Neurology & Pain Management Coding Alert

Question: My doctor wants to start administering trigger point injections (TPIs). May I bill for a visit and injection on the same day? If so, do I need a modifier?

Arizona Subscriber

Answer: The simple answer is yes, you can code for both the injection and the E/M visit if you meet certain conditions.

You should append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code if the neurologist's documentation indicates he performed a separate E/M service.

Example: An established patient arrives for a prescheduled injection to treat myalgia in the neck region (729.1, Myalgia and myositis, unspecified). He also complains of a new symptom -- muscle weakness in both of his lower extremities (728.87, Generalized muscle weakness).

The neurologist performs an expanded, problem-focused history and exam (99213-25, Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity; Significant, separately identifiable E/M service-) based on this new symptom and decides to order additional diagnostic testing. The neurologist also performs the scheduled TPI (20552, Injection[s]; single or multiple trigger points, one or two muscles, or 20553, - single or multiple trigger point[s], three or more muscles) for myalgia. You may report 20552 linked with 729.1, and 99213-25 with 728.87.

Remember: Do not report the E/M code if the patient presents only for the injection. In this example, if the patient does not complain of a new symptom that prompts a separate E/M service, you would report only 20552 or 20553 for the injection(s).

Keep your finger on the trigger point: A trigger point is a localized area of muscle causing pain in a remote area when the muscle is pressed. A TPI is used to treat painful areas of muscle by easing myofascial pain. Injections into joints or ligaments are not TPIs.