Documenting the Initial Pain Assessment

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August 9, 2018

Question:
What needs to be documented for the initial assessment for a pain management patient to support medical necessity for interventional pain management procedures?

Answer:
To support medical necessity, documentation should include the site of pain, along with the severity of pain (pain scale 0-10.  It is important to also document the methods of conservative treatment that has be tried and failed which includes nonsteroidal anti-inflammatory drugs, physical therapy etc..  A full pain assessment should be documented including a comprehensive history and examination of the musculoskeletal and/or neuro systems.  There should be a complete assessment and plan of care including the number of anticipated or planned injections, frequency and any other alternative treatment options.  The results of any diagnostic tests performed should be documented along with diagnoses that are specific to the condition treated.

*This response is based on the best information available as of 08/09/18.

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