NR511 Midterm Exam (Preview)
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Week
1
1. Define diagnostic reasoning
Reflective
thinking because the process involves questioning one’s thinking to determining
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. Discuss and identify subjective &
objective data
– Subjective: What the pt tells you,
complains of, etc. *Chief complaint, HPI, ROS
– Objective: What YOU can see, hear, or
feel as part of your exam. *lab, data, dx test results.
3. Discuss and identify the components of
the HPI
Specifically
related to the CC only. Detailed breakdown of CC. OLDCART.
4. Describe the differences between
medical billing and medical coding
– Medical coding: The use of codes to
communicate with payers about which procedures were performed and why
– 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.
5. Compare and contrast the 2 coding classification
systems that are currently used in the US healthcare system
– CPT codes: Common procedural
terminology. Offers the official procedural coding rules and guidelines required
when reporting medical services and procedures performed by physician and
nonphysician orders.
– ICD codes: International
classification of disease. Used to provide payer info on necessity of visit or
procedure performed.
6. Discuss how specificity, sensitivity
& predictive value contribute to the usefulness of the diagnostic data
– Specificity: The ability of the test to
correctly detect a specific condition. If a patient has a condition but test is
negative, it is a false negative. If a patient does NOT have a condition but
the test is positive , it is a 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.
7. Discuss the elements that need to be
considered when developing a plan
Patient’s
preferences and actions. Research evidence. Clinical state/circumstances.
Clinical expertise.
8. 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 the
MDM!
9. Correctly order the E&M office
visit codes based on complexity from least to most complex
New
patient:
1. Minimal/RN visit: 99201
2. Problem focused: 99202
3. Expanded problem focused: 99203
4. Detailed: 99204
5. Comprehensive: 99205
Established
patient:
6. Minimal/RN patient: 99211
7. Problem focused: 99212
8. Expanded problem focused: 99213
9. Detailed: 99214
10. Comprehensive: 99215
10. Discuss a minimum of three purposes of the written history and physical
in relation to the importance of documentation
– Important reference document that vies
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 patient’s care.
– is a medical legal document
– is essential in order to accurately code
and bill for services
11. Accurately document why every procedure code must have a corresponding
diagnosis code
Diagnosis code explains the necessity of the procedure code. Insurance won’t pay if they do not correspond.
5. Discuss the diagnosis of
diverticulitis, risk factors, and treatments
– Diagnosis = occurs when a patient’s diverticulosis
becomes inflamed and when the projection becomes eroded it can progress to the
point of eruption causing left lower quad pain and tenderness, fever, change in
bowel habits (usually diarrhea), N/V, mass, rebound tenderness with involuntary
guarding and rigidity, occult blood. If there is a fistula, UA may show
increased WBC and RBC, urine culture may be positive.
– Risk Factors = low fiber diet, hypertrophy of the
segments of the circular muscle of the colon, chronic constipation and
straining, irregular and uncoordinated bowel contractions, obesity, and
weakness of the bowel muscle brought on by aging. Directly related to the
suspected causes of the disease: older than age 40, low-fiber diet, previous
diverticulitis, and the number of diverticula present in the colon.
– Treatments = metronidazole 500mg TID x 10-14 days along with Ciprofloxacin 500mg BID or trimethoprim/sulfamethoxazole DS 160/800 BID. Close office follow up should occur upon completion of abx therapy as complications such as abscess and perforation can occur.
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