Week One
● 1.Define diagnostic reasoning.
-To solve problems, to promote health, and to screen for disease or illness all require a
sensitivity to complex stories, to contextual factors, and to a sense of probability and
uncertainty.
-Diagnostic reasoning can be seen as a kind of critical thinking. Critical thinking involves
the process of 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. Diagnostic
reasoning then includes a systematic way of thinking that evaluates each new piece of
data as it either supports some diagnostic hypothesis or reduces the likelihood of others.
● 2.Identify subjective & objective data.
-Subjective:
-reports
-complains of
-tells you in response to your questions.
-Includes ROS, CC, and HPI
-Objective:
-what you can see, hear, or feel as part of your clinical exam.
-It also includes laboratory data and test results.
● 3.Identify the components of the HPI.
-O: Onset of CC
-L: Location of CC
-D: Duration of CC
-C: Characteristics of CC
-A: Aggravating factors for CC
-R: Relieving factors for CC
-T: Treatments tried for CC
-S: Severity of CC
● 4.Develop an appropriate differential.
-Differential diagnosis, or differential, is a list (single) of plausible diagnoses (plural)
that fit the historical and clinical presentation of your patient in order of priority.
-This is different than the problem list, which is a list that includes all of the active
medical problems for the patient.
● 5.Accurately describe why every procedure code must have a corresponding diagnosis
code.
-Every procedure code needs a diagnosis to explain the necessity whether the code
represents an actual procedure performed or a nonprocedural encounter like an office
visit.
● 6.Identify the three components required in determining an outpatient, office visit E&M
code.
-Place of service
-Inpatient
-Outpatient
, -Type of service
-Consolations
-Office visit
-Hospital admission
-Patient status
-New patient: one who has not received professional service from a
provider from the same group practice within the past 3 years.
-Established patient of your practice: has received professional
● 7.Describe the differences between medical billing and medical coding.
-Medical coding: is the use of codes to communicate with payers about which
procedures were performed and why.
-Medical billing: is the process of submitting and following up on claims made to a
payer to receive payment for medical services rendered by a healthcare provider.
● 8.Compare and contrast the two coding classification systems that are currently used in
the U.S. healthcare system.
-The CPT system offers the official procedural coding rules and guidelines required
when reporting medical services and procedures performed by physician and non-
physician providers.
-CPT codes are recognized universally and provide a logical means to be able to track
healthcare data, trends, and outcomes.
-ICD-10 codes are shorthand for the patient’s diagnoses, which are used to provide the
payer information on the necessity of the visit or procedure performed.
● 9.Discuss how specificity, sensitivity, and predictive value contribute to the usefulness of
diagnostic data.
-Specificity of a test, we are referring to the ability of the test to correctly detect a
specific condition.
-Predictive value is the likelihood that the patient has the condition and is, in part,
dependent upon the prevalence of the condition in the population.
-When a test is very sensitive, we mean it has few false negatives.
● 10. Discuss the elements that need to be considered when developing a plan.
-Acknowledge the list
-Negotiate what to cover
-Be Honest
-Make a follow-up
● 11.Describe the components of medical decision making in E&M coding.
- There are three key components that determine risk-based E&M codes.
-History
-Physical
-Medical Decision Making (MDM) E&M coding requires a medical
decision maker
-Medical decision making is another way of quantifying the complexity of the thinking
that is required for the visit.
-Complexity of a visit is based on three criteria:
-Risk
-Data
-Diagnosis
, -Now, medical decision making is a special category. Why is this so important?
Well, the MDM score gives us credit for the excess work involved in management of a
more complex patient.
● 12.Correctly order the E&M office visit codes based on complexity from least to most
complex.
-99212 least complex
-99213
-99214 most complex
● 13.Define the components of a SOAP note.
-Subjective
-Objective
-Assessment
-Plan
● 14.Discuss a minimum of three purposes of the written history and physical in relation to
the importance of documentation.
A. It is an important reference document that gives concise information about a
patient's history and exam findings.
B. It outlines a plan for addressing the issues that prompted the visit. This
information should be presented in a logical fashion that prominently features all
data immediately relevant to the patient's condition.
C. It is a means of communicating information to all providers who are involved in
the care of a particular patient.
D. It is an important medical-legal document.
E. It is essential to accurately code and bill for services.
● 15.Correctly identify a patient as new or established given the historical information.
-Patient status
-New patient: one who has not received professional service from a
provider from the same group practice within the past 3 years.
-Established patient of your practice: has received professional service from a
provider of your office within the last 3 years
● 16.Correctly identify the most specific ICD-10 code with the information given
Question about strep and the rapid strep was down.... acute pharyngitis
unspecified
● 17.Explain what a "well rounded" clinical experience means.
-a true well-rounded experience will include both children from birth through young adult
visits for well-child and acute visits, as well as adults for wellness and acute or routine
visits.
● 18.Discuss the maximum number of hours that time can be spent "rounding" in a facility.
15 hours/ <25%
● 19.Discuss nine things that must be documented when inputting data into clinical
encounter logs.
-date of service
-age
-gender and ethnicity
-insurance (NOT THE INSURANCE CARRIER)
-visit E&M code (e.g., 99203)
-chief concern
-procedures
-tests performed or ordered
-diagnoses
-level of involvement (mostly student, mostly preceptor, together, etc.)
● 1.Define diagnostic reasoning.
-To solve problems, to promote health, and to screen for disease or illness all require a
sensitivity to complex stories, to contextual factors, and to a sense of probability and
uncertainty.
-Diagnostic reasoning can be seen as a kind of critical thinking. Critical thinking involves
the process of 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. Diagnostic
reasoning then includes a systematic way of thinking that evaluates each new piece of
data as it either supports some diagnostic hypothesis or reduces the likelihood of others.
● 2.Identify subjective & objective data.
-Subjective:
-reports
-complains of
-tells you in response to your questions.
-Includes ROS, CC, and HPI
-Objective:
-what you can see, hear, or feel as part of your clinical exam.
-It also includes laboratory data and test results.
● 3.Identify the components of the HPI.
-O: Onset of CC
-L: Location of CC
-D: Duration of CC
-C: Characteristics of CC
-A: Aggravating factors for CC
-R: Relieving factors for CC
-T: Treatments tried for CC
-S: Severity of CC
● 4.Develop an appropriate differential.
-Differential diagnosis, or differential, is a list (single) of plausible diagnoses (plural)
that fit the historical and clinical presentation of your patient in order of priority.
-This is different than the problem list, which is a list that includes all of the active
medical problems for the patient.
● 5.Accurately describe why every procedure code must have a corresponding diagnosis
code.
-Every procedure code needs a diagnosis to explain the necessity whether the code
represents an actual procedure performed or a nonprocedural encounter like an office
visit.
● 6.Identify the three components required in determining an outpatient, office visit E&M
code.
-Place of service
-Inpatient
-Outpatient
, -Type of service
-Consolations
-Office visit
-Hospital admission
-Patient status
-New patient: one who has not received professional service from a
provider from the same group practice within the past 3 years.
-Established patient of your practice: has received professional
● 7.Describe the differences between medical billing and medical coding.
-Medical coding: is the use of codes to communicate with payers about which
procedures were performed and why.
-Medical billing: is the process of submitting and following up on claims made to a
payer to receive payment for medical services rendered by a healthcare provider.
● 8.Compare and contrast the two coding classification systems that are currently used in
the U.S. healthcare system.
-The CPT system offers the official procedural coding rules and guidelines required
when reporting medical services and procedures performed by physician and non-
physician providers.
-CPT codes are recognized universally and provide a logical means to be able to track
healthcare data, trends, and outcomes.
-ICD-10 codes are shorthand for the patient’s diagnoses, which are used to provide the
payer information on the necessity of the visit or procedure performed.
● 9.Discuss how specificity, sensitivity, and predictive value contribute to the usefulness of
diagnostic data.
-Specificity of a test, we are referring to the ability of the test to correctly detect a
specific condition.
-Predictive value is the likelihood that the patient has the condition and is, in part,
dependent upon the prevalence of the condition in the population.
-When a test is very sensitive, we mean it has few false negatives.
● 10. Discuss the elements that need to be considered when developing a plan.
-Acknowledge the list
-Negotiate what to cover
-Be Honest
-Make a follow-up
● 11.Describe the components of medical decision making in E&M coding.
- There are three key components that determine risk-based E&M codes.
-History
-Physical
-Medical Decision Making (MDM) E&M coding requires a medical
decision maker
-Medical decision making is another way of quantifying the complexity of the thinking
that is required for the visit.
-Complexity of a visit is based on three criteria:
-Risk
-Data
-Diagnosis
, -Now, medical decision making is a special category. Why is this so important?
Well, the MDM score gives us credit for the excess work involved in management of a
more complex patient.
● 12.Correctly order the E&M office visit codes based on complexity from least to most
complex.
-99212 least complex
-99213
-99214 most complex
● 13.Define the components of a SOAP note.
-Subjective
-Objective
-Assessment
-Plan
● 14.Discuss a minimum of three purposes of the written history and physical in relation to
the importance of documentation.
A. It is an important reference document that gives concise information about a
patient's history and exam findings.
B. It outlines a plan for addressing the issues that prompted the visit. This
information should be presented in a logical fashion that prominently features all
data immediately relevant to the patient's condition.
C. It is a means of communicating information to all providers who are involved in
the care of a particular patient.
D. It is an important medical-legal document.
E. It is essential to accurately code and bill for services.
● 15.Correctly identify a patient as new or established given the historical information.
-Patient status
-New patient: one who has not received professional service from a
provider from the same group practice within the past 3 years.
-Established patient of your practice: has received professional service from a
provider of your office within the last 3 years
● 16.Correctly identify the most specific ICD-10 code with the information given
Question about strep and the rapid strep was down.... acute pharyngitis
unspecified
● 17.Explain what a "well rounded" clinical experience means.
-a true well-rounded experience will include both children from birth through young adult
visits for well-child and acute visits, as well as adults for wellness and acute or routine
visits.
● 18.Discuss the maximum number of hours that time can be spent "rounding" in a facility.
15 hours/ <25%
● 19.Discuss nine things that must be documented when inputting data into clinical
encounter logs.
-date of service
-age
-gender and ethnicity
-insurance (NOT THE INSURANCE CARRIER)
-visit E&M code (e.g., 99203)
-chief concern
-procedures
-tests performed or ordered
-diagnoses
-level of involvement (mostly student, mostly preceptor, together, etc.)
