ICD 10 Coding Alert

Question: Our pulmonologist frequently circles rule-out diagnoses on his charts and then doesn’t record a final diagnosis. We have been told not to report rule-out diagnoses, but in this case, what are our options?

Maine Subscriber

Answer: When your pulmonologist confirms a diagnosis, you have to use that ICD-10-CM code, according to CMS and ICD-10-CM regulations. But when your physician doesn’t specify a particular diagnosis, you should report the patient’s signs and symptoms instead.

What to do: Suppose a patient’s primary care physician requests that your pulmonologist examine the patient for suspected sarcoidosis (D86.0). Your pulmonologist documents, “Rule out sarcoidosis” in the medical chart. ICD-10-CM coding guidelines state that you should not report “rule out” diagnoses.

But you can still assign other symptoms, such as fatigue (R53.83), cough (R05), and shortness of breath (R06.02) if documented, to describe the patient’s symptoms in the absence of a sarcoidosis diagnosis.

Bottom line: If the pulmonologist ultimately concludes that a patient does not have the diagnosis the physician once suspected, you can report only documented symptoms and secondary codes.