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:

Check Brief Description

Practitioner progress notes

  • Support at least 3 months of moderate to severe pain
  • Pain level and ADL limitations
  • Prior and current medical and functional conditions and comorbidities
  • Support percentage of pain relief obtained from initial injection
  Medication Administration Record (MAR) and/or infusion flowsheet documenting the quantity administered include a dose, route, and frequency given
  Operative/procedure report
  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.

Documentation Submission

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.

View the Drugs, Biologicals and Injections webpage for additional information and resources.


Last Updated Dec 09 , 2023