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103 ICD-10 codes available

E11.65Endocrine, Nutritional and Metabolic Diseases

Type 2 Diabetes Mellitus with Hyperglycemia

Type 2 diabetes mellitus with hyperglycemia represents inadequate blood glucose control in patients with established diabetes, typically defined as blood glucose levels consistently above target ranges (fasting >130 mg/dL or random >180 mg/dL) without acute metabolic decompensation.

Follow-up visit for patient with uncontrolled diabetes and HbA1c >9%Emergency department visit for symptomatic hyperglycemia (glucose 300-400 mg/dL) not meeting criteria for DKA/HHSInpatient encounter where diabetes management is adjusted due to persistent elevated glucose readings
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E11.22Endocrine, Nutritional and Metabolic Diseases

Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease

Type 2 diabetes mellitus with chronic kidney disease (CKD) represents progressive kidney damage caused by longstanding diabetes, characterized by persistent albuminuria and/or declining glomerular filtration rate (GFR) attributable to diabetic nephropathy.

Annual diabetic screening reveals new-onset microalbuminuria with GFR 55 mL/minFollow-up for established diabetic CKD with monitoring of kidney functionNephrologist visit for progressive diabetic nephropathy requiring treatment adjustment
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E11.40Endocrine, Nutritional and Metabolic Diseases

Type 2 Diabetes Mellitus with Diabetic Neuropathy, Unspecified

Type 2 diabetes mellitus with diabetic neuropathy represents nerve damage caused by prolonged hyperglycemia affecting peripheral, autonomic, or focal nerve function, with the specific type of neuropathy not specified or documented.

Office visit for diabetic patient complaining of foot pain and numbness, physician documents 'diabetic neuropathy'Referral to podiatry for diabetic neuropathy without specification of typePrescription of gabapentin or pregabalin for 'painful diabetic neuropathy'
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E10.9Endocrine, Nutritional and Metabolic Diseases

Type 1 Diabetes Mellitus Without Complications

Type 1 diabetes mellitus without complications represents autoimmune destruction of pancreatic beta cells resulting in absolute insulin deficiency, currently without documented diabetic complications such as neuropathy, retinopathy, nephropathy, or circulatory disorders.

Routine follow-up visit for well-controlled type 1 diabetes with no documented complicationsAnnual comprehensive diabetes visit with no complications found on screeningSick day management visit for type 1 diabetic with intercurrent illness but no acute diabetes complications
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E11.21Endocrine, Nutritional and Metabolic Diseases

Type 2 Diabetes Mellitus with Diabetic Nephropathy

Type 2 diabetes mellitus with diabetic nephropathy represents kidney damage specifically characterized by diabetic glomerular disease, typically manifesting as persistent albuminuria and/or declining kidney function directly attributable to longstanding diabetes.

Nephrology follow-up for established diabetic nephropathy with progressive proteinuriaAnnual diabetes visit where screening reveals new-onset macroalbuminuria and provider documents diabetic nephropathyHospital admission for nephrotic syndrome secondary to diabetic glomerulosclerosis
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E11.42Endocrine, Nutritional and Metabolic Diseases

Type 2 Diabetes Mellitus with Diabetic Polyneuropathy

Type 2 diabetes mellitus with diabetic polyneuropathy represents bilateral, symmetric nerve damage affecting multiple peripheral nerves, typically manifesting in a glove-and-stocking distribution with sensory, motor, and autonomic symptoms caused by chronic hyperglycemia.

Neurology or podiatry referral for bilateral diabetic foot neuropathyOffice visit for painful diabetic peripheral neuropathy requiring medication managementAnnual diabetic foot screening revealing loss of protective sensation with 10g monofilament
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E11.51Endocrine, Nutritional and Metabolic Diseases

Type 2 Diabetes Mellitus with Diabetic Peripheral Angiopathy Without Gangrene

Type 2 diabetes mellitus with diabetic peripheral angiopathy represents vascular disease affecting peripheral arteries due to diabetes, causing reduced blood flow to extremities without tissue necrosis or gangrene, manifesting as claudication, diminished pulses, or other signs of arterial insufficiency.

Vascular surgery consultation for diabetic patient with claudication and absent pedal pulsesOffice visit where ABI testing reveals PAD in diabetic patient, documented as diabetic peripheral angiopathyReferral to wound care clinic for diabetic with poor peripheral perfusion but no ulceration yet
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I11.9Diseases of the Circulatory System

Hypertensive Heart Disease Without Heart Failure

Hypertensive heart disease without heart failure represents cardiac structural or functional changes caused by chronic systemic hypertension, including left ventricular hypertrophy, diastolic dysfunction, or coronary artery disease attributable to hypertension, but without current clinical heart failure.

Cardiology follow-up for patient with hypertension and echocardiogram showing left ventricular hypertrophyPrimary care visit documenting 'hypertensive heart disease' based on ECG showing LVH voltage criteriaStress test showing ischemia in patient with long-standing hypertension, no prior MI, no heart failure symptoms
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I12.9Diseases of the Circulatory System

Hypertensive Chronic Kidney Disease with Stage 1 Through Stage 4 CKD, or Unspecified CKD

Hypertensive chronic kidney disease represents kidney damage and declining renal function directly caused by longstanding systemic hypertension, with current chronic kidney disease stage 1-4 or stage not specified, characterized by persistent albuminuria, reduced GFR, or both attributable to hypertensive nephrosclerosis.

Nephrology follow-up for patient with hypertension and declining kidney function attributed to hypertensive nephrosclerosisPrimary care visit documenting 'hypertensive chronic kidney disease' based on elevated creatinine and hypertension historyHospitalization for acute on chronic kidney injury in patient with chronic hypertensive kidney disease
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I13.0Diseases of the Circulatory System

Hypertensive Heart and Chronic Kidney Disease with Heart Failure and Stage 1 Through Stage 4 CKD, or Unspecified CKD

Hypertensive heart and chronic kidney disease with heart failure represents the coexistence of heart failure and chronic kidney disease (stage 1-4 or unspecified) both caused by longstanding systemic hypertension, reflecting multi-organ damage from sustained elevated blood pressure.

Cardiology visit for patient with systolic heart failure, hypertension, and stage 3 CKDHospital admission for acute decompensated heart failure in patient with known hypertensive heart and kidney diseaseHeart failure clinic follow-up for patient with reduced EF and declining renal function
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I11.0Diseases of the Circulatory System

Hypertensive Heart Disease with Heart Failure

Hypertensive heart disease with heart failure represents cardiac dysfunction (systolic, diastolic, or combined) directly caused by longstanding systemic hypertension, with clinical manifestations of heart failure present during the encounter.

Cardiology visit for patient with documented hypertensive heart disease and reduced EF with symptomsHospital admission for acute decompensated heart failure in patient with known hypertensive cardiomyopathyHeart failure clinic follow-up for patient with HFpEF attributed to longstanding hypertension
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I15.0Diseases of the Circulatory System

Renovascular Hypertension

Renovascular hypertension is secondary hypertension caused by renal artery stenosis (RAS), typically due to atherosclerotic disease or fibromuscular dysplasia, resulting in reduced renal perfusion and activation of the renin-angiotensin-aldosterone system (RAAS).

Nephrology visit for patient diagnosed with renal artery stenosis causing hypertensionPost-renal angiography encounter documenting 80% right renal artery stenosis as cause of resistant hypertensionHypertension evaluation revealing fibromuscular dysplasia on CT angiography
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J44.0Diseases of the Respiratory System

Chronic Obstructive Pulmonary Disease with Acute Lower Respiratory Infection

COPD with acute lower respiratory infection represents an acute worsening of chronic obstructive pulmonary disease precipitated by bacterial or viral infection of the lower respiratory tract (bronchi, bronchioles, or lung parenchyma), characterized by increased dyspnea, sputum production, and/or sputum purulence.

Hospital admission for COPD exacerbation with chest X-ray showing infiltrate and productive coughEmergency department visit for COPD patient with acute bronchitis (purulent sputum, fever)Outpatient visit for COPD flare with viral upper respiratory infection progressing to lower tract
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J45.909Diseases of the Respiratory System

Unspecified Asthma, Uncomplicated

Unspecified asthma, uncomplicated represents chronic inflammatory airway disease with reversible airflow obstruction, where the specific asthma type (mild intermittent, mild persistent, moderate persistent, or severe persistent) is not documented and no acute exacerbation or status asthmaticus is present.

Routine follow-up visit for patient with established asthma diagnosis, currently stable on controller medicationsRefill visit for asthma inhalers (albuterol, inhaled corticosteroid) without current symptomsPrimary care visit documenting 'asthma' without severity specification, patient doing well
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J18.9Diseases of the Respiratory System

Pneumonia, Unspecified Organism

Pneumonia, unspecified organism represents acute infection and inflammation of the lung parenchyma (alveoli and interstitium) where the causative pathogen has not been identified or specified, presenting with clinical and/or radiographic evidence of pulmonary infiltration.

Emergency department visit with chest X-ray showing right lower lobe infiltrate, organism unknownHospital admission for community-acquired pneumonia (CAP) with empiric antibiotic therapy startedOutpatient treatment of pneumonia diagnosed clinically and radiographically without cultures obtained
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J20.9Diseases of the Respiratory System

Acute Bronchitis, Unspecified

Acute bronchitis, unspecified is inflammation of the bronchial tubes (large and medium airways) typically caused by viral infection, characterized by cough (with or without sputum production), often following upper respiratory infection, where the causative organism is not specified.

Urgent care visit for cough lasting 10 days following upper respiratory infection, no focal findings on lung examPrimary care visit for productive cough and chest discomfort, chest X-ray normal (rules out pneumonia)Walk-in clinic encounter for cough and mild wheezing, diagnosed as acute viral bronchitis
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J44.9Diseases of the Respiratory System

Chronic Obstructive Pulmonary Disease, Unspecified

COPD, unspecified represents chronic inflammatory lung disease causing persistent airflow limitation without specification of subtype (chronic bronchitis vs. emphysema) and without current acute exacerbation, characterized by progressive dyspnea, cough, and sputum production.

Routine pulmonology follow-up for stable COPD, spirometry showing obstruction, no current exacerbationPrimary care visit for COPD management, medication refills (tiotropium, albuterol), patient doing wellPre-operative assessment documenting COPD as comorbidity, currently stable on bronchodilators
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J06.9Diseases of the Respiratory System

Acute Upper Respiratory Infection, Unspecified

Acute upper respiratory infection (URI), unspecified represents viral or bacterial infection of the upper respiratory tract (nose, sinuses, pharynx, larynx) without specification of the exact anatomic site or causative organism, commonly known as the 'common cold' or 'upper respiratory tract infection.'

Primary care or urgent care visit for cold symptoms: nasal congestion, sore throat, mild cough, no focal findingsTelemedicine visit for patient with rhinorrhea and sneezing, diagnosed as viral URIWalk-in clinic encounter for 'head cold' symptoms, examination unremarkable
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J45.40Diseases of the Respiratory System

Moderate Persistent Asthma, Uncomplicated

Moderate persistent asthma, uncomplicated represents chronic inflammatory airway disease classified as moderate severity based on symptom frequency (daily symptoms, nighttime awakenings >1x/week) and lung function (FEV1 60-80% predicted), currently stable without acute exacerbation or status asthmaticus.

Pulmonology follow-up for established moderate persistent asthma, currently well-controlled on fluticasone/salmeterolPrimary care visit for asthma action plan review, patient using daily controller inhaler, symptoms controlledAsthma clinic encounter documenting severity classification after spirometry testing
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J02.9Diseases of the Respiratory System

Acute Pharyngitis, Unspecified

Acute pharyngitis, unspecified represents acute inflammation of the pharynx and/or tonsils, typically presenting as sore throat, where the causative organism (viral vs. bacterial) is not identified or specified, requiring clinical assessment to guide treatment decisions.

Urgent care visit for sore throat, rapid strep test negative, diagnosed as viral pharyngitisPrimary care visit for pharyngitis, rapid strep pending, empiric treatment withheldPediatric visit for child with sore throat and fever, clinical diagnosis of pharyngitis without testing
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J03.90Diseases of the Respiratory System

Acute Tonsillitis, Unspecified

Acute tonsillitis, unspecified represents acute inflammation and infection of the palatine tonsils, presenting as severe sore throat with tonsillar enlargement and often exudate, where the causative organism is not identified but clinical presentation suggests tonsillar involvement is predominant feature.

Pediatric visit for child with severe sore throat, enlarged tonsils with exudate, fever 102.5°FUrgent care visit for acute tonsillitis, rapid strep negative, presumed viral etiologyEmergency department visit for severe throat pain with large tonsils nearly meeting in midline
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J45.20Diseases of the Respiratory System

Mild Intermittent Asthma, Uncomplicated

Mild intermittent asthma, uncomplicated represents the mildest classification of asthma based on symptom frequency (≤2 days/week), minimal nighttime awakenings (≤2x/month), and normal lung function (FEV1 ≥80% predicted) between exacerbations, currently stable without acute exacerbation.

Annual asthma review for patient with infrequent symptoms, using albuterol occasionally (1-2x/month)Primary care visit for child with exercise-induced asthma symptoms only, normal baselineAllergy clinic follow-up for patient with seasonal asthma symptoms, symptom-free most of year
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J43.9Diseases of the Respiratory System

Emphysema, Unspecified

Emphysema, unspecified represents chronic obstructive pulmonary disease characterized by permanent, abnormal enlargement of air spaces distal to the terminal bronchioles with destruction of alveolar walls, resulting in loss of elastic recoil and air trapping, without specification of emphysema subtype (centrilobular, panlobular, paraseptal).

Pulmonology follow-up for patient with CT-confirmed emphysema, currently stablePrimary care visit documenting 'emphysema' on problem list based on prior imaging and spirometryPre-operative assessment for patient with known emphysema as comorbidity
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M25.511Diseases of the Musculoskeletal System and Connective Tissue

Pain in Right Shoulder

Pain in right shoulder without identification of specific underlying pathology, used when pain is the primary complaint and definitive diagnosis cannot be established.

Primary care visit for right shoulder pain, examination non-specific, X-ray orderedUrgent care for acute right shoulder pain after lifting, no trauma, limited ROMFollow-up for persistent right shoulder discomfort, MRI pending
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M25.512Diseases of the Musculoskeletal System and Connective Tissue

Pain in Left Shoulder

Pain in left shoulder without identification of specific underlying pathology.

Primary care visit for left shoulder pain, workup pendingPT evaluation for non-specific left shoulder discomfortUrgent care for acute left shoulder pain without trauma
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M79.1Diseases of the Musculoskeletal System and Connective Tissue

Myalgia

Muscle pain (myalgia) without specification of location or underlying cause, representing diffuse or localized muscle pain that doesn't fit more specific diagnostic categories.

Influenza with body aches and muscle painPatient on statin therapy reporting muscle pain, CK normalPost-viral syndrome with persistent myalgia
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M19.90Diseases of the Musculoskeletal System and Connective Tissue

Unspecified Osteoarthritis, Unspecified Site

Degenerative joint disease without specification of joint location.

OA on problem list without site specification
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M54.2Diseases of the Musculoskeletal System and Connective Tissue

Cervicalgia

Neck pain without specification of cause.

Primary care for neck pain without radiculopathy
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M17.11Diseases of the Musculoskeletal System and Connective Tissue

Unilateral Primary Osteoarthritis, Right Knee

Primary osteoarthritis affecting right knee.

Orthopedic visit for right knee OA
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M17.12Diseases of the Musculoskeletal System and Connective Tissue

Unilateral Primary Osteoarthritis, Left Knee

Primary osteoarthritis affecting left knee.

Orthopedic visit for left knee OA
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M62.81Diseases of the Musculoskeletal System and Connective Tissue

Muscle Weakness (Generalized)

Generalized muscle weakness without specific neuromuscular diagnosis.

Elderly patient with weakness, workup pending
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M75.50Diseases of the Musculoskeletal System and Connective Tissue

Bursitis of Unspecified Shoulder

Shoulder bursitis without laterality specification.

Shoulder bursitis, side not specified
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M25.561Diseases of the Musculoskeletal System and Connective Tissue

Pain in Right Knee

Non-specific right knee pain without identified pathology.

Primary care for right knee pain, workup pending
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M25.562Diseases of the Musculoskeletal System and Connective Tissue

Pain in Left Knee

Non-specific left knee pain without identified pathology.

Primary care for left knee pain
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M54.89Diseases of the Musculoskeletal System and Connective Tissue

Other Dorsalgia

Back pain not classified elsewhere (thoracic, rib, other).

Mid-back or thoracic spine pain
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M79.3Diseases of the Musculoskeletal System and Connective Tissue

Panniculitis, Unspecified

Inflammation of subcutaneous fat without specification of type.

Dermatology/rheumatology for panniculitis
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M25.50Diseases of the Musculoskeletal System and Connective Tissue

Pain in Unspecified Joint

Joint pain without specification of which joint is affected.

Documentation of 'joint pain' without location
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F41.9Mental, Behavioral and Neurodevelopmental Disorders

Anxiety Disorder, Unspecified

Anxiety disorder without specification of type (GAD, panic, social anxiety, etc.).

Primary care documentation of 'anxiety'Medication management for anxiety
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F32.9Mental, Behavioral and Neurodevelopmental Disorders

Major Depressive Disorder, Single Episode, Unspecified

First episode of major depression without severity specification.

New diagnosis of depressionFirst episode MDD on antidepressant
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F33.1Mental, Behavioral and Neurodevelopmental Disorders

Major Depressive Disorder, Recurrent, Moderate

Recurrent major depression, current episode moderate severity.

Psychiatry follow-up for recurrent depressionMedication adjustment for moderate MDD
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F10.10Mental, Behavioral and Neurodevelopmental Disorders

Alcohol Abuse, Uncomplicated

Alcohol use disorder (mild) without physiologic dependence or complications.

Primary care screening identifying risky drinkingCounseling visit for alcohol abuse
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F41.1Mental, Behavioral and Neurodevelopmental Disorders

Generalized Anxiety Disorder

Excessive worry about multiple concerns for ≥6 months with associated symptoms.

Psychiatry/primary care management of GADMedication for chronic excessive worry
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F17.210Mental, Behavioral and Neurodevelopmental Disorders

Nicotine Dependence, Cigarettes, Uncomplicated

Tobacco use disorder via cigarettes without current withdrawal or complications.

Documentation of current smoking statusPre-operative assessmentSmoking cessation counseling visit
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F43.10Mental, Behavioral and Neurodevelopmental Disorders

Post-traumatic Stress Disorder, Unspecified

PTSD without specification of severity, following exposure to traumatic event.

Mental health treatment for PTSDVeterans affairs documentationTrauma-focused therapy visits
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F33.0Mental, Behavioral and Neurodevelopmental Disorders

Major Depressive Disorder, Recurrent, Mild

Recurrent major depression, current episode mild severity.

Stable recurrent depression on maintenance medicationPsychiatry follow-up, depression in remission-to-mild range
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I25.10Diseases of the Circulatory System

Atherosclerotic Heart Disease of Native Coronary Artery Without Angina Pectoris

Coronary artery disease without current anginal symptoms.

Cardiology follow-up for known CAD, asymptomaticPost-stent/CABG with no angina
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I48.91Diseases of the Circulatory System

Unspecified Atrial Fibrillation

Atrial fibrillation without specification of type (paroxysmal, persistent, permanent).

Primary care AFib managementCardiology follow-up for rate control
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I50.9Diseases of the Circulatory System

Heart Failure, Unspecified

Heart failure without specification of type (systolic vs. diastolic, acute vs. chronic).

Heart failure documented without echo/type specified
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I25.5Diseases of the Circulatory System

Ischemic Cardiomyopathy

Cardiomyopathy caused by coronary artery disease, typically with reduced ejection fraction.

Cardiology management of CAD with reduced EFHeart failure due to ischemic disease
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I48.0Diseases of the Circulatory System

Paroxysmal Atrial Fibrillation

Atrial fibrillation that terminates spontaneously or with intervention within 7 days of onset.

Cardiology for intermittent AFibEP study for AFib ablation consideration
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