Facet Injection Documentation Requirements - JF Part A
Facet Injection Documentation Requirements
It is expected that the patient’s medical records reflect the need for care/services provided. The listing of records is not all inclusive. Providers must ensure all necessary records are submitted to support services rendered. They may include:
Practitioner progress notes
|Medication Administration Record (MAR) and/or infusion flowsheet documenting the quantity administered include a dose, route, and frequency given
|Documentation of pre-procedure conservative measures/treatments
|Clinical indication/medical necessity for the injection
|Advance Beneficiary Notice
|Signature log or signature attestation for any missing or illegible signatures within the medical record (all personnel providing services)
|Facility process of how electronic signature is created if using electronic health record
Multiple CMS contractors are charged with completing reviews of medical records. See Identifying Which Entity Completed a Part A Claim Review for detailed information about each of these contractors.
Once a provider compiles all the necessary documentation, it is important to submit them to the appropriate contractor according to the request received. Select the request below to view the appropriate submission instructions.
- Noridian Medical Review: Additional Documentation Request (ADR)
- Comprehensive Error Rate Testing (CERT): CID Request
- Level One Appeal: Redetermination Request
View the Drugs, Biologicals and Injections webpage for additional information and resources.