Spinal Injection Procedure Note Template

This template covers facet joint injections, medial branch blocks, radiofrequency ablation and epidural steroid injections. It opens with the procedure, levels and laterality including the modifiers that apply, then moves through medical necessity, the procedure itself with imaging guidance and sedation, the immediate outcome with percent relief, and the attestation. Medical necessity comes first because that is the section coverage turns on.

Every field in the medical necessity section maps to something a Local Coverage Determination asks for. Conservative therapy with type, duration and outcome. Pain and function scores on named instruments such as NRS, VAS, ODI or PROMIS, because CMS requires the scale used to be documented. Imaging correlating with the level treated. And the requirement almost nobody knows about: for therapeutic injection procedures, documentation of why the patient is not a candidate for radiofrequency ablation must be submitted. The page also notes that where multiple levels are treated the medical necessity of each must be documented separately, that sedation is generally not considered medically necessary for facet joint interventions so its use must be justified, and that modifier KX attests the policy requirements were met, which means the record has to meet them. Optimized for use with Sully.ai's AI medical scribe, it helps streamline note-taking and improve clinical efficiency.