NR511 Final study guide top graded 2024

Define diagnostic reasoning - A list of possible diagnoses based on historical and clinical presentation listed in order of priority Identify subjective and objective data - Subjective data is what the patient tells you (SAYS) objective data is what you see: labs, etc. (OBSERVE) Identify the components of the HPI - OLDCARTS onset location duration characteristics aggravating factors relieving factors timing and severity Develop an appropriate differential: - Confirm or rule out hypotheses screen for conditions monitor progress of the current condition Accurately describe why every procedure code must have a corresponding diagnosis code - To Be able to bill correctly Identify the three components required in determining an out patient office visit E and M code - Number one) history number two) physical examination number three) MDM - medical decision-making Describe the differences between medical billing and medical coding - Medical coding is use of codes to communicate with payers about which procedures were performed and why billing is the process of submitting and follow-up on claims made to a payor in order to receive payment for medical services rendered by health care provider Compare and contrast the two coding classification systems that are currently used in the US healthcare system - CPT: common procedural terminology: official procedural coding rules and guidelines required when reporting medical services and procedures performed by M.D. and non-MD providers; recognized universally; logical means to track healthcare data, trends, and outcomes; five digit code presenting: E and M, anesthesia, surgery, radiology, and pathology ICD: ICD - 10 as current, shorthand for diagnosis - provides the payer info on the necessity of the visit or procedures performed Discuss how specificity, sensitivity, and predictive value contribute to the usefulness of diagnostic data - Specificity is the extent to which diagnostic test is specific for a condition/trait sensitivity is the ability of a test to correctly ID those with the disease predictive value: probability that the patient actually has the condition, truly and with the disease Discuss the elements that need to be considered when developing a plan - Patient preferences and actions insurance family willingness clinical state and circumstances practice setting research evidence Describe the components of medical decision-making in E and M coding risk - History, exam, and medical decision-making Correctly order that E and M office visit codes based on complexity from least to most complex - 99201 office outpatient new 10 minutes 99202 office outpatient new 20 minutes 99203 office outpatient new 30 minutes 99204 office outpatient new 45 minutes 99205 office outpatient new 60 minutes 99211 office outpatient visit 5 minutes 99212 office outpatient visit 10 minutes 99213 office outpatient visit 15 minutes 99214 office outpatient visit 25 minutes 99215 office outpatient visit 40 minutes Define the components of a SOAP note - subjective objective assessment plan Discuss a minimum of three purposes of the written history and physical in relation to the importance of documentation - Document that gives concise information about the patient outlines plan for addressing reasons for visit means of communicating information to other providers medical - legal document