Medicare Compliance & Reimbursement - 2012 Issue 7
Reader Question: Avoid "Rule Outs" in Outpatient Settings
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Article Overview
This reader Q&A addresses how outpatient coding guidance treats rule-out, suspected, probable, and questionable diagnoses. It is aimed at coders and billing staff who work with physician documentation in outpatient and emergency department settings. The article discusses the general principle of coding to the highest degree of certainty supported by the record and points readers to the need to use documented signs and symptoms when a definitive diagnosis is not established.
Why This Topic Matters
Understanding this topic helps prevent reporting unconfirmed diagnoses in outpatient claims and supports more accurate, guideline-based coding practices.
What You Will Learn
- How outpatient guidance treats uncertain diagnosis terminology
- Why symptom-based coding is used when a firm diagnosis is not documented
- How CMS guidance aligns with ICD-9 outpatient coding principles
- Why documentation specificity matters in emergency and outpatient encounters
Who Should Read This
- Medical coders
- Billing staff
- Compliance staff
- Physician practice staff
Codes Discussed
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