16. SYMPTOMS, SIGNS, AND ILL-DEFINED CONDITIONS ICD 9 CODES (780-799)
This section includes symptoms, signs, abnormal results of laboratory 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 are assigned to some category in the preceding part of the classification. In general, categories 780-796 include the more ill-defined conditions and symptoms that point with perhaps equal suspicion to two or more diseases or to two or more systems of the body, and without the necessary study of the case to make a final diagnosis. Practically all categories in this group could be designated as "not otherwise specified," or as "unknown etiology," or as "transient." The Alphabetic Index should be consulted to determine which symptoms and signs are to be allocated here and which to more specific sections of the classification; the residual subcategories numbered .9 are provided for other relevant symptoms which cannot be allocated elsewhere in the classification.
The conditions and signs or symptoms included in categories 780-796 consist of: (a) cases for which no more specific diagnosis can be made even after all 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 diagnoses 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 which represent important problems in medical care and which it might be desired to classify in addition to a known cause.
SYMPTOMS (780-789)
Excludes: alteration of consciousness due to:
intracranial injuries (850.0-854.19)
skull fractures (800.00-801.99, 803.00-804.99)
coma:
diabetic (249.2-249.3, 250.2-250.3)
hepatic (572.2)
originating in the perinatal period (779.2)
Drowsiness
Semicoma
Unconsciousness
Somnolence
Stupor
Hallucinations:
NOS
auditory
gustatory
olfactory
tactile
Excludes: those associated with mental disorders, as functional psychoses (295.0-298.9)
organic brain syndromes (290.0-294.9, 310.0-310.9)
visual hallucinations (368.16)
Blackout
Fainting
(Near) (Pre)syncope
Vasovagal attack
Excludes: carotid sinus syncope (337.0)
heat syncope (992.1)
neurocirculatory asthenia (306.2)
orthostatic hypotension (458.0)
shock NOS (785.50)
Excludes: convulsions:
epileptic (345.10-345.91)
in newborn (779.0)
Febrile seizures NOS
Febrile seizure:
atypical
complex
complicated
Excludes: status epilepticus (345.3)
Excludes: post traumatic epilepsy (345.00-345.91)
Convulsive disorder NOS
Fits NOS
Recurrent convulsions NOS
Seizure NOS
Seizures NOS
Light-headedness
Vertigo NOS
Excludes: Ménière's disease and other specified vertiginous syndromes (386.0-386.9)
Excludes: circadian rhythm sleep disorders (327.30-327.39)
organic hypersomnia (327.10-327.19)
organic insomnia (327.00-327.09)
organic sleep apnea (327.20-327.29)
organic sleep related movement disorders (327.51-327.59)
parasomnias (327.40-327.49)
that of nonorganic origin (307.40-307.49)
Excludes: restless legs syndrome (333.94)
Excludes: effects of reduced environmental temperature (991.0-991.9)
effects of heat and light (992.0-992.9)
fever, chills or hypothermia associated with confirmed infection - code to infection
Chills with fever
Fever NOS
Fever of unknown origin (FUO)
Hyperpyrexia NOS
Pyrexia NOS
Pyrexia of unknown origin
Excludes: chills without fever (780.64)
neonatal fever (778.4)
pyrexia of unknown origin (during):
in newborn (778.4)
labor (659.2)
the puerperium (672)
Code firstunderlying condition when associated fever is present, such as with:
leukemia (conditions classifiable to 204-208)
neutropenia (288.00-288.09)
sickle-cell disease (282.60-282.69)
Excludes: posttransfusion fever (780.66)
postvaccination fever (780.63)
Postimmunization fever
Chills NOS
Excludes: chills with fever (780.60)
Excludes: hypothermia:
associated with low environmental temperature (991.6)
due to anesthesia (995.89)
of newborn (778.2, 778.3)
FNHTR
Posttransfusion fever
Excludes: debility, unspecified (799.3)
fatigue (during):
combat (308.0-308.9)
heat (992.6)
pregnancy (646.8)
neurasthenia (300.5)
senile asthenia (797)
Complete immobility due to severe physical disability or frailty
Excludes: hysterical paralysis (300.11)
immobility syndrome (728.3)
neurologic quadriplegia (344.00-344.09)
quadriplegia NOS (344.00)
Asthenia NOS
Lethargy
Postviral (asthenic) syndrome
Tiredness
Diaphoresis
Excessive sweating
Secondary hyperhidrosis
Excludes: focal (localized) (primary) (secondary) hyperhidrosis (705.21-705.22)
Frey's syndrome (705.22)
Excludes: hypothermia:
NOS (accidental) (991.6)
due to anesthesia (995.89)
of newborn (778.2-778.3)
memory disturbance as part of a pattern of mental disorder
Excludes: excessive crying of child, adolescent or adult (780.95)
Amnesia (retrograde)
Memory loss NOS
Excludes: memory loss due to:
intracranial injuries (850.0-854.19)
skull fractures (800.00-801.99, 803.00-804.99)
mild memory disturbance due to organic brain damage (310.89)
transient global amnesia (437.7)
Excludes: excessive crying of infant (baby) (780.92)
Pain NOS
Change in mental status
Excludes: altered level of consciousness (780.01-780.09)
altered mental status due to known condition - code to condition
delirium NOS (780.09)
Excludes: depression NOS (311)
disorders specifically relating to:
back (724.0-724.9)
hearing (388.0-389.9)
joint (718.0-719.9)
limb (729.0-729.9)
neck (723.0-723.9)
vision (368.0-369.9)
pain in limb (729.5)
Abnormal head movements
Fasciculation
Spasms NOS
Tremor NOS
Excludes: abnormal reflex (796.1)
chorea NOS (333.5)
infantile spasms (345.60-345.61)
spastic paralysis (342.1, 343.0-344.9)
specified movement disorders classifiable to 333 (333.0-333.9)
that of nonorganic origin (307.2-307.3)
Anosmia
Parageusia
Parosmia
Gait:
ataxic
paralytic
spastic
staggering
Excludes: ataxia:
NOS (781.3)
difficulty in walking (719.7)
locomotor (progressive) (094.0)
Ataxia NOS
Muscular incoordination
Excludes: ataxic gait (781.2)
cerebellar ataxia (334.0-334.9)
difficulty in walking (719.7)
vertigo NOS (780.4)
Monoplegia, transient NOS
Excludes: paralysis (342.0-344.9)
Dupre's syndrome
Meningism
Carpopedal spasm
Excludes: tetanus neonatorum (771.3)
tetany:
hysterical (300.11)
newborn (hypocalcemic) (775.4)
parathyroid (252.1)
psychogenic (306.0)
Asomatognosia
Hemi-akinesia
Hemi-inattention
Hemispatial neglect
Left-sided neglect
Sensory extinction
Sensory neglect
Visuospatial neglect
Excludes: visuospatial deficit (799.53)
Excludes: osteoporosis (733.00-733.09)
Facial droop
Excludes: facial weakness due to late effect of cerebrovascular accident (438.83)
Excludes: symptoms relating to breast (611.71-611.79)
Anesthesia of skin
Burning or prickling sensation
Hyperesthesia
Hypoesthesia
Numbness
Paresthesia
Tingling
Exanthem
Excludes: vesicular eruption (709.8)
Subcutaneous nodules
Excludes: localized adiposity (278.1)
Anasarca
Dropsy
Localized edema NOS
Excludes: ascites (789.51-789.59)
edema of:
newborn NOS (778.5)
pregnancy (642.0-642.9, 646.1)
fluid retention (276.69)
hydrops fetalis (773.3, 778.0)
hydrothorax (511.81-511.89)
nutritional edema (260, 262)
Cholemia NOS
Icterus NOS
Excludes: jaundice in newborn (774.0-774.7)
due to isoimmunization (773.0-773.2, 773.4)
Excludes: newborn (770.83)
Excessive blushing
Petechiae
Excludes: ecchymosis in fetus or newborn (772.6)
purpura (287.0-287.9)
Induration of skin
Thickening of skin
Loss of appetite
Excludes: anorexia nervosa (307.1)
loss of appetite of nonorganic origin (307.59)
Excludes: excessive weight gain in pregnancy (646.1)
obesity (278.00)
morbid (278.01)
Use additional code to identify Body Mass Index (BMI), if known (V85.0-V85.54)
Feeding problem (elderly) (infant)
Excludes: feeding disturbance or problems:
in newborn (779.31-779.34)
of nonorganic origin (307.50-307.59)
Excludes: delay in sexual development and puberty (259.0)
gonadal dysgenesis (758.6)
pituitary dwarfism (253.3)
slow fetal growth and fetal malnutrition (764.00-764.99)
specific delays in mental development (315.0-315.9)
Inadequate development
Lack of development
Failure to gain weight
Excludes: failure to thrive in newborn (779.34)
Late talker
Late walker
Growth failure
Growth retardation
Lack of growth
Physical retardation
Excessive thirst
Excessive eating
Hyperalimentation NOS
Excludes: disorders of eating of nonorganic origin (307.50-307.59)
Hypometabolism
Excludes: abnormal basal metabolic rate (794.7)
dehydration (276.51)
other disorders of fluid, electrolyte, and acid-base balance (276.0-276.9)
Excludes: encephalopathy NOS (348.30)
specific symptoms involving neck classifiable to 723 (723.0-723.9)
Facial pain
Pain in head NOS
Excludes: atypical face pain (350.2)
migraine (346.0-346.9)
tension headache (307.81)
Excludes: dysphagia (787.20-787.29)
neck pain (723.1)
sore throat (462)
chronic (472.1)
Space-occupying lesion, intracranial NOS
Excludes: aphasia due to late effects of cerebrovascular disease (438.11)
developmental aphasia (315.31)
Loss of voice
Hoarseness
Change in voice
Excludes: speech disorder due to late effect of cerebrovascular accident (438.10-438.19)
stuttering (315.35)
Excludes: dysarthria due to late effect of cerebrovascular accident (438.13)
Stuttering in conditions classified elsewhere
Code first underlying disease or condition, such as:
Parkinson's disease (332.0)
Excludes: adult onset fluency disorder (307.0)
childhood onset fluency disorder (315.35)
fluency disorder due to late effect of cerebrovascular accident (438.14)
Dysphasia
Slurred speech
Speech disturbance NOS
Excludes: developmental learning delays (315.0-315.9)
Alexia (with agraphia)
Acalculia
Agnosia
Agraphia NOS
Apraxia
Hemorrhage from nose
Nosebleed
Excludes: hemoptysis (786.30-786.39)
Mandibular pain
Maxilla pain
Excludes: temporomandibular joint arthralgia (524.62)
Choking sensation
Feeling of foreign body in throat
Halitosis
Mouth breathing
Sneezing
Excludes: foreign body in throat (933.0)
Excludes: heart failure NOS (428.9)
Rapid heart beat
Excludes: neonatal tachycardia (779.82)
paroxysmal tachycardia (427.0-427.2)
Awareness of heart beat
Excludes: specified dysrhythmias (427.0-427.9)
Heart murmur NOS
Cardiac dullness, increased or decreased
Friction fremitus, cardiac
Precordial friction
Gangrene:
NOS
spreading cutaneous
Gangrenous cellulitis
Phagedena
Code first any associated underlying condition
Excludes: gangrene of certain sites - see Alphabetic Index
gangrene with atherosclerosis of the extremities (440.24)
gas gangrene (040.0)
Failure of peripheral circulation
endotoxic
gram-negative
Code first underlying infection
Use additional code, if applicable, to identify systemic inflammatory response syndrome due to infectious process with organ dysfunction (995.92)
Shock:
hypovolemic
Excludes: shock (due to):
anesthetic (995.4)
anaphylactic (995.0)
due to serum (999.41-999.49)
electric (994.8)
following abortion (639.5)
lightning (994.0)
obstetrical (669.1)
postoperative (998.00-998.09)
traumatic (958.4)
Lymphadenopathy
"Swollen glands"
Excludes: lymphadenitis (chronic) (289.1-289.3)
acute (683)
Bruit (arterial)
Weak pulse
Excludes: hyperventilation, psychogenic (306.1)
Excludes: apnea of newborn (770.81, 770.82)
sleep apnea (780.51, 780.53, 780.57)
Excludes: transitory tachypnea of newborn (770.6)
Excludes: asthma (493.00-493.92)
Respiratory:
distress
insufficiency
Excludes: respiratory distress:
following trauma and surgery (518.52)
newborn (770.89)
syndrome (newborn) (769)
adult (518.52)
respiratory failure (518.81, 518.83-518.84)
newborn (770.84)
Excludes: congenital laryngeal stridor (748.3)
Excludes: cough:
psychogenic (306.1)
smokers' (491.0)
with hemorrhage (786.39)
Pulmonary hemorrhage NOS
Acute idiopathic pulmonary hemorrhage in infant over 28 days old
Excludes: pulmonary hemorrhage of newborn under 28 days old (770.3)
von Willebrand's disease (286.4)
Cough with hemorrhage
Abnormal:
amount of sputum
color of sputum
odor of sputum
Excessive sputum
Pain:
anterior chest wall
pleuritic
Pleurodynia
Excludes: epidemic pleurodynia (074.1)
Discomfort in chest
Pressure in chest
Tightness in chest
Excludes: pain in breast (611.71)
Excludes: lump in breast (611.72)
Abnormal percussion, chest
Friction sounds, chest
Rales
Tympany, chest
Excludes: wheezing (786.07)
Excludes: psychogenic hiccough (306.1)
Breath-holding spell
Excludes: constipation (564.0-564.9)
pylorospasm (537.81)
congenital (750.5)
Emesis
Excludes: hematemesis NOS (578.0)
vomiting:
bilious, following gastrointestinal surgery (564.3)
cyclical (536.2)
associated with migraine (346.2)
fecal matter (569.87)
psychogenic (306.4)
excessive, in pregnancy (643.0-643.9)
habit (536.2)
of newborn (779.32, 779.33)
persistent (536.2)
psychogenic NOS (307.54)
Bilious vomiting
Excludes: bilious emesis (vomiting) in newborn (779.32)
Pyrosis
Waterbrash
Excludes: dyspepsia or indigestion (536.8)
Code first, if applicable, dysphagia due to late effect of cerebrovascular accident (438.82)
Difficulty in swallowing NOS
Cervical dysphagia
Neurogenic dysphagia
Abdominal distention (gaseous)
Bloating
Tympanites (abdominal) (intestinal)
Excludes: aerophagy (306.4)
Hyperperistalsis
Absent bowel sounds
Hyperactive bowel sounds
Encopresis NOS
Incontinence of sphincter ani
Excludes: that of nonorganic origin (307.7)
Fecal incontinence NOS
Excludes: constipation (564.00-564.09)
fecal impaction (560.32)
Fecal soiling
Bulky stools
Excludes: abnormal stool content (792.1)
melena:
NOS (578.1)
newborn (772.4, 777.3)
Excludes: gastrointestinal hemorrhage (578.0-578.9)
intestinal obstruction (560.0-560.9)
specific functional digestive disorders:
esophagus (530.0-530.9)
stomach and duodenum (536.0-536.9)
those not elsewhere classified (564.0-564.9)
Diarrhea NOS
Change in bowel habits
Tenesmus (rectal)
Excludes: hematuria (599.70-599.72)
nonspecific findings on examination of the urine (791.0-791.9)
small kidney of unknown cause (589.0-589.9)
uremia NOS (586)
urinary obstruction (599.60, 599.69)
Colic (recurrent) of:
kidney
ureter
Painful urination
Strangury
Code first, if applicable, hyperplasia of prostate (600.0-600.9 with fifth-digit 1)
Excludes: functional urinary incontinence (788.91)
that of nonorganic origin (307.6)
urinary incontinence associated with cognitive impairment (788.91)
Code, if applicable, any causal condition first, such as:
congenital ureterocele (753.23)
genital prolapse (618.00-618.9)
hyperplasia of prostate (600.0-600.9 with fifth-digit 1)
Enuresis NOS
Excludes: stress incontinence, female (625.6)
Urge and stress
Code first, if applicable, hyperplasia of prostate (600.0-600.9 with fifth-digit 1)
Frequency of micturition
Deficient secretion of urine
Suppression of urinary secretion
Excludes: that complicating:
abortion (634-638 with.3, 639.3)
ectopic or molar pregnancy (639.3)
pregnancy, childbirth, or the puerperium (642.0-642.9, 646.2)
Code first, if applicable, hyperplasia of prostate (600.0-600.9 with fifth-digit 1)
Intermittent urinary stream
Weak stream
Excludes: urge incontinence (788.31, 788.33)
Penile discharge
Urethrorrhea
Urinary incontinence due to cognitive impairment, or severe physical disability or immobility
Excludes: urinary incontinence due to physiologic condition (788.30-788.39)
Extrarenal uremia
Vesical:
pain
tenesmus
The following fifth-digit subclassification is to be used for codes 789.0, 789.3, 789.4, 789.6
0 unspecified site
1 right upper quadrant
2 left upper quadrant
3 right lower quadrant
4 left lower quadrant
5 periumbilic
6 epigastric
7 generalized
9 other specified site
multiple sites
Excludes: symptoms referable to genital organs:
female (625.0-625.9)
male (607.0-608.9)
psychogenic (302.70-302.79)
[0-7,9]
Cramps, abdominal
Enlargement of liver
Enlargement of spleen
[0-7,9]
Diffuse or generalized swelling or mass:
abdominal NOS
umbilical
Excludes: abdominal distention (gaseous) (787.3)
ascites (789.51-789.59)
[0-7,9]
Fluid in peritoneal cavity
Code first malignancy, such as:
malignant neoplasm of ovary (183.0)
secondary malignant neoplasm of retroperitoneum and peritoneum (197.6)
[0-7,9]
Rebound tenderness
Colic NOS
Infantile colic
Excludes: colic in adult and child over 12 months old (789.0)
renal colic (788.0)
Umbilical:
bleeding
discharge
(ICD 9 CM Codes)
(ICD 9 CM Codes)
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