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NR 511/ NR511 Midterm Exam:
Differential Diagnosis and Primary Care
Practicum Guide
Define diagnostic reasoning
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?
Anything the patient tells you or complains of regarding their symptoms
Chief complaint
HPI
ROS
What is objective data?
pg. 1
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Anything YOU can see, touch, feel, hear, or smell as part of your exam
Includes lab data, diagnostic test results, etc.
Identify components of HPI
Specifically related to the chief complaint only
Detailed breakdown of CC
OLDCARTS
Describe the differences between medical billing and medical coding.
Medical billing: process of submitting and following up on claims made to a payer in order to
receive payment for medical services rendered by a healthcare provider
Medical coding: the use of codes to communicate with payers about which procedures were
performed and why.
Compare and contrast the two coding classification systems that are currently used in the US
healthcare system.
ICD: International classification of disease codes are used to provide payer info on necessity of
visit or procedure performed. Shorthand for pt's dx.
pg. 2
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CPT: common procedural terminology codes offer the official procedural coding rules and
guidelines required when reporting medical services and procedures performed by physician
and non-physician providers. Must have corresponding ICD.
How do specificity, sensitivity, and predictive value contribute to the 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. The higher the sensitivity, the lesser the likelihood of a false
negative.
Predictive value: The likelihood that the pt actually has the condition and is, in part, dependent
upon the prevalence of the condition in the population. If a condition is highly likely, the
positive result would be more accurate.
Diagnostic tests can be used to confirm or rule out hypotheses.
Diagnostic tests may be used to screen for conditions.
Diagnostic tests may be used to monitor the progress in managing a chronic condition.
Discuss the elements that need to be considered when developing a plan.
pg. 3
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Pt's preferences and actions
Research evidence
Clinical state/circumstances
Clinical expertise
Describe the components of medical decision making in E&M coding.
Risk, data, diagnosis
The more time and consideration involved in dealing with a pt, the higher the reimbursement
from the payer.
Documentation must reflect MDM
Correctly order the 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. Expanded problem focused: 99203
4. Detailed: 99204
5. Comprehensive: 99205
Established pt:
1. Minimal/RN visit: 99211
pg. 4
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NR 511/ NR511 Midterm Exam:
Differential Diagnosis and Primary Care
Practicum Guide
Define diagnostic reasoning
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?
Anything the patient tells you or complains of regarding their symptoms
Chief complaint
HPI
ROS
What is objective data?
pg. 1
https://www.stuvia.com/user/allatopnotch https://www.stuvia.com/user/allatopnotch https://www.stuvia.com/user/allatopnotch
,https://www.stuvia.com/user/allatopnotch https://www.stuvia.com/user/allatopnotch https://www.stuvia.com/user/allatopnotch
Anything YOU can see, touch, feel, hear, or smell as part of your exam
Includes lab data, diagnostic test results, etc.
Identify components of HPI
Specifically related to the chief complaint only
Detailed breakdown of CC
OLDCARTS
Describe the differences between medical billing and medical coding.
Medical billing: process of submitting and following up on claims made to a payer in order to
receive payment for medical services rendered by a healthcare provider
Medical coding: the use of codes to communicate with payers about which procedures were
performed and why.
Compare and contrast the two coding classification systems that are currently used in the US
healthcare system.
ICD: International classification of disease codes are used to provide payer info on necessity of
visit or procedure performed. Shorthand for pt's dx.
pg. 2
https://www.stuvia.com/user/allatopnotch https://www.stuvia.com/user/allatopnotch https://www.stuvia.com/user/allatopnotch
,https://www.stuvia.com/user/allatopnotch https://www.stuvia.com/user/allatopnotch https://www.stuvia.com/user/allatopnotch
CPT: common procedural terminology codes offer the official procedural coding rules and
guidelines required when reporting medical services and procedures performed by physician
and non-physician providers. Must have corresponding ICD.
How do specificity, sensitivity, and predictive value contribute to the 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. The higher the sensitivity, the lesser the likelihood of a false
negative.
Predictive value: The likelihood that the pt actually has the condition and is, in part, dependent
upon the prevalence of the condition in the population. If a condition is highly likely, the
positive result would be more accurate.
Diagnostic tests can be used to confirm or rule out hypotheses.
Diagnostic tests may be used to screen for conditions.
Diagnostic tests may be used to monitor the progress in managing a chronic condition.
Discuss the elements that need to be considered when developing a plan.
pg. 3
https://www.stuvia.com/user/allatopnotch https://www.stuvia.com/user/allatopnotch https://www.stuvia.com/user/allatopnotch
, https://www.stuvia.com/user/allatopnotch https://www.stuvia.com/user/allatopnotch https://www.stuvia.com/user/allatopnotch
Pt's preferences and actions
Research evidence
Clinical state/circumstances
Clinical expertise
Describe the components of medical decision making in E&M coding.
Risk, data, diagnosis
The more time and consideration involved in dealing with a pt, the higher the reimbursement
from the payer.
Documentation must reflect MDM
Correctly order the 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. Expanded problem focused: 99203
4. Detailed: 99204
5. Comprehensive: 99205
Established pt:
1. Minimal/RN visit: 99211
pg. 4
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