Implementation of standard note templates captures true level of service (LOS) coding

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Conference Proceeding

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Objective: To determine if the implementation of standardized note templates (SNT) upon our inpatient services captured true Level of Service (LOS) coding through complete and consistent documentation. Background: LOS is dependent upon the evaluation and management (E/M) coding. For neurological patients, E/M relies heavily upon the Neurology Single System Exam outlined in the 1997 CMS rules. The physicians taking care of these patients perform a thorough history and physical examination; however, it is not consistently reflected in the LOS secondary to unintended missed or incorrectly documented elements in the patient's note. Design/Methods: SNT were approved by our coders and implemented into our institution's electronic health record in 7/2017. These were the only templates utilized by our inpatient providers after implementation. We compared LOS codes for both initial inpatient visit (1-3) and initial consult visit (1-5) between 1/2016-6/2017 (pre-implementation) and 7/2017-6/2018 (post-implementation). Results: A total of 777 and 4,158 notes were filed for initial consult and inpatient visits, respectively, during the pre-implementation period. A total of 611 and 3,028 notes were filed during the post-implementation period. There was an increase in the overall median (Q25, Q75) LOS consult code from 4 (3,5) to 5 (4,5) (p < 0.001). Additionally, there was an increase in the overall median LOS inpatient code from 3 (2,3) to 3 (2,3) (p < 0.001). Conclusions: The rules of coding are complex and require appropriate documentation to reflect the true intricacies of a neurological patient. At our institution, we believe the implementation of SNT more accurately captured our complex patient encounters as reflected by the increase in LOS coding.





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