Anesthesia Coding Alert

Plus: Keep this list of potential associated diagnoses handy.

Even if you don’t code for pain management services every day, if you have a specialist on your team you’re bound to find yourself reporting trigger point injections (TPIs). The procedure is common because the injections can be used to treat many types of pain and can be administered to virtually muscle group.

Translation: Prepare now for when the inevitable TPI claim crosses your desk so you can be savvy enough to avoid miscoding the encounter and can also stay off auditors’ radars.

Get Clear on What Trigger Points Are

Patients reporting to a pain management physician for TPIs typically have trouble within the connective tissue, or fascia, according to Yvonne Dillon, CPC, CEDC, director of emergency department services at Bill Dunbar and Associates, LLC in Indianapolis, Ind.

“Trigger points are sensitive areas within the connective tissue — fascia — and/or bands of muscle that has become hypersensitive irritability or pain due to compression,” she says. Applying pressure to a trigger point can also help diagnose the condition.

“[Applying pressure] helps identify the part of the body that is generating the pain. Trigger points can also be local area pain, or a point, from which pain can radiate throughout the connective tissue/fascia and/or the muscle. This caused myofascial pain,” Dillon continues.

“Trigger points might be described as knots of muscle that form when muscles do not relax,” explains Joanne Mehmert, CPC, CCS-P, president of Joanne Mehmert and Associates in Kansas City, Mo. “Headaches are another reason that physicians perform a TPI.”

As to what causes trigger points, Dillon says repetitive or acute trauma could result in trigger points, because it “puts too much stress on the fibers. Trigger points may be at different places in both skeletal muscles in the hip, neck, shoulder. They are usually in places where nerves connected the muscle fibers,” she explains.

Tip: You may see the terms myofascitis, myositis, myalgia, myofascial pain, or fibromyalgia, in your provider’s trigger point documentation. Watch for a potential TPI claim if you see these types of ailments in the encounter notes.

Be on the Lookout for Common TPI Diagnoses

Dillon shares a list of conditions that might cause your provider to opt for TPI treatment:

• Musculoskeletal diseases
• Spasms
• Tendonitis or bursitis
• TMJ joint disorders
• Osteoarthritis or other joint dysfunction
• Non-myofascial tender points
• Myalgias
• Fibromyalgia
• Tension-type headaches
• Gout
• Psoriatic arthritis
• Rheumatoid arthritis
• Other soft tissue disorders related to overuse and pressure or the extremities.

Caution: This is not an exhaustive list of conditions that could lead to a TPI. Patients could have different injuries that require TPIs, and a diagnosis from one of those listed above won’t guarantee that the payer will accept the TPI claim. You must go case-by-case, and, payer-by-payer.

“Some carriers ask for a more specific code, and they list the ICD-10 codes according to muscle group,” Mehmert explains. Find more information about this on Medicare carrier websites under local coverage determinations (LCDs).  “The codes Medicare [carriers] accept to describe the condition may be similar, but they differ, too,” Mehmert adds.

Count the Muscles, Not Injections

Once you get past identifying the condition and diagnosing it, coding for TPIs isn’t too laborious; There are only two TPI codes, and when to use them is fairly straightforward.

According to Judith L. Blaszczyk, RN, CPC, ACS-PM, ICDCT-CM, compliance auditor at ACE, Inc. in Overland Park, Kansas, you should report 20552 (Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s)) for TPIs of one or two muscles — not the number of injections. If the provider injects three or more muscles, report 20553 (… single or multiple trigger point(s), 3 or more muscles).

As you can imagine, you’ll need very specific info in the encounter notes to correctly code TPIs.

Last word: “It is very important that the physician document each muscle that is injected so the coder can select the correct code,” Blaszczyk relays.