The term rule out is commonly used in outpatient care to eliminate a suspected condition or disease. While this term works well for clinicians and supports medical-legal requirements, it wreaks havoc on radiology coders and radiology reimbursement. This is particularly true in the outpatient setting where rule-out codes are not accepted as a primary diagnosis by most payers.
Radiology coders are trapped between radiologists and revenue, forced to balance the need for clinical data integrity with administrative demands for fewer denials and more accurate reimbursement. Couple this with a rising volume of outpatient radiologic procedures, and it is easy to see the problem. Help solve that problem with these practical tips for coders, administrators, and radiologists to reduce the use of rule out as a final diagnosis. By following a few straightforward guidelines, coders can support medical necessity and improve outpatient reimbursement, even when a radiologist is ruling out.
Clinicians’ View
In many ways, the entire purpose of a radiological exam is to rule out suspected disease and help the attending physician make a definitive diagnosis and proceed with treatment. Radiologists typically only see images and part of the clinical picture. From a pure radiological perspective, it is not their responsibility to make a diagnosis, only to help rule out or verify something that is suspected by another clinician.