NR511 Midterm Exam
Study Guide
Week 1
1. Define diagnostic reasoning
Reflective thinking because the process involves questioning one’s
thinking to determining 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. Discuss and identify subjective & objective data
- Subjective: What the pt tells you, complains of, etc. *Chief
complaint, HPI, ROS
- Objective: What YOU can see, hear, or feel as part of your exam.
*lab, data, dx test results.
3. Discuss and identify the components of the HPI
Specifically related to the CC only. Detailed breakdown of CC.
OLDCART.
4. Describe the differences between medical billing and medical
coding
- Medical coding: The use of codes to communicate with payers
about which procedures were performed and why
- 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.
5. Compare and contrast the 2 coding classification systems that
are currently used in the US healthcare system
,- CPT codes: Common procedural terminology. Offers the official
procedural coding rules and guidelines required when reporting medical
services and procedures performed by physician and nonphysician
orders.
- ICD codes: International classification of disease. Used to
provide payer info on necessity of visit or procedure performed.
6. Discuss how specificity, sensitivity & predictive value
contribute to the usefulness of the diagnostic data
- 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.
- 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.
- Predictive Value: The 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, the positive result
would be more accurate.
7. Discuss the elements that need to be considered when
developing a plan
Patient’s preferences and actions. Research evidence. Clinical
state/circumstances. Clinical expertise.
8. Describe 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 the MDM!
,9. 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:
6. Minimal/RN patient: 99211
7. Problem focused: 99212
8. Expanded problem focused: 99213
9. Detailed: 99214
10. Comprehensive: 99215
10. Discuss a minimum of three purposes of the written history and
physical in relation to the importance of documentation
- Important reference document that vies concise info about the pt’s
hx and exam findings
- outlines a plan for addressing issues that prompted the visit. Info
should be presented in a logical fashion that prominently features all
data relevant to the pt’s condition
- is a means of communicating info to all providers involved in
patient’s care.
- is a medical legal document
- is essential in order to accurately code and bill for services
11. Accurately document why every procedure code must have a
corresponding diagnosis code
, Diagnosis code explains the necessity of the procedure code. Insurance
won’t pay if they do not correspond.
12. Correctly identify a patient as new or established given the
historical information
New patient: If that patient has never been seen in that clinic or by that
group of providers OR if the pt has not been seen in the past 3 years
13. Identify the 3 components required in determining an
outpatient, office visit E&M code
Place of service, type of service, patient status.
14. Describe the components of Medical Decision Making in E&M
coding
Risk – data – diagnosis
15. Correctly order the E&M office visit codes based on complexity
from least to most complex
· Repeat of #9?
New patient:
a. Minimal/RN visit: 99201
b. Problem focused: 99202
c. Expanded problem focused: 99203
d. Detailed: 99204
e. Comprehensive: 99205
Established patient:
f. Minimal/RN patient: 99211
g. Problem focused: 99212
h. Expanded problem focused: 99213
i. Detailed: 99214
j. Comprehensive: 99215
Study Guide
Week 1
1. Define diagnostic reasoning
Reflective thinking because the process involves questioning one’s
thinking to determining 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. Discuss and identify subjective & objective data
- Subjective: What the pt tells you, complains of, etc. *Chief
complaint, HPI, ROS
- Objective: What YOU can see, hear, or feel as part of your exam.
*lab, data, dx test results.
3. Discuss and identify the components of the HPI
Specifically related to the CC only. Detailed breakdown of CC.
OLDCART.
4. Describe the differences between medical billing and medical
coding
- Medical coding: The use of codes to communicate with payers
about which procedures were performed and why
- 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.
5. Compare and contrast the 2 coding classification systems that
are currently used in the US healthcare system
,- CPT codes: Common procedural terminology. Offers the official
procedural coding rules and guidelines required when reporting medical
services and procedures performed by physician and nonphysician
orders.
- ICD codes: International classification of disease. Used to
provide payer info on necessity of visit or procedure performed.
6. Discuss how specificity, sensitivity & predictive value
contribute to the usefulness of the diagnostic data
- 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.
- 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.
- Predictive Value: The 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, the positive result
would be more accurate.
7. Discuss the elements that need to be considered when
developing a plan
Patient’s preferences and actions. Research evidence. Clinical
state/circumstances. Clinical expertise.
8. Describe 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 the MDM!
,9. 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:
6. Minimal/RN patient: 99211
7. Problem focused: 99212
8. Expanded problem focused: 99213
9. Detailed: 99214
10. Comprehensive: 99215
10. Discuss a minimum of three purposes of the written history and
physical in relation to the importance of documentation
- Important reference document that vies concise info about the pt’s
hx and exam findings
- outlines a plan for addressing issues that prompted the visit. Info
should be presented in a logical fashion that prominently features all
data relevant to the pt’s condition
- is a means of communicating info to all providers involved in
patient’s care.
- is a medical legal document
- is essential in order to accurately code and bill for services
11. Accurately document why every procedure code must have a
corresponding diagnosis code
, Diagnosis code explains the necessity of the procedure code. Insurance
won’t pay if they do not correspond.
12. Correctly identify a patient as new or established given the
historical information
New patient: If that patient has never been seen in that clinic or by that
group of providers OR if the pt has not been seen in the past 3 years
13. Identify the 3 components required in determining an
outpatient, office visit E&M code
Place of service, type of service, patient status.
14. Describe the components of Medical Decision Making in E&M
coding
Risk – data – diagnosis
15. Correctly order the E&M office visit codes based on complexity
from least to most complex
· Repeat of #9?
New patient:
a. Minimal/RN visit: 99201
b. Problem focused: 99202
c. Expanded problem focused: 99203
d. Detailed: 99204
e. Comprehensive: 99205
Established patient:
f. Minimal/RN patient: 99211
g. Problem focused: 99212
h. Expanded problem focused: 99213
i. Detailed: 99214
j. Comprehensive: 99215
