Gastroenterology Coding Alert

You Be the Coder:

Rule Out Problems With Proper 'Rule-Out'Diagnosis Coding

Published on Sun Jun 01, 2003

Question: We have a long-standing question in our billing office. Acouple of years ago, Medicare and other insurance payers eliminated the "rule-out" aspect of diagnosis coding, so now the physician must specifically state a diagnosis. One of our physicians was consulted to see a patient with a left hip prosthesis; the patient had fallen and had hip pain. Infectious Disease saw the patient: he was found to have an infected left hip socket. This raised the question of a possible sinus tract from the left hip to the pelvis.

The only reason our physician was asked to see the patient was to rule out fistulous communication between the left hip and the gastrointestinal tract. However, the symptoms were outside the gastro realm. This patient had no history of gastrointestinal-related problems, constipation, diarrhea, rectal bleeding, or diverticulitis. After the consultation, our physician wrote, "There is nothing to suggest abdominal or pelvic abscess," so he did not have a positive diagnosis. Our regional Medicare office once told me the physician should code the original diagnosis that prompted the visit when the physician's findings don't support the suspected diagnosis.

Colorado Subscriber

Answer: ACMS Program Memorandum, B-01-61, effective Jan. 1, 2002, states the coding policy for outpatient diagnostic tests. It specifies that diagnoses must be reported for these tests, whereas formerly, providers needed to report only the reason that the outpatient diagnostic was ordered, regardless of the test findings or results. Specifically, it states that you cannot code narrative diagnoses for which the given diagnosis is "rule-out, probable, or suspected."

The memorandum explains how to determine the appropriate primary ICD-9-CM diagnosis code for ordered diagnostic tests. Specifically:

If a physician has confirmed a diagnosis based on results of the diagnostic test, then the physician interpreting the test should code that diagnosis. Signs or symptoms that necessitated the test can be reported as additional diagnoses if they are not explained or related to the confirmed diagnosis.

If the results of the diagnostic test are normal or do not provide a specific diagnosis, the interpreting physician should code the signs or symptoms that prompted the treating physician to order the test. And most important, in this particular case:

If the results of the diagnostic test are normal and the referring physician has recorded a diagnosis that indicates uncertainty, such as "probable," "suspected" or "rule-out," the interpreting physician should not code the referring diagnosis. In this case, the interpreting physician should report the sign or symptom that prompted the test. Diagnoses that are uncertain or unconfirmed should not be reported.

Your referring physician's diagnosis indicated uncertainty because he wanted to rule out fistulous communication between the left hip and the gastrointestinal tract. You need to remember the CMS memorandum. Margaret Lamb, RHIT, CPC, at the Great Falls Clinic, states that symptoms being "outside gastro realm" is not an issue. Limited information exists on this situation, she explains, for example, the original hip fall has probably been treated. She would first code the symptom the patient presented with, hip pain, 719.45 (Pain in joint; pelvic region and thigh). She would also code the infection if it is a current condition with 996.66 (Infection and inflammatory reaction due to internal prosthetic device, implant and graft; due to internal joint prosthesis). However, without knowing the complete patient record, Lamb states, it's hard to say if hip pain would still be a symptom or not. She adds that as a secondary code, you could code why the referral was made and that during the referral evaluation, the suspected condition has indeed been ruled out with V71.89 (Observation and evaluation for suspected conditions not found; other specified suspected conditions) because the interpreting physician did not make any additional positive diagnosis. But Lamb says it's important to code the "chief complaint" that the doctor has listed in his consult as to why the patient presented. "If the chief complaint is a rule out or suspected fistula and no symptoms or current disease process is documented, then you need to code V71.89 as your principal diagnosis."

Another opinion comes from Marylou Masters, CPC, of the University of North Texas Health Science Center. "You should not code the referring diagnosis; instead, code the signs or symptoms," she says. Only limited information is available, she adds, so you don't know if the treatment resulted from the fall or if the infected hip socket happened before the fall. Without any abdominal pain, she would report the infection first with 136.9 (Unspecified infectious and parasitic diseases), then the hip pain with 719.45, then V71.89 because, she says, a gastrointestinal diagnosis could not be made. She would lastly code the fall with E888.8 (Other fall) as secondary. Without more detailed information in this case, she says, such as a bone scan, it's difficult to code more specifically. "It's a matter of interpretation," she says.

To summarize the CMS regulations and comments:

Don't code "probable," "suspected" or "rule-out" diagnoses based on results that are pending. These are "uncertain" diagnoses, which the ICD-9-CM guidelines consider to be unconfirmed. Code all diagnostic tests with definitive findings, when possible, and then signs or symptoms.

Select the ICD-9-CM code that provides the highest degree of specificity (accuracy and completeness) for the sign(s)/symptom(s) that prompted the test.

When a final diagnosis does not justify the test, the physician must be careful to include pertinent signs or symptoms that prompted the ordering of the test and must report these as additional diagnoses, particularly if they are not fully explained by or related to the confirmed diagnosis.

The referring physician is also required to provide diagnostic information to the testing entity when the test is ordered, and all tests must be ordered by the physician who is treating the beneficiary.

Code incidental findings only as secondary diagnoses, never primary. You can also report unrelated and co-existing conditions as additional diagnoses.

Even though physicians can now justify tests based on the resulting diagnosis, some carriers'systems may still "kick out" the final diagnosis because it conflicts with the signs and symptoms that initially made the test medically necessary. Check your private payers'guidelines and obtain written guidance to ensure compliance.