diagnosis question

Can we code Rule out & suspected conditions in the inpatient setting for doctor? And does that apply to all specialties-hospitalists & neurosurgeons?

(We know you can for facility billing but not sure about professional.)
Thanks

Comments

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    Yes you can code for Rule out and supsected conditions

    thansk

  • I do not believe you can on the pro fee side even if inpatient.



    DIANA FRANKLIN, CMRS, CPC

    Member American Medical Billing Association

    Member American Academy of Professional Coders

    (931) 879-9854

    dianaf@twlakes.net



  • edited May 2017
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    No, the physician can never code rule-out and suspected conditions,
    regardless of the location of the patient.
    This is in the ICD-10-CM guidelines, and Coding Clinic has confirmed it.

    Donna J Richmond

  • I think that is VERY dangerous or as Porky would say "Vewy Vewy Dangerwous". As an auditor, I LOVE to see rule outs and differentials in progress notes - but I teach the doctors to NEVER code the rule outs or differentials in case some well-meaning biller might end up putting those on a claim. But - keep in mind that I only teach physician billing and not facility billing as I can't spell UB92 or UB04.

    Don


    Don Self & Associates, Inc

    305 Senter Ave, Whitehouse, TX 75791
    903 871-1172 fax 480-247-5650
    donself@donself.com web: www.donself.com
    free webinars at www.donself.com

    DISCLAIMER: This email has not been scanned for correct spelling, grammar or punctuation. It has been created in the language of Texan and may or may not be understood completely to those north of Kentucky.

  • CORRECTION....

    Elmer Fudd - not Porky


    Don


    Don Self & Associates, Inc

    305 Senter Ave, Whitehouse, TX 75791
    903 871-1172 fax 480-247-5650
    donself@donself.com web: www.donself.com
    free webinars at www.donself.com

    DISCLAIMER: This email has not been scanned for correct spelling, grammar or punctuation. It has been created in the language of Texan and may or may not be understood completely to those north of Kentucky.

  • edited May 2017
    NO, physicians cannot code r/o or consistent with etc no matter the location of the patient. This is stated in the Coding Guidelines printed at front of ICD 10 book and has been confirmed by the AHA Coding Clinic.

    Sharon Cohen, RHIA, MSM


  • edited May 2017
    LOL !!



    Karen A. Hurley, BS, CMM, CPC, CNA

    President, HPMSI

    PO Box 409

    Parrish, FL 34219-0409

    Tel: (941) 776-4822

    Fax: (240) 368-0059

    Web: www.hpmsi.com


  • edited May 2017
    I agree here and when you think of it, the ICD10CM provides everything needed for a specific diagnosis, even if it is non-specific, such as symptoms and encounter reasons.



    The health plans are looking for provider expertise for a definitive reason for the patient’s visit.



    It’s what drives the reporting of an insurance-based visit.



    Karen A. Hurley, BS, CMM, CPC, CNA

    President, HPMSI

    PO Box 409

    Parrish, FL 34219-0409

    Tel: (941) 776-4822

    Fax: (240) 368-0059

    Web: www.hpmsi.com



  • The Official Guidelines for Coding and Reporting in the manual are actually terribly vague in this regard. Sections II and III give directions for “inpatient” reporting, while Section IV gives directions for “outpatient” reporting, specifically “hospital-based outpatient services and provider-based office visits.” So inpatient facility coders use the info from Sections II and III. Outpatient facility coders use the slightly different rules in Section IV. (And Section 1 rules apply to everyone.) Physician/professional fee coders are not specifically mentioned in any way. However, as some have stated, the American Hospital Association Coding Clinic newsletter has clearly stated that the Section IV rules, which among other things prohibit the coding of “rule-out” diagnoses, applies to physician/professional fee coding in all settings.

    From Coding Clinic for ICD-9-CM’s “Coding and Reporting for Physician’s Inpatient Care” Q and A published in the third quarter 2000 issue (Volume 17, Number 3, Pages 6-7:

    Question: I am now responsible for the coding being submitted on a physician’s claims. When coding a physician’s services provided during inpatient hospitalization, which set of coding guidelines is applicable, the inpatient or outpatient guidelines? I’m particularly interested because of the guidelines related to inconclusive diagnoses (probable, suspected, rule out).“

    Answer: When coding for physician services, whether provided in the hospital inpatient setting or in the physician office, coders should be guided by the Diagnostic Coding and Reporting Guidelines for Outpatient Services (Hospital-Based and Physician Office). The inpatient guidelines are for hospital coding. Therefore, in the outpatient settings do not code diagnoses documented as ‘probable,’ ‘suspected,’ ‘questionable,’ ‘rule out,’ or ‘working diagnosis.’ Rather, code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit. V-codes may be assigned when appropriate. Please refer to the V-code article published in Coding Clinic, fourth quarter 1996 and fourth quarter 1998, respectively, for further discussion.

    The answer was very clear at the beginning, but got a bit muddied halfway through. Oh well. Just refer to the first sentence of the answer and don’t overthink it. Also, CMS’ old rules for diagnostic coding, which manual section was essentially scrapped when we moved to ICD-10, used to mention that physicians were barred from reporting rule-out diagnoses for pathological analysis diagnostic coding, affirming that the Section IV rules prohibiting this applied to physician/professional fee coding in all settings.

    Seth Canterbury, CPC, CPC-I
    Clinical Data Quality Education Department
    University of Florida Jacksonville Physicians, Inc.
    653 West Eighth Street
    Tower I, Suite 606
    Jacksonville, FL 32209


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