Article Detail - JE Part A

Proper documentation is essential to demonstrate the medical necessity of facet injections and ensure compliance with Medicare guidelines. Providers are expected to maintain records that clearly reflect the need for the care and services provided.

Noridian offers a Facet Injection Documentation Checklist  to help streamline this process. While the list is not all-inclusive, it highlights key elements that should be included in the patient’s medical record. Submitting complete and accurate documentation helps prevent delays and supports appropriate reimbursement.

Examples of records that may be required include:

• Practitioner progress notes supporting at least three months of moderate to severe pain
• Operative/procedure report
• Pre-procedure conservative measures/treatments
• Medication Administration Record (MAR) and/or infusion flowsheet documenting quantity administered including dose, route, and frequency given