If the diagnosis documented at the time of discharge is qualified as "probable", "suspected", "likely", "questionable", "possible", or "still to be ruled out", or other similar terms indicating uncertainty, code the condition as if it existed or was established. The bases for these guidelines are the diagnostic workup, arrangements for further workup or observation, and initial therapeutic approach that correspond most closely with the established diagnosis.
This guideline is applicable only to inpatient admissions to short-term, acute, long-term care and psychiatric hospitals
As you can see, this guideline requires that the diagnostic workup and initial therapeutic approach correspond to that uncertain diagnosis. Simply saying "rule out MI" in a consultation note, or even a discharge summary, does not show that diagnostic workup or therapeutic approach. You need the entire chart (or the majority of it) to support this. So, standalone documents from an inpatient stay are always coded as if they are outpatient documents.
Have a coding question related to risk adjustment, or risk adjustment data validation (RADV)? Send it to us at Coding@scanhealthplan.com