Q&A: How to handle ’rule out’ documentation

Q: When a provider states that the patient is admitted rule out (R/O) a myocardial infarction (MI) would the MI get coded as though it exists? When the provider states that an MI is ruled out does that it mean it did not happen?

A: The diagnosis on admission of “R/O MI” typically means the patient is being admitted to evaluate a possible MI or to “rule it out” as a possible diagnosis. In essence it means the patient has a “possible MI.” Now for questions like these you want to refer to your coding guidelines. It is true that for inpatients, possible and probable diagnoses can be coded as certain IF the diagnosis remains as a possible diagnosis upon discharge and is included in the discharge summary.

The Official Guidelines for Coding and Reporting state that the provider needs to restate the diagnosis as “possible,” “probable,” etc. in the discharge summary if it remains uncertain or validate that the diagnosis is confirmed.

When it is stated in the record that the MI was ruled out it indicates that based on lab findings (cardiac enzymes, troponin levels, EKG readings, etc.) it was determined that there was no infarction.

As a CDI specialist, you have many things to consider when reviewing a record with an admission for R/O MI. Most importantly, you’ll need to find out if the physician found the MI to be present or if he/she ruled out that diagnosis?

Secondly, you’ll need to determine if the MI is the principal diagnosis. Usually such patients have symptom diagnoses such as chest pain, nausea, and chest pressure. Such complaints are known as “symptoms, signs, and ill-defined conditions” from Chapter 16. They are not to be used as a principal diagnosis when a related definitive diagnosis has been established. A CDIS should query the provider to document the known or suspected “possible”, “probable”, or “likely” condition that after study occasioned the admission. Reviewing the notes of the cardiologist may assist you in finding a more definitive diagnosis for the chest pain. Often the goal of the CDI specialist is to link the chest pain to coronary artery disease for a more definitive diagnosis, if there are indicators present to support this linkage.

An admission for R/O MI is always a challenge for CDI specialists, so you are smart to ask questions!

Editor’s Note: Laurie L. Prescott, MSN, RN, CCDS, CDIP, is a CDI Education Specialist with HCPro Inc., in Danvers, Mass., and a lead instructor for its CDI Boot Camps. For more information regarding upcoming Boot Camp dates and locations visit www.hcprobootcamps.com/courses/10040/location-dates.