List all Primary and Other diseases present and select the most appropriate code. This list should include any diseases
previously noted in Section I. Record the disease diagnosis, the ICD-CM code and the associated disease code.
The assessor may need to consult a medical record or medical coding specialist to determine the appropriate ICD-CM code.
Attach additional sheets as necessary for all disease diagnoses.
Coding:
For all diseases present, select the most appropriate code from those listed below.
Not present
Primary diagnosis/diagnoses. One or more diagnoses that are the main reason(s) used to support and justify services being provided.
Diagnosis present, receiving active treatment. Treatment can include medications, therapy, or other skilled interventions such as wound care or suctioning.
Diagnosis present, monitored but no active treatment. Person has a diagnosis that is being monitored (e.g., with laboratory tests or vital signs), but no active treatment is being provided.