Tips for Medical Documentation and Coding

Documentation and coding are not taught well in training programs. When I started practicing, I was frustrated by my lack of knowledge about coding and I dislike mindless repetitive paperwork, so I designed my own templates for outpatient and inpatient consult, admission, and follow up notes. Since they're individualized, they're a pleasure to use. The templates save me hours per week, ensure that I can always code at the highest level, and allow me to concentrate on the most important parts of the note, the assessment and plan. Here are tips I found helpful:

1. Print out and read the Center for Medicare and Medicaid Services 1995 Documentation Guidelines for Evaluation and Management Services.
2. Do the same with the 1997 Documentation Guidelines for Evaluation and Management Services.
3. If you have a Palm, download the demo for Stat E&M Coder at statcoder.com. This program allows you to punch in elements of the history, physical exam, and medical complexity and shows you what level you can code. It makes the 1995 and 1997 E&M Guidelines much easier to understand.
4. Using a word processor or spreadsheet, craft a note template which includes checkboxes for the parts of the history, review of systems, and physical exam that you would typically perform or that would be easy to complete.
5. Use Stat E&M Coder or the Guidelines to ensure that you have all the elements necessary to code at the highest level (assuming a case of appropriately high complexity).
6. Design different templates for consults, new patients, and followups. (My templates are 3 pages for new patients and consults and 1 page for followups.)
7. Put your contact information at the bottom of each template.
8. Print the templates and copy them onto progress note paper if needed. Similar templates could also be designed for dictated notes or electronic medical record systems.

It takes some time and effort to create the templates, but it's worth it.