ALBUMIN, SERUM I10 Essential (primary) hypertension

Transcription

1 ALBUMIN, SERUM I10 Essential (primary) hypertension AMMONIA, PLASMA E72.2 Disorders of urea cycle metabolism (NEEDS 5 TH DIGIT) E72.21 Argininemia E72.22 Arginosuccinic aciduria E72.23 Citrullinemia E72.29 other disorders of urea cycle metabolism AMYLASE, SERUM R10 Abdominal and pelvic pain R10.0 Acute abdomen R10.1 Pain localized to upper abdomen (NEEDS 5 TH DIGIT) R10.11 Right upper quadrant pain R10.12 Left upper quadrant pain R10.13 Epigastric pain R10.2 Pelvic and perineal pain R10.3 Pain localized to other parts of lower abdomen (NEEDS 5 TH DIGIT) R10.31 Right lower quadrant pain R10.32 Left lower quadrant pain R10.33 Periumbilical pain R10.8 Other abdominal pain (NEEDS 5 TH DIGIT) R10.81 Abdominal tenderness (NEEDS 6 TH DIGIT) R Right upper quadrant abdominal tenderness R Left upper quadrant abdominal tenderness R Right lower quadrant abdominal tenderness R Left lower quadrant abdominal tenderness R Periumbilic abdominal tenderness R Epigastric abdominal tenderness R Generalized abdominal tenderness R10.82 Rebound abdominal tenderness (NEEDS 6 TH DIGIT) R Right upper quadrant rebound abdominal tenderness R Left upper quadrant rebound abdominal tenderness R Right lower quadrant rebound abdominal tenderness R Left lower quadrant rebound abdominal tenderness R Periumbilic rebound abdominal tenderness R Epigastric rebound abdominal tenderness R Generalized rebound abdominal tenderness R10.83 Colic R10.84 Generalized abdominal pain ANTI-THYROGLOBULIN AB Z01.84 Encounter for antibody response examination BASIC METABOLIC PANEL

2 I10 Essential (primary) hypertension BMP+GFR I10 Essential (primary) hypertension C.DIFFICILE TOXIN ASSAY C.DIFFICILE TOXIN ASSAY #2 C.DIFFICILE TOXIN ASSAY #3 A04.7 Enterocolitis due to Clostridium difficile CARCINOEMBYONIC ANTIGEN R97.0 Elevated carcinoembryonic antigen [CEA] CBC (WITHOUT DIFF) D50 Iron deficiency anemia D50.0 Iron deficiency anemia secondary to blood loss (chronic) D50.1 Sideropenic dysphagia D50.8 Other iron deficiency anemias D51 Vitamin B12 deficiency anemia D51.0 Vitamin B12 deficiency anemia due to intrinsic factor deficiency D51.1 Vitamin B12 deficiency anemia due to selective vitamin B12 malabsorption with proteinuria D51.2 Transcobalamin II deficiency D51.3 Other dietary vitamin B12 deficiency anemia D51.8 Other vitamin B12 deficiency anemias D52 Folate deficiency anemia D52.0 Dietary folate deficiency anemia D52.1 Drug-induced folate deficiency anemia D52.8 Other folate deficiency anemias D53 Other nutritional anemias D53.0 Protein deficiency anemia D53.1 Other megaloblastic anemias, not elsewhere classified D53.2 Scorbutic anemia D53.8 Other specified nutritional anemias CMP + GFR COMP. METABOLIC PANEL I10 Essential (primary) hypertension COMPLETE CBC (WITH DIFF) D50 Iron deficiency anemia D50.0 Iron deficiency anemia secondary to blood loss (chronic)

3 D50.1 Sideropenic dysphagia D50.8 Other iron deficiency anemias D51 Vitamin B12 deficiency anemia D51.0 Vitamin B12 deficiency anemia due to intrinsic factor deficiency D51.1 Vitamin B12 deficiency anemia due to selective vitamin B12 malabsorption with proteinuria D51.2 Transcobalamin II deficiency D51.3 Other dietary vitamin B12 deficiency anemia D51.8 Other vitamin B12 deficiency anemias D52 Folate deficiency anemia D52.0 Dietary folate deficiency anemia D52.1 Drug-induced folate deficiency anemia D52.8 Other folate deficiency anemias D53 Other nutritional anemias D53.0 Protein deficiency anemia D53.1 Other megaloblastic anemias, not elsewhere classified D53.2 Scorbutic anemia D53.8 Other specified nutritional anemias CORONARY RISK PROFILE #1 (LIPID) HYPERLIPIDEMIA E78 Disorders of lipoprotein metabolism and other lipidemias E78.0 Pure hypercholesterolemia E78.1 Pure hyperglyceridemia E78.2 Mixed hyperlipidemia E78.3 Hyperchylomicronemia E78.4 Other hyperlipidemia E78.6 Lipoprotein deficiency E78.7 Disorders of bile acid and cholesterol metabolism E78.71 Barth syndrome E78.72 Smith-Lemli-Opitz syndrome E78.79 Other disorders of bile acid and cholesterol metabolism E78.8 Other disorders of lipoprotein metabolism E78.81 Lipoid dermatoarthritis E78.89 Other lipoprotein metabolism disorders C-REACTIVE PROTEIN, Hs R79.82 Elevated C-reactive protein (CRP) CREATINE KINASE (CK) R74.8 Abnormal levels of other serum enzymes CREATININE CREATININE, URINE, RANDOM I10 Essential (primary) hypertension

4 CULTURE, BLOOD #1 CULTURE, BLOOD #2 R78.81 Bacteremia CULTURE, GENITAL R86.5 Abnormal microbiological findings in specimens from MALE genital organs R87.5 Abnormal microbiological findings in specimens from FEMALE genital organs CULTURE, SPUTUM R09.3 Abnormal sputum CULTURE, WOUND T81.3 Disruption of wound, not elsewhere classified T81.31 Disruption of external operation (surgical) wound, not elsewhere classified T81.31XA initial encounter T81.31XD subsequent encounter T81.31XS sequela T81.32 Disruption of internal operation (surgical) wound, not elsewhere classified T81.32XA initial encounter T81.32XD subsequent encounter T81.32XS sequela T81.33 Disruption of traumatic injury wound repair T81.33XA initial encounter T81.33XD subsequent encounter T81.33XS sequela DIGOXIN DILANTIN (PHENYTOIN), FREE PHENYTOIN THEOPHYLLINE, TOBRAMYCIN VALPROIC ACID (DEPAKENE), VANCOMYCIN, THROUGH Z79 Long term (current) drug therapy Z79.0 Long term (current) use of anticoagulants and antithrombotics/antiplatelets Z79.01 Long term (current) use of anticoagulants Z79.02 Long term (current) use of antithrombotics/antiplatelets Z79.1 Long term (current) use of non-steroidal anti-inflammatories (NSAID) Z79.2 Long term (current) use of antibiotics Z79.3 Long term (current) use of hormonal contraceptives Z79.4 Long term (current) use of insulin Z79.5 Long term (current) use of steroids Z79.51 Long term (current) use of inhaled steroids Z79.52 Long term (current) use of systemic steroids

5 Z79.8 Other long term (current) drug therapy Z79.81 Long term (current) use of agents affecting estrogen receptors and estrogen levels Z Long term (current) use of selective estrogen receptor modulators (SERMs) Z Long term (current) use of aromatase inhibitors Z Long term (current) use of other agents affecting estrogen receptors and estrogen levels Z79.82 Long term (current) use of aspirin Z79.83 Long term (current) use of bisphosphonates Z79.89 Other long term (current) drug therapy Z Hormone replacement therapy (postmenopausal) Z Long term (current) use of opiate analgesic Z Other long term (current) drug therapy (IF NOT LISTED ELSEWHERE) ERYTHROCYTE SED. RATE M06.4 Inflammatory polyarthropathy FERRITIN FOLATE, SERUM HEMOGLOBIN HEMATOCRIT IRON, IRON BINDING CAPACITY, IRON PROFILE RETICULOCYTE COUNT D50 Iron deficiency anemia D50.0 Iron deficiency anemia secondary to blood loss (chronic) D50.1 Sideropenic dysphagia D50.8 Other iron deficiency anemias D51 Vitamin B12 deficiency anemia D51.0 Vitamin B12 deficiency anemia due to intrinsic factor deficiency D51.1 Vitamin B12 deficiency anemia due to selective vitamin B12 malabsorption with proteinuria D51.2 Transcobalamin II deficiency D51.3 Other dietary vitamin B12 deficiency anemia D51.8 Other vitamin B12 deficiency anemias D52 Folate deficiency anemia

6 D52.0 Dietary folate deficiency anemia D52.1 Drug-induced folate deficiency anemia D52.8 Other folate deficiency anemias D53 Other nutritional anemias D53.0 Protein deficiency anemia D53.1 Other megaloblastic anemias, not elsewhere classified D53.2 Scorbutic anemia D53.8 Other specified nutritional anemias GLUCOSE FASTING E10.9 Type 1 diabetes mellitus without complications REFER TO CODE BOOK IF PATIENT HAS TYPE 1 WITH COMPLICATIONS HEMOGLOBIN A1C E11.9 Type 2 diabetes mellitus without complications REFER TO CODE BOOK IF PATIENT HAS TYPE 2 WITH COMPLICATIONS HEPATIC FUNCTION PANEL Z79 Long term (current) drug therapy Z79.0 Long term (current) use of anticoagulants and antithrombotics/antiplatelets Z79.01 Long term (current) use of anticoagulants Z79.02 Long term (current) use of antithrombotics/antiplatelets Z79.1 Long term (current) use of non-steroidal anti-inflammatories (NSAID) Z79.2 Long term (current) use of antibiotics Z79.3 Long term (current) use of hormonal contraceptives Z79.4 Long term (current) use of insulin Z79.5 Long term (current) use of steroids Z79.51 Long term (current) use of inhaled steroids Z79.52 Long term (current) use of systemic steroids Z79.8 Other long term (current) drug therapy Z79.81 Long term (current) use of agents affecting estrogen receptors and estrogen levels Z Long term (current) use of selective estrogen receptor modulators (SERMs) Z Long term (current) use of aromatase inhibitors Z Long term (current) use of other agents affecting estrogen receptors and estrogen levels Z79.82 Long term (current) use of aspirin Z79.83 Long term (current) use of bisphosphonates Z79.89 Other long term (current) drug therapy Z Hormone replacement therapy (postmenopausal) Z Long term (current) use of opiate analgesic Z Other long term (current) drug therapy (IF NOT LISTED ELSEWHERE) KEPPRA (LEVETIRACETAM)

7 R89.2 Abnormal level of other drugs, medicaments and biological substances in specimens from other organs, systems and tissues MAGNESIUM E87.4 Mixed disorder of acid-base balance NT-PRO-BNP 8-29 I11.0 Hypertensive heart disease with heart failure I11.9 Hypertensive heart disease without heart failure OCCULT BLOOD OCCULT BLOOD #2 OCCULT BLOOD #3 R19.5 Other fecal abnormalities PREALBUMIN, SERUM R68.89 Other general symptoms and signs PROSTATIC SPEC. ANTIGEN R97.2 Elevated prostate specific antigen [PSA] (DIAGNOSTIC) Z12.5 Encounter for screening for malignant neoplasm of prostate (SCREENING) PROTHROMBIN (PT) Z79.01 Long term (current) use of anticoagulants RENAL PROFILE N28 Other disorders of kidney and ureter, not elsewhere classified N28.0 Ischemia and infarction of kidney N28.1 Cyst of kidney, acquired N28.8 Other specified disorders of kidney and ureter N28.81 Hypertrophy of kidney N28.82 Megaloureter N28.83 Nephroptosis N28.84 Pyelitis cystica N28.85 Pyeloureteritis cystica N28.86 Ureteritis cystica N28.89 Other specified disorders of kidney and ureter RPR

8 L53 Other erythematous conditions L53.0 Toxic erythema L53.1 Erythema annulare centrifugum L53.2 Erythema marginatum L53.3 Other chronic figurate erythema L53.8 Other specified erythematous conditions T3 UPTAKE, T3 FREE, T3 TOTAL T4 FREE, T4 TOTAL THYROID PANEL, THYROID PEROXIDASE AB. THYROID PROFILE, THYROID STIM. HORMONE E03 Other hypothyroidism E03.0 Congenital hypothyroidism with diffuse goiter E03.1 Congenital hypothyroidism without goiter E03.2 Hypothyroidism due to medicaments and other exogenous substances E03.3 Postinfectious hypothyroidism E03.4 Atrophy of thyroid (acquired) E03.5 Myxedema coma E03.8 Other specified hypothyroidism E05 Thyrotoxicosis [hyperthyroidism] E05.0 Thyrotoxicosis with diffuse goiter E05.00 without thyrotoxic crisis or storm E05.01 with thyrotoxic crisis or storm E05.1 Thyrotoxicosis with toxic single thyroid nodule E05.10 without thyrotoxic crisis or storm E05.11 with thyrotoxic crisis or storm E05.2 Thyrotoxicosis with toxic multinodular goiter E05.20 without thyrotoxic crisis or storm E05.21 with thyrotoxic crisis or storm E05.3 Thyrotoxicosis from ectopic thyroid tissue E05.30 without thyrotoxic crisis or storm E05.31 with thyrotoxic crisis or storm E05.4 Thyrotoxicosis factitia E05.40 without thyrotoxic crisis or storm E05.41 with thyrotoxic crisis or storm E05.8 Other thyrotoxicosis E05.80 without thyrotoxic crisis or storm E05.81 with thyrotoxic crisis or storm E05.9 Thyrotoxicosis, unspecified E05.90 without thyrotoxic crisis or storm

9 E05.91 with thyrotoxic crisis or storm URIC ACID VITAMIN D M06.4 Inflammatory polyarthropathy E55.0 Rickets, active URINALYSIS CULTURE, URINE & COLONY CT N39 Other disorders of urinary system N39.0 Urinary tract infection, site not specified** Use Additional code (B95-B97), to identify infectious agent** N39.3 Stress incontinence (female) (male) N39.4 Other specified urinary incontinence N39.41 Urge incontinence N39.42 Incontinence without sensory awareness N39.43 Post-void dribbling N39.44 Nocturnal enuresis N39.45 Continuous leakage N39.46 Mixed incontinence N39.49 Other specified urinary incontinence N Overflow incontinence N Other specified urinary incontinence N39.8 Other specified disorders of urinary system VITAMIN B12, SERUM D50 Iron deficiency anemia D50.0 Iron deficiency anemia secondary to blood loss (chronic) D50.1 Sideropenic dysphagia D50.8 Other iron deficiency anemias D51 Vitamin B12 deficiency anemia D51.0 Vitamin B12 deficiency anemia due to intrinsic factor deficiency D51.1 Vitamin B12 deficiency anemia due to selective vitamin B12 malabsorption with proteinuria D51.2 Transcobalamin II deficiency D51.3 Other dietary vitamin B12 deficiency anemia D51.8 Other vitamin B12 deficiency anemias D52 Folate deficiency anemia D52.0 Dietary folate deficiency anemia D52.1 Drug-induced folate deficiency anemia D52.8 Other folate deficiency anemias D53 Other nutritional anemias D53.0 Protein deficiency anemia D53.1 Other megaloblastic anemias, not elsewhere classified D53.2 Scorbutic anemia D53.8 Other specified nutritional anemias

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