NR511 Midterm Exam - Reflective thinking because the process involve...

NR511 Midterm Exam Week 1

• Define diagnostic reasoning

Reflective thinking because the process involves questioning one’s thinking to determining if all possible avenues have been explored and if the conclusions that are being drawn are based on evidence. *Seen as a kind of critical thinking.

• Discuss and identify subjective & objective data
• Subjective: What the pt tells you, complains of, etc. *Chief complaint, HPI, ROS
• Objective: What YOU can see, hear, or feel as part of your exam. *lab, data, dx test results.

• Discuss and identify the components of the HPI

Specifically related to the CC only. Detailed breakdown of CC. OLDCART.

• Describe the differences between medical billing and medical coding
• Medical coding: The use of codes to communicate with payers about which procedures were

performed and why

• Medical billing: Process of submitting and following up on claims made to a payer in order to

receive payment for medical services rendered by a healthcare provider.

• Compare and contrast the 2 coding classification systems that are currently used

in the US healthcare system

• CPT codes: Common procedural terminology. Offers the official procedural coding rules and

guidelines required when reporting medical services and procedures performed by physician and nonphysician orders.

• ICD codes: International classification of disease. Used to provide payer info on necessity of

visit or procedure performed.

• Discuss how specificity, sensitivity & predictive value contribute to the usefulness

of the diagnostic data

• Specificity: The ability of the test to correctly detect a specific condition. If a patient has a

condition but test is negative, it is a false negative. If a patient does NOT have a condition but the test is positive , it is a false positive.

• Sensitivity: Test that has few false negatives. Ability of a test to correctly identify a specific

condition when it is present. The higher the sensitivity, the lesser the likelihood of a false negative.

• Predictive Value: The likelihood that the pt actually has the condition and is, in part, dependent

upon the prevalence of the condition in the population. If a condition is highly likely, the positive result would be more accurate.

• Discuss the elements that need to be considered when developing a plan

Patient’s preferences and actions. Research evidence. Clinical state/circumstances. Clinical expertise. 1 / 3

• Describe the components of Medical Decision Making in E&M coding

Risk – data – diagnosis. The more time and consideration involved in dealing with a pt, the higher the reimbursement from the payer. Documentation must reflect the MDM!

• Correctly order the E&M office visit codes based on complexity from least to most

complex

New patient:

1. Minimal/RN visit: 99201

2. Problem focused: 99202

3. Expanded problem focused: 99203

4. Detailed: 99204

5. Comprehensive: 99205

Established patient:

6. Minimal/RN patient: 99211

7. Problem focused: 99212

8. Expanded problem focused: 99213

9. Detailed: 99214

10. Comprehensive: 99215

• Discuss a minimum of three purposes of the written history and physical in relation

to the importance of documentation

• Important reference document that vies concise info about the pt’s hx and exam findings
• outlines a plan for addressing issues that prompted the visit. Info should be presented in a

logical fashion that prominently features all data relevant to the pt’s condition

• is a means of communicating info to all providers involved in patient’s care.
• is a medical legal document
• is essential in order to accurately code and bill for services

• Accurately document why every procedure code must have a corresponding

diagnosis code Diagnosis code explains the necessity of the procedure code. Insurance won’t pay if they do not correspond.

• Correctly identify a patient as new or established given the historical information

New patient: If that patient has never been seen in that clinic or by that group of providers OR if the pt has not been seen in the past 3 years

• Identify the 3 components required in determining an outpatient, office visit E&M

code Place of service, type of service, patient status.

• Describe the components of Medical Decision Making in E&M coding

Risk – data – diagnosis

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• Correctly order the E&M office visit codes based on complexity from least to most

complex · Repeat of #9?

New patient:

a. Minimal/RN visit: 99201

b. Problem focused: 99202

c. Expanded problem focused: 99203

d. Detailed: 99204

e. Comprehensive: 99205

Established patient:

f. Minimal/RN patient: 99211

g. Problem focused: 99212

h. Expanded problem focused: 99213

i. Detailed: 99214

j. Comprehensive: 99215

• Explain what a “well rounded” clinical experience means

Includes seeing kids from birth through young adult visits for well child and acute visits as well as adults for wellness or acute/routine visits. Seeing a variety of patients including 15% of peds and 15% of women’s health of total time in the program.

• State the maximum number of hours that time can be spent “rounding” in a facility

No more than 25% of total practicum hours in the program

• State 9 things that must be documented when inputting data into clinical encounter
• Date of service
• Age
• Gender and Ethnicity
• Visit E&M code

5. CC

• Procedures
• Tests performed and ordered
• Dx
• Level of involvement (mostly student, mostly preceptor, together, etc.)

• Identify and explain each part of the acronym SNAPPS

- Summarize: present the pt’s H&P findings

• Narrow: based on the H&P findings, narrow down to the top 2-3 differentials
• Analyze: analyze the differentials. Compare and contrast H&P findings for each of the

differentials and narrow it down to the most likely one.

- Probe: ask the preceptor questions of anything you are unsure of.

- Plan: come up with a specific management plan

• Self-directed learning: an opportunity to investigate more about any topics that you are

uncertain of.

Week 2

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