Nr 511 Final Exam Study Guide

1 1 NR 511 FINAL EXAM STUDY GUIDE Week 1 1. Define diagnostic reasoning  To solve problems and promote health screen for diseases or illness  Diagnostic reasoning can be seen as critical thinking  Critical thinking involves the process of questioning one thinking to determine possible avenues  Diagnostic reason is a systemic way of thinking and evaluates each piece of data with some diagnostic hypothesis 2. Discuss and identify subjective & objective data  objective you can see, hear and feel  subjective- things a patient reports (CC, HPI, & ROS) 3. Discuss and identify the components of the HPI OLDCARTS O- ONSET / L: location./ D: Duration / C: Characteristics / A: aggravating/ R: Reliving factors/ T: Treatments tried and S: Severity 4. Describe the differences between medical billing and medical coding  Medical coding: codes communicated with payer of what procedures were preformed and why  Medical billing: process of submitting and following up on claims made to payer to receive payment 5. Compare and contrast the 2 coding classification systems that are currently used in the US healthcare system  CPT- procedural coding on procedures, performed by non physican providers  ICD 10- short hand to provide payer information of visit or procedure preformed 6. Discuss how specificity, sensitivity & predictive value contribute to the usefulness of the diagnostic data  Sensitivity- few false negatives  Specificity – correctly detect specific conditions  Predictive- likelihood the patient has the condition 7. Discuss the elements that need to be considered when developing a plan  Acknowledge the list  Negotiate what to cover  Be honest  Make a follow up 8. Describe the components of Medical Decision Making in E&M coding  History// physical ///medical decision making ( MDM)  Another way: risk/// data///dx  MDM score gives credit for excess work involved in management of complex pt’s 9. Correctly order the E&M office visit codes based on complexity from least to most complex 