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For Complete Documentation A minor procedure, such as PBM, is documented in the medical record with a report that includes: Date of service Patient nameDiagnosis Proceduralists name Title of procedure Indication for the procedure Description of the procedure Discharge instructions Signature per payor guidelines Payor Coverage The directions for use for the Valeda Light Delivery System (LumiThera) 16 provide the needed information to establish which ICD-10 codes would support payment for PBM ( Table 2 )

However, once present, it can have debilitating consequences