Neurology & Pain Management Coding Alert

Limit your claims to one unit of either 20552 or 20553 per patient encounter

You'll report trigger point injections (20552-20553) with confidence if you know what muscle group(s) the neurologist treated, maintain solid documentation and avoid using modifier -59. Our experts offer three tips for improving your trigger point coding:

To select between 20552 (Injection[s]; single or multiple trigger point[s], one or two muscle[s]) and 20553 (... single or multiple trigger point[s], three or more muscles) you must count the number of different muscles the physician treats. If the neurologist treats one or two muscles, report 20552. If the neurologist injects three or more separate muscles, report 20553.

And, you should never report more than a single unit of either 20552 or 20553 per patient encounter, regardless of the number of injections the neurologists administers, says Allison Waxler, practice management policy analyst at the American Academy of Physical Medicine and Rehabilitation.

Follow CPT instructions: The descriptor for 20552 specifies "single or multiple trigger points." Therefore, billing 20552 lets the insurer know that your physician may have performed more than one injection, but reimbursement will not change.

For instance, patients typically have back pain (724.x) that originates in one muscle group. Even so, they feel discomfort throughout their back and in other parts of the body, such as the legs and neck. But if your physician treats the pain with multiple trigger point injections and focuses on just one muscle, you must select 20552, regardless of the total number of injections the neurologist administers.

Coding Example A: A patient who has lower back pain also complains that her arms and legs ache. During the examination, your physician 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 report 20552 because the physician treated only one muscle (multifidus), even though he administered three injections.

Coding Example B: A patient recovering from an auto accident presents with neck pain (723.1, Cervicalgia) and shoulder pain (726.1x). The neurologist identifies three trigger points: the right trapezius, the left trapezius and the right sacroiliac muscles. In this case, you should submit 20553 because the physician injected three muscles.

If your carrier rejects your 20552 or 20553 claim, check your documentation -- the medical record should clearly state which muscles the neurologist treated.

Most likely, insurers will reject claims based on documentation that ambiguously refers to muscles or focuses on the number of injections (which is irrelevant to selecting the proper code).

"Our biggest problem with the trigger points is getting our doctors to identify the injection sites so we know whether we are correctly billing 20552 or 20553," says Boots Alexander, billing representative with Neurology Services Inc. in Woodbridge, Va. "The doctors still want to bill by number of shots -- not by site as described by the codes."

Consider a case in which the neurologist performs three trigger point injections into the trapezius muscle, two injections into the supraspinal muscle, and two injections into the paraspinal muscle, for a total of seven injections into three different muscles.

What NOT to document: The physicians cannot simply report that she injected three muscles, for instance, or administered seven injections, says Jean Ryan-Niemackl, LPN, CPC, an application specialist with QuadraMed Government Programs Division, Fargo, N.D. Such documentation is not precise enough to determine proper coding or reimbursement.

How to document it right: What the physician must do is document the exact muscles he injects. For instance, the documentation could say, "Treated trapezius with three injections, supraspinal with two injections, and paraspinal with two injections." This clear documentation -- which shows precisely that the neurologist injected three separate muscles -- would support a claim of 20553.

Don't even think about attaching modifier -59 (Distinct procedural service) to either 20552 or 20553, no matter how well your neurologist documents the treatment. Because both trigger point codes refer to "single or multiple trigger point(s)," you cannot claim one injection as distinct from another.

Medicare assigns a zero-day global period to 20552 and 20553. This means that Medicare bundles payment for all related services and procedures on the same date into the payment for 20552 and 20553. Therefore, when the neurologist injects three different muscles, you can only report a single code, 20553.