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

 

Advanced 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 Thu, 15 Jul 2021 16:17:16 +0000