Medicare Compliance & Reimbursement

Question: A patient reported to the ED for treatment of severe back spasms. After a level-three E/M, the physician ordered four Trigger Point Injections (TPIs): two in the patient's multifidis, and one each in the longissimus and psoas major. How should I code for this encounter?

Answer: You should first check that the patient's insurer covers TPIs for muscle spasms as acceptable ICD-9s for this service. Covered diagnoses depend entirely on the payer. Provided the payer accepts the diagnosis, report the following:

• 20553 -- Injection[s]; single or multiple trigger point[s], 3 or more muscle[s] for all four TPIs;

• 99283 -- Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; and medical decision making of moderate complexity ... for the E/M;

• modifier 25 -- Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service appended to 99283 to show that the TPIs and E/M were separate services; and

• 728.85 -- Spasm of muscle appended to 20553 and 99283 to represent the patient's condition.

Documentation tip: If your physician doesn't list each muscle that the physician injects during the TPI, your claim might get knocked down to 20552 (... single or multiple trigger point[s], 1 or 2 muscles).

Since the coding is based on number of muscles, insurers want proof of three-plus separate areas for 20553. Also, you should document the drug(s) the provider injects to clarify that the procedure was an injection and not "dry-needling," which some payers do not cover. Drugs the provider could use during TPI, and might be reported by the facility, include:

• Depo-Medrol (J1020, Injection, methylprednisoloneacetate, 20 mg);

• DepoMedalone40, Depo-Medrol, Sano-Drol (J1030, Injection, methylprednisolone acetate, 40 mg); and

• Cortimed, DepMedalone, DepoMedalone80, Depo-Medrol, Duro Cort, Methylcotolone, Pri- Methylate, Sano-Drol (J1040, Injection, methylprednisolone acetate, 80 mg).