NR 511 WEEK 1 MIDTERM EXAM STUDY GUIDE

NR 511 WEEK 1 MIDTERM EXAM STUDY GUIDE Week 1 Exam Study Guide • Define diagnostic reasoning. o Seen as a kind of critical thinking o “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.” • Identify subjective & objective data. • Identify the components of the HPI. o Specifically related to the CC o OLDCART • Develop an appropriate differential. • Accurately describe why every procedure code must have a corresponding diagnosis code. o Insurance won’t pay if they don’t correspond o ICD 10 explains why CPT was done • Identify the three components required in determining an outpatient, office visit E&M code. o Need:  Hx  PE  MDM  Place of service (outpatient/inpatient)  Type of service (consultation, hospitalization, office visit, etc.)  Patient status (new/established)  New:  Established: • Describe the differences between medical billing and medical coding. o Medical coding: the use of codes to communicate with payers about which procedures were performed and why. o 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 two coding classification systems that are currently used in the U.S. healthcare system. o CPT: 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.  Recognized universally, provide logical means to be able to track healthcare data/trends/outcomes  Have to have a corresponding ICD o ICD: international classification of diseases  Shorthand for pt’s dx  Used to provide payer info on necessity of visit or procedure performed • Discuss how specificity, sensitivity, and predictive value contribute to the usefulness of diagnostic data. o Specificity: the ability of the test to correctly detect a specific condition. If a pt has condition but testing is negative, it is false negative. If pt does NOT have condition but test is positive, it is false positive. o Sensitivity: has few false negatives. The higher the sensitivity, the lesser the likelihood of a false negative. o Predictive value: 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, positive result would be more accurate. • Discuss the elements that need to be considered when developing a plan. o Pt’s preferences and actions o Research evidence o Clinical state/circumstances o Clinical expertise • Describe the components of medical decision making in E&M coding. o Risk o Data o Diagnosis o The more time and consideration involved in dealing with a pt, the higher the payback o Documentation must reflect MDM! • Correctly order the E&M office visit codes based on complexity from least to most complex. o New:  Minimal/RN visit (99201)  Problem focused (99202)  Exp. Problem focused (99203)  Detailed (99204)  Comprehensive (99205) o Established:  Minimal/RN visit (99211)  Problem focused (99212)  Exp. Problem focused (99213)  Detailed (99214)  Comprehensive (99215) • Define the components of a SOAP note. o S: subjective (what the pt tells you)  CC  HPI  PMH  Fam Hx  Social Hx  ROS o O: objective (what you can see/examine)  Physical findings  VS  General survey  HEENT  Lymph  Chest  CV  Abdominal  Etc…. o A: assessment  Global assessment of pt including Diff. Dx in order from most likely to least likely.  Combo of subjective and objective  List of dx addressed and billed for at the visit o P: plan  What you will Rx  When to come back  Diagnostic tests  Education • Discuss a minimum of three purposes of the written history and physical in relation to the importance of documentation. o Important reference document that gives concise info about pt’s hx and exam findings o Outlines a plan for addressing issues that prompted the visit. Info should be presented in logical fashion that prominently features all data relevant to pt’s condition. o A means of communicating info to all providers involved in pt’s care o Medical-legal document o Essential in order to accurately code and bill for services • Correctly identify a patient as new or established given the historical information. • Correctly identify the most specific ICD-10 code with the information given