Neurology & Pain Management Coding Alert

Question: How should I report bilateral trigger point injections in three locations for a Medicare patient? Because Medicare doesn't recognize modifier 50, should I use modifiers LT or RT instead?


Washington Subscriber
 

Answer: You should code trigger point injections based on the number of muscles treated, so -left- versus -right- isn't really a factor, even for bilateral injections. So you wouldn't use modifiers LT (Left side) and RT (Right side), or modifier 50 (Bilateral procedure) for the carriers that accept it.
 
Your physician's notes should clearly identify the exact muscles injected, so code from that.
 
Based on the circumstances that you provide, you should report 20552 (Injection[s]; single or multiple trigger point[s], one or two muscle[s]) if the injections were in one or two muscles or 20553 (- single or multiple trigger point[s], three or more muscles) for three or more muscles.