# your expertise on trigger point injections-help please



## Justarose (May 29, 2009)

Here is what I always have to work with on this doc .. .I am told that if he gives a side anywhere on this "h/p op" that should be good enough ? 

Please take a look and tell me how you would code this?  ... 

trigger point 20552  x 3 ??  thats what the doc says ... 

should a -59 be used ? 
_______________________________________________
CHIEF COMPLAINT:	Right shoulder and intermittent arm pain. 

DIAGNOSIS:	Cervical degenerative changes with impingement on the cord from C3 down to C7, greatest at C5-C6. 

HISTORY AND PHYSICAL

HISTORY OF PRESENT ILLNESS:  The patient is a 52-year-old white female who I saw about a week and a half ago injected her at C5-C6 and states she got absolutely no relief from that.  She did not feel any difference she states even though we got a good picture and epidurogram with good placement of the steroids.  The pain is in the shoulders some and having her come back just to see if there are some trigger points that we need to inject for her.  

PHYSICAL EXAMINATION: 
She has three different trigger points in her trapezius and rhomboids that I can inject and she is otherwise strong in her biceps and triceps.  

PROCEDURE NOTE

DESCRIPTION OF PROCEDURE:  I do think we may need to do a cervical epidural on her again.  I think it would be worth a try to do another one, but she wasn't up for it today, so we just took about 20 mg of Kenalog and about 10 cc of 0.5% bupivacaine and 27-gauge 1/2-inch needle in a fan-like distribution and injected around these three different trigger areas to relieve her pain in her shoulder.  We let her sit for a while.  She was feeling at least 50-75% better after trigger point injections. 

IMPRESSION/PLAN:  The patient is a 52-year-old white female with cervical degenerative changes as above,  probably greatest at C5-C6.  I think we will inject there again eventually but I am going to talk to Dr. x and we will get her back into physical therapy and work her a little bit and maybe inject her after that.  The only reason I would want to inject again is that she is still having this radicular pain into her arms, it is pretty significant at times and I think we might be able to cool that down even though the first one did not work too well.  If we did a second one and it did not work then we would know that we cannot advance on any further with the injections.  She is not tolerating the steroids very well and her blood pressure has been up, although it is little better today at 169/90.  I did instruct her to get back with Dr. x on that.  I will discuss with Dr. x who will get back with the patient.  


DISCHARGE SUMMARY:  The patient was admitted for the above described procedure.  The patient tolerated the procedure well without complications.  When discharge criteria had been met, the patient was discharged in good condition in the care of a responsible adult with standard discharge instructions and medications.


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## mbort (May 29, 2009)

sorry but all he gets is 20553 (2 CPT assistants below that reference this):



Year: 2003 

Issue: September 

Pages: 11 

Title: Trigger Point Injections (September 2003) 

Body: Coding Communication:Trigger Point Injections

Centuries ago, the Chinese developed various therapies to alleviate pain in the muscles and surrounding tissue areas. With the advancement of medicine, these methods of treatment have come a long way. While old therapies may be obsolete, variations of the techniques and treatment delivery continue to evolve. Some common examples of pain control injections performed today are known as trigger point injections, trigger point therapy, or pressure point therapy.

In order to clarify and assist in accurate coding of these injections, codes 20552 and 20553 were revised for CPT 2003. Before we discuss the revisions for 2003, we will explain a trigger point, a trigger point injection, some common causes of trigger points, and how trigger points are managed. We will also provide some examples of intra-service work of a typical treatment session.

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

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

You may ask, what exactly is a trigger point and what is involved in a trigger point injection? To begin with, a trigger point is an area of highly sensitive soft tissue within a muscle or around muscles that may cause pain and tenderness. The trigger point is often described as a painful knot or tight band of muscle fiber. When a healthy muscle is active, the muscle will contract and relax. The problem arises in damaged muscle tissue when the muscle ceases to relax and begins to form a knot(s) or tight band(s) of muscle fiber. Upon examination, a physician may detect these knot(s) or tight band(s) by palpating the skin.

Some frequent causes of soft tissue muscle damage can be due to injuries (eg, whiplash), repetitive movements in daily activities (eg, typing), poor posture, pinched nerves, stress, and lack of exercise. Injury sites can become extremely sensitive to touch, become swollen and inflamed, and/or irritated. The most noted indication in patients diagnosed with this type of soft muscle tissue damage is discomfort and pain. In more severe cases, the knots or bands may cause blood flow to become constricted within a muscle or muscle group. Additionally, some patients report a limited range of motion in their joints caused by these knots or bands.

Treatment for the affected trigger points is similar to ancient Chinese methods, it involves injection(s) of medication into the damaged tissue area. The injection serum may include medications such as, a local anesthetic, an anti-inflammatory drug, corticosteroid, and/or normal saline solution. The goal of the injection(s) is to relieve the patient of muscle tension and pain. Depending on the patient's response and level of pain relief achieved from the injection treatment, a combination of the medications may be required. Equally, depending on the number of muscle or muscle groups involved, and the extent of soft tissue damage, several injections or a series of injections may be necessary to alleviate the pain. Possible indications of trigger point injections may include the following:

Fibromyalgia
Plantar fasciitis
Headaches associated with neck pain
Chronic lower back pain
Osteoarthritis
Multiple sclerosis
Chronic myofascial pain
Joint disease
Focal areas of muscle hyperactivity
Scoliosis
Herniated/degenerative disks
Example of Intra-service Work Associated With Code 20552

After identification of the trigger point in the multifidus muscle left of the L5 spinous process by palpation, a 1.5- to 2-in, 25-gauge needle is inserted through the skin into the muscle. The needle is advanced a short distance, about 2 to 4 cm, observing any complaints of paresthesia while searching for the area of maximum tenderness. If any complaints or paresthesia are encountered the needle is withdrawn slightly until the complaints or paresthesia stop. Next the injectant solution is infiltrated in a fanwise method into the trigger point after aspiration is negative for blood. The solution is usually a mixture of 1 to 5 cc of anesthetic containing a corticosteroid. Post procedure, the injection area is cleansed and a bandage applied to the site.

Example of Intra-service Work Associated With Code 20553

After identification of the three trigger points by palpation, a 1.5- to 2-in, 25-gauge needle is inserted through the skin into the muscles. The needle is advanced a short distance, about 1 to 3 cm, observing any complaints of paraesthesia while searching for the areas of maximum tenderness. If any complaints or paraesthesia are encountered, the needle is withdrawn slightly until the complaints stop. Next, 1 to 3 cc of the injectant solution is infiltrated in a fanwise method into the trigger points after aspiration is negative for blood. The solution is usually a mixture of an anesthetic containing a corticosteroid. Post procedure the injection areas are cleansed and bandages are applied to the site if any bleeding occurs.

Following the injection(s), patients may experience some tenderness/soreness at the injection site. Patients are often monitored for approximately 20 to 30 minutes to assess any potential complications from the injection. It is recommended the patient be discharged home with a driver after receiving post-injection instructions and a last evaluation from the physician.

Finally, it is important to update your system to allow for the recognition of these revised CPT codes to ensure accurate reporting. Codes 20552 and 20553 are reported one time per session regardless of the number of injections or muscles injected. This is indicated through the revisions that added an "(s)" to the term injection and to the term muscle.

Trigger point injections provide an alternative treatment for patients who endure pain and discomfort on a daily basis. They make it possible for patients to effectively return to daily activities by easing the severity of pain.


© 2005 American Medical Association







AND:

Year: 2003 

Issue: May 

Pages: 19 

Title: Surgery/Musculoskeletal System, 20552, 20553 (Q&A) 

Body: Coding Consultation:Questions and Answers

Question

My physician performed two trigger point injections in two different muscles. Would it be appropriate to report code 20552 twice for the two injections?

AMA Comment

Code 20552-20553 are reported one time per session, regardless of the number of injections or muscles injected. Therefore, it would not be appropriate to report code 20552 , Injection(s); single or multiple trigger point(s), one or two muscle(s) twice for the two injections administered.


© 2005 American Medical Association


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## Justarose (May 29, 2009)

MMMMWAAAHHHH  is all I can say !


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