NR 511 WEEK 1 ASSIGNMENT: CLINICAL READINESS EXAM

NR 511 WEEK 1 ASSIGNMENT: CLINICAL READINESS EXAM 1. 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. 2. What is subjective data? What the patient tells you, complains of, etc. Chief complaint HPI ROS 3. What is objective data? What YOU can see, hear, or feel as part of your exam. Includes lab data, diagnostic test results. 4. Components of HPI Specifically related to the chief complaint only. Detailed breakdown of CC. OLDCART 5. Why must every procedure code have a corresponding diagnosis code? Diagnosis code explains the necessity of the procedure code. Insurance won't pay if they don't correspond. 6. What are the three components required in determining an outpatient office visit E&M code? Place of service Type of service Patient status 7. What is medical coding? The use of codes to communicate with payers about which procedures were performed and why 8. What is 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. 9. What are CPT codes? Common procedural terminology Offers the official procedural coding rules and guidelines required when reporting medical services and procedures performed by physician and non-physician providers. 10. What are ICD codes? International classification of disease Used to provide payer info on necessity of visit or procedure performed.