Internal Medicine Coding Alert

Question: An established patient with a history of back problems reported to the internist complaining of sharp lower back pain and aching legs. The internist discovered three trigger points in the patient's longissimus muscle, and performed therapeutic injections at each trigger point. Can I report 20553 for this encounter?

Indiana Subscriber

Answer: You cannot report 20553, because the internist treated only one muscle. CPT groups trigger point codes to reflect the number of overall muscles the internist treats, not how many injections he performs.

On the claim, report the following:

• 20552 (Injection[s]; single or multiple trigger point[s], one or two muscles) for the injections

• 724.2 (Lumbago) appended to 20552 to represent the patient's back pain

• 729.5 (Pain in limb) appended to 20552 to represent the patient's leg pain.

Report 20552 whenever the internist treats one or two muscles with injections, regardless of the number of shots he performs.

Exception: When the internist performs trigger points on three-plus muscles, you can report 20553
(... single or multiple trigger point[s], three or more muscle[s]).

Let's say the internist treats the same patient with three trigger point injections; but he performs a single injection on the longissimus muscle, one on the multifidis muscle, and one on the iliocostalis muscle. In this instance, you may report 20553 instead of 20552.