Radiology Coding Alert

Question I have a report from a radiologist in our practice where they captured chest X-rays to rule out pneumonia. I did not include the code for pneumonia in my claim, as my understanding of the ICD-10-CM guidelines instructs me to not code a rule-out diagnosis. However, the radiologist is upset and claiming they should be reimbursed for the information.

Am I correct in leaving out the pneumonia code from my report?

Missouri Subscriber

Answer: You are correct to leave that information out of your claim. According to section IV.H, “Uncertain diagnosis,” of the ICD-10-CM guidelines, you do not “code diagnoses documented as “probable”, “suspected,” “questionable,” “rule out,” “compatible with,” “consistent with,” or “working diagnosis” or other similar terms indicating uncertainty.” You should only be coding condition(s) to the highest degree of certainty for the patient’s visit, which would include any symptoms, signs, abnormal test results, or simply the reason for the encounter.

In this case, you would code the appropriate CPT^® X-ray code as well as any symptoms the patient is presenting. If you were to code the uncertain diagnosis as the radiologist claims, your practice could land in hot water for noncompliance.