Neurosurgery Coding Alert

Be sure to limit your claims to one unit of either 20552 or 20553 per encounter

You'll report trigger point injections (20552-20553) with confidence if you know
what muscle group(s) the neurosurgeon treated, maintain solid documentation, and
avoid using modifier -59. Our experts offer these three tips for improving your trigger
point coding:

Point 1. Count Muscle Groups, Not Injections

To select between 20552 (Injection[s]; single or multiple trigger point[s], one or
two muscle[s]) and 20553 (... single or multiple trigger point[s], three or more muscles)
you must count the number of different muscles the physician treats. If the neurosurgeon
treats one or two muscles, report 20552. If the neurosurgeon injects three or more
separate muscles, report 20553. And, you should never report more than a single unit of
either 20552 or 20553 per patient encounter, regardless of the number of injections the
neurosurgeons administers, says Allison Waxler, practice management policy analyst at
the American Academy of Physical Medicine and Rehabilitation.

Follow CPT Instructions

The descriptor for 20552 specifies "single or multiple trigger points." Therefore,
billing 20552 lets the insurer know that your physician may have performed more than
one injection, but reimbursement will not change.

For instance, patients typically have back pain (724.x) that originates in one muscle
group. Even so, they feel discomfort throughout the back and in other parts of the body,
such as the legs and neck. But if your physician treats the pain with multiple trigger
point injections and focuses on just one muscle, you must select 20552, regardless of
the total number of injections the neurosurgeon administers.

Coding Example A: A patient who has lower back pain also complains that her arms
and legs ache. During the examination, your physician discovers three trigger points in
the multifidus muscle to the left of the L5 spinous process. The physician injects each
trigger point in the multifidus muscle. You report 20552 (one unit) because the physician
treated only one muscle (multifidus), even though he administered three injections.

Coding Example B: A patient recovering from an auto accident presents with neck pain
(723.1, Cervicalgia) and shoulder pain (726.1x). The neurosurgeon identifies three trigger
points: the  right trapezius, left trapezius and the right sacroiliac muscles. In this case, you
should submit  20553 (one unit) because the physician injected three muscles. 

Point 2. Document Each Muscle Treated

If your carrier rejects your 20552 or 20553 claim, check your documentation - the medical
record should clearly state which muscles the neurosurgeon treated.  Most likely, insurers will
reject claims based on documentation that ambiguously refers to muscles or focuses on the
number of injections (which is irrelevant to selecting the proper code). 

"Our biggest problem with the trigger points is getting our doctors to identify the injection sites
so we know whether we are correctly billing 20552 or 20553," says Boots Alexander, billing
representative with Neurology Services Inc. in Woodbridge, Va. "The doctors still want to bill by
number of shots - not by site as described by the codes."

Consider a case in which the neurosurgeon performs three trigger point injections into the trapezius
muscle, two injections into the supraspinal muscle and two injections into the paraspinal muscle - for
a total of seven injections into three different muscles.

What NOT to document: The physicians cannot simply report that she injected three muscles,
for instance, or administered seven injections, says Jean Ryan-Niemackl, LPN, CPC, an
application  specialist with QuadraMed Government Programs Division, Fargo, N.D.  Such
documentation is not precise enough to determine proper coding or reimbursement.

How to document it right: What the physician must do is document the exact muscles he
injects.  For instance, the documentation could say, "Treated trapezius with three injections,
supraspinal with two injections and paraspinal with two injections." This clear documentation -
which shows precisely that the neurosurgeon injected three separate muscles - would support
a claim of 20553.

Point 3. Don't Unbundle Trigger Point Codes

Don't even think about attaching modifier -59 (Distinct procedural service) to either 20552 or
20553, no matter how well your neurosurgeon documents the treatment. 

Because both trigger point codes refer to "single or multiple trigger point(s)," you cannot claim one
injection as distinct from another.

Medicare assigns a zero-day global period to 20552 and 20553. This means that Medicare
bundles payment for all related services and procedures on the same date into the payment for
20552 and 20553. Therefore, when the neurosurgeon injects three different muscles, you can only
report a single code, 20553.