Documenting Medical Necessity for Pain Management Services

Claim Denials Due to Poor Documentation

Pain management billing is been regulated by various agencies like the federal government, medical boards, state government as well as many other regulatory agents. While billing for pain management, physicians follow applicable billing guidelines and payer-specific policies to ensure accurate insurance reimbursement. Still, pain management claims might get denied due to inaccurate documentation. Proper documentation of all medical services with corresponding medical codes and appropriate bills are important aspects of pain management billing. While coding pain management services physicians face various challenges, some of them include: reflecting medical necessity; portraying the location of pain; specifying the degree and type of pain; and following payer-specific documentation guidelines. In this article, we will be focussing on of the documentation challenge i.e., documenting medical necessity for pain management services.

Documenting Medical Necessity for Pain Management Services

In pain management services the most important deciding factor for reimbursement is the medical necessity for any medications or procedures. But for patients with chronic pain and other related illnesses, deciding the medical necessity of any treatment and then reporting it in the medical records can be a difficult task. Government and private insurance will reject any reimbursement claims for treatments that do not justify the medical necessity.

For accurately documenting the medical necessity for pain management services, the severity or degree of pain must be portrayed accurately in order to justify the care provided. Other information such as the history of previous trauma or imaging findings can be supplemented with the pain description to state medical necessity. We shared basic Medicare guidelines that will help to document medical necessity appropriately.

  • The patient’s medical record must contain documentation that fully supports the medical necessity for services. This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
  • A procedure note must be legible and include sufficient detail to allow reconstruction of the procedure. Required elements of the note include a description of the techniques employed, and sites(s) of injections, drugs, and doses with volumes and concentrations as well as pre-and post-procedural pain assessments.
  • For injections of tendon sheaths, ligaments, ganglion cysts, carpal, and tarsal tunnels, the medical record must include a procedural note documenting the reason for the injection at any particular site. If multiple sites are injected, documentation to substantiate that all the injections are reasonable and necessary must be present.
  • For SI joint injections specific requirements must include, documenting the total amount of injectate for all medications used. The amount of injectate should be such that the synovial lining of the joint is not burst and the injectate does not disperse beyond the confines of the target joint.
  • For the treatment of the established trigger point, the patient’s medical record must clearly document:
    • The evaluation leading to the diagnosis of the trigger point in an individual muscle, as detailed in the payer policy.
    • Identification of the affected muscle(s);
    • Reason for selecting the trigger point injection as a therapeutic option, and whether it is being used as an initial or subsequent treatment for myofascial pain.

Pain management can be a stressful area in healthcare as patient volume is constantly rising. Millions of people suffer from chronic pain globally. The estimated cost for the management of chronic pain in the US alone is more than $600 billion. Managing chronic pain can be tricky as patients may often not respond adequately to treatment. As physicians are already burdened with care management, putting the additional weight of insurance reimbursement could be frustrating. Associating with medical billing company could help physicians to focus on patient care while their billing partner handles the challenge of timely and accurate insurance reimbursements.

Medical Billers and Coders (MBC) is a leading medical billing company providing complete revenue cycle services. We can manage complete billing services so that you can focus on patient care only. To know more about our pain management billing and coding services, email us at: or call us at: 888-357-3226.