Anesthesia Coding Alert

Train physicians to clearly document the muscles--so you can code correctly

Your pain management specialist probably administers injections daily, but if you don't know your trigger point from your bursa, you could be noncompliant with every injection claim you submit.

The next time your specialist performs an injection, follow these four steps to pinpoint the appropriate code.

1. Don't Use 90772 as a 'Catchall' 

Say the word "injection" to coders in some specialties, and they'll recommend 90772 (Therapeutic, prophylactic or diagnostic injection [specify substance or drug]; subcutaneous or intramuscular) every time. But you have many more choices in a pain management practice, so don't automatically rely on 90772.

Flashback: Many coders used to rely on 90782 as a "catchall injection code," experts say. CPT 2006 deleted 90782 and introduced 90772--although you'll still steer clear in many cases because the descriptor remained the same.

If your physician doesn't document his injection clearly enough to select an appropriate trigger point or joint/bursa injection code, some coders might assign 90772 for the procedure. More experienced coders, however, say this is usually a bad idea and recommend checking with your provider for clarification.

Why it doesn't work: First, automatically assigning 90772 isn't correct coding because it doesn't follow CPT coding guidelines.

"It is not accurate coding if the procedure is something different from a simple therapeutic injection into a muscle, such as an injection of Toradol versus a procedure that requires higher physician work and malpractice risk," says Marvel J. Hammer, RN, CPC, CCS-P, ACS-PM, CHCO, owner of MJH Consulting in Denver. And second, reporting 90772 every time costs the practice money. In 2007, Medicare reimburses about only $23 for 90772 in an office setting--compared to more than $50 for other common injection codes such as 20600 (Arthrocentesis, aspiration and/or injection; small joint or bursa [e.g., fingers, toes]).

When to use it: Report 90772 only if the physician administers a subcutaneous or intramuscular injection, such as a Demerol shot for a migraine headache or a Toradol injection as an anti-inflammatory. Otherwise, dig into the documentation to report a more accurate, site-specific injection code.

2. Bill 1 TPI per Muscle Group

To report 20552 (Injection[s]; single or multiple trigger points[s], one or two muscle[s]) and 20553 (... single or multiple trigger point[s], three or more muscles) properly, you should know what you're dealing with. A trigger point is "a localized area of muscle that causes pain in a remote area when the muscle is firmly pressed on," Hammer says. If the physician documents an injection into a joint or ligament, for instance, he did not perform a trigger point injection (TPI).

Tip: Examine the physician's documentation to determine how many muscles he injected--don't simply count how many actual injections he performed.

For instance, low-back-pain patients (724.2, Lumbago) typically have discomfort that originates in their paraspinous muscle, but they may feel discomfort throughout their back and in other parts of the body, such as the hips and legs. If your specialist treats the pain with multiple trigger point injections and focuses on just one muscle, you cannot bill for each injection.

Example: When your physician examines a patient with low back pain, he discovers three trigger points in the multifidus muscle to the left of the L5 spinous process. He injects each trigger point in the multifidus muscle. You should report only one unit of 20552 because the physician treated only one muscle (multifidus), even though he administered three injections.

3. Back Multiple Injections With Documentation

If you report 20553, the documentation should reflect that the physician injected three or more muscles.

Example: A patient recovering from an auto accident presents with neck pain (723.1, Cervicalgia) and right shoulder joint pain (719.41, Pain in joint; shoulder region). Your pain specialist identifies three trigger points--the right trapezius, the right deltoid, and the right levator scapulae muscles--and administers injections to each muscle. In this case, you should report one unit of 20553.

Warning: Never report more than one unit of 20553 per treatment session. Because 20553 refers to "single or multiple injections" for "three or more muscles," a single unit of 20553 includes any number of injections in three or more muscles.

If your physician's documentation ambiguously refers to a number of muscles or injections but doesn't name the muscles, your TPI claims might be in jeopardy. Help your physicians understand the importance of clear documentation--and its power to help or hurt claims.

By following CPT's revised descriptors for trigger point injections, physicians should no longer simply document that they injected three trigger points, says Barbara J. Johnson, CPC, MPC, owner of Real Code Inc. in Moreno Valley, Calif. Because you base code selection on the number of muscles injected, the physician should document the specific muscles he injected and list the most specific ICD-9 code.

For example: Your physician treats a patient with muscle pain in the lower back (729.1, Myalgia and myositis, unspecified) by administering five trigger point injections, but he doesn't note the muscle(s) targeted. Because you cannot support coding for more than one muscle, you should only report 20552. In addition, you should link 729.1 to 20552 to support medical necessity.

Bottom-line effect: For 2007, Medicare allows $53.06 nationally for 20552 in an office setting versus $59.50 for 20553. Although the difference of $6.44 might not sound like much, the amounts add up over time.

4. Append 25 to E/M With Injection 

If the pain specialist's documentation indicates that he performed a separate E/M service, you may be able to report both the office visit and the injection. Make sure, however, that the documentation shows that the E/M service is medically necessary, significant and separately identifiable, Hammer says.

For instance: An established patient arrives for a prescheduled injection for cervicalgia (723.1) but also has a new complaint of lower-extremity muscle weakness (728.87). The physician performs an expanded problem-focused history and exam based on this new symptom. He determines that he must proceed with additional diagnostic testing to determine what causes the new symptom (weakness). He performs the scheduled trigger point injection (20552) for cervicalgia and a separate E/M service to evaluate the muscle weakness.

In this case, you would report 20552 linked with 723.1 and 99213 (Office or other outpatient visit for the evaluation and management of an established patient ...) with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) and diagnosis 728.87.

Remember: If the patient presents only for the injection, you should not report an E/M code. For example, in the above case, if the patient does not offer a new complaint that prompts a separate E/M service, you would report only 20552. If the patient is new to your group instead of established, you would submit the appropriate code from 99201-99205 (Office or other outpatient visit for the evaluation and management of a new patient ...) if the E/M service is medically necessary and the documentation indicates that the service was significant beyond the pre- and post-procedure work included in the injection reimbursement.