Description of Documentation in the Management of Chronic Spinal Pain

Abstract

Documentation assists health care professionals in providing appropriate services to patients by documenting indications and medical necessity, and reflects the competency and character of the physician. Documentation is considered a cornerstone of the quality of patient care. This is nowhere more true than in interventional pain management. Thus, 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. 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.” Documentation requirements include an appropriate medical record utilizing recognized and acceptable standards of documentation and an established process. However, the evolution of electronic medical records (EMRs) or electronic health records (EHRs) nullifies many of the issues faced in handwritten documentation. Multiple types of documentation include evaluation and management services and documentations in ambulatory surgery centers, hospital outpatient departments, and in office settings, specifically while performing interventional procedures. Evaluation and management services incorporate 5 levels of service for consultations and visits, with multiple key elements of service including history, physical examination, and medical decision making. Documentation of interventional procedures in general requires a history and physical, indication and medical necessity, intra-operative procedural description, post-operative monitoring and ambulation, discharge, and disposition. With minor variations, these requirements are similar for an in-office setting, hospital out patient department, and ambulatory surgery centers. Key words: Documentation, billing, coding, compliance, fraud and abuse, interventional techniques, evaluation and management services, office visit, consultation, new patient, established patient