Case 1

Use the diagnostic statement in this case note to answer the following questions using the ICD-10-CM Code Book.

Clinic Note This 57-year-old female patient comes to the clinic today. HEENT: Normal LUNGS: Clear ABDOMEN: Soft, nontender RECTAL EXAM: Refused NEUROLOGICAL: Congenital spastic paralysis, left leg

There are no physical findings that need to be addressed at this time. I have reviewed her care plan, and she should continue per her care plan at the residential home where she resides.

Hints:

• Main term: The condition, check the Alphabetic Index for which term is bold.
• Sub term: Check first vertical line indented under the main term for terms that describe the main term (condition).
• Remember to that only the left leg is affected, which is monoplegia.

What is the main term that leads to the ICD-10-CM code for congenital spastic paralysis?

Which ICD-10-CM diagnosis code should be assigned for congenital spastic paralysis of the left leg?