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ACDIS CCDS-O Exam - Topic 5 Question 3 Discussion

review]A patient is evaluated in the primary care clinic for chest pain, slight shortness of breath, and mild nausea. Documentation includes an ECG and chest x-ray to rule out MI. Which of the following diagnoses are reportable?
D) Other chest pain, shortness of breath, and nausea
A) Angina pectoris, unspecified, shortness of breath, and nausea
B) Rule out MI, shortness of breath, and nausea
C) Acute MI, chest pain, shortness of breath, and nausea

ACDIS CCDS-O Exam - Topic 5 Question 3 Discussion

Actual exam question for ACDIS's CCDS-O exam
Question #: 3
Topic #: 5
[All CCDS-O Questions]

review]

A patient is evaluated in the primary care clinic for chest pain, slight shortness of breath, and mild nausea. Documentation includes an ECG and chest x-ray to rule out MI. Which of the following diagnoses are reportable?

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Suggested Answer: D

In the outpatient/ambulatory setting, ICD-10-CM reporting rules applied in CDI education distinguish clearly between confirmed diagnoses and ''uncertain'' or ''rule out'' conditions. Terms such as ''rule out,'' ''suspected,'' or ''probable'' generally are not coded as established diagnoses in the outpatient record because the encounter is often for evaluation and testing rather than definitive confirmation. Instead, coders report the patient's presenting signs and symptoms when a definitive condition has not been documented as confirmed by the provider. Here, the clinician ordered diagnostic testing (ECG and chest x-ray) specifically to rule out myocardial infarction (MI), but no final diagnosis of MI or angina is documented in the scenario. Therefore, ''rule out MI'' is not reportable, and neither is acute MI or angina unless explicitly diagnosed. The reportable conditions are the symptoms that drove the visit and required evaluation: chest pain (captured as ''other chest pain'' in the options), shortness of breath, and nausea.


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Royce
22 days ago
Wait, can you really report "Rule out MI"? Seems odd.
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Avery
27 days ago
I think B is also reportable since it's part of the evaluation.
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Stefany
1 month ago
Definitely A and D are reportable.
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Elke
1 month ago
Wait, are we really reporting shortness of breath and nausea? Seems odd.
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Goldie
1 month ago
D sounds right too, but not as clear-cut as A.
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Carmela
2 months ago
C seems too extreme if MI is ruled out.
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Oren
2 months ago
I think B is a bit misleading, not really a diagnosis.
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Santos
2 months ago
Definitely A, angina pectoris is reportable.
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Lera
2 months ago
I think D could be reportable since it mentions "other chest pain," but I’m not clear on the specifics of what qualifies.
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Lili
2 months ago
I'm not entirely sure, but I think C is definitely reportable if it were an acute MI. But since it’s just a rule out, I’m confused.
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Janna
2 months ago
I feel like we had a similar question about chest pain and shortness of breath, and I think we concluded that angina could be reportable.
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Quinn
3 months ago
I remember we discussed that "rule out MI" isn't a definitive diagnosis, so I think B might not be reportable.
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