Endocrinology Coding Alert
You Be the Coder: Read Charts Carefully if 'Rule-Outs' Are Involved
Question: Our endocrinologist often sees patients to rule out a suspected condition, such as thyroid disease. If, for example, the physician's documentation reads, "Rule out thyroid cancer" and does not state that he made a diagnosis, how should we select a diagnosis code for the visit? Will coding just the patient's signs and symptoms justify a high level of service?
Maryland Subscriber
Answer: You cannot code for a rule-out because there is simply no way to identify a diagnosis code as a rule-out. If the physician documents "Rule out thyroid cancer," it means he is investigating the patient's signs and symptoms to determine whether thyroid cancer might be the cause. Clearly, the physician has not made a definitive diagnosis yet.
Therefore, it would be incorrect for you to report diagnosis code 193 (Malignant neoplasm of thyroid gland). Instead, code for any signs or symptoms the patient has - no matter how seemingly minor they are. For example, a patient who the physician suspects has thyroid cancer may have presented with a lump in the throat (784.2, Swelling, mass, or lump in head and neck).
Coding for a rule-out diagnosis can falsely label a patient with a condition that he does not really have. In addition, Medicare and private payers will not accept rule-out diagnoses because they prefer to see that the physician is investigating the patient's signs and symptoms, rather than a specific suspect diagnosis.
Coding for signs and symptoms may get tricky when you're dealing with screening tests. The patient may not present with any real signs or symptoms, yet the endocrinologist may feel that certain risk factors warrant screening.
For example: A woman presents with no signs or symptoms, but is over 50 years old, has a strong family history of thyroid disease, and has a history of miscarriages. The endocrinologist may determine that the patient is at risk and elect to do a thyroid disease screening test.
You may first feel stumped on how to code this visit, but remember that there are actually codes for many common risk factors. For this woman's screening test you could report V18.1 (Family history of other endocrine and metabolic diseases). Remember, V codes describe reasons for a patient encounter other than disease, illness, signs or symptoms. If a V code is the only appropriate code to report for the patient services, chances are carriers will want to see documentation before paying. Be ready with documentation in the event of a denial. Also, pay attention to very minor symptoms the patient may have mentioned during the visit, such as tiredness or fatigue (780.79, Other malaise and fatigue).
Documentation is key: When you report only signs and symptoms, the carrier's claims adjudicator may need to look at the chart and documentation to understand the medical necessity of the reported service. Painting a full picture of the patient's situation with limited signs and symptoms is often difficult, so make sure your documentation is strong enough to support your claims.
- Published on 2004-04-16
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