Define diagnostic reasoning - answer 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.
What is subjective data? - answer What the patient tells you, complains of, etc.
Chief complaint
HPI
ROS
What is objective data? - answer What YOU can see, hear, or feel as part of your exam.
Includes lab data, diagnostic test results.
Components of HPI - answerSpecifically related to the chief complaint only.
Detailed breakdown of CC.
OLDCART
Why must every procedure code have a corresponding diagnosis code? -
answerDiagnosis code explains the necessity of the procedure code.
Insurance won't pay if they don't correspond.
What are the three components required in determining an outpatient office visit E&M
code? - answerPlace of service
Type of service
Patient status
What is medical coding? - answerThe use of codes to communicate with payers about
which procedures were performed and why
What is medical billing? - answerProcess of submitting and following up on claims made
to a payer in order to receive payment for medical services rendered by a healthcare
provider.
What are CPT codes? - answerCommon procedural terminology
, Offers the official procedural coding rules and guidelines required when reporting
medical services and procedures performed by physician and non-physician providers.
What are ICD codes? - answerInternational classification of disease
Used to provide payer info on necessity of visit or procedure performed.
What is specificity? - answerThe 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.
What is sensitivity? - answerTest 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.
What is predictive value? - answerThe 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. answer is true
What elements need to be considered when developing a plan? - answerPt's
preferences and actions
Research evidence
Clinical state/circumstances
Clinical expertise
What are the components of medical decision making in E&M coding? - answerRisk
Data
Diagnosis
The more time and consideration involved in dealing with a pt, the higher the
reimbursement from the payer.
Documentation must reflect MDM!
Correctly order the E&M office visit codes based on complexity from least to most
complex. - answerNew patient:
1. Minimal/RN visit: 99201
2. Problem focused: 99202
3. Expanded problem focused: 99203
4. Detailed: 99204
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