Neurology & Pain Management Coding Alert

Question: What is the best way to code for trigger point injections to receive the maximum reimbursement (diagnosis: cervicalgia (723.1), lumbar strain (847.2); CPT code 20550)?

Howard D. Chazin, MD
Olney, Md.

Answer: Arnold J. Weil, MD, a pain management expert in Atlanta who served on his states Medicare carrier advisory committee and was instrumental in the formation of Georgias Medicare policy for trigger point injections says that the first consideration in coding for trigger point injections must be state-to-state carrier variations.

Weil says that although the correct code for a trigger point injection is 20550 (injection, tendon sheath, ligament, trigger points or ganglion cyst) the number of reimbursable injections per site, per visit, and per patient per year varies greatly from one state to another. The neurologist should check with his or her state Medicare carrier regarding this issue and verify with major third-party payers whether they follow Medicares guidelines.

In Georgia, for example, Medicare has a set list of reimbursable diagnoses and sites for trigger point injections, which include muscle spasm (728.85) and myofascial pain (729.1). Weir says that a muscle group such as the trapeziae would be viewed by Medicare in Georgia as an acceptable site. Some states and some carriers within different states may have different lists of reimbursable sites and diagnoses, and some may not have such a list at all.

Weir adds that in Georgia, it is not necessary to denote the particular muscle that receives each injection on the claim (it is common for a single site to receive multiple injections). He would bill for cervical injections times six for lower lumbar paravertebral or trigger point injections times eight for upper trapeziae.

Whether a claim may be billed electronically or whether documentation will be required is another state and carrier specific issue. In Georgia, as many as eight injections given to a patient in a single session may be billed electronically. But if more than eight are billed, the claim must be submitted on paper with documentation. Bart W. Balint, MD, DABA, an associate of the American Pain Society and primary physician and owner of Balint Pain Management Center in Weyers Cave, Va., says that Medicare and most third-party payers in his state require the identification of the individual muscles being injected. Reimbursement also may vary greatly. From my experience, payers in Virginia only reimburse for two to two and a half trigger point injections per visit.

Myofascial pain and chronic headache pain are the primary reasons Balint performs trigger point injections. Other conditions that medically might require the pain relief provided by this procedure include injuries stemming from sports activities, automobile accidents, falls, twists, strains, carpal tunnel and even incorrect posture.

Balint says that even if a neurologist is aware that Medicare or a third-party payer will pay only for a certain number of injections, each injection performed should be listed. The neurologist should document the work that is being done.

Kentucky Medicare requirements are similar to those in Virginia, but a greater number of injections may be reimbursed. For example, Medicare carriers in Kentucky will reimburse for three sticks per site and will pay for multiple sites injected on the same daybut payment amounts will be calculated on a sliding scale.

Although each state may have its own requirements, there are several constants in billing for trigger point injections:

1. Attach a -51 modifier (multiple procedures) for each listing of 20550 after the primary code.

2. Attach a -25 modifier (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to any evaluation and management (E/M) codes being billed with the trigger point injections. (Most Medicare carriers will pay new patient E/M visits [99201-99205] billed with trigger point injections; however, many coding experts report difficulty getting reimbursed for re-exams [99211-99215] when billed with a trigger point injection.)

3. Ask your individual state Medicare carriers and major third-party payers to provide detailed written information regarding their claims requirements and reimbursement policies on trigger point injections.