Documentation of medical services is necessary to provide information to assist health care professionals in providing services to patients which are medically necessary. Apart from helping in medical billing and coding, it also reflects the competency and character of the physician. Even though the role played by documentation has always been a supportive one, it’s critical. Documentation is considered a cornerstone of the quality of patient care and its specifically true for pain management services.
Documentation in physicians’ offices, hospital settings, ambulatory surgery centers, rehabilitation centers, and other settings must be accurate, complete, and reflect all of the services provided during each encounter. In this blog, we discussed a few basic elements which will help in improving documentation for pain management services
Basic Elements for Improving Documentation for Pain Management Services
Verifying Medical Necessity
Medical necessity requires appropriate diagnosis and coding by the International Classification of Diseases, Ninth Revision, and Clinical Modification (ICD-10-CM) to justify services rendered and indicate the severity of a patient’s condition.
The Balanced Budget Act requires all physicians to provide diagnostic information for all Medicare/Medicaid patients. Physicians are required to code by listing the ICD-10-CM diagnostic codes shown in the medical record to be chiefly responsible for the services provided. Coding should be to the highest degree of certainty for each encounter.
Medical necessity is defined in numerous ways. The Centers for Medicare and Medicaid Services (CMS) defines medical necessity in these terms: “no payment may be made under Part A or Part B for any expense incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a participant.”
The American Medical Association (AMA) defines medical necessity as, “health care services or procedures that a prudent physician would provide to a patient for the purpose of preventing, diagnosing, or treating an illness, injury, disease, or its symptoms in a manner that is in accordance with generally accepted standards of medical practice, clinically appropriate in terms of type, frequency, extent, site, and duration, and not primarily for the convenience of the patient, physician, or other health care provider.”
List of Documents for Pain Management
The following list is not exclusive, the basic principle is patient’s medical records reflect the need for care/services provided. Providers must ensure all necessary records are submitted to support services rendered. They may include:
- Beneficiary identification, date of service, and provider of the service should be clearly identified on each page of the submitted documentation
- Practitioner, nurse, and ancillary progress notes
- Operative/procedure report
- History and Physical reports (include medical history and current list of medications)
- Vital sign records, weight sheets, care plans, treatment records
- Documentation supporting the diagnosis code(s) required for the item(s) billed
- Documentation to support the code(s) and modifier(s) billed
- List of all non-standard abbreviations or acronyms used, including definitions
- Documentation to support National Coverage Determination (NCD), Local Coverage Determination (LCD), and/or Policy Article
- Signature log or signature attestation for any missing or illegible signatures within the medical record (all personnel providing services)
- Signature attestation and credentials of all personnel providing services
- If an electronic health record is utilized, include your facility’s process of how the electronic signature is created. Include an example of how the electronic signature displays once signed by the physician
- Advance Beneficiary Notice of Non-Coverage (ABN)/Notice of Medicare Non-Coverage (NOMNC)
Maintaining Documentation Standards
Simple, yet extremely important standards of documentation must be followed.
- All entries must be dated with month, day, and year.
- Every page in the chart should be patient-identified.
- Medical records should always be documented in permanent ink (not with a pencil).
- The summary sheet should have identifying information, height, weight, medication list, previous surgeries, and diagnosis.
- All telephone calls must be documented.
- All documents contained inside the chart should belong to that particular patient.
- All additions and corrections should be documented clearly with the date and signature.
- Incorrect entries should be crossed out with a single line with rewriting of the correct entry.
- The credibility of notes written more than 24 to 48 hours after the care was rendered is considered suspect.
- Document all health risk factors, including allergies and adverse reactions to medications, foods, or other substances.
- A document that sufficient information was provided with samples and prescriptions.
- Medical necessity for all diagnostic services or tests and for all procedures and interventions must be established.
- Documentation of follow-up treatment dates for coordination of services and of the time for services based on time is crucial.
Timely, accurate documentation is essential in establishing quality care provided. It helps to eliminate discrepancies and inaccuracies and improves medical coding to the highest level.
We shared a few elements of pain management documentation for reference purposes. In case of professional assistance is needed you can refer to our revenue cycle management services.
Medical Billers and Coders (MBC) is a leading revenue cycle company providing complete medical billing and coding services. To know more about pain management billing services, contact us at info@medicalbillersandcoders.com/ 888-357-3226
Reference:
Description of Documentation in the Management of Chronic Spinal Pain
FAQs
1. Why is medical necessity important in pain management documentation?
Medical necessity justifies the services rendered and ensures the correct diagnosis and coding. Accurate documentation of the patient’s condition is essential for claim approval and reimbursement.
2. What are some key documents needed for pain management services?
Key documents include patient identification, history and physical reports, operative/procedure reports, and progress notes. All documents should support the diagnosis and services provided.
3. What documentation standards should be followed for pain management?
Documentation must be dated, patient-identified, and written in permanent ink. Entries should be clear, with any corrections or additions documented properly with date and signature.
4. How does timely and accurate documentation improve billing for pain management?
Timely, accurate documentation ensures correct medical coding, reduces errors, and supports claim approvals. It helps eliminate discrepancies, preventing claim denials and speeding up reimbursement.
5. How can Medical Billers and Coders (MBC) assist with pain management billing?
MBC offers expert billing and coding services to ensure accurate documentation and compliance with payer guidelines. Our services help streamline your revenue cycle and improve reimbursement rates.
