SAN DIEGO (April 15, 2019) — Winner of the Louise Eisenhardt Travel Scholarship, Laila Malani Mohammad, MD, presented her research, Enhanced Documentation and Accurate Coding with the Introduction of a Standardized Neurosurgery History and Physical Template, during the 2019 American Association of Neurological Surgeons (AANS) Annual Scientific Meeting.

Proper documentation is the cornerstone of good patient care and also vital to proper coding and billing. Most neurosurgical patient cases are high complexity. Proper documentation enhances provider communication and can help ensure appropriate billing. The study’s hypothesis was that the introduction of a dedicated neurosurgery history and physical template (NHPT) would improve documentation and coding for neurosurgical patients.

Authors conducted a retrospective study of neurosurgical patients at the University of New Mexico. 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 a professional coder. Inpatient consult notes and clinic notes were not included in the analysis due to different billing criteria.

The study found that the introduction of an EHR based standardized history and physical template enhanced documentation and resulted in more accurate coding and charges for complex neurosurgical patients.

Author Block: Laila Malani Mohammad, MD, (Albuquerque, N.M.); Kristopher Kimmell, MD; Rebecca Coffman; Christopher Taylor, MD

Disclosure: The author reported no conflicts of interest.

Media Representatives: The 2019 AANS Annual Scientific Meeting website’s press section includes releases on highlighted scientific research, AANS officers and award winners and other relevant information about the 2019 program. Releases will be posted on the 2019 AANS Annual Scientific Meeting website. If you have interest in a topic related to neurosurgery or would like to interview a neurosurgeon — either onsite or via telephone — during or after the event, please contact Alice Kelsey, AANS associate executive director, via email at [email protected]

About the 2019 AANS Annual Scientific Meeting
Attended by neurosurgeons, neurosurgical residents, medical students, neuroscience nurses, clinical specialists, physician assistants, allied health professionals and other medical professionals, the AANS Annual Scientific Meeting is the largest gathering of neurosurgeons in the nation, with an emphasis on the field’s latest research and technological advances. The scientific presentations accepted for the 2019 event will represent cutting-edge examples of the incredible developments taking place within the field of neurosurgery. Find additional information about the 2019 AANS Annual Scientific Meeting and the meeting program here.

About the AANS
Founded in 1931 as the Harvey Cushing Society, the American Association of Neurological Surgeons (AANS) is a scientific and educational association with more than 11,500 members worldwide. The AANS promotes the highest quality of patient care and advances the specialty of neurological surgery. Fellows of the AANS are board-certified by the American Board of Neurological Surgery, the Royal College of Physicians and Surgeons of Canada or the Mexican Council of Neurological Surgery, A.C. Neurosurgery is the medical specialty concerned with the prevention, diagnosis, treatment and rehabilitation of disorders that affect the spinal column, spinal cord, brain, nervous system and peripheral nerves.

For more information, visit www.AANS.org.

Meeting Link: 2019 American Association of Neurological Surgeons Annual Scientific Meeting