Anesthesia Coding Alert

Question: My pain management specialist had a patient present with severe, chronic pain in the right side of her back. He performed an examination and administered two trigger point injections in the right lumbar multifidus muscle. I reported 20552 with one unit of service. The only notes he included in the patient's chart, however, were "the patient is experiencing back pain." He's done this before and diagnosed myofascial pain. Should I just code the diagnosis this way, since I'm pretty sure that's what he meant?

Vermont Subscriber

Answer: Without a clear, documented diagnosis you cannot code myofascial pain (729.1, Myalgia and myositis, unspecified). If you go ahead and code a diagnosis on an assumption, you're opening the door to trouble if a payer audit occurs.

Here's why: The HIPAA-mandated ICD-9 Guidelines state: "List first the ICD-9-CM code for the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the services provided.... In some cases the first-listed diagnosis may be a symptom when a diagnosis has not been established (confirmed) by the physician. Do not code diagnoses documented as 'probable', 'suspected,' 'questionable,' 'rule out,' or 'working diagnosis' or other similar terms indicating uncertainty. Rather, code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit." There may be other diagnoses that might apply, such as 724.5 (Backache, unspecified).

Keep in mind: Your diagnosis coding is especially important because, while myalgia is typically covered for trigger point injections, generic back pain often is not. You must be able to support your diagnosis code choice with your neurologist's documentation or your payer may think you're coding just to get paid.

You have the first part right in coding the trigger point injections using 20552 (Injection[s]; single or multiple trigger point[s], 1 or 2 muscle[s]). Code a trigger point injection based on the number of separate muscles injected, rather than the number of injections given. In the absence of a clear diagnosis, however, you should take your clues from the ICD-9: query your physician, wait for test results, or code for signs and symptoms.