Neurology & Pain Management Coding Alert

Question: When my neurologist injects trigger points in more than three muscles on each side of the upper back, can I use modifier 50 (Bilateral procedure) to report each side's trigger point injection (TPI)?
Maine Subscriber

Answer: When your neurologist injects three or more muscles, you should report 20553 (Injection[s]; single or multiple trigger point[s], three or more muscle[s]) without multiple units or modifiers, regardless of whether the muscles were on one or two sides.

The AMA revised trigger point injection codes 20550-20553 so that physicians would report either 20552 (... single or multiple trigger point[s], one or two muscle[s]) or 20553 a maximum of once per session, regardless of the number of injections given. Apply 20552 when your neurologist injects a total of one or two distinct muscles. Report 20553, in contrast, when your provider injects three or more distinct muscles.

Tip: Trigger point injection documentation should include the specific muscles injected -- for example, the location of injections, the number of trigger points injected, and the medication.