Gastroenterology Coding Alert

Question: Can you use possible, probable or rule-out diagnosis codes as the principle diagnosis?

Judith Keech
Fairbanks, Alaska

Answer: Do not use probable, questionable, suspected or rule-out diagnosis codes when billing for reimbursement. The Medicare Carriers Manual requires that you code the condition to the highest degree of certainty known at the time of the patients visit. This applies to patient encounters in an outpatient or inpatient setting.

Instead of using probable, questionable or rule-out diagnoses, Medicare says you must report the reason for the patient encounter, which means that you probably will have to report signs and symptoms. A sign is any abnormality indicative of disease, discoverable on examination of the patient. A symptom, on the other hand, is a subjective sign of disease. Most of the sign and symptom codes are in Volume I, Chapter 16 of the ICD-9 manual. Some frequently used exceptions to that are hematemesis (578.0, vomiting of blood) and dehydration (276.5).

Although signs and symptoms arent true diagnoses according to the Health Care Financing Administrations billing requirements, they illustrate why a patient sought care and should show medical necessity for the services your gastroenterologist rendered.