Outpatient Facility Coding Alert

Published on Mon Jul 16, 2012 PDF

<strong>Question:</strong> <em>A new co-worker is having trouble understanding why “rule out" diagnoses don't apply to our patients. How should we explain it to her?</em> <br /> Virginia Subscriber <br /><br /> <strong>Answer:</strong> The starting point is that ICD-9 coding guidelines state you should not report "rule out" diagnoses in an outpatient setting. You'll avoid labeling the patient with an unconfirmed diagnosis, but will allow the physician to be paid for his services even if he can't establish a definitive diagnosis. Notes such as "rule out," "suspected," "probable," or "questionable" are not codable as diagnoses. If the physician doesn't document a firm diagnosis, look for any signs or symptoms that the patient has been having, and code based on those. <br /> <strong>Example:</strong> The physician sees a patient in the Emergency Department with a very high fever. He suspects she has sepsis. If he documented a sepsis diagnosis, report the relevant code (such as 038.8, Septicemia; other specified septicemias). If the physician stated that he was attempting to rule out sepsis, report the signs and symptoms instead (such as 780.6, General symptoms; fever). <br /> CMS concurs with the ICD-9 guidelines regarding rule out diagnoses. Outpatient services guidelines specifically state that you should not report 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 …"