Get Your Documentation Straight for TPI Claims
Question: What CPT® codes should I report for this encounter? Also, I know that this is a trigger point injection (TPI) encounter, but what sort of documentation should I include in order to get the claim paid? We don’t do a lot of TPIs in our ED, so I am a little lost: A 43-year-old patient presents to the emergency department (ED) with a three-week history of occipital and cervical neck pain unrelieved by over-the-counter pain medications, heat, or muscle relaxers. They describe the pain as sharp, unrelenting and 8 out of 10 on the pain scale. During an evaluation and management (E/M) service, the ED physician notes palpable trigger points in the trapezius and quadratus lumborum muscles. The ED physician performs three injections in the trapezius and four injections in the quadratus lumborum. RCI Subscriber Questions: You’re right, this is a TPI encounter that you will report with 20552 (Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s)). Also remember to report the appropriate ED E/M code from 99281-99285 (Emergency department visit for the evaluation and management of a patient …) code set. Remember to append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to the ED E/M code to show that the E/M and the TPI were significant, separately identifiable services. Documentation: In order to get this claim as perfect as possible, the notes should include the muscle(s) injected. 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, and prior treatment and responses. In documenting the actual TPI, check the notes for evidence of the following: Chris Boucher, MS, CPC, Senior Development Editor, AAPC
