Medicare Compliance & Reimbursement

You may be submitting injection claims daily, but if you don't know your trigger point from your bursa, you could be noncompliant with every injection. The next time your physician performs an injection, follow these three steps to pinpoint the appropriate code.

Watch out: Say the word "injection" to coders in some specialties, and they'll recommend 90772 (Therapeutic, prophylactic or diagnostic injection [specify substance or drug]; subcutaneous or intramuscular) every time. But jumping to that conclusion could have you falling flat. For instance, more often than not, in a neurology practice 90772 is not the right answer.

Many coders used to rely on 90782 as a "catchall injection code," experts say. CPT 2006 deleted 90782 and introduced 90772--although you'll still usually steer clear because the descriptor remains the same.

If your physician doesn't document his injection clearly enough to select an appropriate trigger point or joint/bursa injection code, some coders might assign 90772 for the procedure. More experienced coders, however, say this is usually a bad idea.

Why it doesn't work: First, automatically assigning 90772 isn't correct coding because it doesn't follow CPT coding guidelines. "It is not accurate coding if the procedure is something different from a simple therapeutic injection into a muscle, such as an injection of Toradol versus a procedure that requires higher physician work and malpractice risk," says Marvel J. Hammer, RN, CPC, CCS-P, ACS-PM, CHCO, owner of MJH Consulting in Denver. And second, reporting 90772 every time costs the practice money.

Take note: In 2007, Medicare reimburses only about $23 for 90772 in an office setting--compared to more than $50 for other common injection codes such as 20600 (Arthrocentesis, aspiration and/or injection; small joint or bursa [e.g., fingers, toes]).

When to use it: Report 90772 only if the physician administers a subcutaneous or intramuscular injection, such as a Demerol shot for a migraine headache or a Toradol injection as an anti-inflammatory. Otherwise, dig into the documentation to report a more accurate, sitespecific code for the injection.

To report 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) properly, you should know what you're dealing with. A trigger point is "a localized area of muscle that causes pain in a remote area when the muscle is firmly pressed on," Hammer says. If the physician documents an injection into a joint or ligament, for instance, he did not perform a trigger point injection (TPI).

Tip: Examine the physician's documentation to determine how many muscles he injected--don't simply count how many injections he performed.

Common scenario: Low back pain (724.5). Patients typically have discomfort that originates in their paraspinous muscle, but they may feel discomfort throughout their back and in other parts of the body, such as the hips and legs. If your physician treats the pain with multiple trigger point injections and focuses on just one muscle, you cannot bill for each injection.

Example: When your physician examines a patient with low back pain, he 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 should report only one unit of 20552 because the physician treated only one muscle (multifidus), even though he administered three injections.