NR511 FINAL TEST AND ANSWERS 100 %
ACCURATE
Define diagnostic reasoning
-A type of critical thinking
-Includes systematic way of thinking that evaluates each new piece of data to support some
hypothesis and reduce others
-Evaluates if all the avenues have been explored and that the conclusion is based on evidence
-To solve problems, promote health, screen for dz/illness: all require sensitivity to complex
stories, contextual factors, sense of probability/uncertainty
Discuss & identify subjective & objective data
Subjective: what a pt reports, complains of, tells me in response to my questions.
Includes ROS, CC, HPI
Objective: info you can see/feel
Lab results/data
Discuss & identify the components of the HPI
O: onset
L: location
D: duration (does it come and go?)
C: characteristics
A: aggravating factors
R: relieving factors
T: treatments attempted
S: severity of pain
Describe the differences between medical billing and medical coding
Billing: process of submitting and following up on claims made to a payer in order to receive
payment for medical services rendered by healthcare provider.
Coding: the use of codes to communicate with payers about which procedures were performed
and why.
Compare & contrast the 2 coding classification systems that are currently used in the US
healthcare system
,CPT: common procedural terminology
Official procedural rules and guidelines required when reporting services/procedures performed
by providers
Recognized universally
Provide logical means to be able to tract healthcare data, trends, outcomes
Represented by 5-digit code
Every CPT must have dx that corresponds/explains why procedure was done
ICD-10: 10th version
Shorthand for pt's dx used to provide payer info on necessity of visit/procedure
Discuss how specificity, sensitivity, predictive value contribute to usefulness of diagnostic data
Specificity: greater when it has few false positives
The number of true negatives divided by the number of all tested individuals who do not have
the dz
Sensitivity: greater when it has few false negatives
The number of true positives divided by the number of tested individuals that do have the dz
Predictive value: in part dependent on prevalence of condition
Positive predictive value: the number of true positives divided by all those that are positive
Negative predictive value: the number of true negatives divided by all those that are negative
False positive: when a pt does NOT have dz, but has positive reading
False negative: when a pt that DOES have dz, but has negative reading
Discuss the elements that need to be considered when developing a plan
Diagnostic testing (what tests need to be conducted to clarify assessment)
Education (specific problems being managed)
Follow-up (when will the pt need to be seen again)
Be honest
Negotiate what to cover
Describe the components of medical decision making (MDM) in E&M coding
Three key components that determine risk-based E&M codes:
History
Physical
,MDM
E&M coding requires a decision-maker
MDM is another way of quantifying complexity of the thinking that is required for the visit
Complexity of visit is based on 3 criteria:
Risk
Data
Dx
MDM score gives us credit for the excess work involved in management of a more complex pt.
Correctly order the E&M office visit codes based on complexity from least to most complex
New:
99201 (minimal/RN visit)
99202 (problem-focused)
99203 (expanded problem-focused)
99204 (detailed)
99205 (comprehensive)
Established:
99211 (minimal/RN visit)
99212 (problem-focused)
99213 (expanded problem-focused
99214 (detailed)
99215 (comprehensive)
Discuss a minimum of 3 purposes of the written H&P in relation to the importance of
documentation
-Important reference that gives concise info about pt's Hx and exam findings
-Outlines plan for addressing issues that prompted visit. Info should be presented in logical
fashion that prominently features all data immediately relevant to pt's condition.
-A means of communicating info to all providers who are involved in care of the pt.
-Important medical-legal document
-Essential in order to accurately code and bill for services.
Why does every procedure code need a corresponding dx code?
, To explain necessity of why it was done
May represent actual procedure or nonprocedural encounter (like office visit)
Correctly ID a pt as new or established given the historical info
New: a pt who has not received services from this provider before or who has not been seen by
provider in >3yrs
Established: pt who has seen provider within last 3yrs
ID 3 components required in determining an outpt office visit E&M code
Plan of service
Type of service
Pt status
Describe the components of MDM in E&M coding
Risk
Data
Dx
Explain what a well-rounded clinical experience means
To experience a variety of pts during clinical across the lifespan
15% peds of total clinical time in program
15% women's health of total clinical time in program
State max number of hrs. that time can be spent rounding in a facility
No more than 25% of total practicum hrs. in that course
State 9 things that must be documented when inputting data into clinical encounter
Date of service
Age
Gender & ethnicity
Visit E&M code
Chief concern
Procedures
Tests performed/ordered
Dx
Level of involvement (mostly student, mostly preceptor, together, etc.)
ID and explain each part of SNAPPS
ACCURATE
Define diagnostic reasoning
-A type of critical thinking
-Includes systematic way of thinking that evaluates each new piece of data to support some
hypothesis and reduce others
-Evaluates if all the avenues have been explored and that the conclusion is based on evidence
-To solve problems, promote health, screen for dz/illness: all require sensitivity to complex
stories, contextual factors, sense of probability/uncertainty
Discuss & identify subjective & objective data
Subjective: what a pt reports, complains of, tells me in response to my questions.
Includes ROS, CC, HPI
Objective: info you can see/feel
Lab results/data
Discuss & identify the components of the HPI
O: onset
L: location
D: duration (does it come and go?)
C: characteristics
A: aggravating factors
R: relieving factors
T: treatments attempted
S: severity of pain
Describe the differences between medical billing and medical coding
Billing: process of submitting and following up on claims made to a payer in order to receive
payment for medical services rendered by healthcare provider.
Coding: the use of codes to communicate with payers about which procedures were performed
and why.
Compare & contrast the 2 coding classification systems that are currently used in the US
healthcare system
,CPT: common procedural terminology
Official procedural rules and guidelines required when reporting services/procedures performed
by providers
Recognized universally
Provide logical means to be able to tract healthcare data, trends, outcomes
Represented by 5-digit code
Every CPT must have dx that corresponds/explains why procedure was done
ICD-10: 10th version
Shorthand for pt's dx used to provide payer info on necessity of visit/procedure
Discuss how specificity, sensitivity, predictive value contribute to usefulness of diagnostic data
Specificity: greater when it has few false positives
The number of true negatives divided by the number of all tested individuals who do not have
the dz
Sensitivity: greater when it has few false negatives
The number of true positives divided by the number of tested individuals that do have the dz
Predictive value: in part dependent on prevalence of condition
Positive predictive value: the number of true positives divided by all those that are positive
Negative predictive value: the number of true negatives divided by all those that are negative
False positive: when a pt does NOT have dz, but has positive reading
False negative: when a pt that DOES have dz, but has negative reading
Discuss the elements that need to be considered when developing a plan
Diagnostic testing (what tests need to be conducted to clarify assessment)
Education (specific problems being managed)
Follow-up (when will the pt need to be seen again)
Be honest
Negotiate what to cover
Describe the components of medical decision making (MDM) in E&M coding
Three key components that determine risk-based E&M codes:
History
Physical
,MDM
E&M coding requires a decision-maker
MDM is another way of quantifying complexity of the thinking that is required for the visit
Complexity of visit is based on 3 criteria:
Risk
Data
Dx
MDM score gives us credit for the excess work involved in management of a more complex pt.
Correctly order the E&M office visit codes based on complexity from least to most complex
New:
99201 (minimal/RN visit)
99202 (problem-focused)
99203 (expanded problem-focused)
99204 (detailed)
99205 (comprehensive)
Established:
99211 (minimal/RN visit)
99212 (problem-focused)
99213 (expanded problem-focused
99214 (detailed)
99215 (comprehensive)
Discuss a minimum of 3 purposes of the written H&P in relation to the importance of
documentation
-Important reference that gives concise info about pt's Hx and exam findings
-Outlines plan for addressing issues that prompted visit. Info should be presented in logical
fashion that prominently features all data immediately relevant to pt's condition.
-A means of communicating info to all providers who are involved in care of the pt.
-Important medical-legal document
-Essential in order to accurately code and bill for services.
Why does every procedure code need a corresponding dx code?
, To explain necessity of why it was done
May represent actual procedure or nonprocedural encounter (like office visit)
Correctly ID a pt as new or established given the historical info
New: a pt who has not received services from this provider before or who has not been seen by
provider in >3yrs
Established: pt who has seen provider within last 3yrs
ID 3 components required in determining an outpt office visit E&M code
Plan of service
Type of service
Pt status
Describe the components of MDM in E&M coding
Risk
Data
Dx
Explain what a well-rounded clinical experience means
To experience a variety of pts during clinical across the lifespan
15% peds of total clinical time in program
15% women's health of total clinical time in program
State max number of hrs. that time can be spent rounding in a facility
No more than 25% of total practicum hrs. in that course
State 9 things that must be documented when inputting data into clinical encounter
Date of service
Age
Gender & ethnicity
Visit E&M code
Chief concern
Procedures
Tests performed/ordered
Dx
Level of involvement (mostly student, mostly preceptor, together, etc.)
ID and explain each part of SNAPPS
