Case Management

Case management Q&A

Case Management Weekly, November 7, 2012

Q. What is a secondary diagnosis? 

A. A principal diagnosis is the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care. The condition (or at least some signs or symptoms referable to the condition) must be present on admission. In some cases, it may be several days before the provider arrives at a definitive diagnosis. This does not mean the condition was not present on admission. 

A secondary diagnosis is additional conditions (either present on admission or occurring after admission) that require the following:

  • Clinical evaluation, or
  • Therapeutic treatment, or
  • Diagnostic procedures, or
  • Increased nursing care/monitoring, or
  • Extended length of stay 

Editor’s note: This Q&A is adapted from 2012 CDI Pocket Guide published by HCPro, Inc.

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