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.

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.

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).

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).

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.