MedEdPORTAL (Jan 2010)
Billing, Coding, and Documentation (Slightly Unorthodox, but Accurate)
Abstract
Abstract Introduction Traditionally, emergency department coding has been taught by a coder, either via individual chart audit or by lecture/seminar training. Because coders are not clinicians, their method of teaching consists largely of tallying up “points” in the various sections of an already documented chart. Unfortunately, this style of teaching does not echo emergency physician work flow. The idea behind this resource is to train emergency physicians that medical decision-making is the prime determinant of a patient's code, not their history and physical exam. Methods Resident learners first read the enclosed document on billing and coding. They then attend a lecture on emergency room coding delivered by faculty. Finally, they attend a one-on-one session with the faculty member to have their charts audited, and to discuss critical care, procedure, and observation coding. Results This curriculum has been in place within our residency for 4 years and has been highly successful. Our residents feel very comfortable at the end of their senior year with coding and documentation of charts, and they annually cite this particular curriculum as the most valuable of their administrative curriculum. In addition, the Chair of our department has now requested that the resource be utilized to train our faculty members, as well. Discussion This resource was created out of a need to educate residents prior to their graduation from residency about the coding requirements used in emergency medicine. The primary limitation of this resource is its length. At 45 pages, this resource takes some time to read, although the print is large and the reading itself is fairly easy. Further, the material may be somewhat institution-specific, and it is not all encompassing. For instance, the resource does not contain much information regarding E&M codes 1 and 2, and it gives only brief information regarding procedural codes. However, it does cover many of the cases and patients seen within emergency departments, and is quite thorough overall.
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