Lawyers PI Program


From the Desk of:



Rule-Out Diagnoses Do Not Exist; Why are you Using Them?


Based upon the recent survey results on clinical competency, a glaring issue was discovered regarding the improper use of the “Rule-Out Diagnosis.”


“ICD-10 was endorsed by the Forty-third World Health Assembly in May 1990 and came into use in WHO Member States as from 1994. The classification is the latest in a series which has its origins in the 1850s. The first edition, known as the International List of Causes of Death, was adopted by the International Statistical Institute in 1893. WHO took over the responsibility for the ICD at its creation in 1948 when the Sixth Revision, which included causes of morbidity for the first time, was published. The World Health Assembly adopted in 1967 the WHO Nomenclature Regulations that stipulate use of ICD in its most current revision for mortality and morbidity statistics by all Member States.


The ICD is the international standard diagnostic classification for all general epidemiological, many health management purposes and clinical use. These include the analysis of the general health situation of population groups and monitoring of the incidence and prevalence of diseases and other health problems in relation to other variables such as the characteristics and circumstances of the individuals affected, reimbursement, resource allocation, quality and guidelines.


It is used to classify diseases and other health problems recorded on many types of health and vital records including death certificates and health records. In addition to enabling the storage and retrieval of diagnostic information for clinical, epidemiological and quality purposes, these records also provide the basis for the compilation of national mortality and morbidity statistics by WHO Member States.”


As a note, ICD-11 is planned for 2015.


A few years back, I was an associate clinical professor at the State University of New York at Stony Brook, Department of Health Science & Technology, teaching college seniors who aspired to have a career in health care administration. My course was a required course towards their degree.


In case you haven’t realized, coding is like a jigsaw or crossword puzzle, or as my friends tell me, it is stuff for nerds when you don’t have a real life. The sad part is, I really enjoy the coding game and that makes me guilty as charged!


Now, here is the rule, and it is a hard rule: you only diagnose what is found. You do not diagnose what you expect to find. This sentence sums up the correct protocol for diagnosing. Now the question arises, “What do you do with issues that you want to rule out?” The answer is simple. In your report, you order tests and document that the test is to rule out certain pathology. An example would be if you wanted to rule out a radiculopathy. The language would be as follows:


A cervical EMG/NCV was ordered to rule out cervical radiculopathy.


You do not diagnose a cervical radiculopathy prior to the test being performed. That is not logical and would be grossly inaccurate. In fact, you border on abuse when you order a test for a disease you have already diagnosed, thereby making the “rule-out diagnosis” a very dangerous entity to use. Why would you order anything when you already have the answer?


If you look at the HCFA form, there are no boxes for “Rule-Out Diagnosis,” only “Diagnosis. Therefore, you can only list what is diagnosed.


Another example is ordering MRI’s. When you order the MRI, in your notes you should include your clinical rationale:


A lumbar MRI was ordered to rule out a lumbar herniated disc.


You don’t create a herniated disc diagnosis prior to the test results. In fact, it has been reported that the insurance industry is going after doctors for abuse issues when a pattern exists in ordering tests with no clinical rationale. Always give the clinical rationale when ordering any test, including x-rays:


A Davis Series of the cervical spine was ordered to rule out osseous pathology and instability upon motion post trauma


Diagnosing and coding is a very easy thing to do if you follow the rules and will ensure that you get paid in a timely manner.