NR511 Midterm Exam Questions and Answers | Fall 2026 Update | 100
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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?: Anything the patient tells you or complains of regarding their symptoms
Chief complaint
HPI
ROS
3. What is objective data?: Anything YOU can see, touch, feel, hear, or smell as part of your exam
Includes lab data, diagnostic test results, etc.
4. Identify components of HPI: Specifically related to the chief complaint only
Detailed breakdown of CC
OLDCARTS
5. Describe the differences between medical billing and medical coding.: 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.
6. Compare and contrast the two coding classification systems that are currently
used in the US healthcare system.: 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 corre-
sponding ICD.
7. How do specificity, sensitivity, and predictive value contribute to the useful-
ness of diagnostic data?: Specificity: ability of a test to correctly detect a specific condition. If a pt has a
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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.
8. Discuss the elements that need to be considered when developing a plan.: Pt's
preferences and actions
Research evidence
Clinical state/circumstances
Clinical expertise
9. 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 MDM
10. Correctly order the E&M office visit codes based on complexity from least to
most complex.: New pt:
1. Minimal/RN visit: 99201
2. Problem focused: 99202
3. Expanded problem focused: 99203
4. Detailed: 99204
5. Comprehensive: 99205
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Established pt:
1. Minimal/RN visit: 99211
2. Problem focused: 99212
3. Expanded problem focused: 99213
4. Detailed: 99214
5. Comprehensive: 99215
11. The 5 key components of a comprehensive treatment plan are:: 1. Diagnostics
2. Medication
3. Education
4. Referral/consultation
5. Follow-up planning
12. Define the components of a SOAP note.: S: subjective (what the pt tells you)
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
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P: plan
What you will Rx
When to come back
Diagnostic tests
Pt education
13. Discuss minimum of three purposes of the written history and physical in
relation to the importance of documentation.: 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
14. Why does every procedure code need a corresponding diagnosis code?: Diag-
nosis code explains the necessity of the procedure code.
Insurance won't pay if they don't correspond.
15. What are the three components required in determining an outpatient,
office visit E&M code?: Plan of service
Type of service
Patient status
16. Correctly ID a pt as a new or established given historical info.: Pt status: whether or
not pt is new or established.
New: has not received professional service from provider in same group within past 3 years.
Established: has received professional service from provider in same group in last 3 years.
17. What does a well-rounded clinical experience mean?: 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.
Correct
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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?: Anything the patient tells you or complains of regarding their symptoms
Chief complaint
HPI
ROS
3. What is objective data?: Anything YOU can see, touch, feel, hear, or smell as part of your exam
Includes lab data, diagnostic test results, etc.
4. Identify components of HPI: Specifically related to the chief complaint only
Detailed breakdown of CC
OLDCARTS
5. Describe the differences between medical billing and medical coding.: 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.
6. Compare and contrast the two coding classification systems that are currently
used in the US healthcare system.: 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 corre-
sponding ICD.
7. How do specificity, sensitivity, and predictive value contribute to the useful-
ness of diagnostic data?: Specificity: ability of a test to correctly detect a specific condition. If a pt has a
, NR511 Midterm Exam Questions and Answers | Fall 2026 Update | 100
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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.
8. Discuss the elements that need to be considered when developing a plan.: Pt's
preferences and actions
Research evidence
Clinical state/circumstances
Clinical expertise
9. 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 MDM
10. Correctly order the E&M office visit codes based on complexity from least to
most complex.: New pt:
1. Minimal/RN visit: 99201
2. Problem focused: 99202
3. Expanded problem focused: 99203
4. Detailed: 99204
5. Comprehensive: 99205
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Established pt:
1. Minimal/RN visit: 99211
2. Problem focused: 99212
3. Expanded problem focused: 99213
4. Detailed: 99214
5. Comprehensive: 99215
11. The 5 key components of a comprehensive treatment plan are:: 1. Diagnostics
2. Medication
3. Education
4. Referral/consultation
5. Follow-up planning
12. Define the components of a SOAP note.: S: subjective (what the pt tells you)
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
, NR511 Midterm Exam Questions and Answers | Fall 2026 Update | 100
Correct
Study online at https://quizlet.com/_i2l3rf
P: plan
What you will Rx
When to come back
Diagnostic tests
Pt education
13. Discuss minimum of three purposes of the written history and physical in
relation to the importance of documentation.: 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
14. Why does every procedure code need a corresponding diagnosis code?: Diag-
nosis code explains the necessity of the procedure code.
Insurance won't pay if they don't correspond.
15. What are the three components required in determining an outpatient,
office visit E&M code?: Plan of service
Type of service
Patient status
16. Correctly ID a pt as a new or established given historical info.: Pt status: whether or
not pt is new or established.
New: has not received professional service from provider in same group within past 3 years.
Established: has received professional service from provider in same group in last 3 years.
17. What does a well-rounded clinical experience mean?: 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.
