Internal Medicine Coding Alert

Question: Our internist has begun performing pain management. Do you have any tips on reporting trigger point injections?

Rhode Island Subscriber

Answer: To properly use 20552 (Injection[s]; single or multiple trigger points[s], one or two muscle[s]) and 20553 (... single or multiple trigger point[s], three or more muscles), you should know the muscles the internist treated Typically, patients have back pain (724.5x) that originates one muscle group. Even so, they feel discomfort throughout their back and in other parts of the body, such as the legs and neck. But if your physician treats the pain with multiple trigger point injections and focuses on just one muscle, you cannot bill for each injection.

You should report 20552 and 20553 once per session, regardless of the number of injections, or per muscle. For example, a patient who has lower back pain also complains that her arms and legs ache. During the examination, your physician discovers three trigger points in the multifidus muscle to the left of the L5 spinous process. The physician injects each trigger point in the multifidus muscle. You report 20552 because the physician treated only one muscle (multifidus), even though he administered three injections.

Also, notice that 20552's descriptor represents single or multiple trigger points. Therefore, billing 20552 lets the insurer know that your physician may have performed more than one injection, although the insurer will pay the same rate.

When reporting 20553, make sure your physician treated multiple muscles. For example, a patient recovering from an auto accident presents with neck pain (723.1, Cervicalgia) and shoulder pain (726.1x). The internist identifies three trigger points: the right trapezius, left trapezius, and the right sacroiliac muscles. In this instance, you should submit 20553 once for your physician injecting three muscles.