NR 511 CEA ACTUAL FINAL EXAM VERIFIED QUESTIONS AND
ANSWERS GRADED A
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? - 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.
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. - 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
2. Problem focused: 99212
3. Expanded problem focused: 99213
4. Detailed: 99214
5. Comprehensive: 99215
The 5 key components of a comprehensive treatment plan are: - 1. Diagnostics
2. Medication
3. Education
4. Referral/consultation
5. Follow-up planning
, Define the components of a SOAP note. - S: subjective (what the pt tells you)
CC
HPI
PMH
Fam Hx
Social Hx
ROS
O: objective (what you can see, hear, feel on exam)
Physical findings
Vital signs
General survey
HEENT
Etc...
A: assessment
Global assessment of pt including differentials in order from most to least likely
Combination of subjective and objective info
List of dx addressed and billed for at the visit
P: plan
What you will Rx
When to come back
Diagnostic tests
Pt education
Discuss minimum of three purposes of the written history and physical in relation to the
importance of documentation. - Important reference document that gives concise info about the
pt's hx and exam findings
Outlines a plan for addressing issues that prompted the visit. Info should be presented in a logical
fashion that prominently features all data relevant to the pt's condition.
Is a means of communicating info to all providers involved in pt's care
Is a medical-legal document
Is essential in order to accurately code and bill for services
Why does every procedure code need a corresponding diagnosis code? - Diagnosis code explains
the necessity of the procedure code.
Insurance won't pay if they don't correspond.
What are the three components required in determining an outpatient, office visit E&M code? -
Plan of service
Type of service
Patient status
Correctly ID a pt as a new or established given historical info. - Pt status: whether or not pt is new
or established.
New: has not received professional service from provider in same group within past 3 years.
Established: has received professional service from provider in same group in last 3 years.
ANSWERS GRADED A
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? - 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.
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. - 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
2. Problem focused: 99212
3. Expanded problem focused: 99213
4. Detailed: 99214
5. Comprehensive: 99215
The 5 key components of a comprehensive treatment plan are: - 1. Diagnostics
2. Medication
3. Education
4. Referral/consultation
5. Follow-up planning
, Define the components of a SOAP note. - S: subjective (what the pt tells you)
CC
HPI
PMH
Fam Hx
Social Hx
ROS
O: objective (what you can see, hear, feel on exam)
Physical findings
Vital signs
General survey
HEENT
Etc...
A: assessment
Global assessment of pt including differentials in order from most to least likely
Combination of subjective and objective info
List of dx addressed and billed for at the visit
P: plan
What you will Rx
When to come back
Diagnostic tests
Pt education
Discuss minimum of three purposes of the written history and physical in relation to the
importance of documentation. - Important reference document that gives concise info about the
pt's hx and exam findings
Outlines a plan for addressing issues that prompted the visit. Info should be presented in a logical
fashion that prominently features all data relevant to the pt's condition.
Is a means of communicating info to all providers involved in pt's care
Is a medical-legal document
Is essential in order to accurately code and bill for services
Why does every procedure code need a corresponding diagnosis code? - Diagnosis code explains
the necessity of the procedure code.
Insurance won't pay if they don't correspond.
What are the three components required in determining an outpatient, office visit E&M code? -
Plan of service
Type of service
Patient status
Correctly ID a pt as a new or established given historical info. - Pt status: whether or not pt is new
or established.
New: has not received professional service from provider in same group within past 3 years.
Established: has received professional service from provider in same group in last 3 years.
