Clinical Medical Assistant Certification Exam Practice Question
The physician writes "rule out acute myocardial Infarction" under diagnosis In the chart of a patient with acute chest pain. Which of the following descriptions should be used to code the diagnosis?
Correct Answer: C
Rationale: When coding a diagnosis, it's essential to reflect the physician's documentation accurately. "Rule out acute myocardial infarction" indicates that the physician suspects a possible heart attack but has not confirmed it.
Option A, "Acute myocardial Infarction," is incorrect as it implies a confirmed diagnosis, which is not the case here. Option B, "Acute and chronic coronary artery disease," is also inaccurate as it does not align with the specific concern of ruling out an acute event.
Option D, "Probable myocardial Infarction," suggests a stronger suspicion than what is documented. Option E, "Rule out acute myocardial Infarction," is misleading in coding terms since it doesn't represent a definitive diagnosis. Therefore, "Chest pain" (Option C) is the most appropriate choice, as it accurately captures the patient's presenting symptom without implying a confirmed diagnosis.
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