Neurology & Pain Management Coding Alert

Document the muscle(s) the neurologists treats for clean injection coding

You may be submitting injection claims daily, but if you don't know your trigger point from your bursa, you could be shorting your practice up to $15 per injection.
 
Follow these three steps to pinpoint the appropriate injection code for your neurologist's services.

1: Don't Use 90782 as a 'Catchall'

Say the word "injection" to most general practice coders, and they'll recommend 90782 (Therapeutic, prophylactic or diagnostic injection [specify material injected]; subcutaneous or intramuscular), but more often than not in neurology practice, you shouldn't rely on 90782.

"A lot of coders use 90782 as a catchall injection code," says Tammy Roesner, billing assistant at Forman Rehab in Illinois. "If the physician doesn't document his injection clearly enough to select an appropriate trigger point or facet joint injection code, the practice might assign 90782, but this is a bad idea." First, she says, automatically assigning 90782 isn't correct coding. And second, reporting 90782 every time costs the practice money because 90782 only reimburses about $26.

Don't forfeit reimbursement: "Practices can make up to $75 for some of the joint injection codes where I live," Roesner says. "Why would you risk losing this by submitting 90782 instead of the right code?" Report 90782 only if the physician administers a subcutaneous or intramuscular injection, such as a Demerol shot for a migraine headache.

2: Bill 1 TPI per Muscle Group

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 that a trigger point is a muscle or fascia. If the physician documents an injection into a joint or ligament, for instance, he did not perform a TPI.

Tip: Examine the neurologist's documentation to determine how many muscle groups he injected - don't simply count how many actual injections he performed.
 
For instance, back-pain (724.5) patients typically have discomfort that originates in one muscle group, but they may feel discomfort throughout their back and in other parts of the body, such as the legs and neck. If your neurologist treats the pain with multiple trigger point injections and focuses on just one muscle, you cannot bill for each injection.

For example: Suppose the back-pain patient also complains that her arms and legs ache. During the examination, the neurologist 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 20552 because the physician treated only one muscle (multifidus), even though he administered three injections.

Back Multiple Injections With Documentation

If you report 20553, the documentation should reflect that the neurologist injected multiple muscles. For example, 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 report one unit of 20553.

Warning: Never report more than one unit of 20553 per session: Because 20553 refers to "single or multiple injections" for "three or more muscles," a single unit of 20553 will suffice to claim any number of injections in three or more muscles.

If your neurologist's documentation ambiguously refers to a number of muscles or injections but doesn't name the muscles, your TPI claims might be in jeopardy.

Physicians can no longer simply document that they injected three muscles, says Jean Ryan-Niemackl, LPN, CPC, an application specialist with QuadraMed Government Programs Division in Fargo, N.D. The physician must document which muscles he injected and list the most specific ICD-9 code, she adds.

For example: The physician treats a patient with lower back pain (724.x) by administering three trigger point injections. The neurologist does not note the muscle(s) targeted, however. Because you cannot support coding for more than one muscle group, you should not list a code higher than 20552. In addition, you should link 724.x to 20552 to support medical necessity.

3: Append -25 to E/M With Injection

 If the neurologist's documentation indicates that he performed a separate E/M service, you may be able to report both the office visit and the injection. Make sure, however, that the documentation shows that the E/M service is separately identifiable, Ryan-Niemackl says.

For instance: An established patient arrives for a prescheduled injection for neck pain (723.1) but also complains of muscle weakness (728.87). In this case, the neurologist might perform the scheduled trigger point injection (20552) for neck pain and a separate E/M service for the muscle weakness.

In this case, you would report 20552 (723.1) and 99213-25 (728.87).
 
Remember: If the patient presents only for the injection, you cannot report an E/M code. For example, in the above case, if the patient does not offer a new complaint that prompts a separate E/M, you should report 20552 only.