NR 511 WEEK 1 CLINICAL READINESS EXAM – QUESTIONS AND ANSWERS

NR 511 Week 1 Clinical Readiness Exam – Questions And Answers
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.