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NR 511 Differential Diagnosis and Primary Care Practicum – Year 2020

NR511 Final Exam Study Guide Week 1 1. Define diagnostic reasoning a. Involves critical thinking in a way that evaluates new data to support the hypothesis and reduce alternative hypothesis. This... is done by evaluating all the avenues to reach a conclusion that gives the best evidence to support the main theory or hypothesis. b. Examples of diagnostic reasoning are problem solving, health promotion, and screening for disease or illness. All of these will require sensitivity, complexity, contest, and a sense of probability and uncertainty. 2. Discuss and identify subjective & objective data a. Subjective- what the patient reports as the CC and the responses to the questions in the interview. Includes ROS, CC, and HPI b. Objective – Information gained through exam, labs, imaging and other diagnostic tests. 3. Discuss and identify the components of the HPI a. Describes the reason the patient came in and include information using the acronym OLDCARTS i. Onset ii. Location iii. Duration iv. Characteristics v. Aggravating factors vi. Relieving Factors vii. Treatments tried viii. Severity of the level of pain 4. Describe the differences between medical billing and medical coding a. Medical billing is the 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. b. Medical coding is the use of code to communicate with payers about the procedures performed and why. 5. Compare and contrast the 2 coding classification systems that are currently used in the US healthcare system – The two systems need to be in line i.e. the CPT code for the activity performed should be followed with a relevant Diagnosis for the procedure performed. a. ICD 10- the newest version of shorthand for the patients diagnosis. It is necessary for all diagnosis and procedures performed. b. CPT- common procedural terminology represented by a 5 digit code that provides a uniform language to describe medical, surgical, and diagnostic services. Allows for tracking of treatments, trend and outcomes. Therer is 3 levels of CPT codes: Category I- used in contemporary medical practice, Category II -tracking codes used for new or performance measurement, and Category IIITemporary coding used for new procedures, technology and services. i. Catergory I has six sections 1. Evaluation and Management 2. Anesthesiology 3. Surgery 4. Radiology 5. Pathology 6. Medicine 6. Discuss how specificity, sensitivity & predictive value contribute to the usefulness of the diagnostic data a. Specificity of a test = greater when it has few false positives no. of true negatives specificity = ----------------------------- no. of all tested indiv, who do not have the dz b. Sensitivity of a test = greater when it has few false negatives no. of the true positives sensitivity = -------------------------------- no. of tested indiv that have the dz c. Predictive value = is in part dependent on the prevalence of the condition true + positive predictive value = ----------- all + true - Negative predictive value = ---------- all – False positive - when a pt that does not have the condition has a positive reading False negative - when a pt that does have the condition but has a negative reading 7. Discuss the elements that need to be considered when developing a plan a. Diagnostic testing-what tests need to be conducted to clarify assessment b. Education-specific problems being managed c. Follow-up: when will the patient be seen again d. Be honest e. Negotiate what to cover 8. Describe the components of Medical Decision Making in E&M coding a. There is three key components the determine risk-based E&M codes i. History ii. Physical iii. Medical Decision Making- a way of quantifying the complexity of the thinking that is required for the visit. And gives credit for the excess work involved in management of a more complex patient. 1. Complexity of a visit is based on a. Risk b. Data c. diagnosis b. Reason for consultation c. HPI d. ROS e. Physical exam f. Recommendation for testing and treatment 9. Correctly order the E&M office visit codes based on complexity from least to most complex a. New: i. 99201 (minimal/RN visit) ii. 992022 (Problem-focused) iii. 99203 (Expanded problem- focused) iv. 99204 (detailed) v. 99215 (comprehensive) b. Established: i. 99211 (minimal/RN visit) ii. 99212 (problem- focused) iii. 99213 (expanded problem focused) iv. 99214 (detailed) v. 99215 (comprehensive) 10. Discuss a minimum of three purposes of the written history and physical in relation to the importance of documentation a. Provides documentation about the findings in the history and physical exam b. Provides an outline for addressing the issues that prompted the visit. c. Form of communication about care involved in patients. d. Medical legal document e. Essential for accurately coding and billing for services. 11. Accurately document why every procedure code must have a corresponding diagnosis code a. Every procedure code needs a diagnosis to explain the necessity whether the code represents an actual procedure performed or a nonprocedural encounter like an office visit. 12. Correctly identify a patient as new or established given the historical information a. New patient- who has not received services from the provider before or who has not seen the provider/ group for over 3 years b. Established patient- has been seen within the last 3 years, 13. Identify the 3 components required in determining an outpatient, office visit E&M code a. Place of service b. Type of Service c. Patient status [Show More]

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