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O31- Complications specific to multiple gestationAHA 12:4Q:p107 – Fetus A and B same as fetus 1 and 2Excludes v: delayed delivery of second twin, triplet, etc. (O63.2)

malpresentation of one fetus or more (O32.9)placental transfusion syndromes (O43.0-)

One of the following 7th characters is to be assigned to each codeunder category O31. 7th character 0 is for single gestations andmultiple gestations where the fetus is unspecified. 7th characters1 through 9 are for cases of multiple gestations to identify thefetus for which the code applies. The appropriate code fromcategory O30, Multiple gestation, must also be assigned whenassigning a code from category O31 that has a 7th character of 1through 9.

0 Not applicable or unspecified1 Fetus 12 Fetus 23 Fetus 34 Fetus 45 Fetus 59 Other fetus

O31.0- Papyraceous fetusFetus compressus

O31.00x- Papyraceous fetus, unspecified trimester — [♀, Age/12-55]O31.01x- Papyraceous fetus, first trimester — [♀, Age/12-55]O31.02x- Papyraceous fetus, second trimester — [♀, Age/12-55]O31.03x- Papyraceous fetus, third trimester — [♀, Age/12-55]

O31.1- Continuing pregnancy after spontaneous abortion of one fetusor more

O31.10x- Continuing pregnancy after spontaneous abortion of onefetus or more, unspecified trimester — [♀, Age/12-55]

2016 Annual and 2016 SoftCover

The Educational Annotation of ICD-10-CMThis PDF brochure contains 2016 version sample pages, including:

• Educational Annotations:• Definitions of Code Categories/Titles• Anatomy and Physiology Reviews• Anatomical Illustrations

• Additional 2016 Educational Annotations Features:• AHA Coding Clinic® Reference Notations• DRG Principles• Medicare Code Edits• Color Highlighting, including:

• Excludes 1 & v• Screened Boxes over 7th Digit Subclassifications• Tab-Edge Printing• Continued Main Terms in Index

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TABULAR LIST OF DISEASES – 2016 ICD-10-CM

Excludes 1: = NOT CODED HERE! (Do not code both) Excludesv: = Not Included Here

O34I

O41

[2016.CM]

O30.81- Other specified multiple gestation with two or more monochorionic fetuses

CC O30.811 Other specified multiple gestation with two or moremonochorionic fetuses, first trimester —[♀, Age/12-55] [Unacceptable PDX]

CC O30.812 Other specified multiple gestation with two or moremonochorionic fetuses, second trimester —[♀, Age/12-55] [Unacceptable PDX]

CC O30.813 Other specified multiple gestation with two or moremonochorionic fetuses, third trimester —[♀, Age/12-55] [Unacceptable PDX]

O30.819 Other specified multiple gestation with two or moremonochorionic fetuses, unspecified trimester —[♀, Age/12-55] [Unacceptable PDX]

O30.82- Other specified multiple gestation with two or more monoamniotic fetuses

CC O30.821 Other specified multiple gestation with two or moremonoamniotic fetuses, first trimester —[♀, Age/12-55] [Unacceptable PDX]

CC O30.822 Other specified multiple gestation with two or moremonoamniotic fetuses, second trimester —[♀, Age/12-55] [Unacceptable PDX]

CC O30.823 Other specified multiple gestation with two or moremonoamniotic fetuses, third trimester —[♀, Age/12-55] [Unacceptable PDX]

O30.829 Other specified multiple gestation with two or moremonoamniotic fetuses, unspecified trimester —[♀, Age/12-55] [Unacceptable PDX]

Use of demonstrativetype fonts for the letters

“O” and “I”

Graphic and coloridentification of Excludes 1

and Excludes v

AHA Coding Clinic Reference Notations with

descriptive titles

Color shading of notations to guide coders in the use of 7th character

extensions

Highlighted TermIdentification of trimesters

Further use of dashes (-) to identify codes requiring

additional characters

Excludes 1 and Excludes v

explanations at the bottom of all Tabular List pages

Further use of placeholder “x”

Highlighted TermDifferentiation

of key word(s) in code titles

Medicare Code EditsUnacceptable PDX,

Sex, Age

10. Chapter 10: Diseases of the Respiratory System (J00-J99)

a. Chronic Obstructive Pulmonary Disease [COPD] and Asthma

1) Acute exacerbation of chronic obstructive bronchitis and asthma

The codes in categories J44 and J45 distinguish between uncomplicated

cases and those in acute exacerbation. An acute exacerbation is a

worsening or a decompensation of a chronic condition. An acute

exacerbation is not equivalent to an infection superimposed on a

chronic condition, though an exacerbation may be triggered by an

infection.

b. Acute Respiratory Failure

1) Acute respiratory failure as principal diagnosis

A code from subcategory J96.0, Acute respiratory failure, or

subcategory J96.2, Acute and chronic respiratory failure, may be

assigned as a principal diagnosis when it is the condition established

after study to be chiefly responsible for occasioning the admission to

the hospital, and the selection is supported by the Alphabetic Index and

Tabular List. However, chapter-specific coding guidelines (such as

obstetrics, poisoning, HIV, newborn) that provide sequencing direction

take precedence.

2) Acute respiratory failure as secondary diagnosis

Respiratory failure may be listed as a secondary diagnosis if it occurs

after admission, or if it is present on admission, but does not meet the

definition of principal diagnosis.

3) Sequencing of acute respiratory failure and another acute

condition

When a patient is admitted with respiratory failure and another acute

condition, (e.g., myocardial infarction, cerebrovascular accident,

aspiration pneumonia), the principal diagnosis will not be the same in

every situation. This applies whether the other acute condition is a

respiratory or nonrespiratory condition. Selection of the principal

diagnosis will be dependent on the circumstances of admission. If

both the respiratory failure and the other acute condition are equally

responsible for occasioning the admission to the hospital, and there are

no chapter-specific sequencing rules, the guideline regarding two or

more diagnoses that equally meet the definition for principal diagnosis

(Section II, C.) may be applied in these situations.

If the documentation is not clear as to whether acute respiratory failure

and another condition are equally responsible for occasioning the

admission, query the provider for clarification.

c. Influenza due to certain identified influenza viruses

Code only confirmed cases of influenza due to certain identified

influenza viruses (category J09), and due to other identified influenza

virus (category J10). This is an exception to the hospital

inpatient guideline Section II, H. (Uncertain Diagnosis).

In this context, “confirmation” does not require documentation of positive

laboratory testing specific for avian or other novel influenza A or other

identified influenza virus. However, coding should be based on the

provider’s diagnostic statement that the patient has avian influenza, or

other novel influenza A, for category J09, or has another particular

identified strain of influenza, such as H1N1 or H3N2, but not

identified as novel or variant, for category J10.

If the provider records “suspected” or “possible” or “probable” avian

influenza, or novel influenza, or other identified influenza, then the

appropriate influenza code from category J11, Influenza due to

unidentified influenza virus, should be assigned. A code from category

J09, Influenza due to certain identified influenza viruses, should not be

assigned nor should a code from category J10, Influenza due to other

identified influenza virus.

d. Ventilator associated Pneumonia

1) Documentation of Ventilator associated Pneumonia

As with all procedural or postprocedural complications, code

assignment is based on the provider’s documentation of the

relationship between the condition and the procedure.

Code J95.851, Ventilator associated pneumonia, should be assigned

only when the provider has documented ventilator associated

pneumonia (VAP). An additional code to identify the organism (e.g.,

Pseudomonas aeruginosa, code B96.5) should also be assigned. Do not

assign an additional code from categories J12-J18 to identify the type

of pneumonia.

Code J95.851 should not be assigned for cases where the patient has

pneumonia and is on a mechanical ventilator and the provider has not

specifically stated that the pneumonia is ventilator-associated

pneumonia. If the documentation is unclear as to whether the patient

has a pneumonia that is a complication attributable to the mechanical

ventilator, query the provider.

2) Ventilator associated Pneumonia Develops after Admission

A patient may be admitted with one type of pneumonia (e.g., code J13,

Pneumonia due to Streptococcus pneumonia) and subsequently develop

VAP. In this instance, the principal diagnosis would be the appropriate

code from categories J12-J18 for the pneumonia diagnosed at the time

of admission. Code J95.851, Ventilator associated pneumonia, would

be assigned as an additional diagnosis when the provider has also

documented the presence of ventilator associated pneumonia.

OFFICIAL CODING GUIDELINES – 2016 ICD-10-CM

CG-18

GUIDELINES

© 2

015 C

hannel P

ublis

hin

g, Ltd

.

[2016.CM]

CHAPTER 10 – RESPIRATORY SYSTEM

Section I. C. 10. CHAPTER 10 – RESPIRATORY SYSTEM

Section I. C. 10. d.

Exposure (to) (see also Contact, with) T75.89 —continued

venereal disease Z20.2viral disease NEC Z20.828war Z65.5water pollution Z77.111

Exsanguination — see HemorrhageExstrophy

abdominal contents Q45.8bladder Q64.10

cloacal Q64.12specified type NEC Q64.19supravesical fissure Q64.11

Extensive — see conditionExtra — see also Accessory

marker chromosomes (normal individual)Q92.61

in abnormal individual Q92.62rib Q76.6

cervical Q76.5Extrasystoles (supraventricular) I49.49

atrial I49.1auricular I49.1junctional I49.2ventricular I49.3

Extrauterine gestation or pregnancy —see Pregnancy, by site

Extravasationblood R58chyle into mesentery I89.8pelvicalyceal N13.8pyelosinus N13.8urine (from ureter) R39.0vesicant agent

antineoplastic chemotherapy T80.810other agent NEC T80.818

Extremity — see condition, limbExtrophy — see ExstrophyExtroversion

bladder Q64.19uterus N81.4

complicating delivery O71.2postpartal (old) N81.4

Extruded tooth (teeth) M26.34Extrusion

breast implant (prosthetic) T85.42eye implant (globe) (ball) T85.328intervertebral disc — see Displacement,

intervertebral discocular lens implant (prosthetic) — see

Complications, intraocular lensvitreous — see Prolapse, vitreous

Exudatepleural — see Effusion, pleuraretina H35.89

Exudative — see conditionEye, eyeball, eyelid — see conditionEyestrain — see Disturbance, vision, subjectiveEyeworm disease of Africa B74.3

FFaber’s syndrome (achlorhydric anemia)

D50.9Fabry(-Anderson) disease E75.21Faciocephalalgia, autonomic (see also

Neuropathy, peripheral, autonomic) G90.09Factor(s)

psychic, associated with diseases classifiedelsewhere F54

psychologicalaffecting physical conditions F54or behavioral

affecting general medical condition F54associated with disorders or diseases

classified elsewhere F54Fahr disease (of brain) G23.8Fahr Volhard disease (of kidney) I12-Failure, failed

abortion — see Abortion, attemptedaortic (valve) I35.8

rheumatic I06.8attempted abortion — see Abortion, attemptedbiventricular I50.9bone marrow — see Anemia, aplasticcardiac — see Failure, heartcardiorenal (chronic) I50.9

hypertensive I13.2cardiorespiratory (see also Failure, heart) R09.2cardiovascular (chronic) — see Failure, heartcerebrovascular I67.9cervical dilatation in labor O62.0circulation, circulatory (peripheral) R57.9

newborn P29.89compensation — see Disease, heartcompliance with medical treatment or regimen

— see Noncompliancecongestive — see Failure, heart, congestivedental implant (endosseous) M27.69

due tofailure of dental prosthesis M27.63lack of attached gingiva M27.62occlusal trauma (poor prosthetic design)

M27.62parafunctional habits M27.62periodontal infection (peri-implantitis)

M27.62poor oral hygiene M27.62

osseointegration M27.61due to

complications of systemic diseaseM27.61

poor bone quality M27.61iatrogenic M27.61

post-osseointegrationbiological M27.62due to complications of systemic disease

M27.62iatrogenic M27.62mechanical M27.63

pre-integration M27.61pre-osseointegration M27.61specified NEC M27.69

descent of head (at term) of pregnancy(mother) O32.4

endosseous dental implant — see Failure,dental implant

engagement of head (term of pregnancy)(mother) O32.4

erection (penile) (see also Dysfunction, sexual,male, erectile) N52.9

nonorgqanic F52.21examination(s), anxiety concerning Z55.2expansion terminal respiratory units (newborn)

(primary) P28.0forceps NOS (with subsequent cesarean

delivery) O66.5

Failure, failed — continuedgain weight (child over 28 days old) R62.51

adult R62.7newborn P92.6

genital response (male) F52.21female F52.22

heart (acute) (senile) (sudden) I50.9with

acute pulmonary edema — see Failure,ventricular, left

decompensation — see Failure, heart,congestive

dilatation — see Disease, heartarteriosclerotic I70.90biventricular I50.9combined left-right sided I50.9compensated I50.9complicating

anesthesia (general) (local) or othersedation

in labor and delivery O74.2in pregnancy O29.12-postpartum, puerperal O89.1

delivery (cesarean) (instrumental) O75.4congestive (compensated) (decompensated)

I50.9with rheumatic fever (conditions in I00)

active I01.8inactive or quiescent (with chorea)

I09.81newborn P29.0rheumatic (chronic) (inactive) (with chorea)

I09.81active or acute I01.8

with chorea I02.0decompensated I50.9degenerative — see Degeneration,

myocardialdiastolic (congestive) I50.30

acute (congestive) I50.31and (on) chronic (congestive) I50.33

chronic (congestive) I50.32and (on) acute (congestive) I50.33

combined with systolic (congestive) I50.40acute (congestive) I50.41

and (on) chronic (congestive) I50.43chronic (congestive) I50.42

and (on) acute (congestive) I50.43due to presence of cardiac prosthesis

I97.13-following cardiac surgery I97.13-high output NOS I50.9hypertensive — see Hypertension, heartleft (ventricular) — see Failure, ventricular,

leftlow output (syndrome) NOS I50.9newborn P29.0organic — see Disease, heartperipartum O90.3postprocedural I97.13-rheumatic (chronic) (inactive) I09.9right (ventricular) (secondary to left heart

failure) — see Failure, heart, congestivesystolic (congestive) I50.20



combined with diastolic (congestive)I50.40



thyrotoxic (see also Thyrotoxicosis) E05.90[I43]

with thyroid storm E05.91 [I43]valvular — see Endocarditis

Duplication of all terms and code

numbers at “— continued” column headers and printed in

color

Clear, concise, sharply-printed text

INDEX TO DISEASES – 2016 ICD-10-CM[2016.CM]

161

DISEASE

INDEX

Failure

Use of demonstrativetype fonts for the letters “O”

and “I”

Gout, chronic (see also Gout, gouty) M1A.9(follows M08) — continued

secondary NEC M1A.40 (follows M08)ankle M1A.47- (follows M08)elbow M1A.42- (follows M08)foot joint M1A.47- (follows M08)hand joint M1A.44- (follows M08)hip M1A.45- (follows M08)knee M1A.46- (follows M08)multiple site M1A.49 (follows M08)shoulder M1A.41- (follows M08)vertebrae M1A.48 (follows M08)wrist M1A.43- (follows M08)

syphilitic (see also subcategory M14.8-)A52.77

tophi M1A.9 (follows M08)Gout, gouty (acute) (attack) (flare) (see also

Gout, chronic) M10.9drug-induced M10.20

ankle M10.27-elbow M10.22-foot joint M10.27-hand joint M10.24-hip M10.25-knee M10.26-multiple site M10.29shoulder M10.21-vertebrae M10.28wrist M10.23-

idiopathic M10.00ankle M10.07-elbow M10.02-foot joint M10.07-hand joint M10.04-hip M10.05-knee M10.06-multiple site M10.09shoulder M10.01-vertebrae M10.08wrist M10.03-

in (due to) renal impairment M10.30ankle M10.37-elbow M10.32-foot joint M10.37-hand joint M10.34-hip M10.35-knee M10.36-multiple site M10.39shoulder M10.31-vertebrae M10.38wrist M10.33-

lead-induced M10.10ankle M10.17-elbow M10.12-foot joint M10.17-hand joint M10.14-hip M10.15-knee M10.16-multiple site M10.19shoulder M10.11-vertebrae M10.18wrist M10.13-

primary — see Gout, idiopathicsaturnine — see Gout, lead-inducedsecondary NEC M10.40

ankle M10.47-elbow M10.42-foot joint M10.47-hand joint M10.44-hip M10.45-knee M10.46-multiple site M10.49shoulder M10.41-vertebrae M10.48wrist M10.43-

syphilitic (see also subcategory M14.8-)A52.77

tophi — see Gout, chronic

Gower’smuscular dystrophy G71.0syndrome (vasovagal attack) R55

Gradenigo’s syndrome — see Otitis, media,suppurative, acute

Graefe’s disease — see Strabismus, paralytic,ophthalmoplegia, progressive

Graft-versus-host disease D89.813acute D89.810acute on chronic D89.812chronic D89.811

Grain mite (itch) B88.0Grainhandler’s disease or lung J67.8Grand mal — see Epilepsy, generalized,

specified NECGrand multipara status only (not pregnant)

Z64.1pregnant — see Pregnancy, complicated by,

grand multiparityGranite worker’s lung J62.8Granular — see also condition

inflammation, pharynx J31.2kidney (contracting) — see Sclerosis, renalliver K74.69

Granulation tissue (abnormal) (excessive)L92.9

postmastoidectomy cavity — seeComplications, postmastoidectomy,granulation

Granulocytopenia (primary) (malignant) —see Agranulocytosis

Granuloma L92.9abdomen K66.8

from residual foreign body L92.3pyogenicum L98.0

actinic L57.5annulare (perforating) L92.0apical K04.5aural — see Otitis, externa, specified NECberyllium (skin) L92.3bone

eosinophilic C96.6from residual foreign body — see

Osteomyelitis, specified type NEClung C96.6

brain (any site) G06.0schistosomiasis B65.9 [G07]

canaliculus lacrimalis — see Granuloma,lacrimal

candidal (cutaneous) B37.2cerebral (any site) G06.0coccidioidal (primary) (progressive) B38.7

lung B38.1meninges B38.4

colon K63.89conjunctiva H11.22-dental K04.5ear, middle — see Cholesteatomaeosinophilic C96.6

bone C96.6lung C96.6oral mucosa K13.4skin L92.2

eyelid H01.8facial(e) L92.2foreign body (in soft tissue) NEC M60.20

ankle M60.27-foot M60.27-forearm M60.23-hand M60.24-in operation wound — see Foreign body,

accidentally left during a procedurelower leg M60.26-pelvic region M60.25-shoulder region M60.21-skin L92.3specified site NEC M60.28subcutaneous tissue L92.3

Granuloma L92.9 — continuedforeign body (in soft tissue) NEC M60.20 —

continuedthigh M60.25-upper arm M60.22-

gangraenescens M31.2genito-inguinale A58giant cell (central) (reparative) (jaw) M27.1

gingiva (peripheral) K06.8gland (lymph) I88.8hepatic NEC K75.3

in (due to)berylliosis J63.2 [K77]sarcoidosis D86.89

Hodgkin C81.9ileum K63.89infectious B99.9

specified NEC B99.8inguinale (Donovan) (venereal) A58intestine NEC K63.89intracranial (any site) G06.0intraspinal (any part) G06.1iridocyclitis — see Iridocyclitis, chronicjaw (bone) (central) M27.1

reparative giant cell M27.1kidney (see also Infection, kidney) N15.8lacrimal H04.81-larynx J38.7lethal midline (faciale(e)) M31.2liver NEC — see Granuloma, hepaticlung (infectious) — see also Fibrosis, lung

coccidioidal B38.1eosinophilic C96.6

Majocchi’s B35.8malignant (facial(e)) M31.2mandible (central) M27.1midline (lethal) M31.2monilial (cutaneous) B37.2nasal sinus — see Sinusitisoperation wound T81.89

foreign body — see Foreign body,accidentally left during a procedure

stitch T81.89talc — see Foreign body, accidentally left

during a procedureoral mucosa K13.4orbit, orbital H05.11-paracoccidioidal B41.8penis, venereal A58periapical K04.5peritoneum K66.8

due to ova of helminths NOS (see alsoHelminthiasis) B83.9 [K67]

postmastoidectomy cavity — seeComplications, postmastoidectomy,recurrent cholesteatoma

prostate N42.89pudendi (ulcerating) A58pulp, internal (tooth) K03.3pyogenic, pyogenicum (of) (skin) L98.0

gingiva K06.8maxillary alveolar ridge K04.5oral mucosa K13.4

rectum K62.89reticulohistiocytic D76.3rubrum nasi L74.8Schistosoma — see Schistosomiasisseptic (skin) L98.0silica (skin) L92.3sinus (accessory) (infective) (nasal) — see

Sinusitisskin L92.9

from residual foreign body L92.3pyogenicum L98.0

spinesyphilitic (epidural) A52.19tuberculous A18.01

stitch (postoperative) T81.89

INDEX TO DISEASES – 2016 ICD-10-CM [2016.CM]

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Easy to follow sub-term indention

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Neoplasm, neoplastic ........ C80.1 C79.9 D09.9 D36.9 D48.9 D49.9 abdomen, abdominal.................. C76.2 C79.8- D09.8 D36.7 D48.7 D49.89

cavity ...................................... C76.2 C79.8- D09.8 D36.7 D48.7 D49.89 organ ...................................... C76.2 C79.8- D09.8 D36.7 D48.7 D49.89 viscera .................................... C76.2 C79.8- D09.8 D36.7 D48.7 D49.89 wall — see also Neoplasm,

abdomen, wall, skin ...... C44.509 C79.2- D04.5 D23.5 D48.5 D49.2 connective tissue ................ C49.4 C79.8- — D21.4 D48.1 D49.2 skin .................................... C44.509 — — — — —

basal cell carcinoma........ C44.519 — — — — —specified type NEC .......... C44.599 — — — — —squamous cell

carcinoma .............. C44.529 — — — — —abdominopelvic .......................... C76.8 C79.8 - — D36.7 D48.7 D49.89 accessory sinus — see

Neoplasm, sinus acoustic nerve .............................. C72.4- C79.49 — D33.3 D43.3 D49.7 adenoid (pharynx) (tissue).......... C11.1 C79.89 D00.08 D10.6 D37.05 D49.0 adipose tissue — see also

Neoplasm, connective tissue .................................. C49.4 C79.89 — D21.9 D48.1 D49.2

adnexa (uterine) ........................ C57.4 C79.89 D07.39 D28.7 D39.8 D49.5 adrenal........................................ C74.9- C79.7- D09.3 D35.0- D44.1- D49.7

capsule .................................... C74.9- C79.7- D09.3 D35.0 - D44.1- D49.7 cortex ...................................... C74.0- C79.7- D09.3 D35.0 - D44.1- D49.7 gland ...................................... C74.9- C79.7- D09.3 D35.0- D44.1- D49.7 medulla .................................. C74.1- C79.7- D09.3 D35.0 - D44.1- D49.7

ala nasi (external) — see alsoNeoplasm, skin, nose .......... C44.301 C79.2 D04.39 D23.39 D48.5 D49.2

alimentary canal or tract NEC .... C26.9 C78.80 D01.9 D13.9 D37.9 D49.0 alveolar ...................................... C03.9 C79.89 D00.03 D10.39 D37.09 D49.0

mucosa .................................... C03.9 C79.89 D00.03 D10.39 D37.09 D49.0 lower .................................. C03.1 C79.89 D00.03 D10.39 D37.09 D49.0 upper .................................. C03.0 C79.89 D00.03 D10.39 D37.09 D49.0

Neoplasm, neoplastic - continuedalveolar - continued ................ C03.9 C79.89 D00.03 D10.39 D37.09 D49.0

ridge or process ...................... C41.1 C79.51 — D16.5 - D48.0 D49.2 carcinoma............................ C03.9 C79.8- — — — —

lower .............................. C03.1 C79.8- — — — — upper .............................. C03.0 C79.8- — — — —

lower .................................. C41.1 C79.51 — D16.5- D48.0 D49.2 mucosa ................................ C03.9 C79.89 D00.03 D10.39 D37.09 D49.0

lower .............................. C03.1 C79.89 D00.03 D10.39 D37.09 D49.0 upper .............................. C03.0 C79.89 D00.03 D10.39 D37.09 D49.0

upper .................................. C41.0 C79.51 — D16.4 - D48.0 D49.2 sulcus ...................................... C06.1 C79.89 D00.02 D10.39 D37.09 D49.0

alveolus ...................................... C03.9 C79.89 D00.03 D10.39 D37.09 D49.0 lower ...................................... C03.1 C79.89 D00.03 D10.39 D37.09 D49.0 upper ...................................... C03.0 C79.89 D00.03 D10.39 D37.09 D49.0

ampulla of Vater ........................ C24.1 C78.89 D01.5 D13.5 D37.6 D49.0 ankle NEC.................................... C76.5 - C79.89 D04.7- D36.7 D48.7 D49.89 anorectum, anorectal

(junction) ............................ C21.8 C78.5 D01.3 D12.9 D37.8 D49.0 antecubital fossa or space .......... C76.4- C79.89 D04.6- D36.7 D48.7 D49.89 antrum (Highmore)

(maxillary) .......................... C31.0 C78.39 D02.3 D14.0 D38.5 D49.1 pyloric...................................... C16.3 C78.89 D00.2 D13.1 D37.1 D49.0 tympanicum ............................ C30.1 C78.39 D02.3 D14.0 D38.5 D49.1

anus, anal .................................. C21.0 C78.5 D01.3 D12.9 D37.8 D49.0 canal........................................ C21.1 C78.5 D01.3 D12.9 D37.8 D49.0 cloacogenic zone .................... C21.2 C78.5 D01.3 D12.9 D37.8 D49.0 margin — see also

Neoplasm, anus, skin...... C44.500 C79.2 D04.5 D23.5 D48.5 D49.2 overlapping lesion with

rectosigmoid junction or rectum ........................ C21.8 — — — — —

skin.......................................... C44.500 C79.2 D04.5 D23.5 D48.5 D49.2 basal cell carcinoma............ C44.510 — — — — —specified type NEC .............. C44.590 — — — — —squamous cell

carcinoma .................. C44.520 — — — — —sphincter.................................. C21.1 C78.5 D01.3 D12.9 D37.8 D49.0

aorta (thoracic) .......................... C49.3 C79.89 — D21.3 D48.1 D49.2 abdominal .............................. C49.4 C79.89 — D21.4 D48.1 D49.2

aortic body .................................. C75.5 C79.89 — D35.6 D44.7 D49.7 aponeurosis ................................ C49.9 C79.89 — D21.9 D48.1 D49.2

palmar .................................... C49.1- C79.89 — D21.1- D48.1 D49.2 plantar .................................... C49.2 - C79.89 — D21.2- D48.1 D49.2

appendix .................................... C18.1 C78.5 D01.0 D12.1 D37.3 D49.0 arachnoid .................................... C70.9 C79.49 — D32.9 D42.9 D49.7

cerebral .................................. C70.0 C79.32 — D32.0 D42.0 D49.7 spinal ...................................... C70.1 C79.49 — D32.1 D42.1 D49.7

areola.......................................... C50.0- C79.81 D05. - D24.- D48.6- D49.3 arm NEC ...................................... C76.4- C79.89 D04.6- D36.7 D48.7 D49.89 artery — see Neoplasm,

connective tissue aryepiglottic fold ........................ C13.1 C79.89 D00.08 D10.7 D37.05 D49.0

hypopharyngeal aspect .......... C13.1 C79.89 D00.08 D10.7 D37.05 D49.0 laryngeal aspect ...................... C32.1 C78.39 D02.0 D14.1 D38.0 D49.1 marginal zone ........................ C13.1 C79.89 D00.08 D10.7 D37.05 D49.0

arytenoid (cartilage) .................. C32.3 C78.39 D02.0 D14.1 D38.0 D49.1 fold — see Neoplasm,

aryepiglottic associated with transplanted

organ .................................. C80.2 — — — — — atlas ............................................ C41.2 C79.51 — D16.6 D48.0 D49.2 atrium, cardiac ............................ C38.0 C79.89 — D15.1 D48.7 D49.89


NEOPLASM

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ICD-10-CM Table of Neoplasms

The list below gives the code numbers for neoplasms byanatomical site. For each site there are six possible code numbersaccording to whether the neoplasm in question is malignant,benign, in situ, of uncertain behavior, or of unspecified nature.The description of the neoplasm will often indicate which of the sixcolumns is appropriate; e.g., malignant melanoma of skin, benignfibroadenoma of breast, carcinoma in situ of cervix uteri.

Where such descriptors are not present, the remainder of theIndex should be consulted where guidance is given to theappropriate column for each morphological (histological) varietylisted; e.g., Mesonephroma — see Neoplasm, malignant;Embryoma — see also Neoplasm, uncertain behavior; Disease,Bowen’s — see Neoplasm, skin, in situ. However, the guidance inthe Index can be overridden if one of the descriptors mentionedabove is present; e.g., malignant adenoma of colon is coded toC18.9 and not to D12.6 as the adjective “malignant” overridesthe Index entry “Adenoma — see also Neoplasm, benign.”

Codes listed with a dash -, following the code have a requiredadditional character for laterality. The tabular list must bereviewed for the complete code.

Highlighted Malignant and Benign

Neoplasm columns to provide an easy-to-follow visual separation


DRUGS

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Drugs & Chemicals

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14-hydroxydihydro-morphinone ................ T40.2x1- T40.2x2- T40.2x3- T40.2x4- T40.2x5- T40.2x6-

1-propanol .......................... T51.3x1- T51.3x2- T51.3x3- T51.3x4- — — 2,4,5-T (trichloro-

phenoxyacetic acid) .... T60.1x1- T60.1x2- T60.1x3- T60.1x4- — — 2,4-D (dichlorophen-

oxyacetic acid) ............ T60.3x1- T60.3x2- T60.3x3- T60.3x4- — — 2,4-toluene diisocyanate .... T65.0x1- T65.0x2- T65.0x3- T65.0x4- — — 2-propanol .......................... T51.2x1- T51.2x2- T51.2x3- T51.2x4- — — ABOB .................................. T37.5x1- T37.5x2- T37.5x3- T37.5x4- T37.5x5- T37.5x6-Abrine ................................ T62.2x1- T62.2x2- T62.2x3- T62.2x4- — — Abrus (seed)........................ T62.2x1- T62.2x2- T62.2x3- T62.2x4- — — Absinthe .............................. T51.0x1- T51.0x2- T51.0x3- T51.0x4- — —

beverage ........................ T51.0x1- T51.0x2- T51.0x3- T51.0x4- — — Acaricide.............................. T60.8x1- T60.8x2- T60.8x3- T60.8x4- — — Acebutolol .......................... T44.7x1- T44.7x2- T44.7x3- T44.7x4- T44.7x5- T44.7x6-Acecarbromal ...................... T42.6x1- T42.6x2- T42.6x3- T42.6x4- T42.6x5- T42.6x6-Aceclidine ............................ T44.1x1- T44.1x2- T44.1x3- T44.1x4- T44.1x5- T44.1x6-Acedapsone ........................ T37.0x1- T37.0x2- T37.0x3- T37.0x4- T37.0x5- T37.0x6-Acefylline piperazine .......... T48.6x1- T48.6x2- T48.6x3- T48.6x4- T48.6x5- T48.6x6-Acemorphan........................ T40.2x1- T40.2x2- T40.2x3- T40.2x4- T40.2x5- T40.2x6-Acenocoumarin.................... T45.511- T45.512- T45.513- T45.514- T45.515- T45.516-Acenocoumarol.................... T45.511- T45.512- T45.513- T45.514- T45.515- T45.516-Acepifylline.......................... T48.6x1- T48.6x2- T48.6x3- T48.6x4- T48.6x5- T48.6x6-Acepromazine .................... T43.3x1- T43.3x2- T43.3x3- T43.3x4- T43.3x5- T43.3x6-Acesulfamethoxypyridazine T37.0x1- T37.0x2- T37.0x3- T37.0x4- T37.0x5- T37.0x6-Acetal .................................. T52.8x1- T52.8x2- T52.8x3- T52.8x4- — — Acetaldehyde (vapor).......... T52.8x1- T52.8x2- T52.8x3- T52.8x4- — —

liquid .............................. T65.891- T65.892- T65.893- T65.894- — — P-Acetamidophenol ............ T39.1x1- T39.1x2- T39.1x3- T39.1x4- T39.1x5- T39.1x6-Acetaminophen .................. T39.1x1- T39.1x2- T39.1x3- T39.1x4- T39.1x5- T39.1x6-Acetaminosalol.................... T39.1x1- T39.1x2- T39.1x3- T39.1x4- T39.1x5- T39.1x6-Acetanilide .......................... T39.1x1- T39.1x2- T39.1x3- T39.1x4- T39.1x5- T39.1x6-Acetarsol.............................. T37.3x1- T37.3x2- T37.3x3- T37.3x4- T37.3x5- T37.3x6-Acetazolamide .................... T50.2x1- T50.2x2- T50.2x3- T50.2x4- T50.2x5- T50.2x6-Acetiamine .......................... T45.2x1- T45.2x2- T45.2x3- T45.2x4- T45.2x5- T45.2x6-Acetic

acid.................................. T54.2x1- T54.2x2- T54.2x3- T54.2x4- — — with sodium acetate

(ointment) .......... T49.3x1- T49.3x2- T49.3x3- T49.3x4- T49.3x5- T49.3x6-ester (solvent) (vapor) T52.8x1- T52.8x2- T52.8x3- T52.8x4- — — irrigating solution ...... T50.3x1- T50.3x2- T50.3x3- T50.3x4- T50.3x5- T50.3x6-medicinal (lotion) ...... T49.2x1- T49.2x2- T49.2x3- T49.2x4- T49.2x5- T49.2x6-

anhydride........................ T65.891- T65.892- T65.893- T65.894- — — ether (vapor) .................. T52.8x1- T52.8x2- T52.8x3- T52.8x4- — —

Acetohexamide.................... T38.3x1- T38.3x2- T38.3x3- T38.3x4- T38.3x5- T38.3x6-Acetohydroxamic acid.......... T50.991- T50.992- T50.993- T50.994- T50.995- T50.996-Acetomenaphthone ............ T45.7x1- T45.7x2- T45.7x3- T45.7x4- T45.7x5- T45.7x6-Acetomorphine.................... T40.1x1- T40.1x2- T40.1x3- T40.1x4- — —Acetone (oils) ...................... T52.4x1- T52.4x2- T52.4x3- T52.4x4- — —

chlorinated ...................... T52.4x1- T52.4x2- T52.4x3- T52.4x4- — — vapor .............................. T52.4x1- T52.4x2- T52.4x3- T52.4x4- — —

Acetonitrile .......................... T52.8x1- T52.8x2- T52.8x3- T52.8x4- — — Acetophenazine .................. T43.3x1- T43.3x2- T43.3x3- T43.3x4- T43.3x5- T43.3x6-Acetophenetedin ................ T39.1x1- T39.1x2- T39.1x3- T39.1x4- T39.1x5- T39.1x6-Acetophenone...................... T52.4x1- T52.4x2- T52.4x3- T52.4x4- — — Acetorphine ........................ T40.2x1- T40.2x2- T40.2x3- T40.2x4- — —Acetosulfone (sodium) ........ T37.1x1- T37.1x2- T37.1x3- T37.1x4- T37.1x5- T37.1x6-Acetrizoate (sodium) .......... T50.8x1- T50.8x2- T50.8x3- T50.8x4- T50.8x5- T50.8x6-Acetrizoic acid...................... T50.8x1- T50.8x2- T50.8x3- T50.8x4- T50.8x5- T50.8x6-Acetyl

bromide .......................... T53.6x1- T53.6x2- T53.6x3- T53.6x4- — — chloride .......................... T53.6x1- T53.6x2- T53.6x3- T53.6x4- — —

Acetylcarbromal .................. T42.6x1- T42.6x2- T42.6x3- T42.6x4- T42.6x5- T42.6x6-Acetylcholine

chloride .......................... T44.1x1- T44.1x2- T44.1x3- T44.1x4- T44.1x5- T44.1x6-derivative ...................... T44.1x1- T44.1x2- T44.1x3- T44.1x4- T44.1x5- T44.1x6-

Acetylcysteine ...................... T48.4x1- T48.4x2- T48.4x3- T48.4x4- T48.4x5- T48.4x6-Acetyldigitoxin .................... T46.0x1- T46.0x2- T46.0x3- T46.0x4- T46.0x5- T46.0x6-Acetyldigoxin ...................... T46.0x1- T46.0x2- T46.0x3- T46.0x4- T46.0x5- T46.0x6-Acetyldihydrocodeine .......... T40.2x1- T40.2x2- T40.2x3- T40.2x4- — —Acetyldihydrocodeinone ...... T40.2x1- T40.2x2- T40.2x3- T40.2x4- — —Acetylene (gas).................... T59.891- T59.892- T59.893- T59.894- — —

dichloride ........................ T53.6x1- T53.6x2- T53.6x3- T53.6x4- — — incomplete combustion of T58.11x- T58.12x- T58.13x- T58.14x- — — industrial ........................ T59.891- T59.892- T59.893- T59.894- — — tetrachloride.................... T53.6x1- T53.6x2- T53.6x3- T53.6x4- — —

vapor .......................... T53.6x1- T53.6x2- T53.6x3- T53.6x4- — — Acetylpheneturide .............. T42.6x1- T42.6x2- T42.6x3- T42.6x4- T42.6x5- T42.6x6-Acetylphenylhydrazine ........ T39.8x1- T39.8x2- T39.8x3- T39.8x4- T39.8x5- T39.8x6-Acetylsalicylic acid (salts) .... T39.011- T39.012- T39.013- T39.014- T39.015- T39.016-

enteric coated.................. T39.011- T39.012- T39.013- T39.014- T39.015- T39.016-Acetylsulfamethoxypyrida-

zine ............................ T37.0x1- T37.0x2- T37.0x3- T37.0x4- T37.0x5- T37.0x6-Achromycin.......................... T36.4x1- T36.4x2- T36.4x3- T36.4x4- T36.4x5- T36.4x6-

ophthalmic preparation .. T49.5x1- T49.5x2- T49.5x3- T49.5x4- T49.5x5- T49.5x6-topical NEC...................... T49.0x1- T49.0x2- T49.0x3- T49.0x4- T49.0x5- T49.0x6-

Aciclovir .............................. T37.5x1- T37.5x2- T37.5x3- T37.5x4- T37.5x5- T37.5x6Acid (corrosive) NEC............ T54.2x1- T54.2x2- T54.2x3- T54.2x4- — — Acidifying agent NEC .......... T50.901- T50.902- T50.903- T50.904- T50.905- T50.906-Acipimox.............................. T46.6x1- T46.6x2- T46.6x3- T46.6x4- T46.6x5- T46.6x6-Acitretin .............................. T50.991- T50.992- T50.993- T50.994- T50.995- T50.996-Aclarubicin .......................... T45.1x1- T45.1x2- T45.1x3- T45.1x4- T45.1x5- T45.1x6-Aclatonium napadisilate .... T48.1x1- T48.1x2- T48.1x3- T48.1x4- T48.1x5- T48.1x6-Aconite (wild) ...................... T46.991- T46.992- T46.993- T46.994- T46.995- T46.996-Aconitine ............................ T46.991- T46.992- T46.993- T46.994- T46.995- T46.996-Aconitum ferox .................... T46.991- T46.992- T46.993- T46.994- T46.995- T46.996-Acridine .............................. T65.6x1- T65.6x2- T65.6x3- T65.6x4- — —

vapor .............................. T59.891- T59.892- T59.893- T59.894- — — Acriflavine .......................... T37.91x- T37.92x- T37.93x- T37.94x- T37.95x- T37.96x-Acriflavinium chloride ........ T49.0x1- T49.0x2- T49.0x3- T49.0x4- T49.0x5- T49.0x6-Acrinol ................................ T49.0x1- T49.0x2- T49.0x3- T49.0x4- T49.0x5- T49.0x6-Acrisorcin ............................ T49.0x1- T49.0x2- T49.0x3- T49.0x4- T49.0x5- T49.0x6-Acrivastine .......................... T45.0x1- T45.0x2- T45.0x3- T45.0x4- T45.0x5- T45.0x6-Acrolein (gas)...................... T59.891- T59.892- T59.893- T59.894- — —

liquid .............................. T54.1x1- T54.1x2- T54.1x3- T54.1x4- — — Acrylamide .......................... T65.891- T65.892- T65.893- T65.894- — — Acrylic resin ........................ T49.3x1- T49.3x2- T49.3x3- T49.3x4- T49.3x5- T49.3x6-Acrylonitrile ........................ T65.891- T65.892- T65.893- T65.894- — — Actaea spicata .................... T62.2x1- T62.2x2- T62.2x3- T62.2x4- — —

berry................................ T62.1x1- T62.1x2- T62.1x3- T62.1x4- — — Acterol ................................ T37.3x1- T37.3x2- T37.3x3- T37.3x4- T37.3x5- T37.3x6-ACTH .................................. T38.811- T38.812- T38.813- T38.814- T38.815- T38.816-Actinomycin C ...................... T45.1x1- T45.1x2- T45.1x3- T45.1x4- T45.1x5- T45.1x6-Actinomycin D .................... T45.1x1- T45.1x2- T45.1x3- T45.1x4- T45.1x5- T45.1x6-Activated charcoal –

see also Charcoal, medicinal .................... T47.6x1- T47.6x2- T47.6x3- T47.6x4- T47.6x5- T47.6x6-

Acyclovir .............................. T37.5x1- T37.5x2- T37.5x3- T37.5x4- T37.5x5- T37.5x6-Adenine .............................. T45.2x1- T45.2x2- T45.2x3- T45.2x4- T45.2x5- T45.2x6-

arabinoside .................... T37.5x1- T37.5x2- T37.5x3- T37.5x4- T37.5x5- T37.5x6-Adenosine (phosphate) ...... T46.2x1- T46.2x2- T46.2x3- T46.2x4- T46.2x5- T46.2x6-ADH .................................... T38.891- T38.892- T38.893- T38.894- T38.895- T38.896-Adhesive NEC ...................... T65.891- T65.892- T65.893- T65.894- — — Adicillin .............................. T36.0x1- T36.0x2- T36.0x3- T36.0x4- T36.0x5- T36.0x6-

Clearly identified Poisoning columns

Clearly identified Adverse Effect columns

Clearly identified Accidental (Unintentional)

columns

Chapter 1 – Certain infectious and parasitic diseases(A00-B99)

Includes: Diseases generally recognized as communicable or transmissible

Use additional code to identify resistance to antimicrobial drugs (Z16.-)

Excludes 1: certain localized infections — see body system, relatedchapters

Excludes v: carrier or suspected carrier of infectious disease (Z22-)infectious and parasitic diseases complicating pregnancy,

childbirth and the puerperium (O98.-)infectious and parasitic diseases specific to the perinatal

period (P35-P39)influenza and other acute respiratory infections (J00-J22)

This chapter contains the following blocks:A00-A09 Intestinal infectious diseasesA15-A19 TuberculosisA20-A28 Certain zoonotic bacterial diseasesA30-A49 Other bacterial diseasesA50-A64 Infections with a predominantly sexual mode of

transmissionA65-A69 Other spirochetal diseasesA70-A74 Other diseases caused by chlamydiaeA75-A79 RickettsiosesA80-A89 Viral and prion infections of the central nervous systemA90-A99 Arthropod-borne viral fevers and viral hemorrhagic feversB00-B09 Viral infections characterized by skin and mucous

membrane lesionsB10 Other human herpesvirusesB15-B19 Viral hepatitisB20 Human immunodeficiency virus [HIV] diseaseB25-B34 Other viral diseasesB35-B49 MycosesB50-B64 Protozoal diseasesB65-B83 HelminthiasesB85-B89 Pediculosis, acariasis and other infestationsB90-B94 Sequelae of infectious and parasitic diseasesB95-B97 Bacterial and viral infectious agentsB99 Other infectious diseases

C. Chapter-Specific Coding Guidelines

In addition to general coding guidelines, there are guidelines for specific

diagnoses and/or conditions in the classification. Unless otherwise

indicated, these guidelines apply to all health care settings. Please refer

to Section II for guidelines on the selection of principal diagnosis.

The complete 2016 ICD-10-CM Official Guidelines for Coding and Reporting are located in the front of the book between the Introduction

and the Alphabetic Index. The guidelines are organized into the

following sections and appendix:

Section I. Conventions, General Coding Guidelines, and

Chapter Specific Guidelines

Section II. Selection of Principal Diagnosis

Section III. Reporting Additional Diagnoses

Section IV. Diagnostic Coding and Reporting Guidelines for

Outpatient Services

Appendix I. Present on Admission Reporting Guidelines

1. Chapter 1: Certain Infectious and Parasitic Diseases (A00-B99)

a. Human Immunodeficiency Virus (HIV) Infections

1) Code only confirmed cases

Code only confirmed cases of HIV infection/illness. This is an

exception to the hospital inpatient guideline Section II, H.

In this context, “confirmation” does not require documentation of

positive serology or culture for HIV; the provider’s diagnostic

statement that the patient is HIV positive, or has an HIV-related

illness is sufficient.

2) Selection and sequencing of HIV codes

(a) Patient admitted for HIV-related condition

If a patient is admitted for an HIV-related condition, the

principal diagnosis should be B20, Human immunodeficiency

virus [HIV] disease followed by additional diagnosis codes for

all reported HIV-related conditions.

(b) Patient with HIV disease admitted for unrelated condition

If a patient with HIV disease is admitted for an unrelated

condition (such as a traumatic injury), the code for the unrelated

condition (e.g., the nature of injury code) should be the principal

diagnosis. Other diagnoses would be B20 followed by additional

diagnosis codes for all reported HIV-related conditions.

(c) Whether the patient is newly diagnosed

Whether the patient is newly diagnosed or has had previous

admissions/encounters for HIV conditions is irrelevant to the

sequencing decision.

(d) Asymptomatic human immunodeficiency virus

Z21, Asymptomatic human immunodeficiency virus [HIV]

infection status, is to be applied when the patient without any

documentation of symptoms is listed as being “HIV positive,”

“known HIV,” “HIV test positive,” or similar terminology. Do

not use this code if the term “AIDS” is used or if the patient is

treated for any HIV-related illness or is described as having any

condition(s) resulting from his/her HIV positive status; use B20

in these cases.

(e) Patients with inconclusive HIV serology

Patients with inconclusive HIV serology, but no definitive

diagnosis or manifestations of the illness, may be assigned

code R75, Inconclusive laboratory evidence of human

immunodeficiency virus [HIV].

(f) Previously diagnosed HIV-related illness

Patients with any known prior diagnosis of an HIV-related

illness should be coded to B20. Once a patient has developed

an HIV-related illness, the patient should always be assigned

code B20 on every subsequent admission/encounter. Patients

previously diagnosed with any HIV illness (B20) should

never be assigned to R75 or Z21, Asymptomatic human

immunodeficiency virus [HIV] infection status.

(g) HIV Infection in Pregnancy, Childbirth and the Puerperium

During pregnancy, childbirth or the puerperium, a patient

admitted (or presenting for a health care encounter) because

of an HIV-related illness should receive a principal diagnosis

code of O98.7-, Human immunodeficiency [HIV] disease

complicating pregnancy, childbirth and the puerperium,

followed by B20 and the code(s) for the HIV-related illness(es).

Codes from Chapter 15 always take sequencing priority.

Patients with asymptomatic HIV infection status admitted

(or presenting for a health care encounter) during pregnancy,

childbirth, or the puerperium should receive codes of O98.7-

and Z21.

(h) Encounters for testing for HIV

If a patient is being seen to determine his/her HIV status, use

code Z11.4, Encounter for screening for human immunodefi-

ciency virus [HIV]. Use additional codes for any associated high

risk behavior.

CHAPTER 1 – CERTAIN INFECTIOUS AND PARASITIC DISEASES – 2016 ICD-10-CM[2016.CM]

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Excludes 1: = NOT CODED HERE! (Do not code both) Excludes v: = Not Included Here

Chapter-Specific Coding Guidelines

A41- Other sepsisCode first: Postprocedural sepsis (T81.4)

Sepsis during labor (O75.3)Sepsis following abortion, ectopic or molar pregnancy

(O03-O07, O08.0)Sepsis following immunization (T88.0)Sepsis following infusion, transfusion or therapeutic injection

(T80.2-)Excludes 1: bacteremia NOS (R78.81)

neonatal (P36.-)puerperal sepsis (O85)sepsis NOS (A41.9)streptococcal sepsis (A40.-)

Excludes v: sepsis (due to) (in) actinomycotic (A42.7)sepsis (due to) (in) anthrax (A22.7)sepsis (due to) (in) candidal (B37.7)sepsis (due to) (in) Erysipelothrix (A26.7)sepsis (due to) (in) extraintestinal yersiniosis (A28.2)sepsis (due to) (in) gonococcal (A54.86)sepsis (due to) (in) herpesviral (B00.7)sepsis (due to) (in) listerial (A32.7)sepsis (due to) (in) melioidosis (A24.1)sepsis (due to) (in) meningococcal (A39.2-A39.4)sepsis (due to) (in) plague (A20.7)sepsis (due to) (in) tularemia (A21.7)toxic shock syndrome (A48.3)

A41.0- Sepsis due to Staphylococcus aureus — Staphylococcus aureus bacteriain the bloodstream marked by high fever, shaking, chills, prostration, and ifuntreated, hypotension, shock, and death.

MCC A41.01 Sepsis due to methicillin susceptible Staphylococcusaureus — A form caused by a form of the bacterium Staphylococcus aureusthat is susceptible to antibiotic treatment.

MSSA sepsisStaphylococcus aureus sepsis NOS

MCC A41.02 Sepsis due to methicillin resistant Staphylococcusaureus — A form caused by a form of the bacterium Staphylococcus aureusthat is resistant to treatment from beta-lactam class antibiotics.

MCC A41.1 Sepsis due to other specified staphylococcusCoagulase negative staphylococcus sepsis

MCC A41.2 Sepsis due to unspecified staphylococcusMCC A41.3 Sepsis due to Hemophilus influenzaeMCC A41.4 Sepsis due to anaerobes

Excludes 1: gas gangrene (A48.0)A41.5- Sepsis due to other Gram-negative organismsMCC A41.50 Gram-negative sepsis, unspecified

Gram-negative sepsis NOSMCC A41.51 Sepsis due to Escherichia coli [E. coli]MCC A41.52 Sepsis due to Pseudomonas

Pseudomonas aeroginosaMCC A41.53 Sepsis due to SerratiaMCC A41.59 Other Gram-negative sepsisA41.8- Other specified sepsisMCC A41.81 Sepsis due to EnterococcusMCC A41.89 Other specified sepsis

MCC A41.9 Sepsis, unspecified organismSepticemia NOS

A42- Actinomycosis — A group of gram-positive infectious diseases classified to the bacterialfamilies Actinomycetaceae and Propionibacteriaceae, often by Actinomyces israelii.Excludes 1: actinomycetoma (B47.1)

CC A42.0 Pulmonary actinomycosisCC A42.1 Abdominal actinomycosisCC A42.2 Cervicofacial actinomycosis

MCC A42.7 Actinomycotic sepsisA42.8- Other forms of actinomycosis

CC A42.81 Actinomycotic meningitisCC A42.82 Actinomycotic encephalitisCC A42.89 Other forms of actinomycosis

CC A42.9 Actinomycosis, unspecifiedA43- Nocardiosis — Infection by bacterium of the genus Nocardia, most commonly Nocardia

asteroides or Nocardia brasiliensis.CC A43.0 Pulmonary nocardiosis

CC A43.1 Cutaneous nocardiosisCC A43.8 Other forms of nocardiosisCC A43.9 Nocardiosis, unspecified

A44- Bartonellosis — An infectious bacterial disease caused by Bartonella bacilliformis, andcharacterized by acute febrile hemolytic anemia, and hemangioma-like nodules on the skin.

CC A44.0 Systemic bartonellosisOroya fever

CC A44.1 Cutaneous and mucocutaneous bartonellosisVerruga peruana

CC A44.8 Other forms of bartonellosisCC A44.9 Bartonellosis, unspecified

A46 Erysipelas — An infectious contagious disease of the skin and subcutaneous tissue causedby Group A Beta-hemolytic Streptococcus, and characterized by obstructed lymphatics,redness and swelling of the affected areas, and sometimes large tension bullae.Excludes 1: postpartum or puerperal erysipelas (O86.89)

A48- Other bacterial diseases, not elsewhere classifiedExcludes 1: actinomycetoma (B47.1)

MCC A48.0 Gas gangrene — An acute infectious disease caused by the genus Clostridium,and characterized by severe, painful histotoxic infection of muscles and subcutaneoustissues which fill with gas and a serosanguineous exudate.

Clostridial cellulitisClostridial myonecrosis

MCC A48.1 Legionnaires’ disease — An infectious disease caused by the genusLegionella, usually by Legionella pneumophila and characterized by infection of therespiratory sytem, fever, chills, and cough.

A48.2 Nonpneumonic Legionnaires’ disease [Pontiac fever] — A milderform resembling the flu.

MCC A48.3 Toxic shock syndrome — An acute infectious bacterial disease caused byStaphylococcus aureus or Group A Streptococcus bacteria, characterized by abruptonset of high fever, vomiting, diarrhea, sunburn-like rash, and myalgia, followed byhypotension and in severe cases, shock and multi-organ failure.Use additional code to identify the organism (B95, B96)Excludes 1: endotoxic shock NOS (R57.8)

sepsis NOS (A41.9)A48.4 Brazilian purpuric fever

Systemic Hemophilus aegyptius infectionA48.5- Other specified botulism

Non-foodborne intoxication due to toxins of Clostridium botulinum[C. botulinum]

Excludes 1: food poisoning due to toxins of Clostridium botulinum(A05.1)

CC A48.51 Infant botulism — [Age/0-17]CC A48.52 Wound botulism

Non-foodborne botulism NOSUse additional code for associated wound

A48.8 Other specified bacterial diseasesA49- Bacterial infection of unspecified site

Excludes 1: bacterial agents as the cause of diseases classified elsewhere(B95-B96)

chlamydial infection NOS (A74.9)meningococcal infection NOS (A39.9)rickettsial infection NOS (A79.9)spirochetal infection NOS (A69.9)

A49.0- Staphylococcal infection, unspecified siteA49.01 Methicillin susceptible Staphylococcus aureus infection,

unspecified site — An infection caused by a form of the bacteriumStaphylococcus aureus that is susceptible to antibiotic treatment.

Methicillin susceptible Staphylococcus aureus (MSSA) infectionStaphylococcus aureus infection NOS

A49.02 Methicillin resistant Staphylococcus aureus infection,unspecified site — An infection caused by a form of the bacteriumStaphylococcus aureus that is resistant to treatment from beta-lactam classantibiotics.

Methicillin resistant Staphylococcus aureus (MRSA) infectionA49.1 Streptococcal infection, unspecified siteA49.2 Hemophilus influenzae infection, unspecified siteA49.3 Mycoplasma infection, unspecified siteA49.8 Other bacterial infections of unspecified siteA49.9 Bacterial infection, unspecified

Excludes 1: bacteremia NOS (R78.81)


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B48.1 Rhinosporidiosis — An infectious fungal disease caused by Rhinosporidiumseeberi that is characterized by small tumor-like masses usually in the nose andnasopharynx.

CC B48.2 Allescheriasis — An infectious fungal disease caused by Allescheria[Petriellidium] boydii that is characterized by suppurative, granulomatous skin andsubcutaneous lesions.

Infection due to Pseudallescheria boydiiExcludes 1: eumycetoma (B47.0)

CC B48.3 Geotrichosis — A fungal infection caused by Geotrichum candidum that affectsthe oral cavity and sometimes the lungs.

Geotrichum stomatitisCC B48.4 Penicillosis — A fungal infection caused by Penicillium marneffei that affects

immunocompromised patients that is characterized by fever, skin lesions, andlymphandenopathy.

CC B48.8 Other specified mycosesAHA 14:2Q:p13 – Sepsis due to non-Candida AlbicansAHA 14:4Q:p46 – Sepsis due to non-Candida Albicans, clarification

AdiaspiromycosisInfection of tissue and organs by AlternariaInfection of tissue and organs by DrechsleraInfection of tissue and organs by FusariumInfection of tissue and organs by saprophytic fungi NEC

B49 Unspecified mycosisCC Fungemia NOS

Protozoal diseases (B50-B64)Excludes 1: amebiasis (A06.-)

other protozoal intestinal diseases (A07.-)B50- Plasmodium falciparum malaria — A mosquito-borne parasitic disease caused

by Plasmodium falciparum that is characterized by respiratory distress, severe anemia,pulmonary edema, circulatory shock, and organ failure.Includes: Mixed infections of Plasmodium falciparum with any other

Plasmodium speciesCC B50.0 Plasmodium falciparum malaria with cerebral complications

Cerebral malaria NOSCC B50.8 Other severe and complicated Plasmodium falciparum

malariaSevere or complicated Plasmodium falciparum malaria NOS

MCC B50.9 Plasmodium falciparum malaria, unspecifiedB51- Plasmodium vivax malaria — A mosquito-borne parasitic disease caused by

Plasmodium vivax that is characterized by fever, headache, chills and vomiting, respiratorydistress, anemia, and weakness. Clinical relapses may occur weeks to months after the firstinfection.Includes: Mixed infections of Plasmodium vivax with other Plasmodium

species, except Plasmodium falciparumExcludes 1: Plasmodium vivav with Plasmodium falciparum (B50.-)

CC B51.0 Plasmodium vivax malaria with rupture of spleenCC B51.8 Plasmodium vivax malaria with other complicationsCC B51.9 Plasmodium vivax malaria without complication

Plasmodium vivax malaria NOSB52- Plasmodium malariae malaria — A mosquito-borne parasitic disease caused by

Plasmodium malariae that is characterized by fever, headache, chills and vomiting,respiratory distress, anemia, and weakness.Includes: Mixed infections of Plasmodium malariae with other Plasmodium

species, except Plasmodium falciparum and Plasmodiumvivax

Excludes 1: Plasmodium falciparum (B50.-)Plasmodium vivax (B51.-)

CC B52.0 Plasmodium malariae malaria with nephropathyCC B52.8 Plasmodium malariae malaria with other complicationsCC B52.9 Plasmodium malariae malaria without complication

Plasmodium malariae malaria NOSB53- Other specified malaria

CC B53.0 Plasmodium ovale malaria — A mosquito-borne parasitic disease causedby Plasmodium ovale that is characterized by fever, headache, chills and vomiting,respiratory distress, anemia, and weakness. Clinical relapses may occur weeks tomonths after the first infection.Excludes 1: Plasmodium ovale with Plasmodium falciparum (B50.-)

Plasmodium ovale with Plasmodium malariae (B52.-)Plasmodium ovale with Plasmodium vivax (B51.-)

CC B53.1 Malaria due to simian plasmodia — A mosquito-borne parasiticdisease caused by Plasmodium knowlesi that is characterized by fever, headache,chills and vomiting, respiratory distress, anemia, and weakness.Excludes 1: malaria due to simian plasmodia with Plasmodium

falciparum (B50.-)malaria due to simian plasmodia with Plasmodium

malariae (B52.-)malaria due to simian plasmodia with Plasmodium

ovale (B53.0)malaria due to simian plasmodia with Plasmodium vivax

(B51.-)CC B53.8 Other malaria, not elsewhere classified

B54 Unspecified malariaCC

B55- Leishmaniasis — Parasitic diseases caused by the protozoan genus Leishmaniasisthrough the bite of sandflies.

CC B55.0 Visceral leishmaniasis — Leishmaniasis that is characterized by fever, chills,weight loss, splenomegaly, leukopenia, anemia, and potentially fatal if untreated.

Kala-azarPost-kala-azar dermal leishmaniasis

CC B55.1 Cutaneous leishmaniasis — Leishmaniasis that is characterized byulcerated sores with small papules on the edge of the sore.

CC B55.2 Mucocutaneous leishmaniasis — Leishmaniasis that is characterized byulceration of the skin and mucous membranes of the throat and nose.

CC B55.9 Leishmaniasis, unspecifiedB56- African trypanosomiasis

CC B56.0 Gambiense trypanosomiasis — A parasitic disease caused byTrypanosoma brucei gambiense, and characterized by a primary lesion at the tsetsefly bite, fever, lymphadenopathy (especially of posterior neck), and invasion of thecentral nervous system with somnolence and coma which develops slower than theRhodesian form.

Infection due to Trypanosoma brucei gambienseWest African sleeping sickness

CC B56.1 Rhodesiense trypanosomiasis — A parasitic disease caused byTrypanosoma brucei rhodesiense that is characterized by a primary lesion at thetsetse fly bite, fever, lymphadenopathy (especially of posterior neck), and invasion ofthe central nervous system with somnolence and coma which develops more rapidlythan the Gambian form.

East African sleeping sicknessInfection due to Trypanosoma brucei rhodesiense

CC B56.9 African trypanosomiasis, unspecifiedSleeping sickness NOS

B57- Chagas’ disease — A parasitic disease caused by Trypanosoma cruzi that ischaracterized by primary lesion at the site of entry (skin, conjunctiva), fever, headache,swollen lymph glands, facial and generalized edema, and can progress to involve variousorgans.Includes: American trypanosomiasis

Infection due to Trypanosoma cruziCC B57.0 Acute Chagas’ disease with heart involvement

Acute Chagas’ disease with myocarditisCC B57.1 Acute Chagas’ disease without heart involvement

Acute Chagas’ disease NOSCC B57.2 Chagas’ disease (chronic) with heart involvement

American trypanosomiasis NOSChagas’ disease (chronic) NOSChagas’ disease (chronic) with myocarditisTrypanosomiasis NOS

B57.3- Chagas’ disease (chronic) with digestive system involvementCC B57.30 Chagas’ disease with digestive system involvement,

unspecifiedCC B57.31 Megaesophagus in Chagas’ diseaseCC B57.32 Megacolon in Chagas’ diseaseCC B57.39 Other digestive system involvement in Chagas’ disease

B57.4- Chagas’ disease (chronic) with nervous system involvementCC B57.40 Chagas’ disease with nervous system involvement,

unspecifiedCC B57.41 Meningitis in Chagas’ diseaseCC B57.42 Meningoencephalitis in Chagas’ diseaseCC B57.49 Other nervous system involvement in Chagas’ disease

CC B57.5 Chagas’ disease (chronic) with other organ involvement


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C16- Malignant neoplasm of stomach — Any new and abnormal growth of thestomach in which tissue growth is uncontrolled and has the properties of anaplasia, invasion,and metastases.Use additional code to identify:

Alcohol abuse and dependence (F10.-)Excludes v: malignant carcinoid tumor of the stomach (C7A.092)ANATOMY OF THE STOMACH — The stomach, located in the upper abdomen, is a pouch-

like organ of the alimentary tract connecting with the esophagus in the proximal(upper) portion and the duodenum in the distal (lower) portion and is about 10 to 12inches (25 to 30 cm) long. The cardia lies at the opening of the esophagus at the fundusof the stomach. The fundus is the upper ballooned area of the stomach. The body is themain part of the stomach and is located between the fundus and the pyloric antrumand the duodenum. When empty, the mucous membrane on the interior surface formslongitudinal folds, called rugae. There are three mucosal glands which secrete digestivejuices and mucus. These are the gastric glands, which are located throughout the bodyof the stomach; the cardiac glands, which are found near the esophageal opening; andthe pyloric glands, which are located in the pyloric (distal) region. There are threelayers of smooth muscle, and a serosal covering of visceral peritoneum. The vagusnerve stimulates the gastric glands. The stomach has a rich arterial blood supplythrough the celiac artery. The venous blood is drained into the hepatic portal system.

PHYSIOLOGY OF THE STOMACH — The stomach functions to receive food from theesophagus, mixes it with the gastric juice, initiates the digestion of proteins with pepsin,carries on a limited amount of absorption, and moves food into the small intestine byperistaltic muscle action. The gastric glands produce mucus, digestive enzymes (pepsin),hydrochloric acid, and an intrinsic factor, forming the gastric juice. The mucus is thoughtto help prevent the pepsin and hydrochloric acid from digesting the stomach surface.The stomach may absorb small quantities of water, glucose, certain salts, and alcohol.The parasympathetic vagus nerve stimulates the gastric glands to secrete large amountsof gastric juice which, in turn, releases gastrin, a hormone that causes the gastric glandsto increase their secretory activity.

CC C16.0 Malignant neoplasm of cardia — The opening and junction of thestomach from the esophagus.

Malignant neoplasm of cardiac orificeMalignant neoplasm of cardio-esophageal junctionMalignant neoplasm of esophagus and stomachMalignant neoplasm of gastro-esophageal junction

CC C16.1 Malignant neoplasm of fundus of stomach — The ballooned upperend of the stomach lying above a transverse line drawn from the cardia.

CC C16.2 Malignant neoplasm of body of stomach — The main pouch-likeportion.

CC C16.3 Malignant neoplasm of pyloric antrum — That portion between thebody and the pylorus.

Malignant neoplasm of gastric antrumCC C16.4 Malignant neoplasm of pylorus — The opening between the pyloric

antrum and the duodenum.Malignant neoplasm of prepylorusMalignant neoplasm of pyloric canal

CC C16.5 Malignant neoplasm of lesser curvature of stomach,unspecified — The smaller, innermost curved vertical portion from theesophagus to the duodenum.

Malignant neoplasm of lesser curvature of stomach, not classifiableto C16.1-C16.4

CC C16.6 Malignant neoplasm of greater curvature of stomach,unspecified — The larger, outermost curved vertical portion from theesophagus to the duodenum.

Malignant neoplasm of greater curvature of stomach, notclassifiable to C16.0-C16.4

CC C16.8 Malignant neoplasm of overlapping sites of stomachCC C16.9 Malignant neoplasm of stomach, unspecified

Gastric cancer NOSC17- Malignant neoplasm of small intestine — Any new and abnormal growth of

the small intestine, including duodenum, in which tissue growth is uncontrolled and has theproperties of anaplasia, invasion, and metastases.Excludes 1: malignant carcinoid tumors of the small intestine (C7A.01)ANATOMY OF THE SMALL INTESTINE — The small intestine is the tubular organ of the

alimentary tract between the stomach and large intestine and is about 16 to 20 feet (5to 6 m) long, and has 3 parts: Duodenum, jejunum, and ileum. The duodenum is thefirst portion about 10 inches (25 cm) long connected at its proximal end to the stomach.The jejunum is the middle, approximately two-fifths, portion. The ileum is the distalportion which connects with the large intestine. Both the jejunum and ileum aresuspended from the posterior abdominal wall by the mesentery.

PHYSIOLOGY OF THE SMALL INTESTINE — The small intestine functions to absorb waterand the nutrients produced through digestion. The food is passed through the smallintestine by the contraction of its circular smooth muscle layer, called peristalsis. Theduodenum releases several enzymes and mixes the pancreatic and bile juices with foodfrom the stomach. The jejunum and ileum continue mixing and absorbing until theremaining substances pass into the large intestine.

CC C17.0 Malignant neoplasm of duodenum — The most proximal portionconnected with the stomach.

CC C17.1 Malignant neoplasm of jejunum — The middle portion which is largerin diameter than the ileum.

CC C17.2 Malignant neoplasm of ileum — The distal portion connecting with thececum.Excludes 1: malignant neoplasm of ileocecal valve (C18.0)

CC C17.3 Meckel’s diverticulum, malignant — A sacculation or appendage of theileum, specified as malignant.Excludes 1: Meckel’s diverticulum, congenital (Q43.0)

CC C17.8 Malignant neoplasm of overlapping sites of small intestineCC C17.9 Malignant neoplasm of small intestine, unspecified

TABULAR LIST OF DISEASES – 2016 ICD-10-CM [2016.CM]

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C18- Malignant neoplasm of colon — Any new and abnormal growth of the largeintestine, including duodenum, in which tissue growth is uncontrolled and has the propertiesof anaplasia, invasion, and metastases.Excludes 1: malignant carcinoid tumors of the colon (C7A.02-)ANATOMY OF THE COLON — The colon (large intestine) is the tubular organ of the

alimentary tract between the small intestine and the rectum, and is about 5 feet(1.5 m) long. The colon has four main segments: Ascending, transverse, descending,and sigmoid. The ascending colon arises from the cecum, the pouch-like structure, andcontinues upwards where it turns (hepatic flexure) and connects to the transverse colon.The transverse colon extends horizontally and turns (splenic flexure) downwardconnecting to the descending colon. The descending colon extends downward to therectum, and is called the sigmoid (flexure) colon where it makes an S-shaped curveover the pelvic brim. The appendix projects downward from the cecum.

PHYSIOLOGY OF THE COLON — The colon (large intestine) functions in a minor capacityto absorb water and electrolytes, and to move by peristalsis, nonabsorbed substances tothe rectum for defecation. Many bacteria normally inhabit the colon and serve tofurther break down substances for colonic absorption.

CC C18.0 Malignant neoplasm of cecum — The dilated pouch at the proximal endof the ascending colon.

Malignant neoplasm of ileocecal valve — The sphincter muscle valvebetween the ileum and the colon.

CC C18.1 Malignant neoplasm of appendix — The closed appendage whichprojects downward from the cecum.

CC C18.2 Malignant neoplasm of ascending colon — That portion whichextends upward from the cecum to the transverse colon at the hepatic flexure.

CC C18.3 Malignant neoplasm of hepatic flexure — The bend of the colonwhere the ascending colon turns to become the transverse colon.

CC C18.4 Malignant neoplasm of transverse colon — That portion which lieshorizontally between ascending colon at the hepatic flexure and the descendingcolon at the splenic flexure.

CC C18.5 Malignant neoplasm of splenic flexure — The bend of the colonwhere the transverse colon turns downward to become the descending colon.

CC C18.6 Malignant neoplasm of descending colon — That portion whichextends downward from the transeverse colon at the splenic flexure to the sigmoidcolon.

CC C18.7 Malignant neoplasm of sigmoid colon — That portion of the colonfrom the descending colon to the rectum, which forms an S-shaped curve over thepelvic brim.

Malignant neoplasm of sigmoid (flexure)Excludes 1: malignant neoplasm of rectosigmoid junction (C19)

CC C18.8 Malignant neoplasm of overlapping sites of colonCC C18.9 Malignant neoplasm of colon, unspecified

Malignant neoplasm of large intestine NOS

C19 Malignant neoplasm of rectosigmoid junction — Any new and abnormalCC growth of the rectosigmoid junction in which tissue growth is uncontrolled and has the

properties of anaplasia, invasion, and metastases.Malignant neoplasm of colon with rectumMalignant neoplasm of rectosigmoid (colon)

Excludes 1: malignant carcinoid tumors of the colon (C7A.02-)C20 Malignant neoplasm of rectum — Any new and abnormal growth of the rectumCC in which tissue growth is uncontrolled and has the properties of anaplasia, invasion, and

metastases.Malignant neoplasm of rectal ampulla — The dilated portion just proximal to the

anus.Excludes 1: malignant carcinoid tumor of the rectum (C7A.026)ANATOMY OF THE RECTUM AND ANUS — The rectum is the musculomembranous

portion of the alimentary tract between the colon and anus, approximately 5 inches (13cm) long. The anus is the internal canal from the rectum which ends the alimentarytract at the anal opening. The rectosigmoid junction is that portion of the alimentarytract between the distal end of the sigmoid colon and the proximal end of the rectum.

PHYSIOLOGY OF THE RECTUM AND ANUS — The rectum and anus function to eliminatefeces from the alimentary tract. A reflex signal is sent when the rectum fills and urgencyto defecate is perceived. The external voluntary muscle is voluntarily relaxed todefecate.

C21- Malignant neoplasm of anus and anal canal — Any new and abnormalgrowth of the anus and anal canal in which tissue growth is uncontrolled and has theproperties of anaplasia, invasion, and metastases.Excludes v: malignant carcinoid tumors of the colon (C7A.02-)

other and unspecified malignant neoplasm of anal margin(C44.500, C44.510, C44.520, C44.590)

other and unspecified malignant neoplasm of anal skin(C44.500, C44.510, C44.520, C44.590)

other and unspecified malignant neoplasm of perianal skin(C44.500, C44.510, C44.520, C44.590)

CC C21.0 Malignant neoplasm of anus, unspecifiedCC C21.1 Malignant neoplasm of anal canal — That portion of the alimentary

tract between the sigmoid colon and the external opening of the anus.Malignant neoplasm of anal sphincter

CC C21.2 Malignant neoplasm of cloacogenic zone — The anorectal regionoriginating from a persistant remnant of the cloacal membrane of the embryo.

CC C21.8 Malignant neoplasm of overlapping sites of rectum, anus andanal canal

Malignant neoplasm of anorectal junctionMalignant neoplasm of anorectumPrimary malignant neoplasm of two or more contiguous sites of

rectum, anus and anal canal

CHAPTER 2 – NEOPLASMS – 2016 ICD-10-CM[2016.CM]

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C22- Malignant neoplasm of liver and intrahepatic bile ducts — Any new andabnormal growth of the liver and intrahepatic ducts in which the tissue growth isuncontrolled, and has the properties of anaplasia, invasion and metastases.Use additional code to identify:

Alcohol abuse and dependence (F10.-)Hepatitis B (B16.-, B18.0-B18.1)Hepatitis C (B17.1-, B18.2)

Excludes 1: malignant neoplasm of biliary tract NOS (C24.9)secondary malignant neoplasm of liver and intrahepatic bile

duct (C78.7)ANATOMY OF THE LIVER — The liver is the largest organ in the body, weighing about 3

pounds (1 kg) in the adult. Located in the upper right quadrant of the abdominalcavity, its superior surface lies under the dome of the diaphragm. There are 4 lobes ofthe liver. The common bile duct is formed by the joining of the hepatic duct, whichcarries bile from the liver, and the cystic duct, which carries bile from the gallbladder.The common duct then carries the bile into the duodenum through an opening on theduodenal papilla. The hepatic artery furnishes arterial blood for the nourishment of theliver cells. The portal vein carries blood containing products of digestion from theintestinal tract into the liver. Internally, the liver lobules are the functional units of liversubstance. Bile is secreted by the liver cells into tiny canals, or canaliculi, and then isemptied into a bile duct.

PHYSIOLOGY OF THE LIVER — One of the regulatory functions of the liver is that ofcontrolling the blood sugar level. The liver is able to both absorb excess sugar anddispense it into the blood. The liver also stores and secretes other essential nutrients. Itchemically processes these materials and detoxifies many substances that could beharmful if allowed to accumulate in the body. Its bile salts are necessary for theabsorption of vitamin K from the gastrointestinal tract, which in turn, is needed for theproduction of prothrombin. Another important liver function is that of producing bile. Abrownish-yellow fluid, it is secreted continuously by the liver in amounts averagingabout 20 fluid ounces (600 ml). per day. Bile contains the bile salts which are veryimportant in the digestion of fat.

CC C22.0 Liver cell carcinoma — A form originating in the liver cells.Hepatocellular carcinomaHepatoma

CC C22.1 Intrahepatic bile duct carcinoma — The small channels between thehepatic lobules, which drain into the bile ductules.

CholangiocarcinomaExcludes 1: malignant neoplasm of hepatic duct (C24.0)

CC C22.2 Hepatoblastoma — A malignant intrahepatic tumor occurring in infants andyoung children and consisting chiefly of embryonic hepatic tissue.

CC C22.3 Angiosarcoma of liverKupffer cell sarcoma

CC C22.4 Other sarcomas of liverCC C22.7 Other specified carcinomas of liverCC C22.8 Malignant neoplasm of liver, primary, unspecified as to typeCC C22.9 Malignant neoplasm of liver, not specified as primary or

secondary

C23 Malignant neoplasm of gallbladder — Any new and abnormalCC growth of the gallbladder in which tissue growth is uncontrolled and has the properties of

anaplasia, invasion, and metastases.ANATOMY OF THE GALLBLADDER — The gallbladder is the musculomembranous, pear-

shaped bile reservoir located on the undersurface of the liver. The cystic duct is thetubular drain of the gallbladder which merges with the hepatic duct to form thecommon bile duct. The common bile duct merges with the pancreatic duct in thedilatated area known as the ampulla of Vater. The sphincter of Oddi is the muscle whichencircles the bile duct where it enters the duodenum.

PHYSIOLOGY OF THE GALLBLADDER — The gallbladder functions to store andconcentrate the bile and release the bile on demand of the small intestine for thedigestion of fats. The cystic duct, hepatic duct, and common bile duct convey the bileinto the duodenum. The sphincter of Oddi contracts to prevent reflux of intestinalcontents back into the bile ducts.

C24- Malignant neoplasm of other and unspecified parts of biliary tractExcludes 1: malignant neoplasm of intrahepatic bile duct (C22.1)

CC C24.0 Malignant neoplasm of extrahepatic bile duct — Any new andabnormal growth in an extrahepatic bile duct (bile ducts which are not within theliver capsule) in which tissue growth is uncontrolled and has the properties ofanaplasia, invasion, and metastases.

Malignant neoplasm of biliary duct or passage NOSMalignant neoplasm of common bile ductMalignant neoplasm of cystic ductMalignant neoplasm of hepatic duct

CC C24.1 Malignant neoplasm of ampulla of Vater — Any new and abnormalgrowth of the ampulla of Vater (the dilation formed by the merger of the pancreaticand common bile ducts just proximal to opening into the duodenum) in which tissuegrowth is uncontrolled and has the properties of anaplasia, invasion, andmetastases.

CC C24.8 Malignant neoplasm of overlapping sites of biliary tractMalignant neoplasm involving both intrahepatic and extrahepatic

bile ductsPrimary malignant neoplasm of two or more contiguous sites of

biliary tractCC C24.9 Malignant neoplasm of biliary tract, unspecified


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C25- Malignant neoplasm of pancreas — Any new and abnormal growth of thepancreas and pancreatic ducts in which the tissue growth is uncontrolled and has theproperties of anaplasia, invasion, and metastases.Use additional code to identify:

Alcohol abuse and dependence (F10.-)ANATOMY OF THE PANCREAS — The pancreas is a slender organ about 6 to 9 inches (15

to 23 cm) long lying horizontally and located in the abdomen behind and under thestomach. The pancreas is divided into 3 areas. The head, lying in the curve formed bythe duodenum; the body, the main portion, lying between the head and tail; and thetail, the most lateral portion blunting up against the spleen. The cells that producepancreatic juice are called pancreatic acinar cells, and they make up the bulk of thepancreas. These cells are clustered around tiny tubes which drain into the pancreaticduct (duct of Wirsung). This duct connects with the duodenum at the same place wherethe bile ducts join the duodenum. The second type of pancreatic cells are arranged ingroups closely associated with blood vessels, and are called islets of Langerhans. Thepancreas arterial blood is supplied via the common hepatic artery, the gastroduodenalartery, the pancreatico-duodenal arches, the splenic artery, and also from the superiormesenteric artery.

PHYSIOLOGY OF THE PANCREAS — The pancreas functions as both an exocrine gland,producing pancreatic juice, and as an endocrine gland, producing the hormones insulinand glucagen. The pancreatic juice contains enzymes capable of digestingcarbohydrates, fats, proteins, and nucleic acids, and is produced by the pancreaticacinar cells. This juice is drained into the duodenum. The pancreatic hormones whichare produced by the islets of Langerhans cells regulate blood glucose level.

CC C25.0 Malignant neoplasm of head of pancreas — The medial portionlying in the duodenal curve.

CC C25.1 Malignant neoplasm of body of pancreas — The main portion lyinghorizontally between the head and tail.

CC C25.2 Malignant neoplasm of tail of pancreas — The most lateral portionblunting up against the spleen.

CC C25.3 Malignant neoplasm of pancreatic duct — The duct that runs thelength of the pancreas emptying the pancreatic juice into the duodenum.

CC C25.4 Malignant neoplasm of endocrine pancreas — The cells within thepancreas that produce hormones.

Malignant neoplasm of islets of LangerhansUse additional code to identify any functional activity

CC C25.7 Malignant neoplasm of other parts of pancreasMalignant neoplasm of neck of pancreas

CC C25.8 Malignant neoplasm of overlapping sites of pancreasCC C25.9 Malignant neoplasm of pancreas, unspecified

C26- Malignant neoplasm of other and ill-defined digestive organsExcludes 1: malignant neoplasm of peritoneum and retroperitoneum

(C48.-)C26.0 Malignant neoplasm of intestinal tract, part unspecified

Malignant neoplasm of intestine NOSC26.1 Malignant neoplasm of spleen — Any new and abnormal growth of the

spleen in which the tissue growth is uncontrolled and has the properties ofanaplasia, invasion, and metastases.Excludes 1: Hodgkin lymphoma (C81.-)

non-Hodgkin lymphoma (C82-C85)ANATOMY OF THE SPLEEN —The spleen is a gland-like organ, located in the

upper abdomen behind the stomach and at the tail of the pancreas, and isabout 5 inches (13 cm) in length. The spleen contains both white pulp and redpulp.

PHYSIOLOGY OF THE SPLEEN — The spleen functions as both a large lymphnode (white pulp) that filters the blood and produces lymphocytes andmonocytes, and as a red blood cell reservoir (red pulp) and disintegrator ofworn-out red blood cells. It also plays a role in producing antibodies. Althoughimportant, the spleen is not essential to life.

C26.9 Malignant neoplasm of ill-defined sites within the digestivesystem

Malignant neoplasm of alimentary canal or tract NOSMalignant neoplasm of gastrointestinal tract NOS

Excludes 1: malignant neoplasm of abdominal NOS (C76.2)malignant neoplasm of intra-abdominal NOS (C76.2)

CHAPTER 2 – NEOPLASMS – 2016 ICD-10-CM[2016.CM]

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Malignant neoplasms of respiratory and intrathoracic organs(C30-C39)

Includes: Malignant neoplasm of middle earExcludes 1: mesothelioma (C45.-)

C30- Malignant neoplasm of nasal cavity and middle earC30.0 Malignant neoplasm of nasal cavity — Any new and abnormal growth

of the nasal cavity in which the tissue growth is uncontrolled and has the propertiesof anaplasia, invasion, and metastases.

Malignant neoplasm of cartilage of noseMalignant neoplasm of nasal conchaMalignant neoplasm of internal noseMalignant neoplasm of septum of noseMalignant neoplasm of vestibule of nose

Excludes 1: malignant melanoma of skin of nose (C43.31)malignant neoplasm of nasal bone (C41.0)malignant neoplasm of nose NOS (C76.0)malignant neoplasm of olfactory bulb (C72.2-)malignant neoplasm of posterior margin of nasal

septum and choana (C11.3)malignant neoplasm of turbinates (C41.0)other and unspecified malignant neoplasm of skin of

nose (C44.301, C44.311, C44.321, C44.391)ANATOMY OF THE NASAL CAVITIES — The nasal cavity is located between the

external nose and the nasopharynx with the nasal bones, and parts of theethmoid, frontal, sphenoid, vomer, and palatine bones forming the roof, andthe maxilla and palatine bones forming the floor.

PHYSIOLOGY OF THE NASAL CAVITIES — The nasal cavity functions to moisten,filter, and warm air as it passes to the lungs. It also contains the sense of smellorgan, and helps with speech.

C30.1 Malignant neoplasm of middle ear — Any new and abnormal growthof the middle ear in which the tissue growth is uncontrolled and has the propertiesof anaplasia, invasion, and metastases.

Malignant neoplasm of antrum tympanicumMalignant neoplasm of auditory tubeMalignant neoplasm of eustachian tubeMalignant neoplasm of inner earMalignant neoplasm of mastoid air cellsMalignant neoplasm of tympanic cavity

Excludes 1: malignant melanoma of skin of (external) ear (C43.2-)malignant neoplasm of auricular canal (external)

(C43.2-,C44.2-)malignant neoplasm of bone of ear (meatus) (C41.0)malignant neoplasm of cartilage of ear (C49.0)other and unspecified malignant neoplasm of skin of

(external) ear (C44.2-)ANATOMY OF THE MIDDLE EAR — The middle ear is the area space behind the

tympanic membrane of the external ear which connects the inner ear, mastoidcells, ossicles, and auditory tube. The auditory tube (Eustachian tube) passesbetween the middle ear and the nasopharynx.

PHYSIOLOGY OF THE MIDDLE EAR — The auditory tube functions to equalizeair pressure within the middle ear to the outside air pressure, and to drain anyfluid that may unnaturally accumulate in the middle ear.

C31- Malignant neoplasm of accessory sinuses — Any new and abnormal growthof the accessory sinuses in which the tissue growth is uncontrolled and has the properties ofanaplasia, invasion, and metastases.ANATOMY OF THE ACCESSORY SINUSES — The paired paranasal sinuses (maxillary,

ethmoidal, frontal, and sphenoidal) are the bony cavities lined with mucousmembranes which communicate with the nasal cavity.

PHYSIOLOGY OF THE ACCESSORY SINUSES — The paranasal cavities function to lightenthe bones of the skull, warm air, and give resonance to the voice.

C31.0 Malignant neoplasm of maxillary sinus — The largest of the one ofthe four paired, air-filled paranasal sinuses located under the eye in the maxillarybone.

Malignant neoplasm of antrum (Highmore) (maxillary)C31.1 Malignant neoplasm of ethmoidal sinus — One of the four paired,

air-filled paranasal sinuses located within the ethmoid bone cavities that liesbetween the nose and the eyes.

C31.2 Malignant neoplasm of frontal sinus — One of the four paired, air-filled paranasal sinuses located above the eye in the frontal bone.

C31.3 Malignant neoplasm of sphenoid sinus — One of the four paired, air-filled paranasal sinuses located behind the eyes and nose in the sphenoid bone.

C31.8 Malignant neoplasm of overlapping sites of accessory sinusesC31.9 Malignant neoplasm of accessory sinus, unspecified

C32- Malignant neoplasm of larynx — Any new and abnormal growth of the larynx inwhich tissue growth is uncontrolled and has the properties of anaplasia, invasion, andmetastases.Use additional code to identify:

Alcohol abuse and dependence (F10.-)Exposure to environmental tobacco smoke (Z77.22)Exposure to tobacco smoke in the perinatal period (P96.81)History of tobacco use (Z87.891)Occupational exposure to environmental tobacco smoke (Z57.31)Tobacco dependence (F17.-)Tobacco use (Z72.0)

ANATOMY OF THE LARYNX — The larynx is the musculocartilaginous structure, lined withmucous membrane located between the root of the tongue and the trachea. The glottisis the slit-like opening of the larynx formed by the true vocal cords. The supraglottis isthat portion of the larynx situated above the glottis. There are nine laryngealcartilages, three paired and three single.

PHYSIOLOGY OF THE LARYNX — The larynx functions to guard the entrance of thetrachea from food and liquids, to control the expulsion of air, and to produce sound.The glottis produces sound, controls pitch, and when closed prevents food from enteringthe trachea. The supraglottis is an area of the larynx which helps to prevent food andliquid from entering the trachea. The laryngeal cartilages frame and support the larynxand its muscles.


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