1. Define diagnostic reasoning
Reflective thinking because thhe process involves questioning one's thinking
to determine if all possible avenues have been explored & if thhe
conclusions that are being drawn are based on evidence.
Seen as a kind of critical thinking.
2. What is subjective data?
Anything thhe patient tells you or complains of regarding thheir symptoms
Chief
complaint
HPI
ROS
3. What is objective data?
Anything YOU can see, touch, feel, hear, or smell as part of
your exam Includes lab data, diagnostic test results, etc.
4. Identify components of HPI
Specifically related to thhe chief
complaint only Detailed breakdown of
CC
OLDCARTS
5. Describe thhe differences between medical billing & medical coding.
Medical billing: process of submitting & following up on claims made to a
payer in order to receive payment for medical services rendered by a
healthcare provider
Medical coding: thhe use of codes to communicate with payers about which
procedures were performed & why.
6. Compare & contrast thhe two coding classification systems that
are currently used in thhe US healthcare system.
ICD: International classification of disease codes are used to provide payer
info on necessity of visit or procedure performed. Shorth& for pt's dx.
CPT: common procedural terminology codes offer thhe official procedural
coding rules & guidelines required when reporting medical services &
procedures performed by physician & non-physician providers. Must have
corresponding ICD.
7. How do specificity, sensitivity, & predictive value contribute to
thhe usefulness of diagnostic data?
Specificity: ability of a test to correctly detect a specific condition. If a pt has
,a condition but test is negative, it is a false negative. If pt does NOT have
condition but test is
,positive, it is false positive.
Sensitivity: test that has few false negatives. Ability of a test to
correctly identify a specific condition when it is present. Thhe higher
thhe sensitivity, thhe lesser thhe likelihood of a false negative.
Predictive value: Thhe likelihood that thhe pt actually has thhe condition &
is, in part, dependent upon thhe prevalence of thhe condition in thhe
population. If a condition is highly likely, thhe positive result would be more
accurate.
Diagnostic tests can be used to confirm or rule out
hypothheses. Diagnostic tests may be used to screen
for conditions.
Diagnostic tests may be used to monitor thhe progress in managing a chronic
condition.
8. Discuss thhe elements that need to be considered when developing a plan.
Pt's preferences &
actions Research
evidence
Clinical
state/circumstances
Clinical expertise
9. Describe thhe components of medical decision making in E&M coding.
Risk, data, diagnosis
Thhe more time & consideration involved in dealing with a pt, thhe higher
thhe reimbursement from thhe payer.
Documentation must reflect MDM
10. Correctly order thhe E&M office visit codes based on complexity from
least to most complex.
New pt:
1. Minimal/RN visit: 99201
2. Problem focused: 99202
3. Exp&ed problem focused: 99203
4. Detailed: 99204
5. Comprehensive: 99205
Established pt:
1. Minimal/RN visit: 99211
2. Problem focused: 99212
3. Exp&ed problem focused: 99213
4. Detailed: 99214
, 5. Comprehensive: 99215
Reflective thinking because thhe process involves questioning one's thinking
to determine if all possible avenues have been explored & if thhe
conclusions that are being drawn are based on evidence.
Seen as a kind of critical thinking.
2. What is subjective data?
Anything thhe patient tells you or complains of regarding thheir symptoms
Chief
complaint
HPI
ROS
3. What is objective data?
Anything YOU can see, touch, feel, hear, or smell as part of
your exam Includes lab data, diagnostic test results, etc.
4. Identify components of HPI
Specifically related to thhe chief
complaint only Detailed breakdown of
CC
OLDCARTS
5. Describe thhe differences between medical billing & medical coding.
Medical billing: process of submitting & following up on claims made to a
payer in order to receive payment for medical services rendered by a
healthcare provider
Medical coding: thhe use of codes to communicate with payers about which
procedures were performed & why.
6. Compare & contrast thhe two coding classification systems that
are currently used in thhe US healthcare system.
ICD: International classification of disease codes are used to provide payer
info on necessity of visit or procedure performed. Shorth& for pt's dx.
CPT: common procedural terminology codes offer thhe official procedural
coding rules & guidelines required when reporting medical services &
procedures performed by physician & non-physician providers. Must have
corresponding ICD.
7. How do specificity, sensitivity, & predictive value contribute to
thhe usefulness of diagnostic data?
Specificity: ability of a test to correctly detect a specific condition. If a pt has
,a condition but test is negative, it is a false negative. If pt does NOT have
condition but test is
,positive, it is false positive.
Sensitivity: test that has few false negatives. Ability of a test to
correctly identify a specific condition when it is present. Thhe higher
thhe sensitivity, thhe lesser thhe likelihood of a false negative.
Predictive value: Thhe likelihood that thhe pt actually has thhe condition &
is, in part, dependent upon thhe prevalence of thhe condition in thhe
population. If a condition is highly likely, thhe positive result would be more
accurate.
Diagnostic tests can be used to confirm or rule out
hypothheses. Diagnostic tests may be used to screen
for conditions.
Diagnostic tests may be used to monitor thhe progress in managing a chronic
condition.
8. Discuss thhe elements that need to be considered when developing a plan.
Pt's preferences &
actions Research
evidence
Clinical
state/circumstances
Clinical expertise
9. Describe thhe components of medical decision making in E&M coding.
Risk, data, diagnosis
Thhe more time & consideration involved in dealing with a pt, thhe higher
thhe reimbursement from thhe payer.
Documentation must reflect MDM
10. Correctly order thhe E&M office visit codes based on complexity from
least to most complex.
New pt:
1. Minimal/RN visit: 99201
2. Problem focused: 99202
3. Exp&ed problem focused: 99203
4. Detailed: 99204
5. Comprehensive: 99205
Established pt:
1. Minimal/RN visit: 99211
2. Problem focused: 99212
3. Exp&ed problem focused: 99213
4. Detailed: 99214
, 5. Comprehensive: 99215
