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General Surgery Coding Alert

Code Number of Trigger-Point Injections by Muscle Groups

Published on Mon Oct 01, 2001

When surgeons provide trigger-point injections, they may perform more than one injection in the same muscle group. The number of injections to be billed, however, does not depend on the number of injections performed.
 
Instead, carriers should be charged for the number of muscle groups that received trigger-point injections, experts say. Some carriers may not pay for more than one injection in any case, and others may pay for only a set number of injections, regardless of the number of muscle groups targeted.
 
If only one muscle group was targeted, only one injection may be charged, even if 10 or more injections were provided. Many carriers allow physicians to bill separately for each muscle group targeted as long as the different groups are documented and modifier -59 (distinct procedural service) is appended to all subsequent injections.
 
Trigger-point injections are used to treat acute or chronic pain in rigger points "" soft-tissue inflammations similar to planter's fascitis (an inflammation in the tendon of the foot). If the injection typically a steroid and often combined with an anesthetic agent provides immediate relief the surgeon knows the patient has a trigger point.
 
For example a surgeon may provide trigger-point injections to patients with severe groin pain. If there is no evidence of hernia but the patient exhibits tenderness in the abdominal wall or continues to have muscular pain the surgeon may perform a trigger-point injection in the area to see if it will relieve the patient's pain.
 
Similarly the surgeon may provide a trigger-point injection to a patient with a painful scar following surgery or to patients with carpal tunnel syndrome.
 
Required Modifiers
 
Code trigger-point injections 20550 (injection tendon sheath ligament trigger points or ganglion cyst) says Kathleen Mueller RN CPC CCS-P an independent general surgery coding and reimbursement specialist in Lenzburg Ill. She notes that because 20550's descriptor includes the word ""points "" carriers -- commercial and Medicare -- interpret this to mean that the code includes more than one injection.
 
""It is inappropriate for surgeons to charge for every pressure-point injection they perform "" Mueller says. ""If you do three injections into the same muscle group in the groin for example that counts as only one injection. However if you do three injections into the groin and two more in a completely separate muscle group two injections may be billed.""
 
Many carriers limit the number of injections that may be billed even when different muscle groups are treated Mueller says. Most Medicare carriers will pay for a maximum of five injections during the same session although some carriers may reimburse as many as eight injections. Other states such as Alaska Arizona Hawaii Nevada Oregon and Washington pay for only one injection regardless of the number of muscle groups treated.
 
Note: A few private carriers reportedly will not cover trigger-point injections at all.
 
In most states Medicare carriers want modifier -59 attached to additional 20550 claims. By appending modifier -59 to 20550 the physician overrides any software edit bundling multiple trigger-point injections by indicating the injections were performed at separate sites i.e. different muscle groups.
 
Most Medicare carriers also want claims involving 20550-59 on separate lines. For example if the surgeon treated three muscle groups with trigger-point injections code the session as follows:
 
20550
20550-59
20550-59.
 
Some carriers however require modifier -51 (multiple procedures) be used not modifier -59. For example notes Lisa Clifford CPC a coding and reimbursement specialist in Naples Fla. First Choice Service Options the Medicare Part B carrier in Florida requires physicians to append modifier -51 to any subsequent trigger-point injections and also to use modifiers -LT (left side) and -RT (right side) if the same muscle on a different side of the body is targeted.
 
Note: Regardless of whether modifier -59 or -51 is appended the multiple-procedure reduction applies which means that subsequent injections will be paid at 50 percent of the rate of the first injection.
 
Because trigger-point injections are relatively straightforward and are reimbursed fairly well (2.88 relative value units) 20550 is carefully watched for abuse and the documentation guidelines covering its use are stringent Clifford says. She notes that multiple trigger points and in some cases individual trigger-point claims will be denied unless medical necessity is indicated. As a result the surgeon's documentation should include:
 
  • An appropriate diagnosis. Many carriers only pay for trigger point injections linked to specific diagnoses such as groin pain or a trigger finger. (Trigger fingers occur when tendonitis inflames the finger which may lock in either the open or closed position.)
     
    Note: To report trigger-finger injections use modifiers FA-F9 to identify the specific finger(s) injected.
     
  • A patient evaluation. In an audit carriers want to see the physician's evaluation of the patient that led to the diagnosis that required trigger-point injections. Therefore the documentation should identify the affected muscle groups and also state that the patient's symptoms have not eased after noninvasive treatments such as nonsteroidal anti-inflammatory drugs or massage have failed. The documentation should also indicate that stimulation of the affected area initiates an attack of neuralgia pain or stiffness.
     
    If as often is the case the injections are delivered in a series the documentation for each injection (other than the first) must support the need for continued injections. If for example the patient obtained no relief from the first injection any subsequent shots would not be supportable or medically necessary Mueller says.

    • Billing E/M and Injection on the Same Day
     
    Evaluation and management services provided on the same day as a trigger-point injection are payable only if the E/M is significant and separately identifiable Clifford notes. In such cases append modifier -25 (significant separately identifiable evaluation and management service by the same physician on the same day as a procedure or other service) to the appropriate E/M code.
     
    ""Typically only the initial evaluation that led to the decision to treat the patient with trigger-point injections is payable if it is appended with modifier -25 "" Clifford says. However subsequent visits also may be payable but in such cases the patient needs to have a different problem especially if the visit is prescheduled.
     
    For example a 47-year-old male patient with right groin pain radiating to the testicle presents at the surgeon's office for a consultation. The patient's attending physician already has treated the patient with nonsteroidal medication and computerized tomography (CT scan) of the abdomen and radiologic tests do not reveal any pathology. The attending physician suspects a possible hernia and requests a consultation with a surgeon.
     
    On examination the surgeon identifies a trigger point that produces symptoms very similar to those the patient has displayed over the past few months. The surgeon decides to inject the patient with a steroid agent (Celestone Soluspan for example) and anesthetic agents such as Marcaine and lidocaine. The patient is then scheduled for re-evaluation in two weeks.
     
    The visit would be billed to Medicare as follows:
     
    20550 (for the injection)
     
    9924x-25 (to bill the consultation)
     
    J0702 -- injection betamethasone acetate and betamethasone sodium phosphate per 3 mg
     
    J2000 -- injection lidocaine HCl 50 cc.
     
     
    If Marcaine is used as an anesthetic the only code available is S0020 (injection bupivacaine hydrochloride 30 ml). According to HCPCS ""S codes are developed by Blue Cross/Blue Shield and other commercial payers to report drugs services and supplies. They may not be used to bill services paid under any Medicare system"" [emphasis added]. Some Medicare carriers also may not pay for lidocaine Mueller says.
     
    When the patient returns two weeks later for re-evaluation the visit is billable even if the surgeon determines that another trigger-point injection is needed because he was scheduled only for an evaluation. Therefore an established patient visit (9921x with modifier -25 appended) may be billed in addition to 20550.
    "

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