Orthopedic Coding Alert

Providers can perform TPIs for various ailments.

Patients in pain will often require trigger point injections (TPIs) for their ailments. These patients come in with a variety of diagnoses, but coding for these services shares a common thread: they're all reported with only two TPI codes.

That doesn't necessarily mean that coding TPIs is easy; when it comes to these injection encounters, the devil's in the details. Diagnosis codes can be difficult to discern, and these injection services aren't coded per shot, like many other injections.

There's no need for alarm, however; only vigilance through knowledge. If you have trouble pulling the trigger on a TPI claim, lean on this coding advice from three experts.

Look for these Injuries with TPI

When it comes to what ICD-10 codes will prove medical necessity for TPIs, there is no definitive list. The covered, and uncovered, diagnoses for TPIs will vary by location, payer, and, often, encounter specifics.

Expert's take: "Many payers have limited payment policies for trigger point injections, so it is important to check the policies when selecting the diagnosis from those that are documented," reports Judith L. Blaszczyk, RN, CPC, ACS-PM, ICDCT-CM compliance auditor at ACE, Inc. in Overland Park, Kansas.

However, there are a few types of injuries that might necessitate TPIs more often than others. According to Yvonne Dillon, CPC, CEDC, director of emergency department services at Bill Dunbar and Associates, LLC in Indianapolis, Indiana, some diagnoses that might be linked to a TPI code include:

• spasms;
• tendinitis/bursitis;
• joint disorders;
• osteoarthritis or other joint dysfunction;
• non-myofascial tender points;
• myalgias;
• fibromyalgia;
• psoriatic arthritis;
• rheumatoid arthritis;
• neuralgias; and
• other soft tissue disorders related to overuse, pressure, or the extremities.

Example: An established patient reports to the orthopedist complaining of spasming pain in her left calf. After performing a level-three evaluation and management (E/M) service, the orthopedist diagnoses muscle spasms in the left calf. The orthopedist performs two TPI injections into the patient's calf muscle, and then instructs her on aftercare.

For this encounter, you'd report:

• 20552 (Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s)) for the TPI.
• 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity ...) for the E/M
• modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) appended to 99213 to show that the E/M and TPI were significant and separate services
• M62.831 (Muscle spasm of calf) appended to 20552 and 99213 to represent the patient's injury.

Potential problem: Even if you knew every ICD-10 code in the book, you could still have problems linking a diagnosis to your TPI code if the provider isn't specific. "Frequently, physicians will document only the location of the pain; neck pain, low back pain, or headache," says Blaszczyk. "But in the case of trigger point injections they should really indicate more specifically the etiology of the pain."

If you have trouble discerning the appropriate ICD-10 code on your TPI claims, go back and ask the provider for more information so you can get the coding right the first time.

Count Muscles, not Injections, for Code Choice

An important factor in choosing the correct TPI code is in the numbers: you'll need to know how many muscles the orthopedist injected. For injections to one or two muscles, you'll report 20552 (Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s)). If the orthopedist performs TPIs on three or more muscles, you'll report 20553 (... single or multiple trigger point(s), 3 or more muscles).

Documentation alert: Since the number of muscles is so vital to proper TPI code choice, Blaszczyk recommends encouraging providers to document all of the muscles they inject in the encounter notes. "It's very important that the physician document each muscle that is injected so the coder can select the correct code," she says.

TPIs Often Target these Muscles

Since trigger points may occur in any skeletal muscle, your provider might inject a trigger point in almost any skeletal muscle, says Blaszczyk.

According to Deborah Messinger, RHIT, CCS, CPC, CPMA, coding manager, Surgery & Anesthesia Team at Massachusetts General Physicians Organization/Professional Billing Office in Charlestown, Massachusetts, some of the more common muscles that fall victim to trigger points include:

• masseter;
• scalene group;
• trapezius (upper and lower);
• rhomboids;
• piriformis gluteus maximus;
• occipital ridge;
• levator scapulae;
• rotator cuffs;
• quadratus lumborum;
• gastrocnemius;
• soleus;
• plantaris; and
• quadratus plantae (for plantar fasciitis).

Example: A new patient reports to the orthopedist with pain in her upper back. After a level-four E/M service, the orthopedist performs TPIs to the patient's masseter muscle, upper trapezius, lower trapezius, and rhomboids. On the claim, you would report:

• 20553 for the TPIs
• 99204 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: a comprehensive history; a comprehensive examination; medical decision making of moderate complexity ...) for the E/M service
• modifier 25 appended to 99204 to show that the E/M was a significantly separate service from the TPIs.

Use this Checklist for TPI Coding Completeness

You always want to have the most complete documentation included in all of your claims, and TPIs are no different. When you submit the TPI claim, Blaszczyk recommends that you make sure you have thefollowing documentation:

• pre-procedure pain score;
• time out;
• method or technique;
• equipment used;
• location of injection;
• substance and amount injected;
• patient's tolerance of the procedure; and
• patient's post-procedure pain rating.