Documentation and Coding for the Pediatric Neurohospitalist

In 2021 and 2023, the American Medical Association (AMA) revised evaluation and management (E/M) service reporting. Clinicians now determine most service levels by medical decision making or total time spent on the date of service. Trainees often receive little formal education about how documentation and coding affect clinical practice. Clinicians may also receive limited structured feedback on their documentation and coding. This review discusses inpatient pediatric neurology notes, critical care reporting, electroencephalography (EEG) interpretation, and attestation by the teaching physician. It also considers improvement models such as pathway-linked templates and department billing and coding review programs.