Professional Documents
Culture Documents
UPDATED 2005
Page 1 OF 27
UPDATED 2005
1. A healthy patient visits the physician for a routine check-up. Principle Diagnosis Routine general medical examination at a health care facility (V70.0) Second Diagnosis (none leave blank) Third Diagnosis (none - leave blank) 2. A patient with a long history of hypertension is diagnosed with arteriosclerosis. During the visit, the patient asks the physician to look at a mole on her arm. Principle diagnosis: Artherosclerosis (440) Second diagnosis: Essential hypertension (401.9) Third diagnosis: Benign neoplasm of skin (216) 3. A woman goes in for a routine prenatal care visit for a second pregnancy. While she is there, she complains of a sore throat. Principle diagnosis: Supervision of other normal pregnancy (V22.1) Second diagnosis: (none leave blank) Third diagnosis: Acute pharyngitis (462) 4. A child comes into the office with an open wound on his ankle caused by getting his foot caught in the spokes of a bicycle. Principle diagnosis: Open wound of knee, leg and ankle (891.0) Second diagnosis: Pedal cycle accident (E826.1) Third diagnosis: (none leave blank) 5. A patient goes to the physician 10 days after having ligation of her varicose veins. The physician diagnoses post-op cellulitis. A swab shows Staphylococcus Aureus. Principle Diagnosis Postoperative infection (998.5) Second Diagnosis Cellulitis of the leg (682.6) Third Diagnosis Staphylococcus (041.1) 6. A patient is diagnosed with dementia in Alzheimers Disease. Principle Diagnosis Dementia in conditions classified elsewhere (294.1) Second Diagnosis Alzheimers Disease (331.0) Third Diagnosis (none leave blank) 7. A patient is diagnosed with chronic renal failure secondary to glomerulonephritis with hypertension. Principle Diagnosis Hypertensive Renal Disease not specified as malignant or benign (403.9) Second Diagnosis Chronic Glomerulonephritis (582.9) Third Diagnosis (none leave blank)
Page 2 OF 27
UPDATED 2005
The International Classification of Diseases Revision Conference, which is an international meeting of experts on disease and related health problem reporting, has provided the following guidelines for recording diagnostic information: 1. The health care practitioner should select the main condition to be recorded, as well as any other conditions, for each episode of health care. 2. Each diagnostic statement should be as informative as possible in order to classify the condition to the most specific ICD category. 3. If no definite diagnosis has been established by the end of an episode of health care, then the information that permits the greatest degree of specificity and knowledge about the condition that necessitated care or investigation should be recorded. 4. Episodes of health care may occur when someone who may not currently be sick requires or receives limited services. The details of the circumstances should be recorded as the main condition (e.g. immunization). 5. Where an episode of health care concerns a number of related conditions, the one that is clearly more severe and demanding of resources should be recorded as the "main" condition. Where no one condition predominates, a term incorporating multiple conditions (e.g. multiple fractures) may be recorded as the "main" condition. 6. When a condition of external causes is recorded, it is important to describe both the nature of the condition and the circumstances that gave rise to it. (e.g. open wound of the chin - patient fell from bicycle and hit chin on the curb). 7. Where an episode of care concerns a residual condition of a disease that is no longer present, the sequela should be fully described and its origin stated with a clear indication that the disease is no longer present. NOTE: Contact the Teleplan Helpdesk with questions concerning the coding and submission of diagnostic codes:
TELEPLAN HELPDESK
Victoria tel: 952-2668 all other areas of BC tel: 1-800-663-7206
Page 3 OF 27
UPDATED 2005
Circulatory System
Respiratory System
Genitourinary System
UPDATED 2005
611 616 626 629 682 692 703 706 709 715 719 723 723.0 723.1 724 724.0 724.5 727 728 729 739.1 739.2 739.3 780 781 782 783 784 785 786 787 788 789 840 842 843 844 845 847
Other Disorders of Breast Inflammatory Disease of Cervix, Vagina and Vulva Disorders of Menstruation and Other Abnormal Bleeding from Female Genital Tract Other Disorders of Female Genital Organs Other Cellulitis and Abscess Contact Dermatitis and Other Eczema Diseases of Nail Diseases of Sebaceous Glands Other Disorders of Skin and Subcutaneous Tissue Osteoarthrosis and Allied Disorders Other and Unspecified Disorder of Joint Other Disorders of Cervical Region Other Disorders of Cervical Region - Spinal Stenosis in Cervical Region Other Disorders of Cervical Region -Cervicalgia Other and Unspecified Disorders of Back Other and Unspecified Disorders of Back - Spinal Stenosis other than Cervical Other and Unspecified Disorders of Back - Backache Unspecified Other Disorders of Synovium, Tendon and Bursa Disorders of Muscle, Ligament and Fascia Other Disorders of Soft Tissues Nonallopathic Lesions, Not Elsewhere Classified - Cervical Region Nonallopathic Lesions, Not Elsewhere Classified - Thoracic Region Nonallopathic Lesions, Not Elsewhere Classified - Lumbar Region General Symptoms Symptoms Involving Nervous and Musculoskeletal Systems Symptoms Involving Skin and Other Integumentary Tissue Symptoms Concerning Nutrition, Metabolism and Development Symptoms Involving Head and Neck Symptoms Involving Cardiovascular System Symptoms Involving Respiratory System and Other Chest Symptoms Symptoms Involving Digestive System Symptoms Involving Urinary System Other Symptoms Involving Abdomen and Pelvis Sprains and Strains of Shoulder and Upper Arm Sprains and Strains of Wrist and Hand Sprains and Strains of Hip and Thigh Sprains and Strains of Knee and Leg Sprains and Strains of Ankle and Foot Sprains and Strains of Other and Unspecified Parts of Back
Page 5 OF 27
UPDATED 2005
Sprains and Strains of Other and Unspecified Parts of Back Neck Sprains and Strains of Other and Unspecified Parts of Back Lumbar Injury, Other and Unspecified Complications of Medical Care, Not Elsewhere Classified
Page 6 OF 27
UPDATED 2005
043
043.0 043.1 043.2 043.3 043.9
044
044.0 044.9
011
011.0 011.1 011.2 011.3 011.4 011.5 011.6 011.7 011.8 011.9
Pulmonary Tuberculosis
Tuberculosis of Lung, Infiltrative Tuberculosis of Lung, Nodular Tuberculosis of Lung With Cavitation Tuberculosis of Bronchus Tuberculous Fibrosis of Lung Tuberculous Bronchiectasis Tuberculous Pneumonia (Any Form) Tuberculous Pneumothorax Other Pulmonary Tuberculosis Unspecified
012
012.0 012.8
UPDATED 2005
017
017.8
018
018.0 018.8 018.9
Miliary Tuberculosis
Acute Other Unspecified
031
031.0
039
039.1
Actinomycotic Infections
Pulmonary
041
041.3 041.5
112
112.4
Candidiasis
Of Lung
114 115
115.0 115.1 115.9
Coccidioidomycosis Histoplasmosis
Infection by Histoplasma Capsulatum Infection by Histoplasma Duboisii Unspecified
117
117.3
Other Mycoses
Aspergillosis
136
136.3
162
162.9
382
382.9
386
386.3
415
415.1
416
416.0
461
461.0 461.1 461.2 461.3 461.8 461.9
Acute Sinusitis
Maxillary Frontal Ethmoidal Sphenoidal Other Unspecified
Page 8 OF 27
UPDATED 2005
462 465
465.0 465.8 465.9
466
466.0
473
473.0 473.1 473.2 473.3 473.8 473.9
Chronic Sinusitis
Maxillary Frontal Ethmoidal Sphenoidal Other Unspecified
478
478.2 478.5
480
480.0 480.1 480.2 480.8 480.9
Viral Pneumonia
Pneumonia due to Adenovirus Pneumonia due to Respiratory Syncytial Virus Pneumonia due to Parainfluenza Virus Pneumonia due to Other Virus, Not Elsewhere Classified Viral Pneumonia, Unspecified
481 482
482.0 482.1 482.2 482.3 482.4 482.8 482.9
Pneumonia due to Other Specified Organism Bronchopneumonia, Organism Unspecified Pneumonia, Organism Unspecified Bronchitis, Not Specified as Acute or Chronic Pneumonitis due to Solids and Liquids
Due to Inhalation of Food or Vomit
510
510.0 510.9
Empyema
With Fistula Without Mention of Fistula
Page 9 OF 27
UPDATED 2005
511
511.0 511.1 511.8 511.9
Pleurisy
Without Mention of Effusion or Current Tuberculosis With Effusion, with Mention of a Bacterial Cause Other Than Tuberculosis Other Specified Forms of Effusion, Except Tuberculosis Unspecified Pleural Effusion
512 513
513.0
515 516
516.0 516.2 516.3 516.8 516.9
518
518.0 518.3 518.8
519
519.8
786
786.0 786.3
799
799.1
036
036.0 036.2
Meningococcal Infection
Meningococcal Meningitis Meningococcaemia
046
046.3 046.8 046.9
047
047.0 047.1 047.8 047.9
UPDATED 2005
049
049.8 049.9
053
053.0 053.1
Herpes Zoster
With Meningitis With Other Nervous System Complications
054
054.3
Herpes Simplex
Herpetic Meningoencephalitis
094
094.8 094.9
Neurosyphilis
Other Unspecified
117
117.5
Other Mycoses
Cryptococcosis
130 239
239.6
320
320.0 320.1 320.2 320.3 320.8 320.9
Bacterial Meningitis
Haemophilus Meningitis Pneumococcal Meningitis Streptococcal Meningitis Staphylococcal Meningitis Meningitis due to Other Specified Bacteria Meningitis due to Unspecified Bacterium
322
322.9
323
323.8 323.9
007
007.1 007.2
008
008.0 008.1
Page 11 OF 27
UPDATED 2005
Aerobacter Aerogenes Proteus (Mirabilis) (Morganii) Other Specified Bacteria Bacterial Enteritis, Unspecified Enteritis due to Specified Virus Other Organism, Not Elsewhere Classified
009
009.0 009.1 009.2 009.3
054
054.2
Herpes Simplex
Herpetic Gingivostomatitis
070
070.0 070.1 070.2 070.3 070.4 070.5 070.6 070.9
Viral Hepatitis
Viral Hepatitis A with Hepatic Coma Viral Hepatitis A without Mention of Hepatic Coma Viral Hepatitis B with Hepatic Coma Viral Hepatitis B without Mention of Hepatic Coma Other Specified Viral Hepatitis With Hepatic Coma Other Specified Viral Hepatitis Without Mention of Hepatic Coma Unspecified Viral Hepatitis with Hepatic Coma Unspecified Viral Hepatitis without Mention Of Hepatic Coma
112
112.0 112.8 112.9
Candidiasis
Of Mouth Of Other Sites Of Unspecified Site
127
127.2
145
145.5
159
159.0 159.9
Kwashiorkor Nutritional Marasmus Other Severe Protein-Calorie Malnutrition Other And Unspecified Protein-Calorie Malnutrition
Malnutrition of Moderate Degree Malnutrition of Mild Degree Other Protein-Calorie Malnutrition Unspecified
264
264.8
Vitamin A Deficiency
Other Manifestations Of Vitamin A Deficiency
Page 12 OF 27
UPDATED 2005
264.9
Unspecified
265
265.0 265.1 265.2
266
266.0 266.1 266.2 266.9
267 268
268.0 268.9
269
269.0 269.1 269.2 269.3 269.8 269.9
276
276.0 276.1 276.2 276.3 276.4 276.5 276.6 276.7 276.8 276.9
530
530.1
Diseases Of Oesophagus
Oesophagitis
558 565
565.0 565.1
566 567
567.2
569
569.4
UPDATED 2005
571
571.4 571.5 571.6 571.8 571.9
572
572.8
573
573.3 573.8 573.9
576
576.1 576.2
577
577.0 577.1
Diseases of Pancreas
Acute Pancreatitis Chronic Pancreatitis
578
578.9
Gastrointestinal Haemorrhage
Haemorrhage of Gastrointestinal Tract, Unspecified
579
579.9
Intestinal Malabsorption
Unspecified
780
780.7
General Symptoms
Malaise And Fatigue
782
782.4 783 783.2
787
787.0 787.2
789
789.0 789.1 789.3 789.5
799
799.4
Page 14 OF 27
UPDATED 2005
Herpes Zoster
With Ophthalmic Complications
054
054.4
Herpes Simplex
With Ophthalmic Complications
078
078.5
360
360.0
361
361.9
362
362.1 362.2 362.3 362.4 362.5 362.6 362.8 362.9
363
363.0 363.1 363.2
369
369.0 369.1 369.6 369.9
372
372.0 372.1 372.2 372.3 372.4 372.5 372.6 372.7 372.8 372.9
Disorders Of Conjunctiva
Acute Conjunctivitis Chronic Conjunctivitis Blepharoconjunctivitis Other and Unspecified Conjunctivitis Pterygium Conjunctival Degenerations and Deposits Conjunctival Scars Conjunctival Vascular Disorders and Cysts Other Disorders of Conjunctiva Unspecified
379
379.2
UPDATED 2005
031
031.8 031.9
038
038.0 038.1 038.2 038.3 038.4 038.8 038.9
Septicaemia
Streptococcal Septicaemia Staphylococcal Septicaemia Pneumococcal Septicaemia Septicaemia due to Anaerobes Septicaemia Ddue to Other Gram-Negative Organisms Other Specified Septicaemias Unspecified Septicaemia
075 112
112.5
200
200.0 200.1 200.2 200.8
202
202.0 202.8 202.9
293
293.0 293.1 293.8 293.9
Page 16 OF 27
UPDATED 2005
294
294.1 294.8 294.9
296
296.0 296.2 296.4 296.5 296.6
Affective Psychoses
Manic-Depressive Psychosis, Manic Type Manic-Depressive Psychosis, Circular Type But Currently Manic Manic-Depressive Psychosis, Circular Type, Mixed Manic-Depressive Psychosis, Circular Type, Current Condition Not Specified Manic-Depressive Psychosis, Other and Unspecified
298
298.8 298.9
300
300.0 300.4
Neurotic Disorders
Anxiety States Neurotic Depression
310
310.1 310.9
311 331
331.8 331.9
348
348.3
195
195.8
199
199.1
421
421.0 421.9
422
422.9
Acute Myocarditis
Other and Unspecified Acute Myocarditis
424
424.9
Page 17 OF 27
UPDATED 2005
425
425.4 425.9
Cardiomyopathy
Other Primary Cardiomyopathies Secondary Cardiomyopathy, Unspecified
780
780.6
General Symptoms
Pyrexia of Unknown Origin
785
785.6
Page 18 OF 27
UPDATED 2005
290
290.0
290.1
Presenile dementia
Senile dementia, depressed or paranoid type Senile dementia with acute confusional state Arteriosclerotic dementia Other
Vascular dementia Dementia due to head trauma; Dementia due to (Indicate the General Medical Condition) Dementia NOS Alcohol withdrawal delirium Alcohol-induced persisting amnesic disorder Alcohol-induced persisting dementia Alcohol-induced psychotic disorder, with hallucinations Alcohol-induced psychotic disorder, with delusions Alcohol-induced sleep disorder, mood disorder, anxiety disorder, sexual dysfunction; Alcohol withdrawal Alcohol-related disorder NOS Withdrawal state due to psychoactive substance abuse, with or without delirium Psychoactive substance-induced psychotic disorder, with hallucination or delusion
290.9
Unspecified
291
291.0 291.1 291.2 291.3 291.4 291.5 291.8
Alcoholic psychoses
Delerium tremens Korsakov's psychosis, alcoholic Other alcoholic dementia Other alcoholic hallucinosis Pathological drunkenness Alcoholic jealousy Other
291.9
Unspecified
292
292.0 292.1
Drug psychoses
Drug withdrawal syndrome Paranoid and/or hallucinatory states induced by drugs
Page 19 OF 27
UPDATED 2005
Psychoactive substance-related disorders NOS Delirium NOS Delirium due to (Indicate the general medical condition); Delirium NOS Psychotic disorder due to (Indicate the general medical condition); Catatonic disorder due to (Indicate the general medical condition) Cognitive disorder NOS due to (Indicate the general medical condition); Delirium NOS; Mental disorder NOS due to (Indicate the general medical condition) Psychoactive substance-induced persisting amnestic disorder; Amnestic disorder due to (Indicate the general medical condition) Dementia due to HIV disease, head trauma, Parkinsons disease, or Huntingtons disease; Dementia due to (Indicate the general medical condition) Psychotic disorder due to (Indicate the general medical condition) Cognitive disorder NOS; Mental disorder NOS due to (Indicate the general medical condition) Schizophrenia Schizophrenia, catatonic type Schizophrenia, paranoid type Schizophreniform disorder Schizotypal personality disorder Schizophrenia, residual type Schizoaffective disorder Schizophreniform disorder Schizophreniform disorder Bipolar I disorder, manic episode mild,
Page 20 OF 27
293
293.0 293.1
293.8
Other
293.9
Unspecified
294
294.0
294.1
294.8 294.9
Other Unspecified
295
295.0 295.1 295.2 295.3 295.4 295.5 295.6 295.7 295.8 295.9
Schizophrenic psychoses
Simple type Hebephrenic type Catatonic type Paranoid type Acute schizophrenic episode Latent schizophrenia Residual schizophrenia Schizoaffective type Other Unspecified
296
296.0
Affective psychoses
Manic-depressive psychosis, manic
UPDATED 2005
ICD9 Code
ICD9 Description type Manic-depressive psychosis, depressed type Manic-depressive psychosis, circular type but currently manic Manic-depressive psychosis, circular type but currently depressed Manic-depressive psychosis, circular type, mixed
DSM IV Equivalent Description moderate or severe, with or without psychotic features Major depressive disorder, single or recurrent episode severe with or without psychotic features Bipolar I disorder, hypomanic or manic episode mild, moderate or severe, with or without psychotic features Bipolar I disorder, depressed episode mild, moderate or severe, with or without psychotic features Bipolar I disorder, mixed episode mild, moderate, severe with or without psychotic features, in partial remission, in full remission, unspecified Bipolar I disorder, unspecified episode; Bipolar disorder NOS Schizoaffective disorder; Bipolar I disorder, unspecified episode; Bipolar disorder NOS Schizoaffective disorder; Bipolar I disorder, single manic episode, in full remission; Bipolar II disorder Mood disorder NOS Delusional disorder Delusional disorder Delusional disorder Shared psychotic disorder Delusional disorder Delusional disorder Major depressive disorder, single or recurrent episode, severe with or without psychotic features Bipolar I disorder, single manic episode mild, moderate, severe with or without psychotic features, in partial remission, in full remission; Brief psychotic disorder Brief psychotic disorder; Dissociative fugue; Acute stress disorder Shared psychotic disorder;
Page 21 OF 27
296.1
296.2
296.3
296.4
296.5 296.6
Manic-depressive psychosis, circular type, current condition not specified Manic-depressive psychosis, other and unspecified Bipolar affective disorder, unspecified Other
296.7 296.8
296.9
Unspecified
297
297.0 297.1 297.2 297.3 297.8 297.9
Paranoid states
Paranoid state, simple Paranoia Paraphrenia Induced psychosis Other Unspecified
298
298.0
298.1
Excitative type
298.2
Reactive confusion
298.3 298.4
UPDATED 2005
DSM IV Equivalent Description Delusional disorder Brief psychotic disorder Psychotic disorder NOS; Unspecified Mental disorder Retts disorder; Autistic disorder Childhood disintegrative disorder Aspergers syndrome Pervasive developmental disorder; Schizophreniform disorder Agoraphobia without history of panic disorder; Panic disorder with agoraphobia; Panic disorder without agoraphobia; Adjustment disorder, with mixed anxiety and depression; Generalized anxiety disorder NOS; Anxiety disorder NOS Conversion Disorder; Dissociative disorder NOS; Dissociative fugue; Dissociative amnesia Specific phobia; Social phobia Obsessive-compulsive disorder Adjustment disorder, with depressed mood; Major depressive disorder, single or recurrent episode mild; Dysthymic disorder Depersonalization disorder Body dysmorphic disorder; Hypochondriasis Unspecified mental disorder (nonpsychotic) Paranoid personality disorder Cyclothymic disorder; Dysthymic disorder; Narcissistic personality disorder Schizoid personality disorder
299
299.0 299.1 299.8 299.9
300
300.0
Neurotic disorders
Anxiety states
300.1
Hysteria
301
301.0 301.1
Personality disorders
Paranoid personality disorder Affective personality disorder
301.2
Page 22 OF 27
UPDATED 2005
ICD9 Description Explosive personality disorder Anankastic personality disorder Hysterical personality disorder Asthenic personality disorder Personality disorder with predominant sociopathic or asocial manifestation Other personality disorders Unspecified
DSM IV Equivalent Description Borderline personality disorder Obsessive-compulsive personality disorder Histrionic personality disorder Dependent personality disorder Antisocial personality disorder Avoidant personality disorder; Narcissistic personality disorder Personality disorder NOS
303 304
304.0 304.1 304.2 304.3 304.4 304.5 304.6 304.7 304.8 304.9
305
305.0 305.1 305.2 305.3 305.4 305.5 305.6 305.7 305.8 305.9
UPDATED 2005
ICD9 Code
ICD9 Description
306
306.0 306.1 306.2 306.3 306.4 306.5 306.6 306.7 306.8 306.9
307
307.0 307.1 307.2
307.3 307.4
307.5
UPDATED 2005
ICD9 Code
ICD9 Description
DSM IV Equivalent Description Attention-deficit/hyperactivity disorder predominantly inattentive type; Disorder of infancy, childhood, or adolescence NOS
308
308.0 308.1 308.2 308.3 308.4 308.9
309
309.0 309.1 309.2 309.3 309.4 309.8 309.9
Adjustment reaction
Brief depressive reaction Prolonged depressive reaction With predominant disturbance of other emotions With predominant disturbance of conduct With mixed disturbance of emotions and conduct Other Unspecified Frontal lobe syndrome Cognitive or personality change of other type Postconcussional syndrome Other Unspecified
310
310.0 310.1 310.2 310.8 310.9
Cognitive disorder not otherwise specified Anxiety disorder due to (Indicate the general medical condition)
311 312
312.0 312.1 312.2 312.3 312.8
Depressive disorder, not Major depressive disorder, recurrent, elsewhere classified unspecified Disturbance of conduct not elsewhere classified
Unsocialized disturbance of conduct Socialized disturbance of conduct Compulsive conduct disorder Mixed disturbance of conduct and emotions Other Conduct disorder, unspecified onset; Conduct disorder, childhood-onset type; Conduct disorder, adolescent-onset type; Oppositional defiant disorder Disruptive behavior disorder
Page 25 OF 27
312.9
Unspecified
UPDATED 2005
ICD9 Code
ICD9 Description With anxiety and fearfulness With misery and unhappiness
DSM IV Equivalent Description Separation anxiety disorder; Selective mutism; Major depressive disorder, single episode, mild; Adjustment disorder, with depressed mood; Selective mutism Sibling relational problem; Reactive attachment disorder of infancy or early childhood Identity problem
313
313.0 313.1
313.2 313.3
313.8 313.9
314
314.0
314.1
Attention-deficit/hyperactivity disorder NOS Reading disorder Mathematics disorder Phonological disorder; Expressive language disorder; Mixed receptive-expressive language disorder; Communication disorder NOS Developmental coordination disorder
315
315.0 315.1 315.2 315.3
316
317 318
318.0 318.1
Psychic factors associated with (Specified psychological factor) diseases classified elsewhere affecting (Indicate the general medical condition) Mild mental retardation Mild mental retardation Other specified mental retardation
Moderate mental retardation Severe mental retardation Moderate mental retardation Severe mental retardation
Page 26 OF 27
UPDATED 2005
319
Page 27 OF 27