NR 511 WEEK 1 STUDY GUIDE, DEFINITIONS AND ANSWERS

Week 1 1. Define diagnostic reasoning 2. Discuss and identify subjective & objective data 3. Discuss and identify the components of the HPI 4. Describe the differences between medical billing and medical coding 5. Compare and contrast the 2 coding classification systems that are currently used in the US healthcare system 6. Discuss how specificity, sensitivity & predictive value contribute to the usefulness of the diagnostic data 7. Discuss the elements that need to be considered when developing a plan 8. Describe the components of Medical Decision Making in E&M coding 9. Correctly order the E&M office visit codes based on complexity from least to most complex 10. Discuss a minimum of three purposes of the written history and physical in relation to the importance of documentation 11. Accurately document why every procedure code must have a corresponding diagnosis code 12. Correctly identify a patient as new or established given the historical information 13. Identify the 3 components required in determining an outpatient, office visit E&M code 14. Describe the components of Medical Decision Making in E&M coding 15. Correctly order the E&M office visit codes based on complexity from least to most complex 16. Explain what a “well rounded” clinical experience means 17. State the maximum number of hours that time can be spent “rounding” in a facility 18. State 9 things that must be documented when inputting data into clinical encounter 19. Identify and explain each part of the acronym SNAPPS