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. [...]