# 20551 for multiple areas



## CBC

I'm seeking advice on billing for injection for lateral epicondylitis, as well as an injection into the knee tendon (not joint) for pain.  20551 for the elbow but can it be billed 2 x for the knee also?


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## LeslieJ

20551 is for trigger points into various muscles, just one or 2.  More than 2 muscles injected is 20552.  Both of these codes can be billed only a single time per encounter.

If your physician is injecting tendons, the code would be 20550 Injection(s); single tendon sheath, or ligament, aponeurosis (eg, plantar "fascia")

For the knee, this would work.

For the elbow, not sure that 20551 is correct.  For epicondylitis, they usually inject the joint or the bursa, which would be 20605 for the elbow for either.  Because it's an inflammation of the tendons, they may inject the tendon or tendinous insertion - in which case you have 20550.

The important thing to do is find out from the physician (and make sure it's documented!) what area is that needle going into?  What is the target of the medicine - nerve, tendon, muscle or joint/bursa?  Without this information documented, you'll be hard-pressed to support your choice of CPT codes.

If two different tendons in two different parts of the body are injected, you can code as follows:

20550  (elbow)
20550-59 (knee)

L J


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## dwaldman

I have used 20550 for tennis elbow injection in the past, because the documentation does not describe the injection at the tendon origin of the extensor carpi radialis brevis but just at the tendon in general. The below example from AMA CPT Changes supports 20551 because of the identification of the tendon origin site as the place of the injection. 

In regards to 2 injections at tendon origin sites in the knee. The note would have to have documentation of separate tendons at separate tendon origin sites.

Below is from 2004 AMA CPT Changes

▲20550 Injection(s); single tendon sheath, or ligament, aponeurosis (eg, plantar “fascia”)

▲20551 single tendon origin/insertion

▲20552 Injection(s); single or multiple trigger point(s), one or two muscle(s)

20553 single or multiple trigger point(s), three or more muscle(s)

(If imaging guidance is performed, see 76003, 76393, 76942)

Rationale

The injection codes 20550-20553 have been revised to clarify the intent of these codes, as related to multiple reporting of these services. In addition, the tendon injections and trigger point injections have been separated into two code families.

The tendon injection codes 20550 and 20551 are intended to be reported for multiple injections per single tendon sheath or ligament. Thus, multiple injections to the same tendon sheath or ligament would be reported only once per session, while injections to multiple tendon sheaths, tendon origins, tendon insertions, ligaments or aponeuroses would be reported for each injection. Code 20550 was also revised to include anatomical language in the descriptor.

The trigger point injection codes 20552 and 20553 are intended to be reported once per session, regardless of the number of trigger points or muscles injected.


Clinical Example (20550)

A 50-year-old woman presents with stenosing tenosynovitis of the right index finger which is treated with a steroid injection into its flexor tendon sheath.

A 46-year-old female diagnosed with plantar fasciitis, who has failed to respond to NSAIDs, modifications in shoe gear and stretching exercises, presents with plantar fasciitis of the right foot which is treated with a steroid injection into the plantar fascia.

Description of Procedure (20550)

The proximal edge of the A-1 pulley of the right index finger is located. The injection is given into the flexor tendon sheath.


The medial and lateral tubercles of the calcaneus are palpated and the point of maximum tenderness is identified. The medial and central bands of the plantar fascia are localized. A medial approach is utilized and the injection is given superficial to the plantar fascia.


Clinical Example (20551)

A 35-year-old man is treated for lateral epicondylitis with an injection into the origin of the extensor carpi radialis brevis (ECRB) on the lateral epicondyle.

A 35-year-old man is treated for peroneus brevis tendonitis of the left foot with an injection into the insertion of the peroneus brevis tendon at the base of the fifth metatarsal.

Description of Procedure (20551)

The region of the insertion of the ECRB on the lateral epicondyle is localized and injected.


The region of the insertion of the peroneus brevis tendon on the base of the fifth metatarsal is localized and injected.


Clinical Example (20552)

A 60-year-old female presents with a 3-month history of pain in the low left back above the posterior iliac crest with radiation of pain into the left buttock. Muscle relaxants, NSAIDs, and physical therapy have been ineffective in relieving her pain. She undergoes injection of the trigger point in the multifidus muscle left of the L5 spinous process.

Description of Procedure (20552)


After identification of the trigger point in the multifidus muscle left of the L5 spinous process by palpation, a needle is inserted through the skin into the muscle. The needle is advanced a short distance, about 2 to 4 centimeters, observing for any complaints of paresthesias but searching for the area of maximum tenderness. If any complaints or paresthesias are encountered, the needle is withdrawn slightly until they stop. Next the injectant solution is infiltrated in a fanwise method into the trigger point after aspiration is negative for blood.


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## dwaldman

I guess with my post I was thinking you were stating two knee tendon injections in addition to the elbow injection. Now that I re looked at it, I would agree with the previous post you received. There was no MUE (medically unlikely edit) I could find published for quantity allowed for 20551.


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## CBC

*Thank You - Multiple example code*

This rationale is very helpful! I have this one to go over with physician and would appreciate your advice:  Patient had injections on - bilateral greater trochanter bursa for bursitis - bilateral knee joints for OA - and bilateral knee ligaments for tendinopathy. (most injections I've seen) Not sure if knee area should be combined into 20610?  

Also, for the elbow (ECRB) for lateral epicondylitis and knee tendon (will confirm insertion or sheath) looks like I can code 20551 & 20551 (59) ?

Thank you again and any reference sugguestions would be appreciated.


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## johnmeyer

And I though I've coded several injections (max I think was 4)...  LOL

I do a lot of knee/hip coding, but very little elbow (our hand/wrist up to the elbow provider is rarley in my clinic).

I know you can code 20610 for both greater trochanteric bursitis and knee OA injections; this is what my providers do.

You could use 20550 or 20551 for the knee ligament injections if either the tendon sheath or origin was injected.


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## dwaldman

CBC,

Code 20551 is a component of Column 1 code 20610 but a modifier is allowed in order to differentiate between the services provided. 

Code 20550 is a component of Column 1 code 20610 but a modifier is allowed in order to differentiate between the services provided

Above is CCI check on the information you provided. And it appears for the same knee that they bundle a tendon or tendon origin/insertion injection into the joint injection and it is my belief for the same knee it would be bundled and the modifier 59 would be only for contralateral knees if performed.

I think for the second part of your question the documentation has to support tendon origin/insertion not just tendon sheath to report 20551.


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## dwaldman

Code 20551 is mutually exclusive to code 20550 but a modifier is allowed in order to differentiate between the services provided. 

If turned out to be tendon sheath for one of the injection and tendon origin/insertion for the other. Since the elbow and knee would meet the definition of separate anatomical site then 20551-59 20550 could be reported. If they both were tendon origin with separate sites so carriers might allow quantity two; for example, WPS Medicare J5 only allows modifier 59 with codes that have NCCI bundling issues the last time I had dealt with that issue with them and requested quantity for procedures of the same CPT that were performed multiple times.


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## CBC

True Blue - thank you for your response!  You gave me a logical perspective on this coding scenario.  I'm new to pain mgt and so many injections.  I also just receive an injection to the rt trochanter bursa, as well as a trigger point to the rt SI area.  This also looks like the same anatomical site.  (20610) Thank you again for the input!


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## dwaldman

CBC, I think they could be seen as separate areas. From the previous treatments I have seen they are for separate conditions and separate locations. So I think you could report both but just an opionion.


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