Secondary Diagnosis Coding and Reporting


This course offers a comprehensive overview of official coding guidelines and practices related to secondary diagnosis coding and reporting. Students will delve into the essential aspects of medical coding, focusing on key areas such as the identification and reporting of additional diagnoses in both inpatient and outpatient settings. The course covers a wide range of topics, including the interpretation of "other diagnoses," coding chronic conditions, understanding uncertain diagnoses, and the significance of social determinants of health.

Included Lessons:

  • Official Guidelines for Coding and Reporting
  • Official Guidelines for Coding and Reporting on Inpatients
  • Other Issues to Consider (Inpatient)
  • Chronic Conditions (Inpatient)
  • Influencing Health Status Codes (Inpatient)
  • Social Determinants of Health
  • Coding Clinics
CEUs available for the following credentials:




Key Takeaways

Overall, completing this course will empower medical coders with the knowledge and skills necessary to code and report secondary diagnoses accurately, contributing to improved patient care, accurate healthcare data, and proper reimbursement. Some key takeaways of this course include:

  • Understanding Official Guidelines: Coders will have a strong grasp of the official coding guidelines for reporting secondary diagnoses, including when and how to apply them in different healthcare scenarios.
  • Identification of Relevant Diagnoses: Coders will learn how to identify and prioritize diagnoses that impact patient care, treatment, diagnostic procedures, length of hospital stays, and nursing care. This includes recognizing conditions that may require clinical evaluation or therapeutic treatment.
  • Handling Uncertain Diagnoses: Coders will be equipped to deal with uncertain diagnoses, such as those labeled as "probable," "suspected," or "questionable." They will learn how to code these conditions based on available documentation and clinical context.
  • Chronic Condition Coding: The course will teach coders how to accurately code chronic conditions that require ongoing treatment and care. This includes understanding which chronic conditions should be reported and how often they should be coded.
  • Clinical Validation: Coders will gain the skills to clinically validate diagnoses by researching and interpreting clinical indicators, laboratory results, and other diagnostic findings. They will learn how to ensure that documented diagnoses are supported by clinical evidence.
  • Coding for Social Determinants of Health: Coders will understand the significance of coding social determinants of health (SDOH) when documented in the medical record. They will learn to identify SDOH-related risk factors and when to assign relevant codes, contributing to a comprehensive patient profile.

Benefits of Taking this Course

  • Enhanced Coding Accuracy
  • Improved Ability to Code for Secondary Diagnosis
  • Career Advancement
  • Comprehensive Understanding of Chronic Conditions
  • Ability to Code with Confidence


What are secondary diagnoses, and why are they important in medical coding?
Secondary diagnoses are additional medical conditions or diseases that a patient has besides the primary reason for seeking medical care. They are crucial in medical coding because they provide a comprehensive view of the patient's health status, impact treatment decisions, and affect reimbursement rates for healthcare facilities.
How should I code uncertain diagnoses or those labeled as "probable" or "suspected"?

In the inpatient setting, code uncertain diagnoses as if they existed or were established. Base your coding on the diagnostic workup, arrangements for further evaluation, and initial therapeutic approach that align most closely with the established diagnosis. Use your clinical judgment while referencing official guidelines.

About our Medical Coding Courses

HIAlearn, powered by Health Information Associates (HIA)—a leader in medical coding and auditing for more than three decades—offers a comprehensive online education platform for medical coders. With a catalog of over 200 medical coding courses accepted by the American Health Information Management Association (AHIMA) for Continuing Education Units (CEUs) and a selection approved by the American Academy of Professional Coders (AAPC), HIAlearn caters to both beginners and experienced medical coders seeking to enhance their skills. The platform provides an array of training plans tailored to meet individual learning needs, from mastering challenging coding procedures to understanding broad conceptual frameworks within the coding world. Courses are available across various coding types including CPTE/M, ICD-10-CMICD-10-PCS, and are designed to cater to different coder levels and coding specialties such as inpatientoutpatientprofee, and CDI. Additionally, HIAlearn offers a Coding Updates bundle to ensure coders are up-to-date with the annual changes in ICD-10-CMICD-10-PCSCPT, and IPPS. Beyond individual learning, HIAlearn supports organizations with group discounts, promoting enhanced coding accuracy, efficiency, and compliance across teams. 

Disclaimer: This course is not available for individual sale. Purchase the Secondary Diagnosis Training Plan below and get access to 5 courses. 

Code Type