Department of Neurology

EVALUATION AND MANAGEMENT (E/M)

CODING AND DOCUMENTATION

FOR

NEUROLOGY HOSPITAL ADMISSIONS

Coding and documentation for neurology admissions to the hospital are similar to that for outpatients. Note some of the major differences when using these codes:

●  there are only 3 levels for the day of admission service

●  there are only 3 levels for subsequent day of service

●  there are separate codes for the day of discharge

●  time spent is not only face to face time with the patient, but also includes time spent on the floor/unit rendering services for patient (e.g., reviewing the chart, writing notes, talking to other doctors, talking to the family, etc.)

The most recent E/M coding and documentation rules are found in the 1997 Documentation Guidelines for Evaluation and Management Services, from the Center for Medicare & Medicaid Services (CMS). A simplified approach, tailored for neurology follows below, based first on determining the level of Medical Decision Making.

The documentation of all E/M codes involves (3) components:

•  History

•  Examination

•  Medical Decision Making

Among these three components, it is the Medical Decision Making (MDM) that is most patient specific. The MDM in essence drives which E/M code to use. Among other factors, it incorporates the severity of the illness, the complexity of the case, review of outside records, and undertaking diagnostic testing and treatment. Thus, one of the best approaches to E/M coding is to first determine the level of MDM (click here to learn how to determine the level of MDM). Once that is determined, the proper E/M code is determined depending if the service is for the day of admission or subsequent follow-up care in the hospital. Then it is straightforward of to determine how much and what detail of History and Physical Examination must be documented.

Selection of the Proper E/M Code and Documentation of the Required History and Examination
 

Once the level of MDM is determined, the correct E/M code is selected depending on whether the visit is for the day of admission, subsequent daily care, or the day of discharge.

Once the code is selected, then there is specific history and exam documentation required for that code (click on each code below to review the specific documentation requirements).

Alternative E/M Coding: Using Time

If you document the total time and note that counseling and coordinating care required more than 50% of the encounter, then time may be used to determine the level of service. Documentation may refer to:

•  diagnostic results, impressions and plans for other studies

•  prognosis

•  differential diagnosis

•  risks, benefits of treatment

•  instructions

•  compliance

•  risk reduction

•  patient and family education

As opposed to outpatients where the total time is only face to face time with the patient, time for hospitalized patients also includes any time spent on the floor/unit rendering services for patient (e.g., reviewing the chart, writing notes, talking to other doctors, talking to the family, etc). The average total times for the E/M hospital admission codes and average Medicare reimbursement are listed below.

Condensed E/M Coding for Hospital Inpatient Services for  Neurology Sheet (pdf): 

Two page file that can be printed for quick reference in the office setting (Download here)