Spinal Injections


June 9, 2016

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

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.

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