NR 511 Midterm Exam Study Guide (Question and Answers)

Week one 1. Define diagnostic reasoning: process of data generation and clustering, hypothesis generation, probabilistic reasoning, pattern matching, planning, problem-solving, and critical reflection. o Diagnostic reasoning then includes a systematic way of thinking that evaluates each new piece of data as it either supports some diagnostic hypothesis or reduces the likelihood of others. Based on experience. Critical thinking OR A scientific process in which practitioners suspect the cause of symptoms and signs based on previous knowledge. 2. Identify subjective & objective data. subjective: thing the pt reports o objective: things I observe, xrays, labs, vitals OR A: Subjective data is anything the patient tells the practitioner. Objective data is anything the practitioner hears, sees, feels or smells during the patient;s examination. 3. Identify the components of the HPI. Chief complaint and related issues; OLDCART 4. Develop an appropriate differential. a. things that are common and things that can kill list b. about 3 OR : A differential diagnosis list is a list of possible diagnoses in order of priority. In developing an appropriate differential, consider “skin in”, after complaint is given the clinician begins to consider all the possible causes beginning with the skin level and visualizing all structures in that area inward. (Dunphy, p55) 5. Accurately describe why every procedure code must have a corresponding diagnosis code. CPT (procedure) codes are recognized universally and also provide a logical means to be able to track healthcare data, trends, and outcomes. Each service or procedure is represented by a five-digit code that is presented in six sections, including evaluation and management; anesthesiology; surgery; radiology; and pathology. ICD-10 codes are shorthand for the patient’s diagnoses, which are used to provide the payer information on the necessity of the visit or procedure performed. This means that every CPT code must have a diagnosis code that corresponds. The takeaway message here is that every procedure code needs a diagnosis to explain the necessity whether the code represents an actual procedure performed or a nonprocedural encounter like an office visit. From lesson Billing and Coding in Lesson 1 6. Identify the three components required in determining an outpatient, office visit E&M code. • Plan of service • Type of service • Patient status 7. Describe the differences between medical billing and medical coding. Medical Billing: The process of submitting and following up on claims made to a payer in order to receive payment for medical services rendered by healthcare provider. Medical Coding: The use of codes to communicate with payers about which procedures were performed and why. 8. Compare and contrast the two coding classification systems that are currently used in the U.S. healthcare system. a. CPT = Procedures i. Office procedural coding ii. Legal means to track health care data, trends, and outcomes iii. Every CPT code must have a corresponding ICD code. b. ICD-10 codes = Diagnosis i. Shorthand for the patient’s diagnoses