Anesthesia Coding Alert

Question: I am having a debate with my physician regarding what he needs to document in his injection notes. He does not think he needs to document the pre- and post-injection pain score/exam because it's an intraarticular steroid injection, not a diagnostic facet block with lidocaine. He also states the same for radiofrequency ablation (RFA). I believe the scores should be documented. Who's right?

Louisiana Subscriber

Answer: You should be able to find the answer in the LCD (local coverage determination) policy for the Medicare contractors you're billing. Some list the pain scores as a requirement, but others don't.

For example, consider this statement regarding RFA from WPS Medicare: "The effects of denervation should last from six months to one year or longer. In some instances the effects may be permanent. Repeat denervation procedures at the same joint/nerve level will only be considered medically necessary when the patient has had significant improvement of pain after the initial facet joint nerve destruction that lasted an appropriate period of time (greater than or equal to six months)." Pre- and post-injection pain scores can help establish the medical necessity and document improvement.

Also check (and print out) the policies for your commercial payers. Create an overview of the documentation requirements for your primary payers, and give it to your physician as a reference. Be prepared to provide the full medical policies if asked.

Last but not least, you may want to check with your practice's medical malpractice carrier to see if they have any feedback on what should be included in procedure documentation. They have a vested interest in having your provider accurately document his services.