Neurology & Pain Management Coding Alert

Question: A patient with chronic myofascial pain syndrome presents for trigger point injections (TPIs) to relieve pain. Notes indicate that the physician injected a single trigger point in three different muscles. What is myofascial pain syndrome, and how can I establish medical necessity for these TPIs?

Kansas Subscriber

Answer: The ICD-10 code for myofascial pain syndrome, or myalgia, is M79.1- (Myalgia). Append M79.1- to 20553 (Injection[s]; single or multiple trigger point[s], 3 or more muscle[s]) on your TPI claim.

Major criteria: According to Noridian local coverage determination (LCD) L34211, all four of the following elements must be present to establish a myalgia diagnosis:

A. “Regional pain complaint
B. “Pain complaint or altered sensation in the expected distribution of referred pain from a trigger point
C. “Taut band palpable in an accessible muscle with exquisite tenderness at one point along the length of it
D. “Some degree of restricted range of motion, when measurable.”

Minor criteria: Noridian’s LCD goes on to state that only one of following four elements is necessary to diagnose myalgia:

A. “Reproduction of referred pain pattern by stimulating the trigger point
B. “Altered sensation by pressure on the tender spot
C. “Local response elicited by snapping palpation at the tender spot or by needle insertion into the tender spot
D. “Pain alleviated by stretching or injecting the tender spot.”

Best bet: Be sure the patient meets the above criteria before choosing the M79.1- code.

For more on Noridian’s TPI coverage, see: https://med.noridianmedicare.com/documents/10525/5321621/Local+Coverage+Determination+for+Trigger+Point+Injections+(L34211).