Neurology & Pain Management Coding Alert
Target These Areas for Can’t-Miss TPI Claims
PM provider must list muscles injected for proper coding. Patients will often report to pain management (PM) clinics for relief via injection. One of the more common injection treatments for pain relief is trigger point injections (TPIs). These shots might seem like a breeze to code, but there are several potential missteps that could lead you to a miscoded claim. Failure to hit all the marks that the payer is looking for on a TPI claim could lead to rejection and refiling. Get the lowdown on TPIs with this FAQ on the condition, how to code for the service, and the types of documentation to include so your claim sails through. What Is a Trigger Point? A trigger point is a sensitive area within the fascia and/or bands of muscle that are hypersensitive or painful due to compression. When the physician presses on a trigger point, it can cause the patient referred pain. This aids the physician in identifying the part of the body generating the pain. Trigger points can also be localized to a “pain point,” from which pain can radiate throughout the connective tissue/fascia and/or the muscle. This is often referred to as myofascial pain. As to its cause, trigger points may be formed by acute or repetitive trauma to the muscle tissue, which puts too much stress on the fibers. Trigger points are usually found in places where nerves connect the muscle fibers. Who Needs TPIs? Since trigger points are possible in any skeletal muscle, your physician can treat almost any skeletal muscle with a TPI. Patients who report to the PM provider for TPI often suffer from issues in the neck and shoulder area, as well as low back pain. Some of the more common muscles affected by trigger points in the neck/shoulder are the trapezius, scalene, sternocleidomastoid, and levator scapulae. Low back pain may be a result of trigger points in the quadratus lumborum, gluteus maximus, gluteus medius, and gluteus minimus muscles, among others. As for specific ICD-10-CM codes, TPIs can be used to treat trigger points in any area of the body. Unfortunately, there isn’t an ICD-10-CM code for “trigger point,” and a list of possible diagnosis codes for TPIs would number in the hundreds. You can, however, narrow TPI diagnosis possibilities somewhat by knowing the conditions that cause trigger points. Some of the most common diagnoses for TPI patients are: Coder beware: Many payers have limited payment policies for TPIs, so it is important to check the policies when selecting the diagnosis from those that are documented. How Do I Code for TPIs? There are only two codes for TPIs. When your PM provider injects one or two muscles, you should report 20552 (Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s)). When the TPI involves three or more muscles, opt for 20553 (… 3 or more muscles). The number of injections performed in each individual muscle is irrelevant, for coding purposes. The language in these code descriptors means the physician must document each muscle that is injected so the coder can select the correct code. Can I Code for Guidance on TPI Claims? Yes, if it is documented and the TPI called for guidance. In the notes beneath the descriptors for 20552 and 20553, CPT® instructs coders to look to the following codes if “imaging guidance is performed”: How Should I Document TPI Claims? Documentation for all TPI claims should include a list of the muscles injected. That way, it’s easy to discern which code you should report for the TPI; it’ll also show the payer the number of muscles your provider treated with TPI. In addition, there should be clear documentation of the medical necessity for the TPI. This should include recording a concise history of the pain, pinpointing the pain’s location, assessing the severity of the pain before injection, and noting previous treatments along with their outcomes.. Example: A 43-year-old patient presents with a three-week history of occipital and cervical neck pain unrelieved by over-the-counter (OTC) pain medications, heat, or muscle relaxers. They describe the pain as sharp, unrelenting and 8 out of 10 on the pain scale. The PM physician finds palpable trigger points in the trapezius and quadratus lumborum muscles, which they inject three times each. When looking at the documentation for this claim, you should ensure the PM physician included this information about the TPI: Can I Ever Report a Separate E/M During a TPI Encounter? Yes, you can report a separate evaluation and management (E/M) service along with the TPI if the PM provider treats a significant, separately identifiable problem during the TPI encounter. For example, a patient reports for a TPI for neck pain but also complains of wrist pain as well. The PM provider performs three TPIs on a single muscle, then addresses the wrist pain. In this instance, you could report 20552 for the TPI and a code from the 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 15 minutes must be met or exceeded.) through 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 40 minutes must be met or exceeded.) code set for the E/M related to the wrist pain. Remember to append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure) to the E/M code to show that the TPI and E/M were separate services. 1 more E/M-25: If the TPI is unscheduled, you’ll also be able to report a separate E/M service. This is because the PM physician will have to do a full workup of the patient before deciding that a TPI is the best course of treatment. Remember: If the purpose of the encounter is to administer the TPI and nothing further, you cannot code a separate E/M. Chris Boucher, MS, CPC, Senior Development Editor, AAPC
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