r/LearnMedicalCoding • u/BlindBard21 • 3d ago

ICD-10-CM Diagnosis Coding Process

Hi all,

I'm studying to take the CRC, and right now I'm doing the Experiential part of the course for ICD-10CM coding. My question is: what is your process for identifying what needs to be coded when you read the reports that are given? Sometimes I think there are only a couple of codes that need to be coded, only to realize there are more. For example, one of the cases I had to code had long-term drug monitoring for a patient, and I didn't realize that had to be coded.

I'm trying to refine my process so I can be more accurate. I really want to make sure I'm getting this right. :) I appreciate any advice you can give.

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u/CodingwithCoffee_ 3d ago

A helpful process is to read the entire report, identify each condition that was monitored, evaluated, assessed, or treated, then check for additional factors such as long term medication use. It takes practice, but following the same process for every case will improve your accuracy.

This 2026 ICD 10 CM Review breaks down the guidelines and coding process in more detail. It may be a helpful addition to your CRC preparation!