Highest level of specificity

Code to the highest level of specificity when supported by the medical record documentation. G. ICD-10-CM code for the diagnosis, condition, problem, or other reason for encounter/visit List first the ICD-10-CM code for the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the services provided.

List additional codes that describe any coexisting conditions. In some cases, the first-listed diagnosis may be a symptom when a diagnosis has not been established (confirmed) by the provider.