New online training course explains best practices for medical record documentation

Managing patient care begins with accurate documentation and coding. You can now participate in a 30-minute online training module to learn more about proper medical documentation.

After completing the course, if you take a 10-question assessment and score 80 percent or better, you’ll receive one continuing education credit from the American Academy of Professional Coders.

To get to the training module, follow these steps:

1. At bcbsm.com/providers, log in to Provider Secured Services using your user name and password.
2. Click on web-DENIS.
3. Click on BCBSM Provider Publications and Resources.
4. Click Newsletters & Resources.
5. Click Patient Care Reporting.
6. In the Training Resources section, click on New online training: Best Practices for Medical Record Documentation (October 2015).

This new online training tool provides helpful information about medical record documentation, according to the Centers for Medicare & Medicaid Services guidelines, including:

• How to demonstrate the condition of the patient
• Principles of sound documentation
• Tips for maintaining quality medical records

The training module also covers the documentation elements needed for different types of Medicare office visits, such as:

• Initial preventive physical examination, also known as a “Welcome to Medicare visit”
• Annual wellness visit for Medicare beneficiaries
• Preventive medicine services
• Problem-oriented office visit E/M

We strive to ensure all patients with chronic conditions are seen at least once a year and that they receive appropriate care. Your detailed documentation and coding of diagnoses, along with any treatment or care each year, are key to managing patient care.

To properly document and code, doctors must manage, evaluate, assess or treat every patient and every condition, every year.

Visit the link above to learn more about best practices in documentation and coding and its advantages to you and your patients.