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Facet Joint Injection Documentation requirements

Date: Dec 13, 2018

Question:

We have a pain clinic that is currently doing facet joint injections. The pain level that is being reported is a level 2, but per Medicare criteria the pain level needs to be a 3 or higher. Can we still bill for the procedure? Also the pre and post pain is not being documented on the procedure note; it is being notated on a separate nurse note. Is that documentation acceptable to use, or does it need to be noted on the procedure note?

Question ID : 11743
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