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ACDIS CCDS-O Exam - Topic 5 Question 3 Discussion
Topic #: 5
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?
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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