Anesthesia Coding Alert

Question: Could you please explain the difference of 20552 and 20553 and include an example?

Louisiana Subscriber

Answer: The difference lies in the number of muscles the physician injects. If he injects two or fewer muscles, report 20552 (Injection[s]; single or multiple trigger point[s], 1 or 2 muscle[s]). If he performs TPI on three or more muscles, report 20553 (… single or multiple trigger points, 3 or more muscle[s]).

Scenario 1: A patient reports to your office complaining of intense neck and shoulder pain. The physician performs six injections on the patient’s trapezius and three on her levator scapulae. Report 20552 in this scenario, as the physician performed TPIs on two muscles.

Scenario 2: A patient is experiencing severe lower back pain. The physician administers a single TPI to the patient’s quadratus lumborum, and two shots each to his gluteus maximus and gluteus medius. Report 20553 in this scenario, as the physician performed TPIs on three muscles.