NR511 MIDTERM ACTUAL EXAM QUESTIONS
AND VERIFIED ANSWERS EXAM PREP
◉ Define diagnostic reasoning. Answer: 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?. Answer: Anything the patient tells you or
complains of regarding their symptoms
Chief complaint
HPI
ROS
◉ What is objective data?. 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. Answer: Specifically related to the
chief complaint only
,Detailed breakdown of CC
OLDCARTS
◉ Describe the differences between medical billing and medical
coding.. Answer: 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.. Answer: 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?. Answer: 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.. Answer: Pt's preferences and actions
Research evidence
Clinical state/circumstances
Clinical expertise
, ◉ Describe the components of medical decision making in E&M
coding.. 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
◉ Correctly order the E&M office visit codes based on complexity
from least to most complex.. 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:.
Answer: 1. Diagnostics
AND VERIFIED ANSWERS EXAM PREP
◉ Define diagnostic reasoning. Answer: 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?. Answer: Anything the patient tells you or
complains of regarding their symptoms
Chief complaint
HPI
ROS
◉ What is objective data?. 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. Answer: Specifically related to the
chief complaint only
,Detailed breakdown of CC
OLDCARTS
◉ Describe the differences between medical billing and medical
coding.. Answer: 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.. Answer: 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?. Answer: 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.. Answer: Pt's preferences and actions
Research evidence
Clinical state/circumstances
Clinical expertise
, ◉ Describe the components of medical decision making in E&M
coding.. 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
◉ Correctly order the E&M office visit codes based on complexity
from least to most complex.. 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:.
Answer: 1. Diagnostics
