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May 25, 2009

Ruling Out the “Rule-Out” Diagnosis
By Jeff Pilato, MHA, RTR, CPC-H, and Gerri Walk, RHIA, CCS-P
For The Record
Vol. 21 No. 11 P. 5

The term “rule out” is commonly used in outpatient care to eliminate a suspected condition or disease. While this term works well for clinicians and supports medical-legal requirements, it wreaks havoc on radiology coders and radiology reimbursement. This is particularly true in the outpatient setting where rule-out codes are not accepted as a primary diagnosis by most payers.

Radiology coders are trapped between radiologists and revenue, forced to balance the need for clinical data integrity with administrative demands for fewer denials and more accurate reimbursement. Couple this with a rising volume of outpatient radiologic procedures, and it is easy to see the problem.

In many ways, the entire purpose of a radiological exam is to rule out suspected disease and help the attending physician make a definitive diagnosis and proceed with treatment. Radiologists typically only see images and part of the clinical picture. From a pure radiological perspective, it is not their responsibility to make a diagnosis, only to help rule out or verify something that is suspected by another clinician.

The attending physician is the one who usually sees the entire picture, including the patient’s history, symptoms, laboratory findings, and other clinical indicators. The attending physician—not the radiologist—assigns the most accurate final diagnosis.

For example, in a normal chest x-ray, the patient may have a clear chest upon radiological exam, and therefore the radiologist could only document rule-out or suspected pneumonia. The attending physician, though, is aware of all the other symptoms (eg, fever, cough) and could accurately diagnose pneumonia, even when the x-ray is clear.

And the converse can also be true. The radiologist may see something in the x-ray, though symptoms are minimal or nonexistent. Nonetheless, it would still be up to the attending physician to make a definitive diagnosis. This handshake, or passing along of information, works well for clinicians. They work together to complete the puzzle and treat the patient.

Unfortunately, radiology coders are often caught in the middle with not enough information to code the attending’s final diagnosis. They can’t justify medical necessity and ensure correct reimbursement when radiological findings are vague. This forces the coder to chase down physicians, spend time researching records, or try to think like an attending physician. None of these options is an efficient, long-term solution. What does work is a three-pronged approach that includes coders, clinicians, and the outpatient registration desk.

Radiology coders can improve the situation, educate radiologists, and improve the likelihood of proper reimbursement for outpatient exams by taking three important steps.

Educate: First and foremost, coders must educate themselves about how to deal with rule-out and suspected findings. Coders should always look for and code a definitive diagnosis. The onus is on the coder to know which symptoms are reimbursable and which are not. Start by creating a list of all the procedures performed by your practice and learn all the associated symptom and abnormal finding codes for those exams. Next, find out which of these codes meet medical necessity edits for your local carrier. This will provide you with a solid baseline.

As a general rule, suspected conditions should never be coded in the outpatient setting. Instead, coders should use the documented signs and symptoms or the current condition. A good example is a radiological exam to rule out appendicitis. When the findings are negative, coders should code only the symptom, which is usually abdominal pain.

Another confusing situation is when rule-out metastasis is ordered. In this case, the current or primary cancer site should be coded. If the patient is no longer being treated for cancer and it is clearly documented that the patient no longer has cancer, only the history of cancer should be coded. Coders should use the observation and evaluation codes (V71.X) when no other indication is listed.

Finally, many coders are faced with rule-out diagnosis when the patient is receiving follow-up or aftercare. A common follow-up exam is for fracture care. For follow-up of a fracture, coders can use V54.X (other orthopedic aftercare) as the primary diagnosis, followed by a code for the fracture.

Prevent: Coders can also work with a physician liaison to educate radiologists about rule-out diagnosis. Most radiologists are not aware of the reimbursement problems associated with this diagnosis and, as a result, coders are forced to use nonspecific codes.
Many organizations have addressed this problem through clinical documentation improvement teams.

Communicate: As a final step, coding and radiology management can work with the outpatient registration staff to reduce the amount of rule-out exams. Train your registrars to look for an appropriate reason for an exam, one that meets medical necessity. Lunch-and-learn meetings are particularly effective. During the meeting, present a monthly report showing real-life examples of rule-out exams that did not meet medical necessity because of incomplete clinical documentation. Also demonstrate the negative impact on reimbursement.

Once you communicate with the outpatient registration staff, provide regular reports to encourage their continued support. Some organizations have implemented simple reward or incentive programs to promote cooperation and teamwork.

— Jeff Pilato, MHA, RTR, CPC-H, is director of corporate coding and compliance at Health Record Services.

— Gerri Walk, RHIA, CCS-P, is senior coding manager at Health Record Services.