Secondary Diagnosis

Field Length: 5 (x10)

Record the patient’s preexisting medical conditions, factors influencing health status, and/or complications during the patient’s hospital stay for the treatment of this cancer using ICD-10-CM codes. The secondary diagnoses are also called comorbidities and complications.

Instructions for Coding

•   Use this item to record ICD-10-CMcodes. Use Comorbidities and Complications to record ICD-9-CMcodes. During the adoption of ICD-10-CM codes, it is possible both will appear in the same patient record. Most hospitals in the United States were expected to implement use of ICD-10 in   2015.

•   Note that, while the ICD-9-CM Comorbidities and Complications codes were to be followed by zeroes if they did not fill the field, only the actual ICD-10-CMcode is to be entered for Secondary Diagnosis fields, leaving blanks beyond those characters.

•   Omit the decimal points when coding.

•   Secondary diagnoses are found on the discharge abstract. Information from the billing department at your facility may be consulted when a discharge abstract is not available.

•   Code the secondary diagnoses in the sequence in which they appear on the discharge abstract or are recorded by the billing department at your facility.

•   Report the secondary diagnoses for this cancer using the following priority rules:

- Surgically treated patients:

    a) following the most definitive surgery of the primary site

    b) following other non-primary site surgeries

- Non-surgically treated patients:

      following the first treatment encounter/episode

- In cases of non-treatment:

      following the last diagnostic/evaluative encounter

•    If the data item Readmission To The Same Hospital Within 30 Days of Surgical Discharge is coded 1, 2, or 3, report  Secondary DiagnosisICD-10-CM codes appearing on the "readmission" discharge  abstract.

•     If no ICD-10-CM secondary diagnoses were documented, then code 0000000in this data item, and

           leave the remaining Secondary Diagnosis data items blank.

•     If fewer than  ten ICD-10-CMsecondary diagnoses are listed, then code the diagnoses listed,and leave the remaining        Secondary Diagnosis data items blank.

•     Allowable values are:

    0000000; all values beginning with

    A-B, E, G-P, R-S; and the following ranges:  

    T36- T50996XX, Y62-Y849ZZZ,  Z1401-Z229ZZZ,

    Z681-Z6854ZZ, Z80-Z809ZZZ, Z8500-Z9989ZZ.