Anesthesia Coding Alert

Question: When the physician injects trigger points in bilateral muscles, is each muscle considered "one" so that bilateral is "two"? For example, he injected left and right sides of the lumbar paraspinous in the L5 region, then injected the right and left sides of the trapezius near the C7 level. How should I code this?

Maryland Subscriber

Answer: When coding trigger point injections, you report the service based on the number of muscles injected, not the number of injections. Your code choices are 20552 (Injection[s]; single or multiple trigger point[s], 1 or 2 muscle[s]) and 20553 (... single or multiple trigger point[s], 3 or more muscle[s]).

In your case, you can consider the injections to the right and left paraspinous muscles as two separate muscles, but one unit of 20552 covers both injections. If your provider injects more than one muscle (such as the trapezius and lumbar paraspinous in your case), you would also report 20553.

Bilateral no-no: Do not report modifier 50 (Bilateral procedure) with trigger point injections even if your provider treats both sides of the muscle. Codes 20552 and 20553 each have a "0" indicator in the "bilateral" column according to the Correct Coding Initiative, so modifier 50 does not apply.

-- Answers to You Be the Coder and Reader Questions were provided by Scott Groudine, MD, an Albany, N.Y., anesthesiologist; and Joanne Mehmert, CPC, CCSP, president of Joanne Mehmert and Associates in Kansas City, Mo.