NR511 iMidterm iExam
iStudy iGuide
Week i1
1. Define idiagnostic ireasoning
Reflective ithinking ibecause ithe iprocess iinvolves iquestioning ione’s ithinking ito idetermining iif iall
ipossible iavenues ihave ibeen iexplored iand iif ithe iconclusions ithat iare ibeing idrawn iare ibased ion
ievidence. i*Seen ias ia ikind iof icritical ithinking.
2. Discuss iand iidentify isubjective i& iobjective idata
- Subjective: iWhat ithe ipt itells iyou, icomplains iof, ietc. i*Chief icomplaint, iHPI, iROS
- Objective: iWhat iYOU ican isee, ihear, ior ifeel ias ipart iof iyour iexam. i*lab, idata, idx itest iresults.
3. Discuss iand iidentify ithe icomponents iof ithe iHPI
Specifically irelated i to i the i CC i only. i Detailed i breakdown iof i CC. iOLDCART.
4. Describe ithe idifferences ibetween imedical ibilling iand imedical icoding
- Medical icoding: iThe iuse iof icodes ito icommunicate iwith ipayers iabout iwhich iprocedures iwere
iperformed iand iwhy
- Medical ibilling: iProcess iof isubmitting iand ifollowing iup ion iclaims imade ito ia ipayer iin iorder ito
ireceive ipayment ifor imedical iservices irendered iby ia ihealthcare iprovider.
5. Compare iand icontrast ithe i2 icoding iclassification isystems ithat iare icurrently iused
iin ithe iUS ihealthcare isystem
- CPT icodes: iCommon i procedural i terminology. i Offers i the i official i procedural icoding irules i and
guidelines i required i when i reporting i medical i services i and i procedures i performed i by i physician
i andinonphysician iorders.
- ICD icodes: iInternational iclassification iof i disease. iUsed ito iprovide ipayer iinfo ion i necessity iof
ivisit ior iprocedure iperformed.
6. Discuss ihow ispecificity, isensitivity i& ipredictive ivalue icontribute ito ithe iusefulness
iof ithe idiagnostic idata
- Specificity: i The i ability i of i the i test i to i correctly i detect i a i specific i condition. i If i a i patient i has
ia
condition ibut itest iis inegative, iit iis ia ifalse inegative. iIf ia ipatient idoes iNOT ihave ia icondition ibut ithe itest
iis ipositive i, iit iis ia ifalse ipositive.
- Sensitivity: iTest ithat ihas ifew ifalse inegatives. iAbility iof ia itest ito icorrectly iidentify ia ispecific
icondition iwhen iit iis ipresent. iThe ihigher ithe isensitivity, ithe ilesser ithe ilikelihood iof ia ifalse inegative.
- Predictive iValue: iThe ilikelihood ithat ithe ipt iactually ihas ithe icondition iand iis, iin ipart, idependent
iupon ithe iprevalence iof ithe icondition iin ithe ipopulation. iIf ia icondition iis ihighly ilikely, ithe ipositive iresult
iwould ibe imore iaccurate.
7. Discuss ithe ielements ithat ineed ito ibe iconsidered iwhen ideveloping ia iplan
Patient’s i preferences i and i actions. i Research i evidence. i Clinical i state/circumstances. i Clinical
iexpertise.
,8. Describe ithe icomponents iof iMedical iDecision iMaking iin iE&M icoding
Risk i – i data i – i diagnosis. i The i more i time i and i consideration i involved i in i dealing i with i a i pt, i the i higher
ithe ireimbursement ifrom ithe ipayer. iDocumentation imust ireflect ithe iMDM!
9. Correctly iorder ithe iE&M ioffice ivisit icodes ibased ion icomplexity ifrom ileast ito imost
icomplex
New ipatient:
1. Minimal/RN ivisit: i99201
2. Problem ifocused: i99202
3. Expanded iproblem ifocused: i99203
4. Detailed: i99204
5. Comprehensive: i 99205
iEstablished ipatient:
6. Minimal/RN ipatient: i99211
7. Problem ifocused: i99212
8. Expanded iproblem ifocused: i99213
9. Detailed: i99214
10. Comprehensive: i 99215
10. Discuss ia iminimum iof ithree ipurposes iof ithe iwritten ihistory iand iphysical iin irelation
ito ithe iimportance iof idocumentation
- Important ireference idocument ithat ivies iconcise iinfo iabout ithe ipt’s ihx iand iexam ifindings
- outlines i a i plan i for i addressing i issues i that i prompted i the i visit. i Info i should i be i presented i in
i ailogical ifashion ithat iprominently ifeatures iall idata irelevant ito ithe ipt’s icondition
- is ia imeans iof icommunicating iinfo ito iall iproviders iinvolved iin ipatient’s icare.
- is ia imedical ilegal idocument
- is iessential iin iorder ito iaccurately icode iand ibill ifor iservices
11. Accurately idocument iwhy ievery iprocedure icode imust ihave ia icorresponding
idiagnosis icode
Diagnosis i code i explains i the i necessity i of i the i procedure i code. i Insurance i won’t i pay i if i they i do
i not
correspond.
12. Correctly iidentify ia ipatient ias inew ior iestablished igiven ithe ihistorical iinformation
iNew ipatient: iIf ithat ipatient ihas inever ibeen iseen iin ithat iclinic ior iby ithat igroup iof iproviders iOR iif itheipt
ihas inot ibeen iseen iin ithe ipast i3 iyears
13. Identify ithe i3 icomponents irequired iin idetermining ian ioutpatient, ioffice ivisit iE&M
icode
Place iof iservice, itype iof iservice, ipatient istatus.
14. Describe ithe icomponents iof iMedical iDecision iMaking iin iE&M icoding
Risk i– idata i– idiagnosis
, 15. Correctly iorder ithe iE&M ioffice ivisit icodes ibased ion icomplexity ifrom ileast ito imost
icomplex
· Repeat iof i#9?
New ipatient:
a. Minimal/RN ivisit: i99201
b. Problem ifocused: i99202
c. Expanded iproblem ifocused: i99203
d. Detailed: i99204
e. Comprehensive: i 99205
iEstablished ipatient:
f. Minimal/RN ipatient: i99211
g. Problem ifocused: i99212
h. Expanded iproblem ifocused: i99213
i. Detailed: i99214
j. Comprehensive: i 99215
16. Explain iwhat ia i“well irounded” iclinical iexperience imeans
Includes iseeing ikids ifrom ibirth ithrough iyoung iadult ivisits ifor iwell ichild iand iacute ivisits ias iwell ias
iadults ifor iwellness ior iacute/routine ivisits. iSeeing ia ivariety iof ipatients iincluding i15% iof ipeds iand
i15% iof iwomen’s ihealth iof itotal itime iin ithe iprogram.
17. State ithe imaximum inumber iof ihours ithat itime ican ibe ispent i“rounding” iin ia ifacility
No imore ithan i25% iof itotal ipracticum ihours iin ithe iprogram
18. State i9 ithings ithat imust ibe idocumented iwhen iinputting idata iinto iclinical iencounter
1. Date iof iservice
2. Age
3. Gender iand iEthnicity
4. Visit iE&M icode
5. CC
6. Procedures
7. Tests iperformed iand iordered
8. Dx
9. Level iof iinvolvement i(mostly istudent, imostly ipreceptor, itogether, ietc.)
19. i Identify iand iexplain ieach ipart iof ithe iacronym iSNAPPS
- Summarize: ipresent ithe ipt’s iH&P ifindings
- Narrow: ibased ion ithe iH&P ifindings, inarrow idown ito ithe itop i2-3 idifferentials
- Analyze: i analyze ithe idifferentials. iCompare iand icontrast iH&P i findings ifor ieach iof ithe
idifferentials iand inarrow iit idown ito ithe imost ilikely ione.
- Probe: iask ithe ipreceptor iquestions iof ianything iyou iare iunsure iof.
- Plan: icome iup iwith ia ispecific imanagement iplan
- Self-directed i learning: i an i opportunity i to i investigate i more i about i any i topics i that i you
i areiuncertain iof.
Week i2
iStudy iGuide
Week i1
1. Define idiagnostic ireasoning
Reflective ithinking ibecause ithe iprocess iinvolves iquestioning ione’s ithinking ito idetermining iif iall
ipossible iavenues ihave ibeen iexplored iand iif ithe iconclusions ithat iare ibeing idrawn iare ibased ion
ievidence. i*Seen ias ia ikind iof icritical ithinking.
2. Discuss iand iidentify isubjective i& iobjective idata
- Subjective: iWhat ithe ipt itells iyou, icomplains iof, ietc. i*Chief icomplaint, iHPI, iROS
- Objective: iWhat iYOU ican isee, ihear, ior ifeel ias ipart iof iyour iexam. i*lab, idata, idx itest iresults.
3. Discuss iand iidentify ithe icomponents iof ithe iHPI
Specifically irelated i to i the i CC i only. i Detailed i breakdown iof i CC. iOLDCART.
4. Describe ithe idifferences ibetween imedical ibilling iand imedical icoding
- Medical icoding: iThe iuse iof icodes ito icommunicate iwith ipayers iabout iwhich iprocedures iwere
iperformed iand iwhy
- Medical ibilling: iProcess iof isubmitting iand ifollowing iup ion iclaims imade ito ia ipayer iin iorder ito
ireceive ipayment ifor imedical iservices irendered iby ia ihealthcare iprovider.
5. Compare iand icontrast ithe i2 icoding iclassification isystems ithat iare icurrently iused
iin ithe iUS ihealthcare isystem
- CPT icodes: iCommon i procedural i terminology. i Offers i the i official i procedural icoding irules i and
guidelines i required i when i reporting i medical i services i and i procedures i performed i by i physician
i andinonphysician iorders.
- ICD icodes: iInternational iclassification iof i disease. iUsed ito iprovide ipayer iinfo ion i necessity iof
ivisit ior iprocedure iperformed.
6. Discuss ihow ispecificity, isensitivity i& ipredictive ivalue icontribute ito ithe iusefulness
iof ithe idiagnostic idata
- Specificity: i The i ability i of i the i test i to i correctly i detect i a i specific i condition. i If i a i patient i has
ia
condition ibut itest iis inegative, iit iis ia ifalse inegative. iIf ia ipatient idoes iNOT ihave ia icondition ibut ithe itest
iis ipositive i, iit iis ia ifalse ipositive.
- Sensitivity: iTest ithat ihas ifew ifalse inegatives. iAbility iof ia itest ito icorrectly iidentify ia ispecific
icondition iwhen iit iis ipresent. iThe ihigher ithe isensitivity, ithe ilesser ithe ilikelihood iof ia ifalse inegative.
- Predictive iValue: iThe ilikelihood ithat ithe ipt iactually ihas ithe icondition iand iis, iin ipart, idependent
iupon ithe iprevalence iof ithe icondition iin ithe ipopulation. iIf ia icondition iis ihighly ilikely, ithe ipositive iresult
iwould ibe imore iaccurate.
7. Discuss ithe ielements ithat ineed ito ibe iconsidered iwhen ideveloping ia iplan
Patient’s i preferences i and i actions. i Research i evidence. i Clinical i state/circumstances. i Clinical
iexpertise.
,8. Describe ithe icomponents iof iMedical iDecision iMaking iin iE&M icoding
Risk i – i data i – i diagnosis. i The i more i time i and i consideration i involved i in i dealing i with i a i pt, i the i higher
ithe ireimbursement ifrom ithe ipayer. iDocumentation imust ireflect ithe iMDM!
9. Correctly iorder ithe iE&M ioffice ivisit icodes ibased ion icomplexity ifrom ileast ito imost
icomplex
New ipatient:
1. Minimal/RN ivisit: i99201
2. Problem ifocused: i99202
3. Expanded iproblem ifocused: i99203
4. Detailed: i99204
5. Comprehensive: i 99205
iEstablished ipatient:
6. Minimal/RN ipatient: i99211
7. Problem ifocused: i99212
8. Expanded iproblem ifocused: i99213
9. Detailed: i99214
10. Comprehensive: i 99215
10. Discuss ia iminimum iof ithree ipurposes iof ithe iwritten ihistory iand iphysical iin irelation
ito ithe iimportance iof idocumentation
- Important ireference idocument ithat ivies iconcise iinfo iabout ithe ipt’s ihx iand iexam ifindings
- outlines i a i plan i for i addressing i issues i that i prompted i the i visit. i Info i should i be i presented i in
i ailogical ifashion ithat iprominently ifeatures iall idata irelevant ito ithe ipt’s icondition
- is ia imeans iof icommunicating iinfo ito iall iproviders iinvolved iin ipatient’s icare.
- is ia imedical ilegal idocument
- is iessential iin iorder ito iaccurately icode iand ibill ifor iservices
11. Accurately idocument iwhy ievery iprocedure icode imust ihave ia icorresponding
idiagnosis icode
Diagnosis i code i explains i the i necessity i of i the i procedure i code. i Insurance i won’t i pay i if i they i do
i not
correspond.
12. Correctly iidentify ia ipatient ias inew ior iestablished igiven ithe ihistorical iinformation
iNew ipatient: iIf ithat ipatient ihas inever ibeen iseen iin ithat iclinic ior iby ithat igroup iof iproviders iOR iif itheipt
ihas inot ibeen iseen iin ithe ipast i3 iyears
13. Identify ithe i3 icomponents irequired iin idetermining ian ioutpatient, ioffice ivisit iE&M
icode
Place iof iservice, itype iof iservice, ipatient istatus.
14. Describe ithe icomponents iof iMedical iDecision iMaking iin iE&M icoding
Risk i– idata i– idiagnosis
, 15. Correctly iorder ithe iE&M ioffice ivisit icodes ibased ion icomplexity ifrom ileast ito imost
icomplex
· Repeat iof i#9?
New ipatient:
a. Minimal/RN ivisit: i99201
b. Problem ifocused: i99202
c. Expanded iproblem ifocused: i99203
d. Detailed: i99204
e. Comprehensive: i 99205
iEstablished ipatient:
f. Minimal/RN ipatient: i99211
g. Problem ifocused: i99212
h. Expanded iproblem ifocused: i99213
i. Detailed: i99214
j. Comprehensive: i 99215
16. Explain iwhat ia i“well irounded” iclinical iexperience imeans
Includes iseeing ikids ifrom ibirth ithrough iyoung iadult ivisits ifor iwell ichild iand iacute ivisits ias iwell ias
iadults ifor iwellness ior iacute/routine ivisits. iSeeing ia ivariety iof ipatients iincluding i15% iof ipeds iand
i15% iof iwomen’s ihealth iof itotal itime iin ithe iprogram.
17. State ithe imaximum inumber iof ihours ithat itime ican ibe ispent i“rounding” iin ia ifacility
No imore ithan i25% iof itotal ipracticum ihours iin ithe iprogram
18. State i9 ithings ithat imust ibe idocumented iwhen iinputting idata iinto iclinical iencounter
1. Date iof iservice
2. Age
3. Gender iand iEthnicity
4. Visit iE&M icode
5. CC
6. Procedures
7. Tests iperformed iand iordered
8. Dx
9. Level iof iinvolvement i(mostly istudent, imostly ipreceptor, itogether, ietc.)
19. i Identify iand iexplain ieach ipart iof ithe iacronym iSNAPPS
- Summarize: ipresent ithe ipt’s iH&P ifindings
- Narrow: ibased ion ithe iH&P ifindings, inarrow idown ito ithe itop i2-3 idifferentials
- Analyze: i analyze ithe idifferentials. iCompare iand icontrast iH&P i findings ifor ieach iof ithe
idifferentials iand inarrow iit idown ito ithe imost ilikely ione.
- Probe: iask ithe ipreceptor iquestions iof ianything iyou iare iunsure iof.
- Plan: icome iup iwith ia ispecific imanagement iplan
- Self-directed i learning: i an i opportunity i to i investigate i more i about i any i topics i that i you
i areiuncertain iof.
Week i2
