Internal Medicine Coding Alert

Question: When a physician injects more than three muscles on each side of the upper back, can I use modifier 50 (Bilateral procedure) to report each side's trigger point injection (TPI)?

Michigan Subscriber

Answer: When the physician injects three or more muscles, you should report 20553 (Injection[s]; single or multiple trigger point[s], three or more muscle[s]) without units or modifiers, regardless of whether the muscles were on one or two sides.

The intent behind CPT 2004's changes to TPI codes 20550-20553 was to have physicians report codes 20552 (... single or multiple trigger point[s], one or two muscle[s]) and 20553 one time per session, regardless of the number of injections given.

Use 20552 when the physician injects one or more muscles. Code 20553 specifies three or more muscles.

The documentation for the claim should include the location of injections, number of injections, and number of muscles involved.