Essentials of documentation in interventional pain medicine

Documentation in interventional pain medicine is an important, and, at times, most crucial facet of practice. For physicians, documentation has always meant providing information or evidence on multiple issues, including evaluation and management services, procedural services, billing and coding. With the increasing sophistication and complexity of interventional medical practices, the need to record specific clinical data has grown in importance. Documentation reflects competency, character and caring of the pain management specialists. The Office of the Inspector General reported overpayments of $23.3 billion in 1996, $20.3 billion in 1997, $12.6 billion in 1998, $13.5 billion in 1999, $11.9 billion in 2000, and $12.1 billion in 2001 in health fraud. Thus, the government has been increasing its efforts to prevent fraud and abuse by reducing the error rate for Medicare-fee-for-service and by improving documentation. Documentation errors have contributed to 70% to 80% of the errors. This review describes various elements of documentation, documentation standards and the government's perspective on documentation, as well as the process of documentation.