Neurology & Pain Management Coding Alert

Question: Our provider performed significant, separately identifiable level-three evaluation and management service for a patient with upper back pain, and then made the decision to perform trigger point injections (TPIs). The provider injected the patient’s rhomboid and trapeziusmuscles with one injection each. How should I code this encounter? Can I report the drug supply separately from the TPI?

Colorado Subscriber

Answer: On TPIs, “you can code separately for the drug, any drug, that is therapeutic such as corticosteroids,” confirms Deborah Messinger, RHIT, CCS, CPC, CPMA, coding manager for the surgery & anesthesia team at Massachusetts General Physicians Organization/Professional Billing Office in Charlestown.

As long as the drug was therapeutic, you should report it along with the TPI. On the claim, report the following:

• 20552 (Injection[s]; single or multiple trigger point[s], 1 or 2 muscle[s]) for the TPIs
• 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity …) for the E/M
• modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care profes­sional on the same day of the procedure or other service) appended to 99213 to show that the E/M was a significant, separately identifiable service from the E/M.
• M54.89 (Other dorsalgia) Appended to 20552 and 99213 to represent the patient’s back pain.
• the appropriate J code for the drug the provider used during the TPI.

Potential drug codes: Since you didn’t specify the drug the provider injected during the TPI, here is a list of potential drugs that your provider might use during a TPI:

• J3301 (Injection, triamcinolone acetonide, not otherwise specified, 10 mg)
• J1020 (Injection, methylprednisolone acetate, 20 mg), J1030 (... 40 mg), or J1040 (... 80 mg)
• J1100 (Injection, dexamethasone sodium phosphate, 1 mg)

Anesthetic conundrum: Although Medicare will not provide you any separate reimbursement for local anesthetics that the provider uses during the TPIs, some private payers might. If you are filling a TPI claim with a local anesthetic to a non-Medicare provider, check your contract to see if you can separately report the anesthetic.