ANSWERS 100% CORRECT!
(2026 UPDATE)
, 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 - ANSWER Specifically related to the chief complaint only.
Detailed breakdown of CC.
OLDCART
Why must every procedure code have a corresponding diagnosis code? - ANSWER
Diagnosis 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? - ANSWER Place of service
Type of service
Patient status
What is medical coding? - ANSWER The use of codes to communicate with payers
about which procedures were performed and why