Neurology & Pain Management Coding Alert

Question: Medicare is denying us for trigger point code 20553 on the pretext that the information submitted does not support the frequency of services. Can you please help us understand the reason for this denial?

Florida Subscriber

Answer: You shouldn’t bill units with codes 20552 (Injection[s]; single or multiple trigger point[s], 1 or 2 muscle[s]) or 20553 (… single or multiple trigger point[s], 3 or more muscle[s]). Once the medical necessity for injections is established, use the appropriate ICD-9 code to support your diagnosis. Always keep a record of the muscles injected.

Since trigger point injections (TPIs) are per-session codes and not per-injection codes, do not append any modifiers. Select the appropriate code by the number of muscles injected.

Example: A patient presents with pain in his abdominal area and your physician administers six injections on the patient’s transverse abdominis and four injections on his rectus abdominus. You should report CPT^® 20552 because the physician injected two muscles. Also include the appropriate J code from HCPCS if the physician used any type of therapeutic drug.

Tip: When repeat TPIs are necessary, the medical record must reflect the reason for repeated injections. The patient’s response to the previous injection is an important factor in deciding any subsequent treatments. Evidence of any improvement to the range of motion in any muscle area after an injection could potentially justify a repeat injection. When services are performed in excess of established parameters, they may be subject to a review for medical necessity.

In this case, the denial seems most probably due to the Medicare contractor’s LCD specifies how frequently in a specific time period that trigger point injections can be reported.  For example, the following is from the Cahaba LCD: “More than four (4) trigger point injections in a year’s time will not be covered by this Contractor. If a patient requires more than four (4) procedures of either CPT codes 20552 or 20553 during one year, a report stating the unusual circumstances and medical necessity for giving the additional injections must be documented in the patient’s medical record and made available to Medicare upon request.” Evidence of partial improvements to the range of motion in any muscle area after an injection, but with persistent significant pain, would justify a repeat injection. The medical record must clearly reflect the medical necessity for repeated injections.