GML-04 - Documentation for Interventions: Covering the Operating Room and Clinic Settings

Learning Objectives:

• Identify the key documentation elements required for interventional pain procedures in both the operating room and clinic settings, ensuring alignment with medicolegal and reimbursement standards.
• Differentiate between clinical, procedural, and billing documentation requirements to optimize compliance with CMS, private payer, and malpractice protection guidelines.
• Apply structured documentation templates and workflows to improve accuracy, efficiency, and defensibility in procedure notes, including fluoroscopic-guided interventions and neuromodulation procedures.
• Evaluate common documentation deficiencies and audit triggers in pain practices, with strategies to mitigate risk and enhance coding compliance.
• Integrate best practices for real-time documentation during interventions, including consent, time-outs, intra-procedural findings, and post-procedure plans, to support high-quality patient care and audit readiness.