ED Coding and Reimbursement Alert

Coders who are just itching to hit the mark on their trigger point injection (TPI) claims can answer the -who, what, and why- of TPIs with this guide.

Most patients that require TPIs are suffering from head or muscle pain.

-Trigger points might be described as knots of muscle that form when muscles do not relax. Headaches are another reason that physicians perform TPI,- explains Joanne Mehmert, CPC, CCS-P, owner of Joanne Mehmert & Associates in Kansas City.

When your ED physician performs TPIs, -the most common diagnosis reported is 729.1 (Myalgia and myositis, unspecified),- according to Judith Blaszczyk RN, CPC, ACS-PM, president of Veritas Consulting in Greencastle, Pa.

Keywords: Physicians might also use these synonyms for myalgia/myositis: -myfascitis, myofascial pain, fibromyalgia.- Code any of these diagnoses with 729.1,Mehmert recommends.

Other diagnoses that might accompany a TPI claim include muscle spasm (728.85) or contracture of neck or torticollis (723.5).

-Frequently physicians will document only the location of the pain -- neck pain, low back pain, or headache -- but in the case of trigger point injections they should really indicate more specifically the etiology of the pain,- Blaszczyk says. For instance, it would help to distinguish if the pain is from muscular spasm rather than an old fracture.

Many payers have limited payment policies for trigger point injections -- and the physician can perform TPI on any of the 600-plus muscles in the human body, Mehmert says. So it is important that you check with each payer to see what it considers medically necessary for TPIs, as policy can vary widely from insurer to insurer.

The number of muscles the ED 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-plus muscles, report 20553 (- single or multiple trigger points, 3 or more muscle[s]), Blaszczyk confirms.

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

Example 2: A patient reports to the ED with severe lower back pain. The ED physician performs 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.

If the auditor comes calling about a TPI claim, you-ll easily be able to prove medical necessity if you keep certain information on file, experts say.

On your TPI claims, keep a record of the muscles the physician injects, Mehmert recommends.

-In addition, documentation of the medical necessity for the procedure should be clear. Included in this would be documentation of a brief pain history, the location of the pain, the pre-injection intensity of the pain, prior treatment, and responses,- explains Blaszczyk.

Check out this example of solid documentation for a 20552 claim:

-43-YO male with 3-week history of occipital, cervical neck and back pain. Unrelieved by over-the-counter pain medications, heat, or muscle relaxers. He describes the pain as sharp, unrelenting, and 8 out of 10 on the pain scale. Palpable TPs found in trapezius and quadratus lumborum muscles. Injected each TP twice with 3 cc of Lidocaine. Patient tolerated treatment well; post-TPI pain rating a 2.-