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January 23, 2013

Rule-out Diagnosis Codes

The term “rule-out” is commonly used in patient care to eliminate a suspected condition or disease. While this term works well for clinicians and supports many medical and legal requirements, rule-out diagnoses are not acceptable as primary diagnoses on Medicare claims.  For Medicare purposes, claims must be submitted with one or more ICD-9-CM diagnosis codes and must be coded to the highest level of specificity.  In the context of ICD-9-CM coding, the “highest degree of specificity” means assigning the most precise ICD-9-CM code that fully explains the narrative description of the symptom or diagnosis.

You may report the full ICD-9-CM code for up to eight coexisting diagnoses.  For instance, if the patient is seen in the office for evaluation of hypertension and the medical record also documents diabetes, report diabetes as another (secondary) diagnosis.

Rules for reporting diagnosis codes on Medicare claims:

Coding Diagnoses Based on Test Results

Situation Primary Diagnosis Other Notes

Physician confirms diagnosis based on test results

Confirmed diagnosis

May code signs/symptoms as additional diagnoses, if not explained by the test

Diagnostic test is normal or did not provide results and referring physician noted signs/ symptoms

Use signs or symptoms that prompted treating physician to order test

N/A

Test results are normal or non-diagnostic and referring physician provided a “rule-out” or uncertain diagnosis

Use signs or symptoms that prompted treating physician to order test

Do not code the “rule-out” diagnosis

References:


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