Neurology & Pain Management Coding Alert

Question: Encounter notes indicate that the provider performed three total trigger point injections (TPIs) in two of a patient’s shoulder muscles. Final diagnosis “idio gout, shoulder. What is the correct coding for this scenario?

Florida Subscriber

Answer: The CPT^® code for your claim is clear; the ICD-10 code choice, however, is more opaque.

You should report 20552 (Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s)) for the TPI. Remember, TPI codes count the number of muscles — not the number of injections. So, even if the provider had performed six TPIs on two muscles, you’d still report 20552.

As for the ICD-10 code, you’re going to need to go deeper into the notes and, hopefully, dig up some more information that you can use to arrive at the most specific diagnosis code possible. What’s pretty clear is that the patient suffers from idiopathic gout of the shoulder. This condition is also sometimes marked as “gouty bursitis” or “primary gout” in encounter notes, so be on the lookout for those synonymous terms.

What you need to find out is the laterality of the gout, if possible.

Once you recheck the notes, use one (or more) of the following ICD-10 codes to pain the most accurate picture possible of the patient’s condition:

• M10.011 (Idiopathic gout, right shoulder)
• M10.012 (Idiopathic gout, left shoulder)
• M10.019 (Idiopathic gout, unspecified shoulder).