Optometry Coding & Billing Alert

Question: Is it OK for me to report those conditions I-m trying to rule out as the diagnosis for the encounter?

California Subscriber

Answer: ICD-9 coding guidelines clearly state that you should not report "rule-out" diagnoses in the outpatient setting.

Instead, you should report the patient's signs and symptoms. You-ll avoid labeling the patient with an unconfirmed diagnosis, and by coding the presenting signs and symptoms, you should still get paid for your services, even if you cannot establish a definitive diagnosis.

Tip: "Rule-out," "suspected," "probable" or "questionable" are words you may sometimes use in a patient's chart. You shouldn't report a diagnosis qualified by one of these terms.

If there is no definitive diagnosis, look for any signs or symptoms that the patient presented with.

Example: You see an elderly patient who complains of pain and decreased vision in her right eye, and you suspect that the woman may have nerve damage from a previously removed foreign body.

Correct coding in this instance depends on what you document. If you note that you are attempting to "rule out" the nerve damage, you should report the signs and symptoms (e.g., 379.91, Unspecified disorder of eye and adnexa; pain in or around eye, for the generalized eye pain; or 369.9, Decreased vision).

Remember: CMS outpatient services guidelines explicitly state that practices should not use the condition being ruled out as the diagnosis. Instead, "code the condition(s) to the highest degree of certainty for that encounter/visit such as symptoms, signs, abnormal test results," the guidelines state.

Good practice: Always use the most accurate terms in your documentation. If you can come to a definite conclusion about the patient's diagnosis, state this in your dictation so you may choose the best code.

But documenting the "rule-out" or "possible" problems in your documentation to support the reason for ordering diagnostic tests and support medical necessity is certainly appropriate.