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Anesthesia Coding Alert

Reader Question:

Check Local Policies to Guide Pain Score Documentation

Published on Thu Apr 12, 2012

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 SubscriberAnswer: 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 [...]
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