EM Coding Alert

Remember to count muscles injected.

Therapeutic injections and infusions aren’t typically billable physician services in the ED setting — but that doesn’t mean you have to give up on reporting a procedure code every time the ED physician pulls out a needle.

Take trigger point injections (TPIs); these can be performed in many different areas of the body, and ED physicians are trained to identify trigger points and alleviate the patient’s pain. What you’ll need to do is identify TPIs and know how to code them when you file the claim.

Here’s a look at the high points of TPI coding.

E/M Will Lead to TPI

Before learning to code TPIs, you should be able to identify trigger points.

The basics: “Trigger points are also often referred to as “knots” in the muscles. “These can restrict range of motion and make it difficult to perform daily activities,” said Karen F. Perry, CPC, CPB, CPC-I, OCS, during her HEALTHCON 2024 presentation.

The specifics: “Trigger points are sensitive areas within the connective tissue and/or bands of muscle that have become hypersensitive or pain due to compression,” explains Yvonne Bouvier, CPC, CEDC, manager of coding documentation at ZOTEC Partners in Carmel, Indiana. “When pressing on a trigger point referred pain can be caused. This helps identify the part of the body that is generating the pain. Trigger points can also be local area pain … from which pain can radiate throughout the connective tissue/fascia and/or the muscle.”

When it comes to identifying trigger points, you’ll be selecting an ED evaluation and management (E/M) code set for the service. Watch for encounter specifics, because the E/M level could vary — particularly if the ED physician orders an ultrasound (US) when identifying a trigger point. US isn’t typically used to identify trigger points, but they are used when the ED physician wants to rule out any other injuries in addition to the trigger point.

Example: A patient reports to the ED complaining of pain in their upper right arm. They describe the pain as a 7 on a scale of 10, and that it radiates down their right arm. There is also swelling in the injured area. The ED physician uses palpation to check for tight bands of muscle; they finally locate a spot in the patient’s arm that causes a brief muscle contraction when it is palpated. The physician then orders an MRI to rule out any other damage, and diagnoses the patient with causalgia of the upper right arm.

For this patient, you would report an appropriate code from the 99281 (Emergency department visit for the evaluation and management of a patient that may not require the presence of a physician or other qualified health care professional) through 99285 (Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making) code set with G56.41 (Causalgia of right upper limb) appended to represent the patient’s causalgia.

Check Out These Common TPI Areas

According to Bouvier, trigger points “are usually in places where nerves connect to the muscle fibers.” Patient conditions that might require TPI include:

• Muscle spasms
• Tendonitis/bursitis
• Temporomandibular joint (TMJ) disorders
• Osteoarthritis or other joint dysfunction
• Non-myofascial tender points
• Myalgias
• Fibromyalgia
• Tension-type headaches
• Gout
• Psoriatic arthritis
• Rheumatoid arthritis
• Neuralgias

Note: This is not a list of conditions that payers will automatically accept on a TPI claim, merely a list of injuries that could require TPI. Always code to the notes, and check with your provider or payer if you have questions about diagnosis codes and TPIs.

Tally Muscles Before TPI Code Choice

When you are reporting your physician’s TPI service, you’ll choose from 20552 (Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s)) or 20553 (… single or multiple trigger point(s), 3 or more muscles), depending on encounter specifics. Things can get tricky here, though, as CPT^® instructs you to report 20552 for injections of one or two muscles, and 20553 for injections of three of more muscles. So, you’ll be counting the muscles treated, not the number of injections, before making your code choice.

Muscle memory: Since you’ll be counting muscles for an accurate TPI count, it’ll be useful to know which muscles are often the target of TPIs. Bouvier offers a few of the muscles commonly involved in TPIs: Longissimus, iliocostalis, multifidus, quadratus, psoas major, masseter, temporalis, levator scapulae, sternocleidomastoid, trapezius, piriformis.

Example: A patient with causalgia of the right arm is being prepped for a TPI. The patient is sitting in an examining chair while the physician assistant (PA) palpates the muscle and marks the trigger points with a skin marker. The PA then cleans the skin and applies a topical anesthetic. The ED physician uses a 25-gauge needle to insert lidocaine 1% and triamcinolone into the biceps brachii (two injections) and triceps brachii (three injections). The PA then applies a gauze pad and small bandage to the injection site.

For this claim, you’d report 20552 for the TPI because only two muscles were injected with modifier RT (Right side) appended to indicate laterality. Don’t forget to include G56.41 to represent the patient’s causalgia.

Perry stressed that documentation for TPIs must be very specific, stating which muscles were injected, how many times, and patient status pre- and post-injection.

Chris Boucher, MS, CPC, Senior Development Editor, AAPC