Correctly documenting what was done for a patient, and why, are essential for the coding systems that have become indispensable to the efficient management of contemporary medical care. Learn how to master this fundamental skill set in a learning module designed expressly for physicians in training.
The literally tens of thousands of code combinations are essential to record and share basic facts about diagnoses and other factors that establish the need for care, how it’s paid for, as well as provide a deep well of data for study about how health care is delivered. Documentation and coding are an integral part of virtually every physician’s career.
A concise, 19-minute module from the AMA provides an both an overview of coding and the key steps to create a solid coding portion of the patient record. “Coding and Documentation for Resident Physicians,” is one of the AMA GME Competency Education Program offerings, which include dozens of courses that residents can access online, on their own schedule. The modules are available to residency institutions that have subscribed to the AMA’s program.
Among the program’s experts are several who contributed to the AMA’s Health Systems Science textbook, which draws insights from faculty at medical schools that are part of the Association’s Accelerating Change in Medical Education Consortium.
Modules cover five of the six topics—patient care, practice-based learning and improvement, interpersonal and communication skills, professionalism, and system-based practice—within the Accreditation Council for Graduate Medical Education’s core competency requirements. The sixth requirement, medical knowledge, is one that is typically addressed during clinical education.
One patient, two coding concerns
In the hospital setting where residents typically work, specialized medical coders on staff read the patient medical record and distill the information into codes. The two commonly used code systems covered in in the module are the World Health Organization’s International Statistical Classification System of Diseases and Related Health Problems (ICD) and the reporting- and payment-oriented Current Procedural Terminology (CPT®) published by the AMA.
Both systems require all physicians, including medical residents, to express the facts of the record in a precise and coherent manner.
“A medical coder is not a diagnostician and may not interpret or ‘read into’ the medical record. It is crucial that physicians be clear, detailed and concise when documenting,” notes the module.
Once finished with the course, a medical resident will be ready do their part in the process and able to do the following.
Describe uses and best practices of medical record documentation. The module covers the basics of a medical record as a communication tool, business record, legal record and resource for data analytics.
Emphasis is put on practical tips including what information to include from each patient encounter, which and how many data elements should be used to be sure the correct patient is connected to the medical record, and insights on proper abbreviations. Of special note are detailed instructions on how to handle errors. The module also offers advice on the common, but problematic, use of cut and paste for inserting information into the medical record.
Describe the basics of ICD coding. The ICD is now in its 10th revision—hence, it’s commonly referred to as ICD-10—with a special inpatient version for hospitals. The module covers the scope and elements of alphanumeric style ICD-10 codes. It contrasts ICD-10 with CPT and how procedural codes are used to describe medical, surgical and diagnostic services.
Describe the fundamentals of diagnostic and procedural coding. The two code sets are distinct, but complement one another. The medical record has to support assignment for both. The module includes a discussion on how to create a medical record that reflects the highest levels of specificity and certainty.
The module also provides additional coding resources.