Anesthesia Coding Alert

An article in the December issue of Pain Management Coding Alert described the revisions to coding for trigger-point injections (TPIs). At that time, the relative value unit (RVU) of the two new codes, 20552 (Injection; single or multiple trigger point[s], one or two muscle group[s]) and 20553 ( single or multiple trigger point[s], three or more muscle groups), was unknown. CMS has now established interim RVUs for these codes.
 
As published in the Federal Register, Vol. 66, No. 212, the RVUs are as follows in the above chart:


There are no global periods attached to these codes.
 
Mary Jo Marcely, CPC, senior vice president of NAPA Management Service Corp., a firm in Syracuse, N.Y., specializing in anesthesiology and pain management consulting and billing, says, "It is evident from these changes that CMS has been evaluating these procedures from the standpoint of cost-effectiveness. Clearly, these changes will reduce reimbursement to practitioners. The final RVU will unlikely meet or exceed that which was previously used for TPIs, when some carriers allowed billing for up to eight injections per visit."
 
The AMA's relative value committee met at the end of January 2002 to establish final RVUs for these procedures.

Using the New Trigger-Point Injection Codes

Codes 20552 and 20553 are for single and multiple TPIs based on muscle group(s). Marcely notes, "This should eliminate the need to use modifier -51 (Multiple procedures) or modifier -59 (Distinct procedural service) that some local Medicare carriers previously required for multiple TPIs."
 
Marcely advises coders to be aware of the sites in the ICD-9 table of diagnoses. "When one of the defined sites is injected, it will be considered one injection service regardless of the number of injections administered."
 
"Not all carriers define muscle groups in the same manner," says Cindy C. Parman, CPC, CPC-H, co-founder of Coding Strategies in Denver, Ga., a healthcare consultancy that provides national support for anesthesia and pain management practices. "Instead of using an ICD-9 Codes table that corresponds to certain muscles for the purpose of TPIs, some carriers define specific sites." Parman cites the policy of HGSAdministrators, Pennsylvania's Medicare Part B carrier. For TPIs, the carrier recognizes eight body regions and defines eight sites:

 1. head
 2. cervical spine
 3. left upper extremities, including shoulder
 4. right upper extremities, including shoulder
 5. thoracic spine
 6. lumbosacral spine
 7. left lower extremities
 8. right lower extremities, including hip.

Carriers are also inconsistent in the reimbursement for bilateral muscle groups, such as the trapezius, deltoid or gluteus maximus. "Some local medical review policies (LMRPs) list these as one muscle group regardless of right or left injections," Parman says. "Other carriers' LMRPs allow for bilateral payment when modifier -50 (Bilateral procedure) is appended to the procedure code."
 
When billing these new codes to Medicare carriers, check with the carrier on submission of J codes. "Certain carriers now require that the appropriate J code be reported on the claim form, along with the amount administered, even if you are not seeking reimbursement for the drugs," Marcely says. If you are using an unlisted agent, you may need to include the national drug code. Some carriers may not require the J code when the injection is used to treat certain diagnoses, such as 726.32 (Lateral epicondylitis).
 
Marcely suggests that physicians and their staff maintain adequate documentation for these procedures: "It is important to record which muscle groups are injected, unilateral or bilateral, the agent being administered, and the amount of the agent used."

Medical Necessity

Empire Medicare (New York's Part B Medicare carrier) says to obtain an advance beneficiary notice when trigger-point services exceed "the accepted standard of medical practice." Another Medicare carrier says: "It is expected that this procedure would not be performed on more than three body regions on a given date of service, nor would it be expected that TPIs would be performed more often than once a month." Some payers also limit the number of TPIs to no more than eight sets of injections in a year.
 
Parman says that even with the reduction in reimbursement for TPIs, documentation requirements are not expected to decrease. "The patient record should include, at a minimum, a record of the evaluation leading to the specific diagnosis of trigger point(s), identification of the affected muscle(s), the reason for selecting TPIs as the method of treatment, and the need for reinjection or multiple sets of injections," she says.