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Anesthesia Coding Alert

Use New TPI Codes for More Accurate Billing

Published on Wed May 01, 2002

Trigger point injections (TPIs) have become common procedures for anesthesia specialists, especially with the growth of pain management care in the last few years. With the new TPI codes included in CPT this year, coders and practitioners should pay more attention to the procedure performed to code it correctly.

Expanding TPI Reporting

The addition of new codes and the revision of existing ones means that TPIs can be coded more accurately to reflect the services and describe multiple TPIs better. Most carriers recognize eight body regions and sites for TPIs: the head, cervical spine, left upper extremities including shoulder, right upper extremities including shoulder, thoracic spine, lumbosacral spine, left lower extremities including hip, and right lower extremities including hip.

The primary code for TPIs is 20550* (Injection; tendon sheath, ligament, ganglion cyst), although the subcodes associated with it are now used to report TPIs. The descriptor for 20550* used to include "trigger points," but this part of the definition was deleted when the new TPI codes were added to CPT Codes 2002.

Another change in 2002 is the notation that other codes may be used with 20550* if imaging guidance is performed. These codes are 76003 (Fluoroscopic guidance for needle placement [e.g., biopsy, aspiration, injection, localization device]), 76393 (Magnetic resonance guidance for needle placement [e.g., for biopsy, needle aspiration, injection, or placement of localization device] radiological supervision and interpretation) and 76942 (Ultrasonic guidance for needle placement [e.g., biopsy, aspiration, injection, localization device], imaging supervision and interpretation). But anesthesia providers such as Scott Groudine, MD, of Albany, N.Y., do not expect these codes to come into play often with TPIs because TPIs are given to spasmodic muscles, which do not show up on x-rays associated with these codes.

Three new subcodes are connected to 20550*, two of which deal exclusively with TPIs:

  • CPT 20551 Injection; tendon origin/insertion
  • CPT 20552 single or multiple trigger point(s), one or two muscle group(s)
  • CPT 20553 single or multiple trigger point(s), three or more muscle groups.

    When using the new codes, remember that 20551 is for a tendon injection and is not the same as a TPI into muscle. Code 20552 is used to report any number of TPIs to a single muscle group, such as five injections in the neck area, or single injections in two muscle groups, such as one TPI in the left upper extremity and one in the thoracic area. Code 20553 is used for any number of injections to three or more muscle groups, such as one injection to the head, two to the neck and one to the right lower extremity.

    TPIs are often performed at the same session as other services. In addition to the appropriate TPI code, you can also bill applicable E/M outpatient office visit codes (99201-99205 or 99212-99215) if conditions meet the criteria of a separate, identifiable service, according to Linda Runfola, CPC, anesthesia and pain management consultant for the billing firm NAPA Management Services in Syracuse, N.Y. For example, Groudine says a patient may be evaluated for back pain (using an appropriate E/M code) and during the same visit may receive a TPI for neck pain due to whiplash. Because the two services are not related, they are considered two different visits, and you should append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M service.

    "Other procedures can also be done the same day as the TPIs," Runfola adds. "You report the highest value procedure first on the claim and append modifier -51 (Multiple procedures) to each of the additional procedures."

    Coding Then,Coding Now

    In the past, 20550* was used to report all TPIs, no matter how many were administered. The physician coded 20550* for the initial injection, and 20550* with either modifier -51 or -59 (Distinct procedural service) appended for each additional injection to a different body region or muscle group, depending on the circumstances.

    Along with the advantage of having more specific codes to report services now, Runfola says billing for TPIs will be simplified because the modifiers will no longer be used. But along with that simplification comes lower reimbursement.

    "One problem with the new codes is that because the codes carry the same weight, the physician gets paid the same regardless of how many muscle groups are injected," Runfola explains.

    But as Groudine points out, having equal reimbursement for the different TPIs can help end some cases of fraud. "Good physicians were often shocked at the abuse TPIs had," he says. "A few physicians would bill for 20 or more TPIs in one sitting and generate bills in the thousands for a rather simple procedure. This limits the extensive fraud going on, but the price is under-reimbursing good physicians during the few times it's appropriate to do more than three muscle groups at one sitting."

    Coding Tips for TPIs

    Runfola says her group never had problems being reimbursed for TPIs with 20550*, and they are also having success billing with 20552 and 20553. Her primary advice when reporting TPIs is that you should ask the carrier about proper coding. She offers these tips to keep in mind as you code for the procedure:

  • A J code might have to be billed on the claim even if you are not seeking reimbursement for the service. This is done to seek reimbursement for medications even if the provider will not be paid for the TPI.
  • Documentation of the service must include the muscle group injected, whether it was unilateral or bilateral, and the amount of drug administered.
  • When possible, negotiate reimbursement for multiple TPIs in commercial or managed care contracts to help get more appropriate reimbursement for extra services.
  • When billing TPIs for Medicare, bill 1 for the number of services for 20552 or 20553. You cannot bill both of these codes for the same time of service, and modifier -59 should not be used with these codes.

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