Follow these tips for compliant injection documentation.

Anyone who has perused the 1995 or 1997 evaluation and management (E&M) guidelines knows that the rules for appropriately documenting E&M visits are extensive. But there are also rules you shouldn’t overlook for documenting procedures — even minor office procedures, such as injections. With the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) and local carriers on the lookout for improper billing of these services, it’s a good idea for you and your providers to brush up on the requirements for injection billing. A good place to start is with your carrier or Medicare administrative contractor (MAC) local coverage determination (LCD). Most of these policies include documentation requirements. For example, here are the documentation requirements from a CIGNA LCD for joint injections (L15602): “Office records including procedure notes should be maintained. Medical necessity of the procedure(s) must be clearly documented and provided to Medicare upon request. The records must clearly indicate the specific anatomical site injected, the drug(s) used in the injections and, if appropriate, the number of injections given. Records must clearly state the medical necessity for repeat injections.” Make sure you are following procedurespecific carrier documentation rules. Trailblazer, for example, requires the following in its pain management LCD (L26743): “Preprocedural evaluation leading to suspicion of the presence of facet joint pathology must be explicitly documented in the patient’s medical records, along with postprocedural conclusions. “When using code 729.1 with [current procedural terminology] codes 20552 and 20553 for trigger point injection, medical documentation must be clearly maintained noting the anatomic location of the injection site(s).” In addition to LCDs, payers sometimes publish articles on the subject of documentation. For example, a 2008 article on the National Government Services (NGS) Web site warns against illegible documentation and “cookie cutter” physician notes “where all patients are getting the same procedure, with the same complaint, the same findings and the provider is treating them all with the same exact plan of care” — a typical pitfall of some electronic medical records systems.