Exam (elaborations) NR511 WEEK 1-3 LECTURES

Exam (elaborations) NR511 WEEK 1-3 LECTURES Primary care is different than tertiary care. The types of problems that are solved in primary care are different than those seen in acute- or critical-care settings, which you may be used to as a bedside nurse. Upper respiratory infections, abdominal complaints, skin rashes, and vague somatic complaints are problems that are not often encountered in the hospital setting. Even chronic conditions present differently in primary care. HTN, CHF, arthritis, and DM present with day-to-day management problems that are different from the crises that acute-care nurses must respond to in a tertiary-care setting. As you will soon find, primary care is a new world with a different set of problems to be solved, different kinds of constraints on choices, and a different culture of care. Diagnosing and treating up to 30 different patients or families in a day is both challenging and mentally exhausting. Although an office visits allows for focused one-on-one care with an individual patient, the NP must still recognize that healthcare is a business. In order to meet office overhead costs, including provider and staff salaries, the business must be profitable or at least have equal income to operational cost margins. Because of this, a nurse practitioner needs to have a solid understanding of how to obtain and process information in an organized approach. Learning to practice primary care in an artful way requires a certain kind of thinking. The mental task of eliciting and sorting through large amounts of data, clustering data elements into meaningful patterns, connecting patterns to reasonable diagnostic statements, considering risk factors, and selecting appropriate interventions require a high level of diagnostic reasoning. Diagnostic reasoning can be seen as a kind of critical thinking. Critical thinking involves the process of 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. 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. Developing expertise as a nurse practitioner takes time. Students who are experts in hospital or specialty care become novices in the advanced practice role. Clinical judgment and diagnostic reasoning is based on experience. As a student, you will hopefully gain skills to function at the advanced beginner level through didactic work and the added clinical practicum experience. It took years for you to become an expert nurse, so you can expect that it will take years to become an expert NP. On your journey towards graduation from the FNP program, you will be given the necessary tools to help you be successful on the board certification exam and become a competent advanced beginner. The type of data that you collect depends on the type of visit. Most visits are episodic or problem-focused where 1 or 2 specific issues need to be addressed. One thing I want to point out is that the information in the H&P should only be relevant to the complaint or problems that you are addressing. So, a patient with only a skin complaint does not need a full H&P. Rather, a focused history and exam as it relates to the skin complaint or associated symptoms should be recorded. First, I want to go over two important, distinct concepts that seem to be an area of confusion for many students: subjective and objective findings. We will discuss these in more detail when we introduce the SOAP note lecture. NR511 WEEK 1-3 LECTURES To start, subjective information is what the patient: 1) reports, 2) complains of; or 3) tells you in response to your questions. Examples of subjective information include the following:  Constitutional: fever, chills, lethargy, weight loss or gain, and so on  HEENT: headache, blurred vision, otalgia, sore throat, and so on  Neck: swollen lymph nodes, and so on  Lungs: SOB, cough, wheezing, and so on These are all examples of subjective information. Subjective information is the S part of the SOAP note, which includes CC, HPI, and ROS, as these are all things that the patient reports to you in an interview. Objective information is what you can see, hear, or feel as part of your clinical exam. It also includes laboratory data and test results. Examples of objective information include the following:  Constitutional: well-developed, well-groomed, thin, cachectic, obese, and so on  HEENT: Normocephalic, PERRL  Neck: anterior cervical lymph nodes are swollen and tender  Lungs: clear, wheezing in RLL, bronchospastic cough  Results: you might list the CBC, strep test, U/A, CXR, CT, and so on Objective information is the “O” part of the SOAP. Eliciting a detailed patient history through open-ended questioning and active listening offers critical clues to determining a diagnosis. Obtaining a meaningful history involves collecting subjective information and organizing it into meaningful chunks of knowledge. Data acquisition in history taking is most effective if it is hypothesis driven. In other words, when the information selected and gathered is related to the list of possible diagnoses. Hypothesis-driven data means that data that would confirm or disprove a specific hypothesis are specifically sought and recorded. However, obtaining data that fit one possible problem is not enough. Competing hypotheses must be ruled out by seeking additional data, and the provider needs to consider that the priority list of hypotheses may change based on new information. For example, symptoms of runny nose may be due to a viral infection. If in the history- taking the provider specifically asks if these symptoms have occurred before and the patient replies, “Yes, this also happened 2 weeks ago,” the likelihood of a viral infection decreases and the likelihood of an allergy increases. In other words, your hypothesis for the etiology of rhinitis has now changed. The chief complaint (CC) is a one-to-few word statement identified by the patient as the reason for their visit to you today. Try to identify the chief complaint in this scenario: Johnny, a 5-year-old, is brought to your office by his mother. The mother reports that the school nurse called because Johnny said he had a tummy ache. Several other students in the school also have complained of some GI symptoms. He did not throw up, but he says he feels like he could. In this case, an acceptable CC would be nausea or “tummy ache.” It’s short and to the point. You will expand on information about the chief complaint in the history of present illness (HPI). The HPI is a detailed breakdown of the CC, written out as the OLDCARTS acronym. Each letter in the acronym represents important information about the CC, which will help you to develop a differential diagnosis. The HPI is focused on the CC only, so each letter of the acronym should address that one issue. Any additional information that you feel is pertinent to report in the case but is not directly related to the CC should be reported in the ROS. HPI O: Onset of CC L: Location of CC D: Duration of CC C: Characteristics of CC A: Aggravating factors for CC R: Relieving factors for CC T: Treatments tried for CC S: Severity of CC There are two things I want to point out here. Do not get confused on duration. Duration is not referring to the onset of the symptom. Rather, it is an assessment of whether the symptom is constant or if it comes and goes. Also, don’t forget to ask about severity. Severity refers to the level of pain (such as reported on a pain scale) or how the symptom has impacted the patient’s ability to go to school, to go to work, or to perform their daily routine. This should be included in every HPI. Be sure to watch the video lecture on the ROS, which is again, assessment of subjective information. Because you have successfully completed NR509, it is expected that you are competent in performing a head-to-toe physical exam. Although some of your patients may present for a complete physical where you need to address all of the body systems, you must now learn to focus your assessment skills to be appropriate for the patient’s complaint and history as part of a problem-focused visit. This will become clearer as you go through the lecture on billing and coding. Differential diagnosis, or differential, is a list (single) of plausible diagnoses (plural) that fit the historical and clinical presentation of your patient in order of priority. This is different than the problem list, which is a list that includes all of the active medical problems for the patient. You will be seeing these in your clinical rotations, but for the purposes of your first clinical course, we will not be putting together problem lists. The focus in this course is on how to formulate a differential diagnosis. There is a separate video lecture on the differential diagnosis for you to view this week which presents the concept of formulating a differential diagnosis in a meaningful way. Diagnostic tests can be used to confirm or to rule out hypotheses. They may also be used to screen for conditions or monitor the progress in managing a chronic condition. Diagnostic tests vary in usefulness based on sensitivity, specificity, and predictive value. When we describe the specificity of a test, we are referring to the ability of the test to correctly detect a specific condition. If the patient has the condition but testing is negative, we describe this as a false negative. If the patient does not have the condition but the test result is positive, this is considered to be a false positive test. When a test is very sensitive, we mean it has few false negatives. The higher the sensitivity, the lesser the likelihood of a false negative. A sensitivity of 99% means that it is very unlikely for a false negative result. In a perfect world, a test would have 100% specificity and sensitivity, but we know that it is not the case. Therefore, it is important to consider the specificity and sensitivity of a test when considering its usefulness in ruling your hypothesis in or out. Predictive value is the likelihood that the patient actually has the condition and is, in part, dependent upon the prevalence of the condition in the population. If a condition is highly likely, a positive test result is more likely to be accurate. If a condition is very unlikely, a positive test needs to be questioned and perhaps additional testing would need to be done. When deciding whether or not to order a test, five things must be considered.  Cost  Convenience  Sensitivity  Specificity  Risk of missing a condition (predictive value) In today’s healthcare system, patients are encouraged to be proactive and informed members of the healthcare team. One method that is advocated by popular groups such as AARP, the NIH and the CDC is for patients to create a list of questions or issues for their provider visits. Lists can be challenging for providers because many patients have the unrealistic expectation that their provider will address every item on the list. You will see this frequently in your practicum rotations. The reality is that the medical office is still a business, and time constraints often prevent providers from addressing every issue in one visit. Prioritizing the patient’s needs while maintaining the allotted time requires a patient-centered communication approach. Although you may not be able to cover the list in its entirety, this approach acknowledges to the patient that you hear their concerns and together have developed a plan to address them. This tactic not only improves patient satisfaction but helps keep the provider on schedule. In the next few slides, we will be discussing a useful approach to prioritizing a patient’s list. Keep in mind that these are suggestions and not rules. At the beginning of each practicum rotation, I encourage you to discuss with your preceptor how he/she deals with this issue. Some offices may have a policy in place or the provider may have a personal preference in handling prioritization of patient’s lists. These suggestions may not be the best approach for the practice setting that you are currently in but may be useful in another office or in your own practice. Acknowledge the patient’s list of questions and concerns. It is important to acknowledge that the patient took the time to prepare for the visit in compiling a list. This can be done simply by stating “I see you have a list of concerns (or questions), let’s look at it together. Mutually negotiate what to cover during the visit. If the patient’s list is too long or does not match your own priorities for the visit, you will need to negotiate which items you will address at the current visit. The key to the negotiating process is to use positive language. So, instead of saying “we don’t have enough time to discuss all of these”, a better approach would be to say “I would like to cover as much as we can from your list, but I also want to take a few minutes to talk about your (diabetes, HTN, COPD, etc). Be honest. Being honest about the time allotted for the visit while planning jointly on how to use that time is important. To take this approach, you might say “Since this visit is only scheduled for 15 minutes, let’s decide on the 3 most important issues for today.” Most patients are willing to accept this but occasionally there will be a more demanding patient. In cases such as this, being honest and telling the patient that in covering all of the issues, you cannot be as thorough. Make a plan for follow-up. Mutually set an agenda and time frame for the next visit. Recap what you were not able to address at this visit and what you intend to go over the next time. If a patient is overdue for an annual physical, you might make the recommendation that one is scheduled since more time is typically allotted for these visits. Be sure to document this plan in your note as a reminder to you for the next patient visit. All healthcare providers are called to provide evidence-based care, which involves providing care and making treatment and screening choices based on current research findings. Generally, EBP refers to using research findings from multiple studies that are convincing enough that a consensus is formed recommending the findings be used for clinical decision-making or practice guidelines. EBP also involves inclusion of patient and provider preferences, patient values, and cultural considerations in the clinical decision-making process. Guidelines should be followed in the majority of cases unless there is a clear rationale for deviating from them to serve the particular needs of the patient. There are some examples of Clinical Practice Guidelines/Evidence-Based Guidelines developed by organization or agencies that I have listed here. Some examples are: For allergen and immunotherapy, the American Academy of Asthma and Allergy group is one example. The Infectious Disease Society of America is also another group that puts out clinical practice guidelines. Now that you understand each individual component of the history and physical, it is time to document and record your information in a SOAP note. SOAP notes are used to provide accurate information about the patient’s status and the visit. They include the subjective and objective findings from the history and physical as well as your assessment (or diagnosis) and plan. Please view the video lecture on SOAP notes. Hi. In this brief presentation, we will be discussing the importance of influences on health promotion. There is an opportunity for disease prevention, screening for high-risk problems, and health promotion at every visit. There are three levels of prevention: primary, secondary, and tertiary. Focusing healthcare efforts on all three levels of prevention is important, but primary prevention has become the ultimate goal of health promotion. Primary prevention is the prevention of disease. Examples: Health education, immunizations, use of sunscreen and seatbelts, nutrition counseling, weight control, stress reduction, exercise, etc. Secondary prevention is the detection of a disease through its very early stages through early screening. Examples of this include skin cancer and breast cancer screening, testicular selfexam, HTN screening, cervical cancer screening, pediatric developmental screening, and Fecal Occult Blood samples (FOB). Tertiary prevention is the restoration of health after illness or disease has already occurred in order to prevent further sequelae of the disease and complication. Some examples of this include dialysis and chronic kidney disease, chemotherapy in cancer, biologics in autoimmune disease, and statins for hyperlipidemia. The identification of risk factors is an essential component of health promotion. The key components to effective health promotion are to screen patients for potential known risk factors and to intervene when appropriate. Obviously, some risk factors are modifiable, and some are not. Nonmodifiable risk factors include age, gender, and family history, whereas modifiable risk factors include weight, level of physical activity, elevated cholesterol and blood pressure, stress level, and smoking. Early identification of both modifiable and nonmodifiable risk factors are integral so that patients also with modifiable risk factors can make changes to affect more favorable outcomes with a disease. One factor that influences health promotion is health literacy. Health literacy can be described as the degree to which individuals have the capacity to obtain, process, and understand basic information and services needed to make appropriate healthcare decisions. Health literacy includes reading skills and comprehension, writing, listening, speaking, and conceptual knowledge. Assessing health literacy levels should be part of your daily practice so that you can identify patients at risk for misunderstanding instructions and for those who may not have the ability to adhere to recommendations. Although an entire day can be spent on this topic, this lecture is designed to teach you the basic elements that you will need in order to determine a level of service for each visit, which subsequently determines the level of payment to the provider. I’m sure I do not need to tell you that payment is very important in any business, even healthcare. Whether in a solo practice or group practice, providers must generate income to keep the practice afloat and, ideally, profitable. Unless you will be operating a nonprofit practice that is funded entirely by donations, there are universal rules that you must know in order to correctly bill for your services. I encourage you to speak more to your preceptors about the billing process while in your clinical setting. So you might ask, why is this important to me as a student? Understanding the levels of office visit billing is important to you as a student because this information should be reflected in your log of patient encounters and can be reviewed by faculty to ensure that you are seeing patients of all ages and complexities. We will get more into documentation of your encounters in the next lecture, but just know that it is important to accurately document the types of patients that you see in your clinical rotations. Now, let’s talk about the importance of documentation. The written history and physical (H&P) serves several purposes. 1. It is an important reference document that gives concise information about a patient's history and exam findings. 2. It outlines a plan for addressing the issues that prompted the visit. This information should be presented in a logical fashion that prominently features all data immediately relevant to the patient's condition. 3. It is a means of communicating information to all providers who are involved in the care of a particular patient. 4. It is an important medical-legal document. 5. It is essential in order to accurately code and bill for services. Currently in the United States, our healthcare system operates on a fee-for-service model. This means that a provider is given a set amount of monetary reimbursement for a specific visit or procedure performed that is adjusted for geographical location. Payment is dependent, though, on showing the necessity for the service provided to the payer by means of accurate documentation. Now, a payer can be a public or private entity. Private entities include insurance companies that you’re contracted with in your office, whereas public payers include Medicare and Medicaid. Medical coding is the use of codes to communicate with payers about which procedures were performed and why. Medical billing, on the other hand, is the 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. In order to send a claim (or bill) to a payer such as Medicare, the provider’s documentation must be translated into alphanumeric codes and transferred to the payers. Keep in mind that only codes are submitted for each individual claim, which means you are not faxing your actual documentation over. Therefore, you want to be sure that the codes accurately reflect the type of service that you provided. There are two different designated coding systems that are used today, which were developed as a means to standardize terminology and simplify medical records. The first system is the Common Procedural Terminology (CPT) system, and the second system is the International Classification of Diseases method of coding and that’s known as the ICD system. The CPT system offers the official procedural coding rules and guidelines required when reporting medical services and procedures performed by physician and nonphysician providers. CPT 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;  pathology; and  Now, we are going to move onto the second system used in medical coding, which is the ICD codes. Currently, we are in the tenth revision of the system, and, therefore, the classification system is known as ICD-10. 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. Let me give you an example. Let’s say that when submitting my claim to a payer I used the CPT code 69210 to identify that I manually removed cerumen from the patient’s ear canal. Let’s also suppose that I listed one of the patient’s many diagnosis on the claim. For instance, here I listed I10 which is the ICD-10 code for HTN. Procedure Code (CPT) Diagnosis Code (ICD-10) 69210 I10 (HTN) Well, when the payer reviews this claim for reimbursement, the procedure is not likely to be reimbursed. Why you might ask? Because the diagnosis code that is tied to the procedure code does not explain its necessity. You see, payers are very particular in making sure that they are not giving money to providers for unnecessary procedures. So, in order for the claim for this procedure (cerumen removal) to be paid, I would need to attach a diagnosis code that explains the necessity. In this case, the ICD-10 code H61.20 gives the diagnosis of cerumen impaction, which is an appropriate reason to perform the procedure of the cerumen removal. Procedure Code (CPT) Diagnosis Code (ICD-10) 69210 H61.20 (Cerumen impaction) 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. Understanding and accurately recording procedure and diagnosis codes are necessities in order for you or your practice to get reimbursed. As I said before, reimbursement is paid on a fee-forservice model where you are paid a certain amount based on the complexity of your work. In the United States, the Centers for Medicare and Medicaid Services (CMS) have what is known as the Medicare Physician and Nonphysician Practitioner Fee Schedule, which, in a nutshell, assigns a value to each CPT code for reimbursement purposes and this is also adjusted for geographic location. Although private payers vary in their reimbursement rates and policies, most are tied in some form to the Medicare system, so understanding Medicare’s rules for coding is essential. For the rest of this lecture we are going to discuss CPT codes as they apply to Evaluation and Management (E&M) coding. This is important to understand because you will be inputting this information as evidence for the types of patients seen in your clinical encounter logs. E&M coding is very complex, so my goal today is to teach you the high points of E&M coding in a simplified version so that when you go into your clinical setting you have a basic understanding of the requirements for each office visit level. This is not a substitute for a coding course but rather a demonstration of the key things you need to know. Thankfully, some EMR programs automatically compute the E&M code for you, but it is still important to know nonetheless. Before you can determine your E&M, code you must first identify the place of service, type of service, and the patient status. The place of servicerefers to where the service was rendered. There are several categories to choose from, but the two most common are the inpatient and outpatient settings. This is pretty straightforward. The type of service refers to the type of service provided. Some examples of types of services include consultation, hospital admission, office visit, and so forth. Again, pretty straightforward. As a student in your practicum rotations, nearly all of your places and types of service will be outpatient office visits. Finally, you need to identify the patient’s status. Patient status refers to whether or not the patient is a new patient or an established patient of your practice. By definition, a new patient is one who has not received professional service from a provider from the same group practice within the past 3 years. Conversely, an established patient has received professional service from a provider of your office within the last 3 years. So, let’s look at an example. Let’s say that Jane is scheduled to see you today for a CC of sore throat. She has a medical record on file in your system, and you see that her last visit was in 2012 with your partner, Dr. Tom. Is she considered an established patient or a new patient? She is considered a new patient because even though she has been seen by someone in your office previously, it has been more than 3 years since her last visit. Here’s another example. John has been seeing you at your office for 20 years. He informs you that his mother is ill and he is moving to Florida to care for her. 18 months later, he returns to your office requesting a refill on his antidepressant (which he was not on when you last saw him). He informs you that he was being treated by the provider in Florida but that he decided to move back to the area after his mother died. Should John be considered a new or established patient for this office visit? If you guessed established, you are correct because even though he began treatment with a different provider in Florida, his return visit to you today is within that 3- year timeframe. Okay, so let’s discuss how you choose the right E&M code. There are several E&M codes that are available to choose from for an outpatient, office-based visit. The codes are chosen based on patient status (whether this is a new or established) as well as the complexity of the visit. The codes are ordered from lowest complexity to highest. So, 99205 and 99215 are the highest levels of complexity for a new and established patient, respectively. Outpatient-Office Visit New Established Minimal/RN visit Problem focused Exp. problem focused 99203 99213 Detailed Comprehensive Once you have determined the status of the patient (new or established), you then can then determine which one of the five E&M codes correspond with the visit. To do this, we are going to apply the principles of risk-based coding. There are three key components that determine risk-based E&M codes. 1. History 2. Physical 3. Medical Decision Making (MDM) Each one of these components (history, physical, and MDM) must have a specific number of elements documented to meet the visit requirements. Let’s look at the history requirements first. For example, for an established patient level two visit (99212), which is considered a problemfocused visit, your documentation of history must show the following. HPI One to three elements ROS N/A PFSH N/A CC Required For a higher level of service such as a 99214, which is considered an established detailed visit, more elements from the history are required. HPI Four or more elements of OLDCARTS ROS Two to nine elements from any of the body systems PFSH Three elements from previous, family, or social history CC Required Similar to the history, your physical exam documentation must show a specific number of required elements to meet the level of service code. For the 99212, code your PE documentation must include a minimum of the following. PE One to five elements from a single body system With the 99214 code (the higher level visit code), you must show the following. PE At least 12 elements from a single body system Although you will not be required to know the requirements for each visit level for an exam, you must be able to understand and communicate that each level has a minimum requirement of H&PE elements that must be met and that the higher the level, the more documentation required The third element that is needed to determine the level of a visit is MDM. Medical decision making is another way of quantifying the complexity of the thinking that is required for the visit. Complexity of a visit is based on three criteria.  Risk  Data  Dx Let’s go over those principles again. There are three main components in determining the E&M code: the Hx, PE, and MDM; and there are 3 key elements to medical decision making, which are risk, data, and diagnosis. E&M Code Hx PE MDM Risk Data Dx Now, medical decision making is a special category. Why is this so important? Well, the MDM score gives us credit for the excess work involved in management of a more complex patient. Here’s an example. Let’s say you have two patients with a sinus infection that will require antibiotic therapy. The first patient is a 15-year-old healthy teen with no known medical problems and is on no medication. The second patient is a 72-year-old man with uncontrolled diabetes, CKD, and HTN. He is also on a list of medications as long as your arm. In the first case, the medical decision making is pretty straightforward. Meaning, you write a RX for an antibiotic after considering the history and physical. There are no data to review, and the patient has a single diagnosis for the encounter (sinusitis). Now, let’s consider the older gentlemen. When deciding on an antibiotic for this person, a lot more has to be considered. For instance, drug-to-drug interaction would have to be checked. Because the patient has known CKD, you need to take into account his current renal status when choosing an antibiotic because a dose adjustment may be required. While you are doing this, he informs you that he needs you to write a prescription for his metformin. He has been out for at least 3 weeks. So, in addition to writing the antibiotic prescription, you now are renewing a prescription for his metformin. But when you look back at his most recent labs, you see that his A1C wasn’t at goal even on the metformin. So, now you n