Diagnosis Coding for Secondary Diagnosis

Diagnosis coding is a pivotal component of hospital billing. Selecting the correct principal and secondary diagnosis codes facilitates timely and accurate claims processing.

The attending physician is responsible for listing the patient’s principal and secondary diagnoses on the “attestation” or “discharge face sheet” when a patient is discharged from the hospital.

The National Uniform Billing Committee (NUBC) Official UB-04 Data Specifications Manual defines secondary or other diagnoses codes as "all conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or the length of stay."

Note: Historical diagnoses that have no bearing on the current hospital stay should not be used as secondary diagnoses. Secondary diagnoses that may be coded are those that present a substantial complication or comorbidity which requires significant resources for treatment.

The facility's medical records staff may notify the physician if a secondary diagnosis is omitted from the discharge face sheet but is supported in the patient record. If the physician believes the secondary diagnosis should be added, the physician should note this fact on the discharge face sheet and initial and date the addition. Secondary diagnoses that are not approved, dated and initialed by the attending physician should not be used on the claim.

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