SCIMP RECOMMENDED READ CODE FORMULARY(v4.0) : Jan 2009
Page
INDEX -click on hyperlinks
2
3
A. INFECTIOUS & PARASITIC DISEASES
B. NEOPLASMS
C. ENDOCRINE, NUTRITIONAL METABOLIC & IMMUNITY DISORDERS
D. DISORDERS OF BLOOD & BLOOD FORMING ORGANS
E. MENTAL DISORDERS
F. NERVOUS SYSTEM & SENSE ORGAN DISEASES
G. CIRCULATORY SYSTEM DISEASE
H. RESPIRATORY SYSTEM DISEASE
J. DIGESTIVE SYSTEM DISEASE
K. GENITO-URINARY SYSTEM DISEASE
L. COMPLICATION OF PREGNANCY, CHILDBIRTH & PUERPERIUM
M. SKIN & SUBCUTANEOUS TISSUE DISEASE
N. MUSCULOSKELETAL & CONNECTIVE TISSUE DISEASES
P. CONGENITAL ANOMALIES
Q. PERINATAL CONDITIONS
R. SYMPTOMS, SIGNS & ILL-DEFINED CONDITIONS
S. INJURY & POISONING
T. CAUSES OF INJURY & POISONING
U. EXTERNAL CAUSES OF MORBIDITY & MORTALITY
Z. UNSPECIFIED CONDITIONS
1. HISTORY/ SYMPTOMS
2. EXAMINATION/ SIGNS
3. DIAGNOSTIC PROCEDURES
4. LABORATORY PROCEDURES
5. RADIOLOGY/ PHYSICS IN MEDICINE
6. PREVENTATIVE PROCEDURES
7. OPERATIONS, PROCEDURES & SITES
8. OTHER THERAPEUTIC PROCEDURES
9. ADMINISTRATION
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5
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6
7
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9
10
10
11
11
12
13
13
13
14
15
15
15
16
16
17
17
18
18
21
21
NOTES
1. These codes are a recommended list of codes. If no appropriate code is found in this formulary you may need to find a more
suitable code by searching the whole Read code thesaurus (as in your clinical system).
2.Codes that are relevant to the GMS Contract are indicated by a 'C' in the first column. Not all Contract codes are included in this
list. The full list can be accessed via New GMS Contract Guidance and Searches webpage on the SCIMP site.
3. Codes are presented in Chapters as they appear in the Read Code heirachy. Within each chapter they are listed
alphabetically/numerically by code using the preferred terms. Some synonyms are indicated where these may be more
appropriate.
4. Codes added in version 4.0 are highlighted in red
1
To Index
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Cont
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Code
CLINICAL TERM
A. INFECTIOUS & PARASITIC DISEASES
Cholera
Typhoid and paratyphoid fevers
Salmonella gastroenteritis
Shigellosis
Escherichia coli gastrointestinal tract infection
Viral gastroenteritis
Tuberculosis
Pulmonary tuberculosis
Brucellosis
Diphtheria
Whooping cough
Scarlet fever - scarlatina
Meningococcal infection
Septicaemia
Legionella
Toxic shock syndrome
Methicillin resistant staphylococcus aureus
Gardnerella vaginalis
Acute poliomyelitis
Viral meningitis NOS
Chickenpox - varicella
Herpes zoster
Herpes zoster with ophthalmic complication
Genital herpes simplex
Measles
Rubella
Viral hepatitis
Viral (infectious) hepatitis A
Viral (serum) hepatitis B
Chronic viral hepatitis C
Mumps
Infectious mononucleosis
Genital warts
Asymptomatic human immunodeficiency virus infection
Acquired human immunodeficiency virus infection syndrome NOS
Chlamydial infection
Coxsackie virus
Malaria
Lyme disease
Other primary syphilis
Other and unspecified syphilis
Gonococcal infections NOS
Reiter's disease / syndrome
Nonspecific urethritis
Leptospirosis
Toxoplasmosis
Sarcoidosis
A00..
A01..
A020.
A03..
A070.
A07y0
A1...
A11..
A23..
A32..
A33..
A341.
A36..
A38..
A3A4.
A3Ay1
A3B11
A3By7
A40..
A42z.
A52..
A53..
A532.
A541.
A55..
A56..
A70..
A701.
A703.
A7072
A72..
A75..
A7812
A7881
A788z
A78A.
A792.
A84..
A8710
A912.
A97..
A98z.
A993.
A994.
AA0..
AD0..
AD5..
2
NOTES
S=Glandular fever
To Index
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C
C
C
C
C
C
C
C
C
C
C
C
C
C
C
C
C
C
C
C
C
C
C
C
C
C
C
C
C
C
C
C
C
C
C
C
C
C
C
C
C
C
C
C
C
C
C
C
C
C
C
C
C
C
Read
Code
CLINICAL TERM
B. NEOPLASMS
Malignant neoplasm of lip
Malignant neoplasm of tongue
Malignant neoplasm of major salivary glands
Malignant neoplasm of gum
Malignant neoplasm of mouth NOS
Malignant neoplasm of pharynx unspecified
Malignant neoplasm of oesophagus NOS
Malignant neoplasm of stomach NOS
Malignant neoplasm of small intestine NOS
Malignant neoplasm of colon
Malignant neoplasm of rectum
Primary malignant neoplasm of liver
Malignant neoplasm of liver unspecified
Malignant neoplasm of gallbladder
Malignant neoplasm of pancreas NOS
Malignant neoplasm of spleen NEC
Malignant neoplasm of larynx NOS
Malignant neoplasm of trachea NOS
Mesothelioma
Malignant neoplasm of bronchus or lung NOS
Malignant neoplasm of thymus, heart and mediastinum
Malignant neoplasm of bone and articular cartilage NOS
Malignant neoplasm of connective and other soft tissue
Malignant melanoma of skin
Other malignant neoplasm of skin
Malignant neoplasm of female breast
Malignant neoplasm of male breast
Malignant neoplasm of uterus, part unspecified
Malignant neoplasm of cervix uteri NOS
Malignant neoplasm of body of uterus
Malignant neoplasm of ovary
Malignant neoplasm of vagina
Malignant neoplasm of vulva unspecified
Malignant neoplasm of prostate
Malignant neoplasm of testis NOS
Malignant neoplasm of penis, part unspecified
Malignant neoplasm of urinary bladder NOS
Malignant neoplasm of kidney and other unspecified urinary organs
Malignant neoplasm of eye
Malignant neoplasm of brain
Malignant neoplasm of spinal cord
Malignant neoplasm of thyroid gland
Malignant neoplasm of adrenal gland
Disseminated malignancy NOS
Kaposi's sarcoma, unspecified
Hodgkin's disease
Mycosis fungoides
Non - Hodgkin's lymphoma
Malignant lymphoma NOS
Multiple myeloma
Solitary myeloma
Acute lymphoid leukaemia
Chronic lymphoid leukaemia
Acute myeloid leukaemia
Chronic myeloid leukaemia
Benign neoplasm of parotid gland
Benign neoplasm of colon
B00..
B01..
B02..
B03.
B05z.
B0z0.
B10z.
B11z.
B12z.
B13..
B141.
B150.
B152.
B160.
B17z.
B1z1.
B21z.
B220z
B226.
B22z.
B24..
B30z.
B31..
B32..
B33..
B34..
B35..
B40..
B41z.
B43..
B440.
B450
B454.
B46..
B47z.
B483.
B49z.
B4A..
B50..
B51..
B522.
B53..
B540.
B590.
B59zX
B61..
B621.
B627.
B62y.
B630.
B6301
B640.
B641.
B650.
B651.
B7020
B713.
3
NOTES
Benign neoplasm of rectum
Benign neoplasm of skin NOS
Benign neoplasm of breast
Uterine leiomyoma - fibroids
Benign neoplasm of brain and other parts of nervous system
Acoustic neuroma
Benign neoplasm of thyroid gland
Neoplasm of uncertain behaviour of parotid gland
Neurofibromatosis - Von Recklinghausen's disease
Polycythaemia vera
B7141
B76z.
B77..
B78..
B7F..
B7F10
B7G..
B9000
B927.
B934.
S=Fibroids
To Index
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Code
CLINICAL TERM
C. ENDOCRINE, NUTRITIONAL METABOLIC & IMMUNITY
C
C
C
C
DISORDERS
Simple and unspecified goitre
Thyrotoxicosis
Congenital hypothyroidism NOS
Acquired hypothyroidism
Thyroiditis NOS
Type 1 diabetes mellitus
Type 2 diabetes mellitus
Hypoglycaemic coma
Hyperparathyroidism
Hypoparathyroidism
Gigantism
Acromegaly
Panhypopituitarism
Pituitary dwarfism
Diabetes Insipidus
Pituitary disorders NOS
Cushing's syndrome
Primary hyperaldosteronism
Addisons disease
Adrenal Gland Disorder NOS
Premature menopause NOS
Polycystic ovaries
Testicular dysfunction
Vitamin B deficiency
Vitamin D deficiency
Active rickets
Osteomalacia unspecified
Phenylketonuria
Pure hypercholesterolaemia
Hyperlipidaemia NOS
Gout
Haemochromatosis
Haemosiderosis NOS
Cystic fibrosis
Amyloidosis
Obesity
C00..
C02..
C03z.
C04..
C05z.
C10E.
C10F.
C110.
C120.
C121.
C1301
C1302
C132.
C133.
C135.
C13z.
C150.
C1510
C1541
C15z.
C1631
C164.
C17..
C26z.
C28..
C280.
C282.
C301.
C320.
C324.
C34..
C3500
C3504
C370.
C373.
C380.
4
NOTES
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Code
CLINICAL TERM
D. DISORDERS OF BLOOD & BLOOD FORMING ORGANS
Iron deficiency anaemia NOS
Pernicious anaemia
Folate-deficiency anaemia
Megaloblastic anaemia
Hereditary spherocytosis
Thalassaemia
Thallasaemia - Alpha Trait
Thallasaemia - Beta Trait
Sickle cell anaemia
Haemolytic anaemias NOS
Aplastic anaemia
Anaemia unspecified
Haemophilia-A (factor VIII deficiency)
Haemophilia-B (factor IX deficiency)
Haemophilia-C (factor XI deficiency)
Von Willebrand's disease
Purpura
Thrombocytopenia NOS
Agranulocytosis
Myelofibrosis
NOTES
D00zz
D010.
D012
D01z0
D100.
D104.
D1044
D1045
D106.
D1z..
D20..
D21z.
D300.
D301.
D302.
D304.
D3121
D315.
D400.
D41y1
To Index
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C
C
C
C
C
C
C
C
C
C
C
C
C
Read
Code
CLINICAL TERM
E. MENTAL DISORDERS
Acute schizophrenic episode
Schizophrenia NOS
Paranoid psychosis NOS
Reactive depressive psychosis
Infantile autism
Anxiety states
Anxiety with depression
Chronic anxiety
Phobic disorders
Obsessive-compulsive disorders
Personality disorders
Psychosexual dysfunction
Alcohol dependence syndrome
Drug dependence
Glue sniffing dependence
Nondependent alcohol abuse, unspecified
Misuse of drugs NOS
Psychogenic hyperventilation
Grief reaction
Disturbance of conduct NEC
Child attention deficit disorder
Attention deficit with hyperactivity
Specific delays in development
[X]Dementia in Alzheimer's disease
[X]Vascular dementia
[X] Unspecified dementia
[X]Delusional disorder
[X]Hypomania
[X]Bipolar affective disorder
[X]Depressive episode
[X]Recurrent depressive disorder
[X]Post - traumatic stress disorder
[X]Anorexia nervosa
[X]Bulimia nervosa
[X]Mental and behavioural disorders associated with the puerperium, not
elsewhere classified
E104.
E10z.
E12z.
E130.
E140.
E200.
E2003
E2004
E202.
E203.
E21..
E227.
E23..
E24..
E246.
E2500
E25z.
E2613
E2900
E2C..
E2E0.
E2E01
E2F..
Eu00.
Eu01.
Eu02z
Eu220
Eu300
Eu31.
Eu32.
Eu33.
Eu431
Eu500
Eu502
Eu53.
5
NOTES
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Code
CLINICAL TERM
F. NERVOUS SYSTEM & SENSE ORGAN DISEASES
Bacterial meningitis
Meningitis of unspecified cause
Encephalitis NOS
C Alzheimer's disease
Hydrocephalus
Parkinsons disease
Huntingtons chorea
Friedreich's ataxia
Motor neurone disease
Autonomic neuropathy due to diabetes
Multiple sclerosis
Hemiplegia
Congenital cerebral palsy
Quadriplegia
Paraplegia
Cauda equina syndrome
C Epilepsy
Grand mal seizure
Migraine
Unspecified encephalopathy
Chronic fatigue syndrome
Trigeminal neuralgia NOS
Bell's (facial) palsy
Carpal tunnel syndrome
Ulnar neuropathy
Peripheral neuropathy
Guillain-Barre syndrome
Polyneuropathy in diabetes
Alcoholic polyneuropathy
Myasthenia gravis
Muscular dystrophies and other myopathies
Retinal detachment NOS
Background diabetic retinopathy
Preproliferative diabetic retinopathy
Diabetic maculopathy
Diabetic retinopathy NOS
Hypertensive retinopathy
Proliferative retinopathy NOS
Retinal vascular occlusion
C Amaurosis fugax
Central retinal vein occlusion
Degeneration of macula and posterior pole
Retinitis pigmentosa
Acute and subacute iridocyclitis
Anterior uveitis
Glaucoma
Ocular hypertension
Cataract
Blindness and low vision
Blindness both eyes NOS
Blindness, one eye, unspecified
Corneal ulcer
Chronic conjunctivitis
Dry eye syndrome
Optic neuritis
Strabismus and other disorders of binocular eye movements
Scleritis and episcleritis
Nystagmus and other irregular eye movements
F00..
F02..
F03z.
F110.
F115.
F12..
F134.
F140.
F152.
F1711
F20..
F22..
F23..
F240.
F241.
F246.
F25..
F2516
F26..
F283.
F286.
F301z
F310.
F340.
F3424
F367.
F3700
F372.
F375.
F380.
F39..
F41z.
F4200
F4202
F4204
F420z
F4213
F422z
F423.
F4236
F4238
F425.
F4276
F440.
F4430
F45..
F4504
F46..
F49..
F490z
F4950
F4A0.
F4C1.
F4F14
F4H3.
F4J..
F4K0.
F4K5.
6
NOTES
Otitis Externa
Chronic suppurative otitis media NOS
Otitis media NOS
Acute mastoiditis
Tympanic membrane perforation
Unspecified cholesteatoma
Meniere's disease
Benign paroxysmal positional vertigo or nystagmus
Labyrinthitis
Otosclerosis
Hearing loss
F502z
F523.
F52z.
F530.
F542.
F5530
F560.
F5611
F563.
F57..
F59..
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Code
CLINICAL TERM
G. CIRCULATORY SYSTEM DISEASE
C
C
C
C
C
C
C
C
C
C
C
C
C
C
C
C
C
C
Chronic Rheumatic Heart Disease
Mitral stenosis
Hypertensive Disease
Essential hypertension
Malignant essential hypertension
Benign essential hypertension
Systolic hypertension
Secondary hypertension
Anterior myocardial infarction NOS
Posterior myocardial infarction NOS
Lateral myocardial infarction NOS
Subendocardial infarction
Inferior myocardial infarction NOS
Acute myocardial infarction NOS
Preinfarction syndrome
Acute coronary syndrome
Angina pectoris
Coronary atherosclerosis
Ischaemic heart disease NOS
Acute cor pulmonale
Pulmonary embolism
Post operative pulmonary embolus
Primary pulmonary hypertension
Acute pericarditis
Acute and subacute endocarditis
Acute myocarditis
Mitral valve incompetence
Aortic valve disorders
Aortic stenosis
Valvular heart disease
Alcoholic cardiomyopathy
Cardiomyopathy NOS
Conduction disorders NOS
Paroxysmal tachycardia unspecified
Atrial fibrillation
Atrial flutter
Cardiac arrest
Supraventricular tachycardia NOS
G1...
G110.
G2…
G20..
G200.
G201.
G202.
G24..
G301z
G304.
G305.
G307
G308.
G30z.
G311.
G3115
G33..
G340.
G3z..
G400.
G401.
G4010
G410.
G50..
G51..
G52..
G540.
G541.
G5415
G54z5
G555.
G55z.
G56zz
G572.
G5730
G5731
G575.
G57y9
7
NOTES
C
C
Heart failure
Left ventricular failure
Cerebrovascular disease
Subarachnoid haemorrhage
Intracerebral haemorrhage
Extradural haemorrhage - nontraumatic
Subdural haematoma - nontraumatic
Carotid artery stenosis
Cerebral infarction NOS
Basilar artery syndrome
Transient cerebral ischaemia NOS
Stroke and cerebrovascular accident unspecified
Cerebral atherosclerosis
Cerebral aneurysm, nonruptured
Aortic aneurysm
Raynauds disease
Buerger's disease
Peripheral vascular disease NOS
Polyarteritis nodosa
Kawasaki disease
Giant cell arteritis
Deep vein phlebitis and thrombophlebitis of the leg
Varicose veins of the leg NOS
Haemorrhoids
Oesophageal varices with bleeding
Oesophageal varices without bleeding
Noninfective lymphatic disorders
Primary (congenital) lymphoedema
C
C
C
C
C
G58..
G581.
G6…
G60..
G61..
G620.
G622.
G634.
G64z.
G650.
G65zz
G66..
G670.
G673.
G71..
G7300
G7310
G73z.
G750.
G7510
G755.
G801.
G83z.
G84..
G850.
G851.
G86..
G8610
Not a Contract code
Not a Contract code
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Code
CLINICAL TERM
H. RESPIRATORY SYSTEM DISEASE
C
C
C
C
Acute sinusitis NOS
Acute tonsillitis
Croup
Acute bronchiolitis
Nasal polyps
Chronic sinusitis
Peritonsillar abscess - quinsy
Allergic rhinitis NOS
Lobar (pneumococcal) pneumonia
Pneumonia due to other specified organisms
Pneumonia due to unspecified organism
Chronic bronchitis
Emphysema
Asthma NOS
Bronchiectasis
Extrinsic allergic alveolitis
Chronic obstructive airways disease NOS
Asbestosis
Pneumoconiosis NOS
Empyema
Pleurisy
Pleural effusion NOS
Pneumothorax
Idiopath fibrosing alveolitis
Diffuse pulmonary fibrosis
Pulmonary sarcoidosis
Respiratory failure
Sleep apnoea
H01z.
H03..
H044.
H061.
H11..
H13..
H15..
H17z.
H21..
H23..
H26..
H31..
H32..
H33zz
H34..
H35..
H3z..
H41..
H45..
H50..
H51..
H51z.
H52..
H563.
H5631
H57y2
H59..
H5B..
8
NOTES
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Code
CLINICAL TERM
J. DIGESTIVE SYSTEM DISEASE
Parotitis NOS
Sialolithiasis
Oesophagitis
Ulcerative oesophagitis
Oesophageal stricture and stenosis
Mallory - Weiss tear
Tracheo-oesophageal fistula
Oesopheal reflux without mention of oesophagitis
Gastric ulcer-(GU)
Duodenal ulcer-(DU)
Acute duodenal ulcer with perforation
Peptic ulcer NOS
Chronic gastritis
Duodenitis
Dyspepsia
Inguinal Hernia
Femoral hernia
Umbilical hernia
Diaphragmatic hernia
Noninfective enteritis and colitis
Regional enteritis - Crohn's disease
Ulcerative colitis
Chronic ischaemic colitis
Intussusception
Diverticulosis NOS
Constipation NOS
Irritable colon - Irritable bowel syndrome
Idiopathic megacolon
Fistula-in-ano
Perianal abscess
Peritonitis
Rectal prolapse
Haemorrhage of rectum and anus
Acute hepatic failure
Cirrhosis and chronic liver disease
Chronic hepatitis
Cirrhosis - non alcoholic
Primary biliary cirrhosis
Secondary biliary cirrhosis
Alcoholic hepatitis
Other non-alcoholic chronic liver disease
Liver abscess - excluding amoebic liver abscess
Portal hypertension
Cholelithiasis
Other cholecystitis
Cholangitis
Acute pancreatitis
Chronic pancreatitis
Gastrointestinal haemorrhage
Haematemesis
Melaena
Intestinal malabsorption
Coeliac disease
Pancreatic steatorrhoea
Protein-losing enteropathy
J0722
J075.
J101.
J1016
J103.
J108.
J10y2
J10y4
J11..
J12..
J1202
J13z.
J151.
J157.
J16y4
J30..
J31..
J32..
J34..
J4...
J40..
J4101
J4213
J500.
J510z
J520z
J521.
J5270
J531.
J540.
J55..
J571.
J573.
J6000
J61..
J614.
J615.
J6160
J6161
J617.
J61y.
J620.
J623.
J64..
J651.
J661.
J670.
J671.
J68..
J680.
J681.
J69..
J690.
J694.
J69y1
9
NOTES
S=Barretts Oesophagus
S=Gallstones
To Index
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Code
CLINICAL TERM
K. GENITO-URINARY SYSTEM DISEASE
Acute glomerulonephritis
Nephrotic syndrome
Chronic glomerulonephritis
Acute renal failure
Chronic renal failure
Renal failure - end stage
Renal failure unspecified
Chronic pyelonephritis
Acute pyelonephritis
Hydronephrosis
Calculus of kidney and ureter
Vesicoureteric reflux
Bladder calculus
Detrusor instability
Recurrent urinary tract infection
Benign prostatic hypertrophy
Acute prostatitis
Chronic prostatitis
Hydrocele NOS
Male infertility
Torsion of testis
Epididymal cyst
Fibrocystic disease of breast
Fibroadenosis of breast
Gynaecomastia
Breast abscess
Female pelvic inflammatory diseases
Acute salpingitis and oophoritis
Chronic salpingitis and oophoritis
Chlamydia cervicitis
Endometriosis
Genital prolapse
Ovarian cyst NOS
Polyp of corpus uteri
Premenstrual tension syndrome
Stress incontinence - female
Absence of menstruation
Menorrhagia
Postmenopausal bleeding
Menopausal symptoms NOS
Infertility - female
K00..
K01..
K02..
K04..
K05..
K050.
K06..
K100.
K101.
K11..
K12..
K137.
K140.
K1653
K1903
K20..
K210.
K211.
K23z.
K26..
K282.
K28y6
K301.
K302.
K3110
K318.
K4...
K400.
K401.
K4209
K50..
K51..
K532z
K540.
K584.
K586.
K590.
K5920
K5A1.
K5A2z
K5B..
NOTES
S=Amenorrhoea
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Code
CLINICAL TERM
L.
NOTES
COMPLICATION OF PREGNANCY, CHILDBIRTH & PUERPERIUM
Missed abortion
Ectopic pregnancy
Spontaneous abortion
Legally induced abortion
Placenta praevia
Antepartum haemorrhage NOS, unspecified
Gestational hypertension
Pre-eclampsia - unspecified
Eclampsia
L02..
L03..
L04..
L05..
L116.
L11z0
L1235
L1246
L126.
L13..
Excessive pregnancy vomiting
S = Termination of pregnancy
S=Hyperemesis of pregnancy
Gestational diabetes mellitus
L1809
L20..
Normal delivery in a completely normal case
Normal delivery but antenatal or postnatal conditions present
Twin pregnancy
Triplet pregnancy
Breech presentation
Intrauterine death
Postpartum haemorrhage (PPH)
Forceps delivery
Vacuum extractor delivery
Caesarean delivery
L200.
L210.
L211.
L222.
L264.
L36..
L395.
L396.
L398.
10
S=Spontaneous Vaginal
Delivery
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Code
CLINICAL TERM
M. SKIN & SUBCUTANEOUS TISSUE DISEASE
Other cellulitis and abscess
Contact dermatitis and other eczemas
Contact dermatitis due to adhesive plaster
Photodermatitis
Eczema NOS
Bullous disorders
Dermatitis herpetiformis
Pemphigus
Pemphigoid
Erythema nodosum
Acne rosacea
Lupus erythematosus
Psoriatic arthropathy
Psoriasis NOS
Pityriasis rosea
Lichen sclerosus et atrophicus
Alopecia areata
Hirsutism - hypertrichosis
Acne vulgaris
Arterial leg ulcer
Venous ulcer of leg
NOTES
M03..
M12..
M1241
M1273
M12z1
M14..
M140.
M144.
M145.
M152.
M1530
M154.
M160.
M161z
M163.
M2102
M2401
M241.
M2610
M2713
M2715
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Code
CLINICAL TERM
NOTES
N.
MUSCULOSKELETAL & CONNECTIVE TISSUE DISEASES
Systemic lupus erythematosus NOS
Scleroderma
Antiphospholipid syndrome
Pyogenic arthritis
Rheumatoid arthritis
Juvenile rheumatoid arthritis - Still's disease
Generalised osteoarthritis-OA
Osteoarthritis NOS, pelvic region/thigh
Osteoarthritis NOS, of knee
Unspecified polyarthropathy or polyarthritis
Ankylosing spondylitis
Sacroiliitis NEC
Spondylosis and allied disorders
Cervical spondylosis without myelopathy
Cervical disc displacement without myelopathy
Lumbar disc displacement
Brachial (cervical) neuritis
Lumbar spinal stenosis
Sciatica
Polymyalgia rheumatica
Adhesive capsulitis of the shoulder
Dupuytren's contracture
Fibromyalgia
Osteomyelitis, periostitis and other infections affecting bone
Osteitis deformans - Paget's disease of the bone
Osteochondropathies
Perthes' disease - osteochondritis of the femoral head
Osgood-Schlatter's disease - osteochondrosis of tibial tubercle
Osteoporosis
Pathological fracture
Fragility fracture
Kyphoscoliosis and scoliosis
Adolescent idiopathic scoliosis
[X]Osteopenia
N000z
N001.
N006.
N010.
N040.
N043.
N050.
N05z5
N05zL
N065.
N100.
N102.
N11..
N110.
N120.
N122.
N134.
N1402
N143.
N20..
N210.
N236.
N248.
N30..
N310.
N32..
N3211
N3244
N330.
N331.
N331N
N373.
N3737
NyuBC
11
S=Hip Osteoarthritis NOS
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Code
CLINICAL TERM
P. CONGENITAL ANOMALIES
Spina bifida
Spinal meningocele
Meningocele-cerebral
Microcephalus
Congenital hydrocephalus
Congenital eye anomalies
Ear anomalies with hearing impairment
Transposition of great vessels
Tetralogy of fallot
Ventricular septal defect
Ostium secundum atrial septal defect
Other congenital heart anomalies
Congenital tricuspid atresia and stenosis
Ebstein's anomaly
Congenital aortic valve stenosis
Congenital aortic valve insufficiency
Congenital mitral stenosis
Congenital mitral insufficiency
Hypoplastic left heart syndrome
Congenital malformation of aortic and mitral valves unspecified
Patent ductus arteriosus
Coarctation of aorta
Renal artery stenosis
Arteriovenous malformation
Respiratory system congenital anomalies
Cleft palate
Cleft lip (harelip)
Cleft palate with cleft lip
Congenital pyloric stenosis
Small intestine atresia and stenosis
Atresia and stenosis of large intestine, rectum and anal canal
Hirschsprung's disease
Undescended testicle
Hypospadias
Urinary system congenital anomalies
Renal agenesis and dysgenesis
Congenital absence of kidney
Polycystic kidney disease
Congenital dislocation and subluxation of the hip
Congenital talipes varus
Congenital talipes valgus
Congenital hip dysplasia
Craniosynostosis
Spina bifida occulta
Down's syndrome - trisomy 21
Turners syndrome
Fragile X syndrome
Absent spleen
Marfan's syndrome
P1...
P113.
P203.
P21..
P23..
P3...
P40..
P51..
P52..
P54..
P55..
P6...
P61..
P62..
P63..
P64..
P65..
P66..
P67..
P6W..
P70..
P71..
P7690
P76D.
P8...
P90..
P91..
P92..
PA52.
PB1..
PB2..
PB30.
PC5..
PC60.
PD...
PD0..
PD02.
PD11.
PE3..
PE50.
PE60.
PF631
PG03.
PG17.
PJ0..
PJ63.
PJyy4
PK01.
PKy2.
12
NOTES
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Code
CLINICAL TERM
Q. PERINATAL CONDITIONS
Fetal growth retardation NOS
Born premature NOS
Birth trauma
Intrauterine hypoxia and birth asphyxia
Respiratory distress syndrome
Perinatal bronchopulmonary dysplasia
Haemolytic disease of fetus and newborn due to isoimmunisation
Congenital anaemia
[X] Stillbirth
NOTES
Q10z.
Q11z.
Q20..
Q21..
Q30..
Q3170
Q42..
Q455.
Q48D.
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Code
CLINICAL TERM
NOTES
R.
SYMPTOMS, SIGNS & ILL-DEFINED CONDITIONS
[D]Convulsions, febrile
[D]Acute vertigo
[D]Hypersomnia with sleep apnoea
[D]Chronic intractable pain
[D]Dyslexia
[D]Heart murmur, innocent
[D]Haemoptysis
[D]Chest pain NOS
[D]Incontinence of faeces
[D]Renal colic
[D]Incontinence of urine
[D]Impaired fasting glycaemia
[D]Impaired glucose tolerance
C [D] Albuminuria
C [D] Microalbuminuria
[D]Abnormal liver function test
R0030
R0044
R0053
R00zC
R0463
R0523
R063.
R065z
R076.
R080.
R083.
R10D0
R10E.
R1100
R1103
R148.
Not for isolated dipstick
results
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Code
CLINICAL TERM
S.
INJURY & POISONING
Fracture of skull
Fracture of face bones
Fracture - mandible- closed
Fracture of nasal bones
Fracture of mandible
Fracture of spine without mention of spinal cord injury
Fracture of sternum
Fracture or disruption of pelvis
Fracture of humerus
Fracture of lower end of humerus
Fracture of radius and ulna
Fracture of Neck of femur
Fracture of shaft of femur
Fracture of patella
Fracture of tibia and fibula
Fracture of ankle
S0...
S02..
S022.
S0280
S0283
S10..
S128.
S13..
S22..
S228.
S23..
S30..
S314.
S32..
S33..
S34..
13
NOTES
Dislocation or subluxation of shoulder
Dislocation or subluxation of elbow
Dislocation or subluxation of hip
Dislocation or subluxation of knee
Acute meniscal tear, medial
Acute meniscal tear, lateral
Complete tear, knee ligament
Cerebral haemorrhage following injury
Traumatic subdural haematoma
Traumatic extradural haematoma
Head injury
Complete division, tendocalcaneus (Achilles tendon)
Burns
Anaphylactic shock
Non-accidental injury to child
Maltreatment syndromes
Egg allergy
Post operative deep vein thrombosis
S41..
S42..
S45..
S46..
S460.
S461.
S5C..
S62..
S629.
S62A.
S646.
SA124.
SH…
SN50.
SN552
SN57.
SN580
SP122
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Code
CLINICAL TERM
T.
NOTES
Advise using TJ… heirachy codes for
drug adverse reactions. If can't find in the
list below, search the main heirachy. If
not there suggest using nearest code and
adding an extension.
T1z..
T970.
TJ0..
TJ00.
TJ002
TJ003
TJ004
TJ03.
TJ05.
TJ0yC
TJ0yD
TJ103
TJ153
TJ1z0
TJ281
TJ303
TJ420
TJ421
TJ520
TJ522
TJ524
TJ53.
TJ540
TJ56.
TJ560
TJ562
TJ565
TJ567
TJ568.
TJ5y1
TJ632
TJ83z
TJ851
TJC24
TJC25
TJC44
TJC6.
TJC78
TJF71
TJHyx
TJJ4.
CAUSES OF INJURY & POISONING
Motor vehicle traffic accident NOS
Accidental poisoning by CO from incomplete combustion of piped gas
Adverse reaction to antibiotics
Adverse reaction to penicillins
Adverse reaction to flucloxacillin
Adverse reaction to amoxycillin
Adverse reaction to ampicillin
Adverse reaction to erythromycin and other macrolides
Adverse reaction to cephalosporin group
Adverse reaction to trimethoprim
Adverse reaction to cotrimoxazole
Adverse reaction to sulphamethoxazole
Adverse reaction to metronidazole
Adverse reaction to ciprofloxacin
Adverse reaction to iodine or iodide
Adverse reaction to metoclopramide
Adverse reaction to heparin
Adverse reaction to warfarin sodium
Adverse reaction to morphine salts
Adverse reaction to codeine phosphate
Adverse reaction to dihydrocodeine tartrate
Adverse reaction to salicylates
Adverse reaction to paracetamol
Adverse reaction to antirheumatics
Adverse reaction to ibuprofen
Adverse reaction to fenbufen
Adverse reaction to indomethacin
Adverse reaction to naproxen
Adverse reaction to piroxicam
Adverse reaction to mefenamic acid
Adverse reaction to carbamazepine
Adverse reaction to intravenous anaesthetic NOS
Adverse reaction to lignocaine hydrochloride
Adverse reaction to simvastatin
Adverse reaction to pravastatin
Adverse reaction to dipyridamole
Adverse reaction to betablockers
Adverse reaction to enalapril
Adverse reaction to ipratropium bromide
Adverse reaction to contrast media used for diagnostic x-rays NOS
Adverse reaction to tetanus vaccine
14
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C
C
C
C
Read
Code
CLINICAL TERM
NOTES
U. EXTERNAL CAUSES OF MORBIDITY & MORTALITY
[X]Accidental poisoning by and exposure to noxious substances
U1A..
[X]Unspecified fall
U10z.
[X]Intentional self-harm
U2…
[X]Intentional self poisoning by and exposure to noxious substances
U20..
[X]Clopidogrel causing adverse effects in therapeutic use
U6048
[X]Angiotensin-converting-enzyme inhibitors causing adverse effects in
U60C4
therapeutic use
[X]Statin causing adverse effect in therapeutic use
U60CA
[X]Angiotensin II receptor antagonists causing adverse effects in therapeutic U60CB
use
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Code
CLINICAL TERM
Z. UNSPECIFIED CONDITIONS
[V]Problem with sexual function
[V]Fitting or adjustment of hearing aid
[V]Palliative care
NOTES
ZV417
ZV532
ZV57C
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Code
CLINICAL TERM
NOTES
1. HISTORY/ SYMPTOMS
FH: * - gastrointestinal tract
1241.
FH: * - trachea/bronchus/lung
FH: * - breast
FH: * - female genital organ
FH: Thyroid disorder
FH Diabetes Mellitus
FH Osteoporosis
Family history of familial hypercholesterolaemia
FH Thalassaemia
FH Sickle cell anaemia
FH Sickle cell trait
FH Mental Disorder
FH Drug Dependency
FH Schizophrenia
FH Suicide
FH: Huntington's chorea
FH Glaucoma
FH Hypertension
1242.
1243.
1245.
1251.
1252.
1268.
1269.
1273.
1274.
1275.
128..
1283.
1284.
1289.
1291.
12A1.
12C1.
15
S=FH Intestinal Cancer, FH
Stomach Cancer or FH Bowel
Cancer
S=FH Bronchus Cancer
S=FH Breast Cancer
S=FH Ovarian Carcinoma
C
C
C
C
C
C
C
C
C
C
FH Ischaemic heart disease <60
FH Ischaemic heart disease >60
FH CVA/ stroke
FH: Myocardial infarction
FH Asthma
FH Congenital anomaly
Alcohol - teetotaller
Never smoked tobacco
Exercise physically impossible
Avoids even trivial exercise,
Enjoys light exercise,
Enjoys moderate exercise,
Enjoys heavy exercise,
Competitive athlete
Vulnerable adult
Alcohol intake above recommended sensible limits
Alcohol intake within recommended sensible limits
Current non drinker
Current smoker
Ex smoker
Takes inadequate exercise
Bereavement
Child on at risk register
Removed - child abuse register
Vulnerable child
Death of infant
At risk of falls
No relevant past medical hist.
Chronic low back pain
Double incontinence
Enuresis
Chronic kidney disease stage 1
Chronic kidney disease stage 2
Chronic kidney disease stage 3
Chronic kidney disease stage 4
Chronic kidney disease stage 5
Chronic kidney diseas stage 3A
Chronic kidney diseas stage 3B
12C2.
12C3.
12C4.
12C5.
12D2.
12J..
1361.
1371.
1381.
1382.
1383.
1384.
1385.
1386.
133P.
136K.
136L.
136M.
137R.
137S.
138O.
13Hc.
13IC.
13IC0
13IF.
13M2.
14OC.
14Z1.
16C9.
16F..
1A22.
1Z10.
1Z11.
1Z12.
1Z13.
1Z14.
1Z15.
1Z16.
To Index
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C
C
C
C
C
C
Read
Code
CLINICAL TERM
2. EXAMINATION/ SIGNS
Epilepsy resolved
Hypertension resolved
Asthma resolved
Diabetes resolved
Atrial fibrillation resolved
Depression resolved
0/E - cardiac murmur
21260
21261
21262
21263
212R.
212S.
24D..
16
NOTES
To Index
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C
C
C
C
C
C
C
C
C
Read
Code
CLINICAL TERM
3. DIAGNOSTIC PROCEDURES
EEG normal
EEG abnormal
Fundoscopy normal
Fundoscopy abnormal
Ambulatory blood pressure recording
Infertility investigations NOS
Exercise ECG normal
Exercise ECG abnormal
Ambulatory ECG normal
Ambulatory ECG abnormal
ECG normal
ECG abnormal
ECG: atrial fibrillation
Serial peak expiratory flow rate
Forced expired volume in 1 second
Spirometry reversibility positive
Negative reversibility test to salbutamol
31130
31140
31280
31281
315B.
3189.
32130
32131
32140
32141
3216.
3217.
3272.
339g.
339O.
33G1.
33H0.
33H1.
C Positive reversibility test to salbutamol
C Negative reversibility test to ipratropium bromide
33I0.
33I1.
C
Positive reversibility test to ipratropium bromide
Negative reversibility test to combination of salbutamol and ipratropium
bromide
Positive reversibility test to a combination of salbutamol and ipratropium
C
bromide
Endoscopy normal
Bronchoscopy normal
Endoscopy abnormal
Bronchoscopy abnormal
Colonoscopy - normal
Colonoscopy - abnormal
NOTES
Contract Asthma only
Contract COPD
Contract Asthma only.
Contract COPD only
Both Contract Asthma and
COPD
Contract COPD only
Both Contract Asthma and
COPD
33J0.
C
33J1.
Contract COPD only
Both Contract Asthma and
COPD
3614.
36141
3615.
36151
3617.
3618.
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Code
CLINICAL TERM
4. LABORATORY PROCEDURES
Rhesus negative
Rhesus positive
C Lithium level therapeutic
C Urine microalbumin positive
C Urine microalbumin negative
Bone marrow exam. normal
Bone marrow exam. abnormal
Helicobacter serology positive
Helicobacter serology negative
Helicobacter breath test positive
Helicobacter breath test negative
CLO test positive
CLO test negative
Cervical smear: negative
Cerv.smear: mild dyskaryosis
Cerv.smear: severe dyskaryosis
Cerv.smear:severe dysk.?inv.ca
Cervical smear: ? gland neopl.
Cerv.smear: mod.dyskaryosis
Cerv.smear: borderline changes
4321.
4322.
44W80
46W0.
46W1.
4C12.
4C13.
4JD6.
4JD7.
4JM0.
4JM1.
4JO0.
4JO1.
4K22.
4K23.
4K24.
4K25.
4K26.
4K28.
4K29.
17
NOTES
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C
C
C
C
C
C
C
C
C
Read
Code
CLINICAL TERM
5. RADIOLOGY/ PHYSICS IN MEDICINE
Mammogram - normal
Mammogram - abnormal
Barium meal - normal
Barium meal - abnormal
Barium Enema - normal
Barium Enema - abnormal
I-V pyelography normal
Intravenous pyelography - abnormal
Biliary contr.radiog. normal
Biliary contr.radiog.abnormal
Angiocardiography normal
Angiocardiography abnormal
Coronary arteriography normal
Coronary arteriograph.abnormal
CAT Scan - normal
CAT scan - abnormal
CAT scan - brain - abnormal
Nuclear magn reson normal
Nuclear magn.reson. abnormal
Magnetic resonance imaging of brain abnormal
Magnetic resonance imaging of brain normal
Thyroid iodine isotope uptake
Isotope static scan kidneys normal
Isotope static scan kidneys abnormal
Isotope dynamic heart scan
Echocardiogram - normal
Echocardiogram - abnormal
Doppler studies - normal
Doppler studies - abnormal
U-S kidneys
Hip DXA scan result normal
Hip DXA scan result osteoporotic
Hip DXA scan result osteopenic
Lumbar DXA scan result normal
Lumbar DXA scan result osteoporotic
Lumbar DXA scan result osteopenic
Bone density scan
CT scan brain - normal
5372.
5373.
5482.
5483.
54A2.
54A3.
54C2.
54C3.
54G2.
54G3.
5532.
5533.
5542.
5543.
5672.
5673.
567C.
5692.
5693.
5694.
569F.
5711
57350
57351
5744.
58530
58531
58580
58581
585B.
58EF.
58EG.
58EH.
58EL.
58EM.
58EN.
58F..
5C00.
NOTES
Contract Heart Failure
Contract Heart Failure
Contract Stroke
Contract Stroke
Contract Stroke
Contract Stroke
Contract Stroke
Contract CHD
Contract Heart Failure
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Code
CLINICAL TERM
NOTES
6.
PREVENTATIVE PROCEDURES
IUD fitted
IUD removed
Depot contraceptive
Subcutaneous contraceptive NOS
Pneumococcal vaccination given
C Influenza vaccination
Antibiotic prophylaxis recommended
Viral hepatitis carrier
On lithium
C Lithium stopped
Health ed. - alcohol
Health ed. - exercise
Health ed. - diet
C Diabetic retinopathy screening
Fit to Drive
Unfit to Drive
6151.
6152.
61B61KZ.
65720
65E..
65N8.
65Q7.
6657.
665B.
6792.
6798.
6799.
68A7.
692A.
692B.
18
S=Started lithium
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Code
CLINICAL TERM
7. OPERATIONS, PROCEDURES & SITES
Vagotomy & pyloroplasty
70224
Carpal tunnel release
70560
Excision of pituitary gland
7100.
Total thyroidectomy
71100
Subtotal thyroidectomy
71101
Excision of parathyroid gland operations
7114.
Partial adrenalectomy
71223
Adrenalectomy NEC
71224
Total mastectomy NOS
7130z
Partial mastectomy NEC
71311
Excision of lesion of breast
71312
Enucleation of eyeball
72001
Eye muscle operations
723..
Surgical iridectomy
72541
Other extraction of lens
7266
Insertion of prosthetic replacement for lens
72670
Exenteration of mastoid air cells
7310.
Repair of tympanic membrane
7312.
Myringotomy
73131
Myringotomy and insertion of long term grommet
73134
Stapedectomy
73150
Excision of cholesteatoma
73232
FESS - diagnostic endoscopy of nose and sinus
7415
Adenoidectomy
74210
Excision of larynx
7430.
Exteriorisation of trachea
7443.
Total pneumonectomy
74510
Lobectomy of lung
74512
Excision of tonsil
7530.
Dissection tonsillectomy and adenoidectomy
75308
Excision of oesophagus and stomach
7600.
Repair of diaphragmatic hernia
760K.
Total excision of stomach
7610.
Partial excision of stomach
7611.
Gastrostomy operation
7617.
Pyloroplasty NEC
761B2
Creation of ileostomy
7645.
Closure of ileostomy
76462
Emergency excision of appendix NOS
7700z
Total excision of colon
7711.
Other excision of right hemicolon NOS
7713z
Excision of left hemicolon
7715.
Other exteriorisation of colon
771B.
Diagnostic endoscopic exam. sigmoid colon using rigid sigmoidoscope NOS 771Qz
Haemorrhoidectomy
77340
Pilonidal sinus operations
773B.
Transplantation of liver
7800.
Excision of gall bladder
7810
Endoscopic cholecystectomy
78105
Diagnostic endoscopic retrograde examination - bile duct & pancreatic duct 782G.
Total excision of pancreas
7831.
Oth partial excision pancreas
7833.
Splenectomy NEC
78403
Transplantation of heart and lung
7900.
Other transplantation of heart
7901.
Coronary artery operations
792..
Transluminal balloon angioplasty of coronary artery
7928.
Insertion of coronary artery stent
79294
Implantation of cardiac pacemaker system NEC
79370
Catheterisation of heart
7939.
Other replacement of aneurysmal segment of aorta
7A14.
Endarterectomy of carotid artery NEC
7A204
Other bypass of femoral artery or popliteal artery
7A48.
Other operations on varicose vein of leg
7A69.
Transplantation of kidney
7B00.
Total nephrectomy
7B01.
Partial nephrectomy
7B02.
Percutaneous nephrostomy
7B0A4
Unspecified open ureterolithotomy
7B150
Total excision of bladder
7B20.
Partial cystectomy
7B211
Endoscopic extirpation of bladder lesion
7B27.
Diagnostic cystoscopy
7B2A.
Transurethral prostatectomy
7B390
19
NOTES
S=Breast Lumpectomy
S=Ops for squint
S=Mastoidectomy
S=Tonsillectomy
S=Colostomy. NOS
S = Sigmoidoscopy NEC
S=Cor art bypass graft ops
S=Cardiac catheterisation
S=TURBT
Other hypospadias repair
Bilateral orchidectomy
Unilateral total orchidectomy - unspecified
Bilateral orchidopexy
Unilateral orchidopexy
Reduction of torsion of testis
Bilateral vasectomy for contraception
Reversal of vasectomy - unspecified
Standard circumcision
Repair of vaginal prolapse and amputation of cervix uteri
Other repair of vaginal prolapse
Large loop excision transformation zone
Colposcopy of cervix
Total abdominal hysterectomy NEC
Subtotal abdominal hysterectomy
Abdominal hysterectomy and right salpingoopherectomy
Abdominal hysterectomy and left salpingoophorectomy
Total abdominal hysterectomy and bilateral salpingoophorectomy
Vaginal excision of uterus
Termination of pregnancy NEC
Trans-cervical resection endometrium
Endometrial ablation
Diagnostic endoscopic examination of uterus
Salpingoophorectomy NEC
Salpingectomy NEC
Oophorectomy NEC
Open bilateral occlusion of fallopian tubes
Open reversal of female sterilisation
7B410
7C02.
7C032
7C05.
7C06.
7C092
7C110
7C120
7C242
7D17.
7D18.
7E004
7E034
7E043
7E044
7E047
7E048
7E049
7E05.
7E086
7E0D5
7E0D6
7E0E.
7E120
7E121
7E122
7E15.
7E17.
7E1C.
Endoscopic bilateral occlusion of fallopian tubes
Ovarian cystectomy
Manual removal of placenta from delivered uterus
Excision lesion of skin NEC
Thoracoplasty
Primary repair of inguinal hernia
Primary repair of femoral hernia
Repair of umbilical hernia
Primary repair of incisional hernia
Exploratory laparotomy
Diagnostic endoscopic examination of peritoneum
Primary laminectomy excision of cervical intervertebral disc
Primary fusion of joint of cervical spine
Primary lumbar discectomy
Back fusion
Revision of total prosthetic replacement of hip joint NEC
Total prosthetic replacement of hip joint NOS
Primary total knee replacement NEC
Open operations on semilunar cartilage
Therapeutic arthroscopic operations on semilunar cartilage
Diagnostic arthroscopy of knee
Primary arthrodesis of joint NEC
Diagnostic endoscopic examination of other joint
Amputation of arm
Amputation of hand
Amputation of finger NEC
Amputation of leg
Amputation above knee
Amputation below knee
Amputation of foot
Amputation hallux
7E203
7F210
7G033
7H000
7H11.
7H13.
7H15.
7H16.
7H220
7H29.
7J200
7J22.
7J32.
7J48J
7K222
7K22z
7K320
7K33.
7K34.
7K36.
7K6C2
7K6Y.
7L04.
7L05.
7L053
7L06.
7L062
7L064
7L07.
7L080
20
S=Vaginal hysterectomy
S=hysteroscopy
S=Laproscopic bilateral
female sterilization
S=laparoscopy
hallux = big toe
Amputation lesser toe
Renal dialysis
Peritoneal dialysis
Haemodialysis NEC
External resuscitation
Radiotherapy NEC
7L083
7L1A0
7L1A1
7L1A2
7L1H.
7M371
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Code
CLINICAL TERM
8. OTHER THERAPEUTIC PROCEDURES
Faradism to nervous system
C Over the counter aspirin therapy
Helicobacter eradication therapy
Cancer chemotherapy
Treatment for infertility
C Smoking cessation advice
C On gold standards palliative care framework
Emerg psychiatric admiss MHA
8642.
8B3T.
8BAC.
8BAD0
8C8..
8CAL.
8CM1.
8H230
NOTES
S=ECT therapy
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Code
CLINICAL TERM
NOTES
9.
ADMINISTRATION
On learning disability register
C Notes summarised to computer
C Computer summary updated
MED3 issued to patient
MED5 issued to patient
MED4 - issued to patient
GP out of hours service notified
Date records held from
C Ethnic groups (census)
Advanced directive signed (copy in notes)
918e.
9344.
9348.
9D11.
9D21.
9DF0.
9e0..
9R8..
9S%
9X20.
21
any code in heirarchy.