{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,18]],"date-time":"2026-08-18T17:30:13Z","timestamp":1787074213444,"version":"build-2736575974"},"reference-count":29,"publisher":"SAGE Publications","license":[{"start":{"date-parts":[[2026,8,16]],"date-time":"2026-08-16T00:00:00Z","timestamp":1786838400000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/journals.sagepub.com\/page\/policies\/text-and-data-mining-license"}],"content-domain":{"domain":["journals.sagepub.com"],"crossmark-restriction":true},"short-container-title":["The Neurohospitalist"],"abstract":"<jats:p>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.<\/jats:p>","DOI":"10.1177\/19418744261477795","type":"journal-article","created":{"date-parts":[[2026,8,17]],"date-time":"2026-08-17T01:11:35Z","timestamp":1786929095000},"update-policy":"https:\/\/doi.org\/10.1177\/sage-journals-update-policy","source":"Crossref","is-referenced-by-count":0,"title":["Documentation and Coding for the Pediatric Neurohospitalist"],"prefix":"10.1177","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-9638-0930","authenticated-orcid":false,"given":"Matthew Chase","family":"Lustig","sequence":"first","affiliation":[{"name":"Emory University School of Medicine"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"179","published-online":{"date-parts":[[2026,8,16]]},"reference":[{"key":"e_1_3_5_2_2","doi-asserted-by":"publisher","DOI":"10.1002\/ana.24483"},{"key":"e_1_3_5_3_2","doi-asserted-by":"publisher","DOI":"10.1002\/jhm.27410"},{"key":"e_1_3_5_4_2","doi-asserted-by":"publisher","DOI":"10.1002\/aet2.10102"},{"key":"e_1_3_5_5_2","volume-title":"Current Procedural Terminology (CPT) 2026 Professional Edition","author":"American Medical Association","year":"2025","unstructured":"American Medical Association. Current Procedural Terminology (CPT) 2026 Professional Edition. Chicago, IL: American Medical Association; 2025."},{"key":"e_1_3_5_6_2","doi-asserted-by":"publisher","DOI":"10.1002\/jhm.2379"},{"key":"e_1_3_5_7_2","doi-asserted-by":"publisher","DOI":"10.12788\/jhm.2898"},{"key":"e_1_3_5_8_2","doi-asserted-by":"publisher","DOI":"10.1111\/1475-6773.14097"},{"key":"e_1_3_5_9_2","unstructured":"Centers for Medicare & Medicaid Services. Revisions to consultation services payment policy. 2009. Medicare Claims Processing Manual Pub 100-04 Transmittal 1875 Change Request 6740. https:\/\/www.cms.gov\/regulations-and-guidance\/guidance\/transmittals\/downloads\/r1875cp.pdf. Accessed July 16 2026."},{"issue":"11","key":"e_1_3_5_10_2","first-page":"1","article-title":"Reporting CPT modifier 25","volume":"33","author":"American Medical Association","year":"2023","unstructured":"American Medical Association. Reporting CPT modifier 25. CPT Assistant. 2023;33(11):1-12. https:\/\/www.ama-assn.org\/system\/files\/reporting-CPT-modifier-25.pdf. Accessed July 16, 2026.","journal-title":"CPT Assistant"},{"key":"e_1_3_5_11_2","unstructured":"Centers for Medicare & Medicaid Services. Evaluation and management services. MLN006764. Medicare Learning Network. 2026. https:\/\/www.cms.gov\/files\/document\/mln006764-evaluation-management-services.pdf. Accessed July 20 2026."},{"key":"e_1_3_5_12_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.pediatrneurol.2026.05.019"},{"key":"e_1_3_5_13_2","doi-asserted-by":"publisher","DOI":"10.1002\/jhm.13180"},{"key":"e_1_3_5_14_2","doi-asserted-by":"publisher","DOI":"10.1002\/jhm.2283"},{"key":"e_1_3_5_15_2","doi-asserted-by":"publisher","DOI":"10.5698\/1535-7597-16.1.48"},{"key":"e_1_3_5_16_2","doi-asserted-by":"publisher","DOI":"10.1212\/WNL.55.5.616"},{"key":"e_1_3_5_17_2","doi-asserted-by":"publisher","DOI":"10.1212\/WNL.0000000000012032"},{"key":"e_1_3_5_18_2","doi-asserted-by":"publisher","DOI":"10.1097\/WNP.0000000000000166"},{"key":"e_1_3_5_19_2","doi-asserted-by":"publisher","DOI":"10.1097\/WNP.0000000000000165"},{"key":"e_1_3_5_20_2","doi-asserted-by":"publisher","DOI":"10.1097\/WNP.0000000000001120"},{"key":"e_1_3_5_21_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.clinph.2021.07.016"},{"key":"e_1_3_5_22_2","unstructured":"Physician Fee Schedule Payment for Services of Teaching Physicians. 42 CFR \u00a7415.172. Accessed July 16 2026. https:\/\/www.ecfr.gov\/current\/title-42\/chapter-IV\/subchapter-B\/part-415\/subpart-D"},{"key":"e_1_3_5_23_2","unstructured":"Centers for Medicare & Medicaid Services. Evaluation and management (E\/M) services. Medicare Claims Processing Manual Pub 100-04. Chapter 12 Section 100.1.1. https:\/\/www.cms.gov\/Regulations-and-Guidance\/Guidance\/Manuals\/Downloads\/clm104c12.pdf. Accessed July 16 2026."},{"key":"e_1_3_5_24_2","volume-title":"E\/M Service Documentation Provided by Students (Manual Update)","author":"Centers for Medicare & Medicaid Services","year":"2018","unstructured":"Centers for Medicare & Medicaid Services. E\/M Service Documentation Provided by Students (Manual Update). Medicare Claims Processing Manual; 2018. Pub 100-04, Transmittal 4068, Change Request 10412. https:\/\/www.cms.gov\/Regulations-and-Guidance\/Guidance\/Transmittals\/2018Downloads\/R4068CP.pdf. 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