III.3.13 Secondary DX 1

III.3.13 Secondary Diagnosis 1 - 10

Secondary Diagnosis data fields 1-10 are designed to capture the patient’s preexisting or secondary diagnosis, factors influencing health status, and/or complications during the admission to the reporting facility for the treatment of cancer using ICD-10-CM codes. These factors may affect treatment decisions and influence outcomes.

These data fields were developed to capture ICD-10-CM, which can be up to 7 characters in length and have a different structure than ICD-9-CM.

NOTE: ICD-10-CM was implemented October 1, 2015.

Coding Instructions:

Use the Secondary Diagnosis 1 – 10 fields when your facility begins using ICD-10-CM. Only ICD-10-CM codes are allowed in these fields.

Data collection of Secondary Diagnosis fields 1 - 10 is required by the CCR if available, and is required from CoC facilities.

These fields are left justified. DO NOT add additional characters, such as 0’s if the ICD-10-CM code is less than 7 characters.

If ICD-9-CM was initially used in the patient record for a case and then the ICD-10-CM was subsequently used, code the relevant ICD-9-CM codes in Comorbidities and Complications and the relevant ICD-10-CM codes in Secondary Diagnoses. Do not attempt to convert between versions.

If multiple ICD-10-CM codes are available to enter into these fields, use the Secondary Diagnosis fields in order beginning with Secondary Diagnosis 1 and use the other nine (9) fields in order, using as many as needed.

If you have a secondary diagnosis that is stated in the medical record but is not coded, do not attempt to code the condition.

EXAMPLE: If diabetes is mentioned in the medical record and it is not coded in the medical record do not attempt to code the condition in ICD-10-CM or fill in these fields.

Code the secondary diagnoses in the sequence in which they appear in the discharge summary or recorded by the billing department.

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

Surgically treated patients:

Following the most definitive surgery of the primary site
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 no ICD-10-CM secondary diagnoses were documented, code 0000000 in the field Secondary Diagnosis #1 and leave the remaining fields blank.

If fewer than 10 ICD-10-CM secondary diagnoses are listed, then code the diagnoses listed, and leave the remaining blank.

For further information, please refer to the current FORDS Manual.

Note: For ICD-10-CM codes there is an assumed decimal between the third and fourth characters.