Neurology & Pain Management Coding Alert

Question: A patient came to our office with pain and spasms in the bilateral cervical regions, with associated tenderness radiating to the lower cervical region. He also complained of pain and spasms in the lower lumbar region, with associated tenderness radiating to the lower extremities. The physician injected Lidocaine and Kenalog into trigger points in the following muscles:

• Right and left supraspinatus muscle
• Right and left trapezius muscle
• Right and left cervical paraspinal muscles
• Right and left glutei muscles
• Right and left lumbar paraspinal muscles
• Right and left sacral paraspinal muscles.

The physician recommended that we code the encounter with 20553, J3301, 96372, and an office visit code. I don’t agree, but what do you think?

Vermont Subscriber

Answer: Your physician’s recommendation of 20553 (Injection[s]; single or multiple trigger point[s], 3 or more muscle[s]) is correct for the trigger point injections. You should not submit 96372 (Therapeutic, prophylactic, or diagnostic injection [specify substance or drug]; subcutaneous or intramuscular) since no intramuscular injections were administered separate from the trigger point injections. In addition, 20553 includes the actual process of injecting so reporting the 96372 as a separate code would be considered unbundling.

We cannot recommend the number of billable units for J3301 (Injection, triamcinolone acetonide, not otherwise specified, 10 mg) without knowing the total amounts injected. Just remember that you can only bill for the Kenalog, not the Lidocaine.

If the office visit included additional physician work beyond the decision to perform the trigger point injections or if you have documentation of E/M services unrelated to the patient’s back pain, you can submit the appropriate E/M code separate from the injection procedure. Be sure to include modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other health care professional on the same day of the procedure or other service) with the E/M code to distinguish the services.