review] A patient is evaluated in the primary care clinic for chest pain, slight shortness of breath, and mild nausea. Documentation includes an ECG…

In an outpatient setting, such as a primary care clinic, diagnoses documented as "rule out," "suspected," or "probable" are not coded as if they are established. The official coding guidelines direct the coder to report the signs, symptoms, or abnormal findings that prompted the encounter. In this case, the patient's presenting symptoms were chest pain, shortness of breath, and nausea. Therefore, these are the correct diagnoses to report for this visit.

A: Angina pectoris is a specific diagnosis that was not documented by the provider; the documented symptom was chest pain.

B: "Rule out" diagnoses are never coded in the outpatient setting; only confirmed conditions are reported.

C: Acute MI was the condition being ruled out, not a confirmed diagnosis, and coding it would be inaccurate.

1. National Center for Health Statistics. (2023). ICD-10-CM Official Guidelines for Coding and Reporting FY 2024. Centers for Disease Control and Prevention. Section IV.H, "Uncertain Diagnosis," p. 117.

2. American Hospital Association. (2021). Coding Clinic for ICD-10-CM and ICD-10-PCS, First Quarter 2021, p. 31. "Coding of Signs and Symptoms."