Payers usually have guidelines and/or policies on this. Did you check your policy? Normal documentation requirements would have to be met. Also, check to see if there is a CPT Assistant Article or Auditor's Desk reference about these. If you or someone has access to APTA:
https://www.apta.org/apta-magazine/...1/considering-providing-dry-needling-services
I am assuming due to your screen name it would also follow this:
https://www.modahealth.com/-/media/modahealth/shared/Provider/Policies/RPM039.pdf
This is from a
retired CMS article talking about trigger points but the idea is the same
as an example:
Documentation Requirements:
The patient's medical record must contain documentation that fully supports the medical necessity for services included within the LCD. (See "Indications and Limitations of Coverage.") This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
A procedure note must be legible and include sufficient detail to allow reconstruction of the procedure. Required elements of the note include a description of the techniques employed, and sites(s) of injections, drugs and doses with volumes and concentrations as well as pre- and post-procedural pain assessments.
For the treatment of established
trigger point, the patient’s medical record must clearly document:
- The evaluation leading to the diagnosis of the trigger point in an individual muscle, as detailed in the “Indications and Limitations of Coverage and/or Medical Necessity” section of this LCD;
- Identification of the affected muscle(s);
- Reason for selecting the trigger point injection as a therapeutic option, and whether it is being used as an initial or subsequent treatment for myofascial pain.
For
injections of tendon sheaths, ligaments, ganglion cysts, carpal and tarsal tunnels, the medical record must include a procedural note documenting the reason for the injection at any particular site. If multiple sites are injected, documentation to substantiate that all the injections are reasonable and necessary must be present.
This is general guidance from CMS:
https://www.cms.gov/outreach-and-ed...wnloads/certmedrecdoc-factsheet-icn909160.pdf
Old NGS example see pg 37:
https://www.ngsmedicare.com/documen...a-61a9-d1f5-9b1f-853c04ac102d?t=1670356263777
State scope of practice rules also have to be considered, and because these live in the "surgery" section of the CPT book it has to meet procedure note requirements and consent.
Example below pulled from here:
https://dchealth.dc.gov/release/policy-statement-guidance-dry-needling-practice-physical-therapy
A physical therapist who performs dry needling procedures should obtain written informed consent from each patient that will receive dry needling, and should provide the patient with a copy of the informed consent form prior to performing the procedure.
• The
informed consent form should include: the patient’s signature, the risks and benefits of dry needling, the physical therapist’s level of education and training in dry needling, and a clearly and conspicuously written statement that the patient is not receiving acupuncture. It should further advise the patient that acupuncture treatment, as performed by a licensed acupuncturist, might yield a holistic benefit not available through a limited dry needling treatment.
•
A physical therapist who performs dry needling procedures should maintain a separate procedure note in the patient’s chart for each treatment and the note must indicate how the patient tolerated the technique as well as the outcome after the procedure.
• A physical therapist that performs dry needling procedures must be able to produce documentation of meeting these requirements upon request by the board or an agent of the board as proof that the physical therapist is practicing within the scope of practice of physical therapy.