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. 11. What is 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. 12. What is 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. 13. What is predictive value? The likelihood that the patient 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. 14. What elements need to be considered when developing a plan? Pt's preferences and actions Research evidence Clinical state/circumstances Clinical expertise 15. What are 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! 16. 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: 1. Minimal/RN visit: 99211 2. Problem focused: 99212 3. Expanded problem focused: 99213 4. Detailed: 99214 5. Comprehensive: 99215 17. 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 VS 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 P: plan What you will Rx When to come back Diagnostic tests Pt education 18. What are purposes of the written H&P 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 the pt's care. Is a medical-legal document. Is essential in order to accurately code and bill for services. 19. When is a pt considered a "new" pt? If that pt has never been seen in that clinic or by that group of providers OR if the pt has not been seen in the past 3 years. 20. 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. Seeing a variety of pt's, including 15% of peds and 15% of women's health of total time in the program. 21. What are the maximum number of hours that time can be spent "rounding" in a facility during clinicals? No more than 25% of total practicum hours in the program 22. What are 9 things that must be documented in the clinical encounter logs? Date of service Age Gender and ethnicity Visit E&M code CC Procedures Tests performed and ordered Dx Level of involvement (mostly student, mostly preceptor, together, etc.) 23. What is the first "S" in the SNAPPS presentation? Summarize: present the pt's H&P findings