Anesthesia Coding Alert

Question: My understanding is that the paraspinal muscle is a group of individual muscles that combine and run along the spine. Our provider administered bilateral trigger point injections in the cervical paraspinal area. From a coding perspective, should I consider these two injections into two separate muscles?

Answer: Coding for trigger point injections is based on the total number of individual muscles. Injections of trigger points into one or two muscles would be billed with 20552 (Injection[s]; single or multiple trigger point[s], 1 or 2 muscle[s]) whereas trigger point injections into three or more muscles would be reported with 20553 (Injection[s]; single or multiple trigger point[s], 3 or more muscle[s]).

Compliant documentation for trigger point injections would include the specific muscles injected rather than use of a broad term such as paraspinal. Bilateral muscles that have separate origin and insertion sites typically are considered to be separate muscles. For example, trigger point injections into separate and distinct bilateral muscles would be considered to be two muscles for coding purposes.