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NR511 Final study guide Questions and Answers 2024
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NR511 Final study guide
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NR511 Final study guideDefine diagnostic reasoning - answer A list of possible diagnoses based on historical
and clinical presentation
listed in order of priority
Identify subjective and objective data - answer Subjective data is what the patient tells
you (SAYS)
objective data is what you see: labs, etc. (OBSERVE)
Identify the components of the HPI – answer OLDCARTS
onset
location
duration
characteristics
aggravating factors
relieving factors
timing and severity
Develop an appropriate differential: - answerConfirm or rule out hypotheses
screen for conditions
monitor progress of the current condition
Accurately describe why every procedure code must have a corresponding diagnosis
code - answerTo Be able to bill correctly
Identify the three components required in determining an out patient office visit E and M
code - answerNumber one) history
number two) physical examination
number three) MDM - medical decision-making
Describe the differences between medical billing and medical coding - answerMedical
coding is use of codes to communicate with payers about which procedures were
performed and why
billing is the process of submitting and follow-up on claims made to a payor in order to
receive payment for medical services rendered by health care provider
Compare and contrast the two coding classification systems that are currently used in
the US healthcare system - answerCPT: common procedural terminology: official
procedural coding rules and guidelines required when reporting medical services and
procedures performed by M.D. and non-MD providers; recognized universally; logical
,means to track healthcare data, trends, and outcomes; five digit code presenting: E and
M, anesthesia, surgery, radiology, and pathology
ICD: ICD - 10 as current, shorthand for diagnosis - provides the payer info on the
necessity of the visit or procedures performed
Discuss how specificity, sensitivity, and predictive value contribute to the usefulness of
diagnostic data - answerSpecificity is the extent to which diagnostic test is specific for a
condition/trait
sensitivity is the ability of a test to correctly ID those with the disease
predictive value: probability that the patient actually has the condition, truly and with the
disease
Discuss the elements that need to be considered when developing a plan -
answerPatient preferences and actions
insurance
family
willingness
clinical state and circumstances
practice setting
research
evidence
Describe the components of medical decision-making in E and M coding risk -
answerHistory, exam, and medical decision-making
Correctly order that E and M office visit codes based on complexity from least to most
complex - answer99201 office outpatient new 10 minutes
99202 office outpatient new 20 minutes
99203 office outpatient new 30 minutes
99204 office outpatient new 45 minutes
99205 office outpatient new 60 minutes
99211 office outpatient visit 5 minutes
99212 office outpatient visit 10 minutes
99213 office outpatient visit 15 minutes
99214 office outpatient visit 25 minutes
99215 office outpatient visit 40 minutes
Define the components of a SOAP note - answersubjective
objective
assessment
plan
Discuss a minimum of three purposes of the written history and physical in relation to
the importance of documentation - answerDocument that gives concise information
about the patient
outlines plan for addressing reasons for visit
, means of communicating information to other providers
medical - legal document
essential to accurately code and bill for services
Quickly identify a patient as new or established given the historical information -
answerEstablished: may be seen by any provider in the practice of must of been seen
within the past three years
new: patients not seen within the practice or have not been seen within three years
Explain what a "well rounded" clinical experience means - answer15%
pediatrics/women's health
variety of patients
Discuss the max number of hours that time can be spent "rounding" in a facility -
answer25%
Discussed nine things that must be documented when inputting data into clinical
encounter logs - answerDate of service
age
gender
ethnicity
E and M
complexity
diagnosis
procedures and test performed/ordered
RX given
level of preceptor involvement
Explain each part of the acronym of the SNAPPS presentation - answerSummarize
narrow the differential
analyze the differential
probe the preceptor
plan
self-directed learning
Identify the most common type of pathogens responsible for acute gastroenteritis -
answerAdults: Norovirus
peds: rotavirus (although becoming less prevalent due to vaccines)
Identify when stools studies are warranted - answerPatient has severe or prolonged
diarrhea. There still should be checked for consistency, blood, and fecal leukocytes. Do
cultures for severe diarrhea, of fever of greater than 38.5 centigrade, bloody stools, or
stools that test positive or leukocytes or occult blood because these symptoms are
indicative of diffuse colonic inflammation, likely from a bacterial pathogen
Correctly identify the most specific ICD - 10 code with the information given - answer
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