Orthopedic Coding Alert

Question: How should I report bilateral trigger point injections in three locations for a Medicare patient? Because our Medicare carrier doesn't recognize modifier 50, should I use modifiers LT or RT instead?


Washington Subscriber

Answer: You should code trigger point injections based on the number of muscles treated, so -left- versus -right- isn't really a factor, even for bilateral injections. You wouldn't use modifiers LT (Left side) and RT (Right side), or modifier 50 (Bilateral procedure) for the carriers that accept it.

Your physician's notes should clearly identify the exact muscles injected, so code according to the muscles that he documented injecting.

Based on the circumstances you provide, you should report 20552 (Injection[s]; single or multiple trigger point[s], one or two muscle[s]) if the injections were in one or two muscles or 20553 (- single or multiple trigger point[s], three or more muscles) for three or more muscles.

Reader Questions were reviewed by Heidi Stout, CPC, CCS-P, director of orthopaedic coding services at The Coding Network, LLC; and Bill Mallon, MD, orthopedic surgeon and medical director at Triangle Orthopaedic Associates in Durham, N.C.