Correctly documenting what was done for a patient, and why, is 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 and 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 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 just one of the AMA GME Competency Education Program offerings, which include more than 50 courses that residents can access online through their residency program’s subscription, on their own schedules. The program also features six faculty development courses.
The AMA GME Competency Education Program delivers education to help institutions more easily meet Accreditation Council for Graduate Medical Education common program requirements. 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 core competency requirements. The sixth requirement, medical knowledge, is one that is typically addressed during clinical education.
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 ChangeMedEd initiative.
Current program subscribers have access to award-winning online education designed for residents on the go. It’s easy to use and saves time with simple tracking and reporting tools for administrators. Learn more.
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 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 to do their part in the process, including 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.
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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 each other. 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.
Dive deeper:
- New AMA resource helps overstretched GME program directors
- How programs can address the 5 top resident physician stressors
- The do’s and don’ts of EHR use for new resident physicians
Easy to track progress
Residency program directors have access to dashboards and reports that provide a view of progress at the program and institution levels. In addition, customizable reports make it easy to track learner performance and demonstrate compliance for accreditation.
The AMA GME Competency Education Program covers topics including well-being, QI and patient safety, residents as teachers, navigating health systems, health equity, professionalism and faculty development. Schedule a meeting to discuss your organization’s needs.
