NR511 MIDTERM Certification Exam
Questions and Answers (Verified Answers)
What is objective data? <Correct Answer>>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 <Correct Answer>>Specifically related to the chief
complaint only
Detailed breakdown of CC
OLDCARTS
Describe the components of medical decision making in E&M coding. --
<CORRECT ANSWER>>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
Page 1 of 68
,Correctly order the E&M office visit codes based on complexity from least to
most complex. <Correct Answer>>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: <Correct
Answer>>1. Diagnostics
2. Medication
3. Education
4. Referral/consultation
5. Follow-up planning
Define the components of a SOAP note. <Correct Answer>>S: subjective (what
the pt tells you)
Page 2 of 68
,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
Page 3 of 68
, Diagnostic tests
Pt education
Discuss minimum of three purposes of the written history and physical in
relation to the importance of documentation. <Correct Answer>>
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? --
<CORRECT ANSWER>>Diagnosis code explains the necessity of the
procedure code.
Insurance won't pay if they don't correspond.
Page 4 of 68
Questions and Answers (Verified Answers)
What is objective data? <Correct Answer>>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 <Correct Answer>>Specifically related to the chief
complaint only
Detailed breakdown of CC
OLDCARTS
Describe the components of medical decision making in E&M coding. --
<CORRECT ANSWER>>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
Page 1 of 68
,Correctly order the E&M office visit codes based on complexity from least to
most complex. <Correct Answer>>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: <Correct
Answer>>1. Diagnostics
2. Medication
3. Education
4. Referral/consultation
5. Follow-up planning
Define the components of a SOAP note. <Correct Answer>>S: subjective (what
the pt tells you)
Page 2 of 68
,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
Page 3 of 68
, Diagnostic tests
Pt education
Discuss minimum of three purposes of the written history and physical in
relation to the importance of documentation. <Correct Answer>>
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? --
<CORRECT ANSWER>>Diagnosis code explains the necessity of the
procedure code.
Insurance won't pay if they don't correspond.
Page 4 of 68
