Evaluation and Management (E/M) Documentation Template for Ovarian Vein Embolization in Chronic Pelvic Pain

The evaluation of chronic pelvic pain for ovarian vein embolization documentation templates was developed by the Society of Interventional Radiology (SIR) Carrier Advocacy workgroup to support interventional radiologists in producing comprehensive, guideline-aligned IR consultation documentation. 

These templates help physicians efficiently document medical necessity, complexity of medical decision-making, and procedural justification in a structured format aligned with payer expectations. By standardizing key elements of E/M documentation, they support appropriate coding, strengthen prior authorization submissions, and reduce variability that can lead to denials. 

The templates are designed for ease of use and future integration into Electronic Medical Record (EMR) systems.  If you are using EPIC EMR, it is available for download through the EPIC user web and can be located by searching PeVD or the University of Cincinnati templates. 

A subscription model applies to this product. The text, graphics, and information are of a general nature; it is not a substitute for obtaining medical advice. We may update the documents at any time without prior notice.

Important Use Notice:

This template is provided as a Microsoft Word document to support ease of use and integration into clinical workflows. To preserve the integrity of the content and alignment with SIR guidance, the template should not be altered. Any modifications made to this document are at the discretion of the user, and the user assumes full responsibility and risk for any changes, including impacts to documentation, coding, or reimbursement outcomes.