NR511 Midterm Study Guide {UPDATED} | NR 511 Midterm Study Guide {UPDATED}

NR511 Midterm Study Guide {UPDATED} Week 1 1. Define diagnostic reasoning Reflective thinking because the process involves questioning one’s thinking to determining 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. 2. Discuss and identify subjective & objective data - Subjective: What the pt tells you, complains of, etc. *Chief complaint, HPI, ROS - Objective: What YOU can see, hear, or feel as part of your exam. *lab, data, dx test results. 3. Discuss and identify the components of the HPI Specifically related to the CC only. Detailed breakdown of CC. OLDCART. 4. Describe the differences between medical billing and medical coding - Medical coding: The use of codes to communicate with payers about which procedures were performed and why - 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. 5. Compare and contrast the 2 coding classification systems that are currently used in the US healthcare system - CPT codes: Common procedural terminology. Offers the official procedural coding rules and guidelines required when reporting medical services and procedures performed by physician and nonphysician orders. - ICD codes: International classification of disease. Used to provide payer info on necessity of visit or procedure performed. 6. Discuss how specificity, sensitivity & predictive value contribute to the usefulness of the diagnostic data - Specificity: The ability of the test to correctly detect a specific condition. If a patient has a condition but test is negative, it is a false negative. If a patient does NOT have a condition but the test is positive , it is a 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. 7. Discuss the elements that need to be considered when developing a plan Patient’s preferences and actions. Research evidence. Clinical state/circumstances. Clinical expertise. 8. 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 the MDM! 9. Correctly order the E&M office visit codes based on complexity from least to most complex New patient: 1. Minimal/RN visit: 99201 2. Problem focused: 99202 3. Expanded problem focused: 99203 4. Detailed: 99204 5. Comprehensive: 99205 Established patient: 6. Minimal/RN patient: 99211 7. Problem focused: 99212 8. Expanded problem focused: 99213 9. Detailed: 99214 10. Comprehensive: 99215 10. Discuss a minimum of three purposes of the written history and physical in relation to the importance of documentation - Important reference document that vies 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 patient’s care. - is a medical legal document - is essential in order to accurately code and bill for services 11. Accurately document why every procedure code must have a corresponding diagnosis code Diagnosis code explains the necessity of the procedure code. Insurance won’t pay if they do not correspond. 12. Correctly identify a patient as new or established given the historical information New patient: If that patient has never been seen in that clinic or by that group of providers OR if the pt has not been seen in the past 3 years 13. Identify the 3 components required in determining an outpatient, office visit E&M code Place of service, type of service, patient status. 14. Describe the components of Medical Decision Making in E&M coding Risk – data – diagnosis 15. Correctly order the E&M office visit codes based on complexity from least to most complex · Repeat of #9? New patient: a. Minimal/RN visit: 99201 b. Problem focused: 99202 c. Expanded problem focused: 99203 d. Detailed: 99204 e. Comprehensive: 99205 Established patient: f. Minimal/RN patient: 99211 g. Problem focused: 99212 h. Expanded problem focused: 99213 i. Detailed: 99214 j. Comprehensive: 99215 16. Explain what a “well rounded” clinical experience means Includes seeing kids from birth through young adult visits for well child and acute visits as well as adults for wellness or acute/routine visits. Seeing a variety of patients including 15% of peds and 15% of women’s health of total time in the program. 17. State the maximum number of hours that time can be spent “rounding” in a facility No more than 25% of total practicum hours in the program 18. State 9 things that must be documented when inputting data into clinical encounter 1. Date of service 2. Age 3. Gender and Ethnicity 4. Visit E&M code 5. CC 6. Procedures 7. Tests performed and ordered 8. Dx 9. Level of involvement (mostly student, mostly preceptor, together, etc.) - - - - - - - - - - - - - - - - - - - - - - - -- - - - 14. Recognize common eye emergency conditions that require emergency room evaluation Chemical burns, Gonococcal infection, complicated orbital cellulitis (can turn into meningitis), Eye led laceration, subconjunctival hemorrhage (severe or trauma)-check vision, foreign bodies, hyphema (blood is trapped b/w iris and cornea), ruptured globe (trauma, vision threatening, need surgery. 15. Discuss glaucoma, diagnosis and treatment -Progressive damage to the optic nerve, resulting in atrophy and blindness, most typically related to increase in IOP. - open-angle-most common, the chronic form, usually asymptomatic until loss of peripheral vision, good prognosis if treated early. Common in ages >40, but can occur at any age, African Americans have a higher incidence - closed-angle- sub-acute and chronic components, significant eye pain, redness, and acute visual loss, which if left untreated can rapidly lead to permanent blindness. Most common in ages 55-70. -congenital- seen in infants -or primary/secondary -the use of steroid therapy can increase IOP, antidepressant, anticholinergic, acute stress can contribute to an acute episode. Diagnostic: Tonometry reading for IOP, but not sensitive for glaucoma, no guidelines for glaucoma screening by the primary care provider. Refer to opthamologist (gonioscopy-measures ant chamber angle), appearance(color & contour) of optic nerve and visual fields most impt for diagnosis, size of the cup relative to optic nerve. Diagnosis is made on finding of characteristic degenerative changes in the optic disc and defects in visual fields. Tx: if nerve damage present-irreversible. Goal is to prevent progression- decrease IOP. Beta-blockers usually first-line, but prostaglandin analogs may be first-line or added soon after the beta-blocker. If medication does not work, then surgery is next (laser- (pressure may build back up after several years) or external trabeculectomy). Acute closed-angle requires emergency tx, medications( Diamox and IV mannitol) are used initially to lower IOP, so that surgical intervention can occur. Close and life-long F/U essential 16. Discuss diabetic retinopathy -noninflammatory disorder of the retina that develops in patients with diabetes. -stage 1: background diabetic retinopathy-microaneurysms, intraretinal hemorrhage, macular edema, and lipid deposits may be present -stage 2: preproliferative diabetic retinopathy-cotton-wool spots (infarctions), venous beading and dilation, edema and in some cases extensive retinal hemorrhage. -stage3: proliferative diabetic retinopathy- new blood vessel proliferation on retinal surface, optic nerve, and iris, laser surgery recommended, other tx cryoretinopexy (decrease neovascular stimulus), vitrectomy (severe proliferative) -diabetic patients-always refer to opthamologist -caused by uncontrolled hyperglycemia -patient will complain of visual changes, but asymptomatic in early stages -changes noted in funduscopic exam -risk is significantly increased in BG >200 - keep A1c <7% - in patients w/ HTN and diabetes-lisinopril shown slow progression -pt w/ diabetes- yearly opthamologist visit, and w/ known hx of retinopathy, Q 6 M, and if known hx of proliferative (stage 3) Q 3-4M, and if acute proliferative Q 8 wks. NOTES from Chapter 11 readings:( Please fill in any notes from your reading for any topics that have not listed down here)--This is where we can easily skim through the notes. Jaundice: Yellow of skin & mucous membrane, sclera; increase accumulation of bilirubin==need Emergency attention; Hyperbilirubinemia: result ↑production, ↓ uptake, ↓ conjugation, or ↓ excretion of bilirubin. DDx:Lab values: 1) Icterus not evident until bili level >2-3 mg/dl; (normal bili== 0.3 to 1.0 mg/dl) Most Bili—from heme portion, a break down of RBC; unconjugated bili (indirect bilirubin)-water insoluble and only bound to albumin; then conjugated by the liver (water soluble—direct bilirubin, found in urine) 2) AST and ALT==good indicators of hepatocyte damage; AST (in liver, skeletal muscle, brain, and heart); ALT --only in hepatocyte cytoplasm—more specific; AST and ALT with extreme elevation can be diagnostic, or otherwise <300U/L are nonspecific; AST >15 times indicate cholangitis; AST and ALT > 1,000 U/L—acute viral hepatitis; if ratio AST/ALT is high—severe hepatic necrosis (alcoholic hepatitis) 3) Alkaline phosphatase found in biliary canalicular membranes, useful in assessing cholestasis, (a condition where bile cannot flow from the liver to the duodenum). 4) GGT and 5-nucleotidase also increase in cholestasis. ↑ alkaline phosphatase with GGT== mechanical obstruction of the biliary system by a Tumor, stricture, or stone. 5) Alkaline Phosphatase is also found in bone without ↑ GGT==bone disorder. Sx: pruritus, anorexia, nausea, vomiting, fever, light-colored stools, weight loss, fatigue. Exam with RUQ pain and tenderness, dark urine, abdo distension. - Pruritus, dark urine, light-colored stools, jaundice indicate cholestasis d/t cholelithiasis, cirrhosis, or other biliary obstruction.