Orthopedic Coding Alert

Trio of experts runs down some of the finer points of TPI.

Coding for trigger point injections (TPIs) is pretty easy … right?

The provider performs a TPI or TPIs; you count the number of muscles the provider injected, and choose one of the following codes:

• 20552 — Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s)
• 20553 — … single or multiple trigger point(s), 3 or more muscles.

As is often the case with CPT^® coding, the devil’s in the details — the details in the encounter notes, which you’ll need to pore over in order to ensure the proper documentation accompanies your TPI claims.

To help you with any TPI-related coding anxiety, we gathered Deborah Pellon, RHIT, CCS, CPC, CPMA, coding manager, Surgery & Anesthesia Team at Massachusetts General Physicians Organization/Professional Billing Office in Charlestown, Massachusetts; Judith L. Blaszczyk, RN, CPC, ACS-PM, ICDCT-CM, compliance auditor at ACE, Inc. in Overland Park, Kansas; and Joanne Mehmert, CPC, CCS-P,  president of Joanne Mehmert and Associates in Kansas City, Missouri.

Here’s what they had to say about TPI coding, documentation, and how to file a successful claim.

What types of diagnoses/symptoms are typical of patients receiving TPIs?

Mehmert

“Trigger points might be described as knots of muscle that form when muscles do not relax. Headaches are another reason that physicians perform a TPI. Doctors will call it myofascitis, myositis, myalgia, myofascial pain, fibromyalgia.

“Some Medicare carriers ask for a more specific code, and they list the ICD-10 codes according to muscle group. You can find them on various Medicare carrier web sites in the LCDs [local coverage determinations] — the codes Medicare [carriers] accept to describe the condition may be similar, but they differ, too.”

Pellon

“AMA CPT^® Assistant September 2003, Coding Communication on Trigger Point Injections listed fibromyalgia,

• plantar fasciitis,
• headaches associated with neck pain,
• chronic low back pain,
• osteoarthritis,
• multiple sclerosis,
• chronic myofascial pain,
• joint disease,
• focal areas of muscle hyperactivity,
• scoliosis, and
• herniated degenerative disks as indications for trigger point injections.”

So, you should report 20552 when the provider injects one or two muscle groups (regardless of the number of individual injections), and 20553 for injections to three or more muscles?

Blaszczyk

“That is correct. The description of these codes states this. Therefore, the differentiation in the code chosen is the number of muscles, not the number of individual injections.

“This makes it very important that the physician document each muscle that is injected so the coder can select the correct code.”

Pellon

“CPT^® Assistant June 2017 instructs that this code set is reported once per session based on the number of muscles injected. If bilateral muscles are injected that would count as two muscles.”

I’ve heard some coders say that documentation for TPI should include a list of the muscles injected. Would you recommend this?

Mehmert

“Absolutely I agree that the physician should document the muscles s/he injects from a record of patients’ condition and treatment to a risk management. Physicians also need to document how they arrived at the conclusion that the patient required the injection. History of condition, exam, supporting documentation etc.”

Blaszczyk

“I completely agree that the muscle(s) injected must be documented. In addition, documentation of the medical necessity for the procedure should be clear. Included in this would be documentation of a brief

pain history, the location of the pain, the pre-injection intensity of the pain, prior treatment, and responses.”

Pellon

“I agree that identification of muscles injected should be documented, as well as indications, description of injection type, and amount of infiltrate and description of infiltration, and cleaning bandaging, if applicable, of injection areas post-procedure, based on CPT^® Assistant September 2003.”

Could you provide an example of solid documentation for a TPI encounter?

Blaszczyk

“A 43-year-old male presents with a three-week history of occipital and cervical neck pain unrelieved by over the counter pain medications, heat, or muscle relaxers. He describes the pain as sharp, unrelenting and 8 out of 10 on the pain scale. Palpable trigger points are found in the trapezius and quadratus lumborum muscles.”

“In documenting the actual procedure the following should be included: Method or technique; equipment used; location of injection; substance and amount injected; the patient’s tolerance of the procedure; and the patient’s post-procedure pain rating.”