Checklist: Paravertebral facet joint injection services documentation
This checklist is intended to provide health care providers with a reference for use when responding to medical documentation requests for paravertebral facet joint injection services. It is not intended to replace the published guidelines. Health care providers retain responsibility to submit complete and accurate documentation.
| Check | Documentation description |
|---|---|
| Documentation is for the correct beneficiary and date (s) of service. | |
| Documentation is complete, legible, signed and dated by a physician or clinician. | |
| Documentation contains a valid physician’s order for date(s) of service when medication(s) were administered, to include the medication name, dosage, frequency, and method of administration. | |
| Medication administration record for dates of service include the medication name, dosage, method of administration, and start / stop times for infusions (when applicable). | |
| Documentation to support the amount of drugs or biologicals discarded (single use packaging) for the relevant beneficiary (when applicable). | |
| Documentation supports a medically reasonable information of the service(s) that includes relevant pre-procedure documentation (e.g., history and physical examination, progress notes, laboratory / diagnostic testing results, etc.). | |
| Documentation for the procedures, operative reports, and anesthesia reports (when applicable). | |
| If billing incident to services, the documentation to support appropriate supervision (billing physician is present in the room during the performance of procedure). | |
| Documentation meets criteria specified in national coverage determinations (NCDs) and local coverage determinations (LCDs). | |
| Documentation includes an advanced beneficiary notice (ABN) of non-coverage was provided (if applicable and required). | |
| Any additional documentation to support medical necessity or any applicable policy guidelines for the services billed. |
Disclaimer
This checklist was created as an aid to assist providers. This aid is not intended as a replacement for the documentation requirements published in national or local coverage determinations, or the CMS documentation guidelines. It is the responsibility of the provider of services to ensure the correct, complete, and thorough submission of documentation.