# Coding for office visit and trigger point injection same visit



## chrislcz (Aug 16, 2016)

Looking for a little clarification. I am getting conflicting information on billing for trigger point injections. Does anyone know if we should be billing an established patient office visit any time a patient gets a trigger point injection? I have been told just to bill the injection and I have read that I should be adding an office code with a modifier 25. Any insight would be greatly appreciated. Thanks!


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## Chelle-Lynn (Aug 16, 2016)

The billing of an E&M in addition to a 20552-20553 would be based on the documentation and whether or not it meets the criteria for the use of modifier 25.  

Modifier 25 =  Is used when a procedure is performed and the provider performs a significant, separately identifiable E/M service – a service above    and beyond the other service provided, or beyond the usual preoperative and postoperative care associated with the procedure that was performed.

Remember that all procedures have a certain amount of evaluation and management built into them.  If the treatment was "pre-scheduled" and there was no significant interval history or examination change, and the follow-up treatment remained unchanged, then it would not be appropriate to bill an E&M in addition to the trigger point injection.

If you have details from the documentation it might clarify if the use of the E&M and modifier 25 is appropriate.


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