Practice Management Alert

Question: One of the physicians in our multi-specialty practice is an endocrinologist who 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 that way. 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 - he 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. And 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 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 physician may think that certain risk factors warrant screening.

Remember, you can sometimes use V codes - which describe reasons for a patient encounter other than disease, illness, signs or symptoms - as the justification for a screening test. For example, if your physician orders a thyroid disease screening test for a patient who has no signs and symptoms but a strong family history of thyroid disease, you could report V18.1 (Family history of other endocrine and metabolic diseases).

- The answers to the Reader Questions were provided and/or reviewed by Wayne J. Miller, attorney with Compliance Law Group in Los Angeles; Judy Richardson, MSA, RN, CCS-P, senior consultant with Hill & Associates in Wilmington, N.C.; and Catherine Brink, CMM, CPC, president of HealthCare Resource Management Inc. in Spring Lake, N.J.