Authors: Laila Malani Mohammad, MD; Kristopher Kimmell, MD; Rebecca Coffman; Christopher Taylor, MD (Albuquerque, NM)


Proper documentation is the cornerstone of good patient care and also vital to proper coding and billing. Most neurosurgical patients are considered high complexity, requiring complex decision making and communication. Proper documentation enhances provider communication and also ensures appropriate level of billing. Our hypothesis was that the introduction of a dedicated neurosurgery history and physical template (NHPT) would improve documentation and coding for neurosurgical patients.


Retrospective study of neurosurgical patients at the University of New Mexico, who received a history and physical (H&P) for an initial inpatient admission from July 2015 to July 2016. A standardized electronic health records (EHR)-based NHPT was introduced in December 2015. Data collected included types of documentation (typed, dictated, dynamic documentation without template, or NHPT), initial coding level (1, 2, or 3), and ultimate coding level based on review by professional coder. Inpatient consult notes and clinic notes were not included in the analysis due to different billing criteria.


In July of 2015, before the introduction of the NHPT, 7/30 (23.33%) of inpatient neurosurgery H&Ps were a level 1, compared to 3/61 (4.92%) in July of 2016, a decrease of 79% (p = 0.008). Prior to the NHPT, the most common causes for down-coding were inadequate documentation, including a lack of complete review of systems or comprehensive physical exam. As the use of the NHPT increased in popularity, the percentage of level 1 coding decreased. No notes that used the NHPT were down-coded for missing elements, and 193/193 (100%) resulted in a level 3. After the implementation of the NPHT, the average billed note increased by 10%.


Introduction of an EHR-based standardized history and physical template enhanced documentation and resulted in more accurate coding and charges for complex neurosurgical patients.

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