2022 ASC Coding Tips: Spine & Pain Management Clinical Documentation

By Mandeara Frye, RHIA, CPC, CPMA, CASCC, Senior Director, Coding

Missing information in an operative report is a common cause of billing delays. If the documentation needed for coding is missing or unclear, the coder must initiate a physician query to obtain the information. The tips below, focusing on the spine and pain management procedures, will help reduce the number of queries required, increase overall compliance, and secure optimal revenue for your ASC.

Diagnoses — Ensure all diagnoses are appropriately documented to the highest level of specificity. Additional tips:

• The level of disc disease, spondylosis, stenosis, etc., should be documented to the specific spinal region (thoracic, lumbar, lumbosacral, etc.).
• Cervical disc disorders require further specification of the disc level(s) involved (C2-3, C4-5, etc.).
• Complex regional pain syndrome (CRPS) must be documented as type 1 or 2 and include the laterality and location (e.g., CRPS type 1 left leg).

Bilateral pain injections — Document the levels and techniques used on each side.

Genicular nerve interventions — Specify all nerve branches treated (common peroneal, femoral, obturator, saphenous, tibial).

Exparel — Even if injected by the anesthesiologist, the physician should note in their operative report the amount (mg) and location injected.

Platelet-rich plasma (PRP) injections — If autologous, include the source and location.

Spinal autografts — Document the location the graft is harvested from and if a separate incision is made.

Spinal fusions — Clearly document all hardware placed with appropriate descriptions, such as cages, allograft types, plates, and screws.

Neurostimulators — Ensure your center is familiar with your state’s local coverage determination (LCD) requirements. Some states require a chronic pain syndrome to be documented while others do not. For states with such a requirement, a failure to comply can lead to denials and missed revenue.