Radiology Coding Alert

Ruled out — two words on a radiology report that should make you sit up and take notice. The ICD-10-CM Official Guidelines provide instruction for how to report conditions that were ruled out, but there are also codes with “ruled out” in their descriptors.

Learn how to handle rule-out diagnoses and what to report when a condition is ruled out.

Start by Understanding Opposite Rules

The official guidelines provide different rules for rule-out diagnoses. One rule applies to coding practices by short-term, acute care, long-term care, and psychiatric hospitals. “In the inpatient setting, diagnoses deemed ‘still to be ruled out’ at discharge may be coded,” says Chelsea Kemp, BS, RHIT, CCS, COC, CPC, CDEO, CPMA, CRC, CCC, CEDC, CGIC, AAPC Approved Instructor, outpatient coding educator/auditor at Yale New Haven Health in New Haven, Connecticut.

But as a pro-fee coder, you usually won’t code rule-out diagnoses (see the last section for a sort of exception). According to the ICD-10-CM Official Guidelines, Section IV.H, “Do not code diagnoses documented as ‘probable,’ ‘suspected,’ ‘questionable,’ ‘rule out,’ ‘compatible with,’ ‘consistent with,’ or ‘working diagnosis’ or other similar terms indicating uncertainty.” This means that you’ll code any appropriate signs, symptoms, abnormal test results, or another reason for the encounter if there is not a definitive diagnosis.

“If a ‘rule out’ diagnosis is present on an outpatient encounter, it is recommended to query the provider for signs or symptoms prompting the ‘rule out’ diagnosis,” Kemp adds.

Know How to Code a Ruled-Out Fracture

Scenario: Patient presents to an urgent care clinic with pain in the right forearm after experiencing a hard fall while playing basketball. The clinic’s radiologist captured anteroposterior (AP) and lateral X-ray views and ruled out a fracture. The physician’s report lists the symptoms as right forearm pain and the diagnosis as arm fracture ruled out.

“The arm fracture diagnosis cannot be coded per the ICD-10-CM coding guidelines. If there are other diagnoses present on the encounter to code from, such as an office visit note detailing the signs and symptoms that led to the X-ray order, the signs and symptoms should be coded,” Kemp says.

You’ll only report the symptoms documented in the physician’s report, which in this case is the right forearm pain. You’d assign M79.631 (Pain in right forearm) to report the symptom the patient was experiencing at the time of the encounter since the physician ruled out a fracture.

Rule Out the Presence of a Foreign Body

Scenario: A 3-year-old patient presents to the emergency department with their parents. The parents fear the child swallowed a small plastic building block with sharp edges, but the child isn’t exhibiting any symptoms. A radiologist employed by the hospital captures AP and lateral X-ray views of the patient’s chest, neck, and abdomen to determine if the foreign body is present in the child. After an examination and imaging, the physician determines there is no foreign body present.

Chapter 21 of the ICD-10-CM code set includes several codes related to ruling out certain conditions. “These codes are reserved for encounters when a patient without a diagnosis is suspected of having an abnormal condition, without signs or symptoms, and after examination the condition is ruled out,” Kemp says.

Code categories in the ICD-10-CM code set with “ruled out” in the expanded code descriptors include:

• Z03.- (Encounter for medical observation for suspected diseases and conditions ruled out)
• Z04.- (Encounter for examination and observation for other reasons)
• Z05.- (Encounter for observation and evaluation of newborn for suspected diseases and conditions ruled out)

The note listed under parent code Z03.- includes the information Kemp mentioned, and since the pediatric patient in the scenario isn’t exhibiting any symptoms, an encounter code is the only diagnosis code option available.

If the physician observed shortness of breath, painful swallowing, or the suspected foreign body was visible in the patient’s body on the X-rays, then you could assign any of the following codes, if documented in the patient’s medical record:

• R06.02 (Shortness of breath)
• R13.10 (Dysphagia, unspecified)
• T18.9XXA (Foreign body of alimentary tract, part unspecified, initial encounter)

However, in this case, you’d assign Z03.821 (Encounter for observation for suspected ingested foreign body ruled out) as the final diagnosis.