NR 511 Week 1 Assignment; Clinical Readiness Exam.docx
1. Define diagnostic reasoning
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.
2. What is subjective data?
What the patient tells you, complains of, etc.
Chief complaint
HPI
ROS
3. What is objective data?
What YOU can see, hear, or feel as part of your exam.
Includes lab data, diagnostic test results.
4. Components of HPI
Specifically related to the chief complaint only.
Detailed breakdown of CC.
OLDCART
5. Why must every procedure code have a corresponding diagnosis code?
Diagnosis code explains the necessity of the procedure code.
Insurance won't pay if they don't correspond.
6. What are the three components required in determining an outpatient office visit E&M code?
Place of service
Type of service
Patient status
7. What is medical coding?
The use of codes to communicate with payers about which procedures were performed and why
8. What is 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.
9. What are CPT codes?
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.
, NR 511 Week 1 Assignment; Clinical Readiness Exam.docx
10. What are ICD codes?
International classification of disease
Used to provide payer info on necessity of visit or procedure performed.
11. What is 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.
12. What is 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.
13. What is predictive value?
The likelihood that the patient 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.
14. What elements need to be considered when developing a plan?
Pt's preferences and actions
Research evidence
Clinical state/circumstances
Clinical expertise
15. What are 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 MDM!
16. 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:
1. Define diagnostic reasoning
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.
2. What is subjective data?
What the patient tells you, complains of, etc.
Chief complaint
HPI
ROS
3. What is objective data?
What YOU can see, hear, or feel as part of your exam.
Includes lab data, diagnostic test results.
4. Components of HPI
Specifically related to the chief complaint only.
Detailed breakdown of CC.
OLDCART
5. Why must every procedure code have a corresponding diagnosis code?
Diagnosis code explains the necessity of the procedure code.
Insurance won't pay if they don't correspond.
6. What are the three components required in determining an outpatient office visit E&M code?
Place of service
Type of service
Patient status
7. What is medical coding?
The use of codes to communicate with payers about which procedures were performed and why
8. What is 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.
9. What are CPT codes?
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.
, NR 511 Week 1 Assignment; Clinical Readiness Exam.docx
10. What are ICD codes?
International classification of disease
Used to provide payer info on necessity of visit or procedure performed.
11. What is 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.
12. What is 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.
13. What is predictive value?
The likelihood that the patient 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.
14. What elements need to be considered when developing a plan?
Pt's preferences and actions
Research evidence
Clinical state/circumstances
Clinical expertise
15. What are 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 MDM!
16. 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:
