Anesthesia Coding Alert

Trigger point injections (20550, injection, tendon sheath, ligament, trigger points or ganglion cyst) should be coded according to the muscle groups targeted, not the number of injections administered. Although multiple injections are often performed at the same site, they are considered a single injection for coding purposes.

Many physicians charge every time they perform a pressure point injection, which is inappropriate, says Patricia Bukauskas, CMM, CPC, a pain management coding and reimbursement specialist in Aliquippa, Pa. If you administer three injections into the trapezius muscle, that counts as only one injection. However, three injections into the trapezius muscle and two more into the supraspinal muscle count as two injections because two different muscle groups were targeted.

Note: Noncovered procedures such as acupuncture should not be billed using 20550.

Billing and Modifiers

Carriers limit the number of injections that may be billed even when different muscle groups are treated, Bukauskas says. Some Medicare carriers may pay for as many as eight injections during the same session, but most reimburse a maximum of five. Medicare carriers in some states, such as Alaska, Arizona, Hawaii, Nevada, Oregon and Washington, only pay for one injection regardless of the number of muscle groups treated. The Medicare limit in Utah, however, is seven injections, says Deanna Clark, a coder with the University of Utahs Pain Management Center in Salt Lake City. She notes that at least one private carrier she deals with doesnt cover trigger point injections at all.

In most states, Medicare carriers want to see modifier -59 (distinct procedural service) attached to additional 20550 claims. By appending this modifier, the physician indicates the injections were performed on different muscle groups and overrides any software edit bundling multiple trigger point injections. Most Medicare carriers also want claims involving 20550-59 on separate lines. For example, if the physician treated three muscle groups with trigger point injections, the session should be coded:

20550
20550-59
20550-59

Note: A few Medicare carriers require modifier -51 (multiple procedures), not -59. Contact your payer if you are uncertain of its policy. Remember also that the multiple procedure reduction applies and therefore the payments for subsequent injection will be reduced by 50 percent.

Documentation and Diagnosis

Because trigger point injections are relatively straightforward and fairly well reimbursed (2.88 relative value units), 20550 is carefully watched for abuse, and documentation guidelines covering its use are stringent. Claims for multiple injections (and in some cases claims for individual injections) will be denied unless medical necessity is indicated. Documentation should include the following:

An appropriate diagnosis. Many carriers only pay for trigger point injections linked to specific diagnoses, such as 726.5 (enthesopathy of hip region); 726.71 (achilles bursitis or tendinitis); 726.72 (tibialis tendinitis); 729.1 (myalgia and myositis, unspecified); and 840.0-847.9 (sprains and strains).

A patient evaluation. In an audit, carriers will want to see the patient evaluation that led to the diagnosis requiring the injections. Therefore, documentation should (a) identify the affected muscle groups; (b) indicate that stimulation of the affected area initiates an attack of neuralgia, pain or stiffness; and (c) provide the rationale for administering injections rather than using less invasive pain management strategies (such as heat and cold packs, spray and stretch physical therapy and massage).

If, as often is the case, the injections are delivered in a series, the documentation for each injection (other than the first) must indicate the amount of relief the patient has already received, Bukauskas says. The documentation cant just say, Patient returns today. It has to indicate how much relief has already been achieved. The chart shouldnt say, Patient returns today for a third series of trigger point injections, without also mentioning, for example, The first trigger point series provided 40 percent relief, and the second provided 30 percent.

Billing E/M and Injections on the Same Day

E/M services provided on the same day as a trigger point injection are payable only if the E/M is significant and separately identifiable. If this is the case, modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day as the procedure or other service) must be appended to the appropriate E/M code.

Although normally only the initial evaluation that led to the decision to use trigger point injections is payable (if appended with modifier -25), subsequent visits may also be reimbursed if the physician must attend to a new patient problem.

For example, a 39-year-old female presents at the doctors office two months after her last visit. Her discomfort level is seven out of 10 (on the McGill pain pattern scale). The diagnosis is chronic lumbar strain and myofascial pain (729.1). The patient tells the physician that the trigger point injections performed during her last visit provided 50 percent relief that lasted for about 3-1/2 weeks; after that time her pain returned to its prior level. She reports consistent use of other prescribed medications (anti-inflammatories), and an examination reveals no sign of past procedure site (i.e., the wound from the previous injection has healed). The specialist decides to proceed with more injections. Trigger points are located in the lumbar paraspinals and are injected with Marcaine, followed by spray and stretch and massage. The patient is scheduled to return in two days for a second set of injections.

In this scenario, the physician can code one injection (20550) and an appropriate established patient E/M code (99212-99215, with modifier -25 appended) because the patient did not have a pre-existing appointment for additional trigger points. Two months have elapsed between her previous and current visits, the later of which was prompted by an exacerbation of her original problem. Therefore, the physician had to perform another evaluation in addition to treating her pain with trigger point injections. An E/M service will not be billable when the patient returns in two days for her next set of injections, however.