Billing and Coding: Epidural Steroid Injections for Pain Management

1. All documentation must be maintained in the patient's medical record and made available to the contractor upon request. 2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient. 3. The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed. 4. SNRBs and TESIs: The procedural report should clearly document the indications and medical necessity for the injections, along with the baseline pain score. SNRBs only: The procedural report should include the baseline pain score and percent (%) pain relief achieved immediately after the injection. 5. Films that adequately document (minimum of two views) final needle position and contrast flow should be retained and made available upon request. 6. The patient’s medical record should include, but is not limited to: - The assessment of the patient by the performing provider as it relates to the complaint of the patient for that visit. - Relevant medical history. - Results of pertinent tests/procedures. - Signed and dated office visit record/operative report (Please note that all services ordered or rendered to Medicare beneficiaries must be signed). 7. Documentation to support the medical necessity of the procedure(s).