Question: Our physician administered bilateral trigger point injections in three locations for a Medicare patient. I know that Medicare won’t accept the bilateral modifier 50, so should I include the left/right modifiers instead?
Based on the circumstances you provide, you should report 20552 (Injection[s]; single or multiple trigger point[s], one or two muscle[s]) if the injections were in one or two muscles or 20553 (- single or multiple trigger point[s], three or more muscles) for three or more muscles.
Washington Subscriber
Answer: Modifiers LT (Left side) or RT (Right side) won’t be necessary, even if Medicare doesn’t require modifier 50 (Bilateral procedure) for bilateral trigger point injections (TPIs).
Here’s why: You code TPIs based on the number of muscles treated, so left/right isn’t a factor, even for bilateral injections. Your physician’s notes should clearly identify the exact muscles injected, so code according to the muscles that he documented injecting.