Coding Coach - Physiatry/Pain

June 9, 2016

Question:
As a pain management physician, I perform spinal injections for pain management. What information should be documented in my procedure notes?

Answer:
When reporting spinal injections, documentation for each procedure should include (1) the approach (epidural, transforaminal, facet); (2) what is injected (anesthetic, steroid, contrast, neurolytic agent); (3) regions treated (cervical, thoracic, lumbar, sacral); (4) the number of levels treated and; (5) unilateral or bilateral.

*This response is based on the best information available as of 06/09/16.