General symptoms and signs (R50-R69)
R50Fever of other and unknown origin
Excludes 1: chills without fever (R68.83)
› febrile convulsions (R56.0-)
› fever of unknown origin during labor (O75.2)
› fever of unknown origin in newborn (P81.9)
› hypothermia due to illness (R68.0)
› malignant hyperthermia due to anesthesia (T88.3)
› puerperal pyrexia NOS (O86.4)
R50.2Drug induced fever
Use Additional Code: code for adverse effect, if applicable, to identify drug (T36-T50) with fifth or sixth character 5)
Excludes 1: postvaccination (postimmunization) fever (R50.83)
R50.8Other specified fever
R50.81Fever presenting with conditions classified elsewhere
Code First: underlying condition when associated fever is present, such as with:
› leukemia (C91-C95)
› neutropenia (D70.-)
› sickle-cell disease (D57.-)
R50.82Postprocedural fever
Excludes 1: postprocedural infection (T81.4-)
› posttransfusion fever (R50.84)
› postvaccination (postimmunization) fever (R50.83)
R50.83Postvaccination fever
› Postimmunization fever
R50.84Febrile nonhemolytic transfusion reaction
› FNHTR
› Posttransfusion fever
R50.9Fever, unspecified
› Fever NOS
› Fever of unknown origin [FUO]
› Fever with chills
› Fever with rigors
› Hyperpyrexia NOS
› Persistent fever
› Pyrexia NOS
R51Headache
Excludes 2: atypical face pain (G50.1)
› migraine and other headache syndromes (G43-G44)
› trigeminal neuralgia (G50.0)
R51.0Headache with orthostatic component, not elsewhere classified
› Headache with positional component, not elsewhere classified
R51.9Headache, unspecified
› Facial pain NOS
R52Pain, unspecified
› Acute pain NOS
› Generalized pain NOS
› Pain NOS
Excludes 1: acute and chronic pain, not elsewhere classified (G89.-)
› localized pain, unspecified type - code to pain by site, such as:
› abdomen pain (R10.-)
› back pain (M54.9)
› breast pain (N64.4)
› chest pain (R07.1-R07.9)
› ear pain (H92.0-)
› eye pain (H57.1)
› headache (R51.9)
› joint pain (M25.5-)
› limb pain (M79.6-)
› lumbar region pain (M54.5-)
› pelvic and perineal pain (R10.2)
› shoulder pain (M25.51-)
› spine pain (M54.-)
› throat pain (R07.0)
› tongue pain (K14.6)
› tooth pain (K08.8)
› renal colic (N23)
› pain disorders exclusively related to psychological factors (F45.41)
R53Malaise and fatigue
R53.0Neoplastic (malignant) related fatigue
Code First: associated neoplasm
R53.1Weakness
› Asthenia NOS
Excludes 1: age-related weakness (R54)
› muscle weakness (generalized) (M62.81)
› sarcopenia (M62.84)
› senile asthenia (R54)
R53.2Functional quadriplegia
› Complete immobility due to severe physical disability or frailty
Excludes 1: frailty NOS (R54)
› hysterical paralysis (F44.4)
› immobility syndrome (M62.3)
› neurologic quadriplegia (G82.5-)
› quadriplegia (G82.50)
R53.8Other malaise and fatigue
Excludes 1: combat exhaustion and fatigue (F43.0)
› congenital debility (P96.9)
› exhaustion and fatigue due to excessive exertion (T73.3)
› exhaustion and fatigue due to exposure (T73.2)
› exhaustion and fatigue due to heat (T67.-)
› exhaustion and fatigue due to pregnancy (O26.8-)
› exhaustion and fatigue due to recurrent depressive episode (F33)
› exhaustion and fatigue due to senile debility (R54)
R53.81Other malaise
› Chronic debility
› Debility NOS
› General physical deterioration
› Malaise NOS
› Nervous debility
Excludes 1: age-related physical debility (R54)
R53.82Chronic fatigue, unspecified
Excludes 1: chronic fatigue syndrome (G93.32)
› myalgic encephalomyelitis (G93.32)
› other post infection and related fatigue syndromes (G93.39)
› postviral fatigue syndrome (G93.31)
R53.83Other fatigue
› Fatigue NOS
› Lack of energy
› Lethargy
› Tiredness
Excludes 2: exhaustion and fatigue due to depressive episode (F32.-)
R54Age-related physical debility
› Frailty
› Old age
› Senescence
› Senile asthenia
› Senile debility
Excludes 1: age-related cognitive decline (R41.81)
› sarcopenia (M62.84)
› senile psychosis (F03)
› senility NOS (R41.81)
R55Syncope and collapse
› Blackout
› Fainting
› Vasovagal attack
Excludes 1: cardiogenic shock (R57.0)
› carotid sinus syncope (G90.01)
› heat syncope (T67.1)
› neurocirculatory asthenia (F45.8)
› neurogenic orthostatic hypotension (G90.3)
› orthostatic hypotension (I95.1)
› postprocedural shock (T81.1-)
› psychogenic syncope (F48.8)
› shock NOS (R57.9)
› shock complicating or following abortion or ectopic or molar pregnancy (O00-O07, O08.3)
› shock complicating or following labor and delivery (O75.1)
› Stokes-Adams attack (I45.9)
› unconsciousness NOS (R40.2-)
R56Convulsions, not elsewhere classified
Excludes 1: dissociative convulsions and seizures (F44.5)
› epileptic convulsions and seizures (G40.-)
› newborn convulsions and seizures (P90)
R56.0Febrile convulsions
R56.00Simple febrile convulsions
› Febrile convulsion NOS
› Febrile seizure NOS
R56.01Complex febrile convulsions
› Atypical febrile seizure
› Complex febrile seizure
› Complicated febrile seizure
Excludes 1: status epilepticus (G40.901)
R56.1Post traumatic seizures
Excludes 1: post traumatic epilepsy (G40.-)
R56.9Unspecified convulsions
› Convulsion disorder
› Fit NOS
› Recurrent convulsions
› Seizure(s) (convulsive) NOS
R57Shock, not elsewhere classified
Excludes 1: anaphylactic shock NOS (T78.2)
› anaphylactic reaction or shock due to adverse food reaction (T78.0-)
› anaphylactic shock due to adverse effect of correct drug or medicament properly administered (T88.6)
› anaphylactic shock due to serum (T80.5-)
› electric shock (T75.4)
› obstetric shock (O75.1)
› postprocedural shock (T81.1-)
› psychic shock (F43.0)
› shock complicating or following ectopic or molar pregnancy (O00-O07, O08.3)
› shock due to anesthesia (T88.2)
› shock due to lightning (T75.01)
› traumatic shock (T79.4)
› toxic shock syndrome (A48.3)
R57.0Cardiogenic shock
Excludes 2: septic shock (R65.21)
R57.1Hypovolemic shock
R57.8Other shock
R57.9Shock, unspecified
› Failure of peripheral circulation NOS
R58Hemorrhage, not elsewhere classified
› Hemorrhage NOS
Excludes 1: hemorrhage included with underlying conditions, such as:
› acute duodenal ulcer with hemorrhage (K26.0)
› acute gastritis with bleeding (K29.01)
› ulcerative enterocolitis with rectal bleeding (K51.01)
R59Enlarged lymph nodes
Includes: swollen glands
Excludes 1: lymphadenitis NOS (I88.9)
› acute lymphadenitis (L04.-)
› chronic lymphadenitis (I88.1)
› mesenteric (acute) (chronic) lymphadenitis (I88.0)
R59.0Localized enlarged lymph nodes
R59.1Generalized enlarged lymph nodes
› Lymphadenopathy NOS
R59.9Enlarged lymph nodes, unspecified
R60Edema, not elsewhere classified
Excludes 1: angioneurotic edema (T78.3)
› ascites (R18.-)
› cerebral edema (G93.6)
› cerebral edema due to birth injury (P11.0)
› edema of larynx (J38.4)
› edema of nasopharynx (J39.2)
› edema of pharynx (J39.2)
› gestational edema (O12.0-)
› hereditary edema (Q82.0)
› hydrops fetalis NOS (P83.2)
› hydrothorax (J94.8)
› newborn edema (P83.3)
› pulmonary edema (J81.-)
R60.0Localized edema
R60.1Generalized edema
Excludes 2: nutritional edema (E40-E46)
R60.9Edema, unspecified
› Fluid retention NOS
R61Generalized hyperhidrosis
› Excessive sweating
› Night sweats
› Secondary hyperhidrosis
Code First: , if applicable, menopausal and female climacteric states (N95.1)
Excludes 1: focal (primary) (secondary) hyperhidrosis (L74.5-)
› Frey's syndrome (L74.52)
› localized (primary) (secondary) hyperhidrosis (L74.5-)
R62Lack of expected normal physiological development in childhood and adults
Excludes 1: delayed puberty (E30.0)
› gonadal dysgenesis (Q99.1)
› hypopituitarism (E23.0)
R62.0Delayed milestone in childhood
› Delayed attainment of expected physiological developmental stage
› Late talker
› Late walker
R62.5Other and unspecified lack of expected normal physiological development in childhood
Excludes 1: HIV disease resulting in failure to thrive (B20)
› physical retardation due to malnutrition (E45)
R62.50Unspecified lack of expected normal physiological development in childhood
› Infantilism NOS
R62.51Failure to thrive (child)
› Failure to gain weight
Excludes 1: failure to thrive in child under 28 days old (P92.6)
R62.52Short stature (child)
› Lack of growth
› Physical retardation
› Short stature NOS
Excludes 1: short stature due to endocrine disorder (E34.3-)
R62.59Other lack of expected normal physiological development in childhood
R62.7Adult failure to thrive
R63Symptoms and signs concerning food and fluid intake
Excludes 1: bulimia NOS (F50.2)
R63.0Anorexia
› Loss of appetite
Excludes 1: anorexia nervosa (F50.0-)
› loss of appetite of nonorganic origin (F50.89)
R63.1Polydipsia
› Excessive thirst
R63.2Polyphagia
› Excessive eating
› Hyperalimentation NOS
R63.3Feeding difficulties
Excludes 2: eating disorders (F50.-)
› feeding problems of newborn (P92.-)
› infant feeding disorder of nonorganic origin (F98.2-)
R63.30Feeding difficulties, unspecified
R63.31Pediatric feeding disorder, acute
› Pediatric feeding dysfunction, acute
Code Also: , if applicable, associated conditions such as:
› aspiration pneumonia (J69.0)
› dysphagia (R13.1-)
› gastro-esophageal reflux disease (K21.-)
› malnutrition (E40-E46)
R63.32Pediatric feeding disorder, chronic
› Pediatric feeding dysfunction, chronic
Code Also: , if applicable, associated conditions such as:
› aspiration pneumonia (J69.0)
› dysphagia (R13.1-)
› gastro-esophageal reflux disease (K21.-)
› malnutrition (E40-E46)
R63.39Other feeding difficulties
› Feeding problem (elderly) (infant) NOS
› Picky eater
R63.4Abnormal weight loss
R63.5Abnormal weight gain
Excludes 1: excessive weight gain in pregnancy (O26.0-)
› obesity (E66.-)
R63.6Underweight
Use Additional Code: code to identify body mass index (BMI), if known (Z68.-)
Excludes 1: abnormal weight loss (R63.4)
› anorexia nervosa (F50.0-)
› malnutrition (E40-E46)
R63.8Other symptoms and signs concerning food and fluid intake
R64Cachexia
Excludes 1: abnormal weight loss (R63.4)
› cachexia due to underlying condition (E88.A)
› nutritional marasmus (E41)
R65Symptoms and signs specifically associated with systemic inflammation and infection
R65.1Systemic inflammatory response syndrome (SIRS) of non-infectious origin
Code First: underlying condition, such as:
› heatstroke (T67.0-)
› injury and trauma (S00-T88)
Excludes 1: sepsis- code to infection
› severe sepsis (R65.2)
R65.10Systemic inflammatory response syndrome (SIRS) of non-infectious origin without acute organ dysfunction
› Systemic inflammatory response syndrome (SIRS) NOS
R65.11Systemic inflammatory response syndrome (SIRS) of non-infectious origin with acute organ dysfunction
Use Additional Code: code to identify specific acute organ dysfunction, such as:
› acute kidney failure (N17.-)
› acute respiratory failure (J96.0-)
› critical illness myopathy (G72.81)
› critical illness polyneuropathy (G62.81)
› disseminated intravascular coagulopathy [DIC] (D65)
› encephalopathy (metabolic) (septic) (G93.41)
› hepatic failure (K72.0-)
R65.2Severe sepsis
› Infection with associated acute organ dysfunction
› Sepsis with acute organ dysfunction
› Sepsis with multiple organ dysfunction
› Systemic inflammatory response syndrome due to infectious process with acute organ dysfunction
Code First: underlying infection, such as:
› infection following a procedure (T81.4-)
› infections following infusion, transfusion and therapeutic injection (T80.2-)
› puerperal sepsis (O85)
› sepsis following complete or unspecified spontaneous abortion (O03.87)
› sepsis following ectopic and molar pregnancy (O08.82)
› sepsis following incomplete spontaneous abortion (O03.37)
› sepsis following (induced) termination of pregnancy (O04.87)
› sepsis NOS (A41.9)
Use Additional Code: code to identify specific acute organ dysfunction, such as:
› acute kidney failure (N17.-)
› acute respiratory failure (J96.0-)
› critical illness myopathy (G72.81)
› critical illness polyneuropathy (G62.81)
› disseminated intravascular coagulopathy [DIC] (D65)
› encephalopathy (metabolic) (septic) (G93.41)
› hepatic failure (K72.0-)
R65.20Severe sepsis without septic shock
› Severe sepsis NOS
R65.21Severe sepsis with septic shock
R68Other general symptoms and signs
R68.0Hypothermia, not associated with low environmental temperature
Excludes 1: hypothermia NOS (accidental) (T68)
› hypothermia due to anesthesia (T88.51)
› hypothermia due to low environmental temperature (T68)
› newborn hypothermia (P80.-)
R68.1Nonspecific symptoms peculiar to infancy
Excludes 1: colic, infantile (R10.83)
› neonatal cerebral irritability (P91.3)
› teething syndrome (K00.7)
R68.11Excessive crying of infant (baby)
Excludes 1: excessive crying of child, adolescent, or adult (R45.83)
R68.12Fussy infant (baby)
› Irritable infant
R68.13Apparent life threatening event in infant (ALTE)
› Apparent life threatening event in newborn
› Brief resolved unexplained event (BRUE)
Code First: confirmed diagnosis, if known
Use Additional Code: code(s) for associated signs and symptoms if no confirmed diagnosis established, or if signs and symptoms are not associated routinely with confirmed diagnosis, or provide additional information for cause of ALTE
R68.19Other nonspecific symptoms peculiar to infancy
R68.2Dry mouth, unspecified
Excludes 1: dry mouth due to dehydration (E86.0)
› dry mouth due to Sjögren syndrome (M35.0-)
› salivary gland hyposecretion (K11.7)
R68.3Clubbing of fingers
› Clubbing of nails
Excludes 1: congenital clubfinger (Q68.1)
R68.8Other general symptoms and signs
R68.81Early satiety
R68.82Decreased libido
› Decreased sexual desire
R68.83Chills (without fever)
› Chills NOS
Excludes 1: chills with fever (R50.9)
R68.84Jaw pain
› Mandibular pain
› Maxilla pain
Excludes 1: temporomandibular joint arthralgia (M26.62-)
R68.89Other general symptoms and signs
R69Illness, unspecified
› Unknown and unspecified cases of morbidity