Checklist: Epidural steroid injection services documentation

Documentation is for the correct beneficiary.

Documentation is for the correct date(s) of service.

Documentation contains a valid and legible signature, which follows CMS Signature Guidelines for Medical Review Purposes.

Documentation supports relevant pre-procedure documentation related to indication for injection (i.e., relevant medical history, assessment/physical examination, progress notes, pertinent testing/procedure results, conservative treatment(s), etc.).

Documentation of the procedural report that clearly document the indications and medical necessity for the blocks along with the pre and post percentage pain relief achieved post-injection utilizing the same scale.

Films and/or interpretations that adequately document (minimum of two views) final needle position and contrast flow utilizing computed tomography or fluoroscopy image guidance.

When contrast usage is contraindicated; documentation to support evidence of contrast allergy or pregnancy.

Documentation to support "incident to" guidelines (if applicable), that includes evidence of billing provider's presence in the office suite, initial assessment and ongoing participation/management of the patient's care.

Documentation includes an advanced beneficiary notice 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.