The Myth of Coding the "Rule Out" Diagnosis

We get a lot of questions in our "Ask A Coder" inbox, coding@scanhealthplan.com.   There is no doubt that far and away, the most frequent question we get is some variation of "can I code all "rule-out" diagnoses for an inpatient"?

I've been coding a lot of years (about 25).  As a disclaimer, I have never been employed by a hospital as a coder --BUT--in my role at SCAN and other health plans, I've coded hundreds (maybe thousands) of inpatient charts. I can honestly tell you, the number of times I've coded a rule-out diagnosis can be counted on the fingers of both of my hands.  I'm sure that hospital coders have done so many more times than I have, but I'd bet they would tell you that this is not a common occurrence. 

Why isn't it?  Let's take a look at the Official Coding Guidelines themselves.  I've highlighted particularly important passages of the guideline.

H. Uncertain Diagnosis If the diagnosis documented at the time of discharge   is qualified as "probable", "suspected", "likely", "questionable", "possible", or "still to be ruled out", or other similar terms indicating uncertainty, code the condition as if it existed or was established. The bases for these guidelines are the diagnostic workup, arrangements for further workup or observation, and initial therapeutic approach that correspond most closely with the established diagnosis.    This guideline is applicable only to inpatient admissions to short-term, acute, long-term care and psychiatric hospitals.  

First, note that the condition is still probable, uncertain--i.e., not yet ruled out, then if the documentation indicates  at the time of discharge it is still a possible condition, then it is possible it can be coded.Second, you must have the entire hospital chart--why? Because you can't know if the treatment during the hospitalization was directed at that condition without it.

As to the related question of whether or not this can be used for the physician's record...the answer is NO.   Coding Clinic and the Official Guidelines indicate that physicians use the Outpatient coding guidelines, no matter what the place of service.

I hope this clarifies when coding a "rule-out" condition is acceptable.

What coding questions do you have?  Send them to us at coding@scanhealthplan.com.  We'll do our best to answer within 72 hours. We de-identify questions of general interest and post them on HCCUniversity.com under Ask A Coder.