Mastering the ICD-10-CM Guidelines

Lab Project 1 – Mastering the ICD-10-CM Guidelines

1. Who is the character of the story? (Summary patient information)
2. What is / are the problem(s)? (List signs and symptoms, presenting problem or complaint, diagnoses based on examination or ancillary testing, such as radiology, laboratory test, pathology)
3. What is the solution? (List diagnostic assessment results, surgery performed, medications administered)
4. How was the solution accomplished? (List surgical results, if applicable)
5. ICD-10-CM coding
   Diagnosis description Index Main term Index Subterm Index Carryover line Index Non-essential modifier ICD-10-CM code POA Indicator
6. Apply the provided ICD-10-CM coding guidelines per case.
7. For multiple diagnoses – assign the principal diagnosis and other diagnoses. Explain the ICD-10-CM coding guidelines to validate your answer. Indicate the Present on Admission Indicator per diagnosis