Define diagnostic reasoning - ANSWER Reflective thinking because the process involves
questioning one's thinking to determine 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.
What is subjective data? - ANSWER What the patient tells you, complains of, etc.
Chief complaint
HPI
ROS
What is objective data? - ANSWER What YOU can see, hear, or feel as part of your exam.
Includes lab data, diagnostic test results.
Components of HPI - ANSWER Specifically related to the chief complaint only.
Detailed breakdown of CC.
OLDCART
1
,Why must every procedure code have a corresponding diagnosis code? - ANSWER Diag-
nosis code explains the necessity of the procedure code.
Insurance won't pay if they don't correspond.
What are the three components required in determining an outpatient office visit E&M
code? - ANSWER Place of service
Type of service
Patient status
What is medical coding? - ANSWER The use of codes to communicate with payers about
which procedures were performed and why
What is medical billing? - ANSWER 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.
What are CPT codes? - ANSWER Common procedural terminology
Offers the official procedural coding rules and guidelines required when reporting medical
services and procedures performed by physician and non-physician providers.
What are ICD codes? - ANSWER International classification of disease
Used to provide payer info on necessity of visit or procedure performed.
What is specificity? - ANSWER The ability of the test to correctly detect a specific condi-
tion.
2
,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.
What is sensitivity? - ANSWER 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.
What is predictive value? - ANSWER The likelihood that the patient actually has the con-
dition 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.
What elements need to be considered when developing a plan? - ANSWER Pt's prefer-
ences and actions
Research evidence
Clinical state/circumstances
Clinical expertise
What are the components of medical decision making in E&M coding? - ANSWER Risk
Data
Diagnosis
The more time and consideration involved in dealing with a pt, the higher the reimburse-
ment from the payer.
Documentation must reflect MDM!
3
, Correctly order the E&M office visit codes based on complexity from least to most complex. -
ANSWER New patient:
1. Minimal/RN visit: 99201
2. Problem focused: 99202
3. Expanded problem focused: 99203
4. Detailed: 99204
5. Comprehensive: 99205
Established patient:
1. Minimal/RN visit: 99211
2. Problem focused: 99212
3. Expanded problem focused: 99213
4. Detailed: 99214
5. Comprehensive: 99215
Define the components of a SOAP note - ANSWER S: subjective (what the pt tells you)
CC
HPI
PMH
Fam Hx
Social Hx
ROS
O: objective (what you can see, hear, feel on exam)
Physical findings
VS
General survey
HEENT
4
questioning one's thinking to determine 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.
What is subjective data? - ANSWER What the patient tells you, complains of, etc.
Chief complaint
HPI
ROS
What is objective data? - ANSWER What YOU can see, hear, or feel as part of your exam.
Includes lab data, diagnostic test results.
Components of HPI - ANSWER Specifically related to the chief complaint only.
Detailed breakdown of CC.
OLDCART
1
,Why must every procedure code have a corresponding diagnosis code? - ANSWER Diag-
nosis code explains the necessity of the procedure code.
Insurance won't pay if they don't correspond.
What are the three components required in determining an outpatient office visit E&M
code? - ANSWER Place of service
Type of service
Patient status
What is medical coding? - ANSWER The use of codes to communicate with payers about
which procedures were performed and why
What is medical billing? - ANSWER 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.
What are CPT codes? - ANSWER Common procedural terminology
Offers the official procedural coding rules and guidelines required when reporting medical
services and procedures performed by physician and non-physician providers.
What are ICD codes? - ANSWER International classification of disease
Used to provide payer info on necessity of visit or procedure performed.
What is specificity? - ANSWER The ability of the test to correctly detect a specific condi-
tion.
2
,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.
What is sensitivity? - ANSWER 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.
What is predictive value? - ANSWER The likelihood that the patient actually has the con-
dition 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.
What elements need to be considered when developing a plan? - ANSWER Pt's prefer-
ences and actions
Research evidence
Clinical state/circumstances
Clinical expertise
What are the components of medical decision making in E&M coding? - ANSWER Risk
Data
Diagnosis
The more time and consideration involved in dealing with a pt, the higher the reimburse-
ment from the payer.
Documentation must reflect MDM!
3
, Correctly order the E&M office visit codes based on complexity from least to most complex. -
ANSWER New patient:
1. Minimal/RN visit: 99201
2. Problem focused: 99202
3. Expanded problem focused: 99203
4. Detailed: 99204
5. Comprehensive: 99205
Established patient:
1. Minimal/RN visit: 99211
2. Problem focused: 99212
3. Expanded problem focused: 99213
4. Detailed: 99214
5. Comprehensive: 99215
Define the components of a SOAP note - ANSWER S: subjective (what the pt tells you)
CC
HPI
PMH
Fam Hx
Social Hx
ROS
O: objective (what you can see, hear, feel on exam)
Physical findings
VS
General survey
HEENT
4
