What is the difference between a primary diagnosis and a secondary diagnosis?

The distinction between primary and secondary diagnoses is crucial for accurately documenting patient encounters and ensuring proper coding and billing.

The primary diagnosis refers to the main reason a patient seeks medical care. It is the principal condition that prompted the visit or encounter. This specific diagnosis is typically the most significant in terms of the patient's treatment and is often the reason for any procedures performed.

On the other hand, secondary diagnoses are additional conditions that may coexist with the primary diagnosis. While they may impact treatment or complicate the patient's overall health status, these conditions are not the primary focus of the visit. They are documented to provide a more comprehensive picture of the patient’s health and may influence the course of treatment or require additional resources.

Understanding this difference is vital in the coding process. For instance, insurance claims rely on accurate documentation of both primary and secondary diagnoses to establish the medical necessity of treatments and procedures provided to the patient.