# Documentation requirements for 01996



## mray32 (Nov 20, 2008)

Does anyone know the Medicare documentation requirements for a physician performing epidural daily management 01996? And, if you could point me to the policy online. Thanks.


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## jdrueppel (Nov 24, 2008)

Melissa,
I saw this in the Anesthesia threads last week and was hopeful someone would respond saying yes I have and here they are.....no such luck.  So here's what I know.

I've been billing anesthesia for 18 years and have never seen industry wide 01996 documentation guidelines.  The only documentation I have ever found is within our BCBS of Nebraska billing guidelines stating the service should be documented in the progress notes but it states nothing of the required content of the documentation.

My providers use an Acute Pain Record form to indicate charges (each form has 10 lines for 10 days of rounds - a second form can be started if, on the rare occasion, an epidural is left intact beyond 10 days) and actually document the "pain round" hand written in the progress notes.  This acute pain record is then checked against the chart in the electronic medical record to confirm documentation of each round.

Julie, CPC


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