Background: Accurate coding and billing are critical for the financial health of hospitals. Neurologic inpatient services have specific, complex documentation requirements, which can result in inadequate billing.
Methods: We retrospectively compared coding practices from July 2013 to June 2014 (FY2014) using evaluation and management codes for initial inpatient encounters (CPT 99221-3) of a neurohospitalist group (NHG) to a hospital medicine group (HMG) and to national benchmarks. We further examined a sample of the lowest level encounters (CPT 99221) from the 4th quarter of FY2014 for specific deficiencies and compared these among groups.
Results: Low codes (CPT 99221) were more common in the NHG than the HMG and national benchmarks (54% vs 7% vs 4%, p < 0.01). Deficiencies in the examination were the most common reason for low coding in the NHG compared to the HMG (62% vs 5%, p < 0.001). Deficiencies in social history were more common in the NHG than the HMG (11% vs 0%, p < 0.003) but deficiencies in family history (34% vs 37%, p = 0.75) and review of systems (30% vs 30%, p = 1.0) were common in both groups. In the NHG group, documentation did not reflect the acuity of patients' medical conditions.
Conclusions: Neurologists should pay close attention to documentation requirements-especially the neurologic examination-in order to allow for accurate coding and billing.