Rule out: Term used in medicine, meaning to eliminate or exclude something from consideration. For example, a normal chest x-ray may “rule out” pneumonia.
Many of us in health care have always heard the directive “never code a rule-out, possible, or probable”, which is true for coding the diagnosis! However, when coding for Evaluation & Management, it is extremely helpful to document any illnesses/injuries that the physician is ruling out because that will support the physician’s medical decision making and will guide the non-clinical/administrative personnel in the physician’s thought processes.
In the “Medical Decision Making-Diagnoses or Management Options” section of the Documentation Guidelines, CMS specifically states, “For a presenting problem without an established diagnosis, the assessment or clinical impression may be stated in the form of differential diagnoses or as a “possible”, “probable”, or “rule out” (R/O) diagnosis.” (http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/eval_mgmt_serv_guide-ICN006764.pdf ; page 44)
In addition, CMS states, in the same document (page 43):
“C. DOCUMENTATION OF THE COMPLEXITY OF MEDICAL DECISION MAKING
The levels of E/M services recognize four types of medical decision making (straightforward, low complexity, moderate complexity and high complexity). Medical decision making refers to the complexity of establishing a diagnosis and/or selecting a management option as measured by:
• the number of possible diagnoses and/or the number of management options that must be considered;”
I highly encourage all physicians and mid-level providers to include their thought processes in their documentation guidelines. Remember, many of the “bean-counters” that decide the appropriateness of your documentation are not clinical!