.0-36.9, adult

V85.37 Body Mass Index 37.0-37.9, adult

V85.38 Body Mass Index 38.0-38.9, adult

V85.39 Body Mass Index 39.0-39.9, adult

V85.4 Body Mass Index 40 and over, adult

V85.41 Body Mass Index 40.0-44.9, adult

V85.42 Body Mass Index 45.0-49.9, adult

V85.43 Body Mass Index 50.0-59.9, adult

V85.44 Body Mass Index 60.0-69.9, adult

V85.45 Body Mass Index 70 and over, adult

V85.5 Body Mass Index, pediatric

Note: BMI pediatric codes are for use for persons age 2-20 years old. These percentiles are based on the growth charts published by the Centers for Disease Control and Prevention (CDC)

V85.51 Body Mass Index, pediatric, less than 5th percentile for age

V85.52 Body Mass Index, pediatric, 5th percentile to less than 85th percentile for age

V85.53 Body Mass Index, pediatric, 85th percentile to less than 95th percentile for age

V85.54 Body Mass Index, pediatric, greater than or equal to 95th percentile for age

ESTROGEN RECEPTOR STATUS (V86)

V86 Estrogen receptor status

Code first malignant neoplasm of breast (174.0-174.9, 175.0-175.9)

V86.0 Estrogen receptor positive status [ER+]

V86.1 Estrogen receptor negative status [ER-]

OTHER SPECIFIED PERSONAL EXPOSURES AND HISTORY PRESENTING HAZARDS TO HEALTH (V87)

V87 Other specified personal exposures and history presenting hazards to health

V87.0 Contact with and (suspected) exposure to hazardous metals

Excludes: exposure to lead (V15.86)

toxic effect of metals (984.0-985.9)

V87.01 Arsenic

V87.02 Contact with and (suspected) exposure to uranium

Excludes: retained depleted uranium fragments (V90.01)

V87.09 Other hazardous metals

Chromium compounds

Nickel dust

V87.1 Contact with and (suspected) exposure to hazardous aromatic compounds

Excludes: toxic effects of aromatic compounds (982.0, 983.0)

V87.11 Aromatic amines

V87.12 Benzene

V87.19 Other hazardous aromatic compounds

Aromatic dyes NOS

Polycyclic aromatic hydrocarbons

V87.2 Contact with and (suspected) exposure to other potentially hazardous chemicals

Dyes NOS


Excludes: exposure to asbestos (V15.84)

toxic effect of chemicals (980-989)

V87.3 Contact with and (suspected) exposure to other potentially hazardous substances

Excludes: contact with and (suspected) exposure to potentially hazardous body fluids (V15.85)

personal history of retained foreign body fully removed (V15.53)

toxic effect of substances (980-989)

V87.31 Exposure to mold

V87.32 Contact with and (suspected) exposure to algae bloom

V87.39 Contact with and (suspected) exposure to other potentially hazardous substances

V87.4 Personal history of drug therapy

Excludes: long-term (current) drug use (V58.61-V58.69)

V87.41 Personal history of antineoplastic chemotherapy

V87.42 Personal history of monoclonal drug therapy

V87.43 Personal history of estrogen therapy

V87.44 Personal history of inhaled steroid therapy

V87.45 Personal history of systemic steroid therapy

Personal history of steroid therapy NOS

V87.46 Personal history of immunosuppression therapy

Excludes: personal history of steroid therapy (V87.44, V87.45)

V87.49 Personal history of other drug therapy



ACQUIRED ABSENCE OF OTHER ORGANS AND TISSUE (V88)

V88 Acquired absence of other organs and tissue

V88.0 Acquired absence of cervix and uterus

V88.01 Acquired absence of both cervix and uterus

Acquired absence of uterus NOS

Status post total hysterectomy

V88.02 Acquired absence of uterus with remaining cervical stump

Status post partial hysterectomy with remaining cervical stump

V88.03 Acquired absence of cervix with remaining uterus

V88.1 Acquired absence of pancreas

Use additional code to identify any associated:

insulin use (V58.67)

secondary diabetes mellitus (249.00-249.91)

V88.11 Acquired total absence of pancreas

Acquired absence of pancreas NOS

V88.12 Acquired partial absence of pancreas

V88.2 Acquired absence of joint

Acquired absence of joint following prior explantation of joint prosthesis

Joint prosthesis explantation status

V88.21 Acquired absence of hip joint

Acquired absence of hip joint following explantation of joint prosthesis, with or without presence of antibiotic-impregnated cement spacer

V88.22 Acquired absence of knee joint

Acquired absence of knee joint following explantation of joint prosthesis, with or without presence of antibiotic-impregnated cement spacer

V88.29 Acquired absence of other joint

Acquired absence of other joint following explantation of joint prosthesis, with or without presence of antibiotic-impregnated cement spacer

OTHER SUSPECTED CONDITIONS NOT FOUND (V89)

V89 Other suspected conditions not found

V89.0 Suspected maternal and fetal conditions not found

Excludes: known or suspected fetal anomalies affecting management of mother, not ruled out (655.00-655.93, 656.00-656.93, 657.00-657.03, 658.00-658.93)

newborn and perinatal conditions - code to condition

V89.01 Suspected problem with amniotic cavity and membrane not found

Suspected oligohydramnios not found

Suspected polyhydramnios not found

V89.02 Suspected placental problem not found

V89.03 Suspected fetal anomaly not found

V89.04 Suspected problem with fetal growth not found

V89.05 Suspected cervical shortening not found

V89.09 Other suspected maternal and fetal condition not found

RETAINED FOREIGN BODY (V90)

V90 Retained foreign body

Embedded fragment (status)

Embedded splinter (status)

Retained foreign body status

Excludes: artificial joint prosthesis status (V43.60-V43.69)

foreign body accidentally left during a procedure (998.4)

foreign body entering through orifice (930.0-939.9)

in situ cardiac devices (V45.00-V45.09)

organ or tissue replaced by other means (V43.0-V43.89)

organ or tissue replaced by transplant (V42.0-V42.9)

personal history of retained foreign body removed (V15.53)

superficial foreign body (splinter) (categories 910-917 and 919 with 4th character 6 or 7, 918.0)

V90.0 Retained radioactive fragment

V90.01 Retained depleted uranium fragments

V90.09 Other retained radioactive fragments

Other retained depleted isotope fragments

Retained nontherapeutic radioactive fragments

V90.1 Retained metal fragments

Excludes: retained radioactive metal fragments (V90.01-V90.09)

V90.10 Retained metal fragments, unspecified

Retained metal fragment NOS

V90.11 Retained magnetic metal fragments

V90.12 Retained nonmagnetic metal fragments

V90.2 Retained plastic fragments

Acrylics fragments

Diethylhexylphthalates fragments

Isocyanate fragments

V90.3 Retained organic fragments

V90.31 Retained animal quills or spines

V90.32 Retained tooth

V90.33 Retained wood fragments

V90.39 Other retained organic fragments

V90.8 Other specified retained foreign body

V90.81 Retained glass fragments

V90.83 Retained stone or crystalline fragments

Retained concrete or cement fragments

V90.89 Other specified retained foreign body

V90.9 Retained foreign body, unspecified material

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