The Transformation of Documenting and Coding for Neurologic Hospital Inpatient and Observation Services

Abstract

Landmark changes to documenting and coding for office or other outpatient evaluation and management (E/M) codes were implemented on January 1, 2021. To decrease clinicians' administrative burden, many documentation requirements were eliminated. In addition, major changes were made in how medical decision making and time spent on the date of the encounter are used to determine the level of service. On January 1, 2023, these changes were extended to inpatient and observation E/M services. The level of service in both inpatient and outpatient settings can now be selected based on the total time dedicated to the patient's care on the day of the encounter or the new method of medical decision making. This article discusses the optimal ways to document and code for inpatient hospital and observation encounters after January 1, 2023.