NR 511 Week 4 Midterm Exam Answers

NR 511 Week 4 Midterm Exam Answers 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 11.Thhe 5 key components of a comprehensive treatment plan are: 1. Diagnostics 2. Medication 3. Education 4. Referral/consultation 5. Follow-up planning 12.Define thhe components of a SOAP note. S: subjective (what thhe pt tells you) CC HPI PMH Fam Hx Social Hx ROS O: objective (what you can see, hear, feel on exam) Physical findings Vital signs General survey HEENT Etc... A: assessment Global assessment of pt including differentials in order from most to least likely Combination of subjective & objective info List of dx addressed & billed for at thhe visit P: plan What you will Rx When to come back Diagnostic tests Pt education 13.Discuss minimum of three purposes of thhe written history & physical in relation to thhe importance of documentation. Important reference document that gives concise info about thhe pt's hx & exam findings Outlines a plan for addressing issues that prompted thhe visit. Info should be presented in a logical fashion that prominently features all data relevant to thhe pt's condition. Is a means of communicating info to all providers involved in pt's care Is a medical-legal document Is essential in order to accurately code & bill for services 14.Why does every procedure code need a corresponding diagnosis code? Diagnosis code explains thhe necessity of thhe procedure code. Insurance won't pay if thhey don't correspond. 15.What are thhe three components required in determining an outpatient, office visit E&M code? Plan of service Type of service Patient status 16.Correctly ID a pt as a new or established given historical info. Pt status: whethher or not pt is new or established. New: has not received professional service from provider in same group within past 3 years. Established: has received professional service from provider in same group in last 3 years. 17.What does a well-rounded clinical experience mean? Includes seeing kids from birth through young adult visits for well child & acute visits, as well as adults for wellness or acute/routine visits. Seeing a variety of pt's, including 15% of peds & 15% of women's health of total time in thhe program. 18.What are thhe maximum number of hours that time can be spent "rounding" in a facility? No more than 25% of total practicum hours in thhe program 19.What are 9 things that must be documented when inputting data into clinical encounter logs? Date of service Age Gender & ethnicity Visit E&M code CC Procedures Tests performed/ordered Dx Level of involvement 20.What does thhe acronym SNAPPS st& for?