Pain Management Coding Alert

Misreporting these shots could trigger an audit.

Patients will often require trigger point injections (TPIs) in order to alleviate pain of various types, in just about any muscle group.

When a TPI claim comes across your desk, you need to have the smarts to avoid miscoding these encounters — which could result in lost revenue or overcoding.

Stay in the middle of the road with your TPI claims using these pointers.

Know TPI Definition

Patient reporting to the PM physician for TPIs typically have trouble within the connective tissue, or fascia, according to Yvonne Dillon, CPC, CEDC, director of emergency department services at Bill Dunbar and Associates, LLC in Indianapolis, Indiana.

“Trigger points are sensitive areas within the connective tissue — fascia — and/or bands of muscle that has become hypersensitive irritability or pain due to compression,” she says. Applying pressure to a trigger point can also help diagnose the condition.

“[Applying pressure] helps identify the part of the body that is generating the pain. Trigger points can also be local area pain, or a point, from which pain can radiate throughout the connective tissue/fascia and/or the muscle. This caused myofascial pain,” Dillon continues.

“Trigger points might be described as knots of muscle that form when muscles do not relax,” explains Joanne Mehmert, CPC, CCS-P,  president of Joanne Mehmert and Associates in Kansas City, Missouri. “Headaches are another reason that physicians perform a TPI. Doctors will call it myofascitis, myositis, myalgia, myofascial pain, fibromyalgia.”

As to what causes trigger points, Dillon says repetitive or acute trauma could result in trigger points, because it “puts too much stress on the fibers. Trigger points may be at different places in both skeletal muscles in the hip, neck, shoulder. They are usually in places where nerves connected the muscle fibers,” she explains.

Tip: Be on the lookout for a potential TPI claim if you see these types of ailments in the encounter notes.

Look to These Common TPI Diagnoses

As Dillon points out, these conditions might cause your provider to opt for TPI treatment:

• Musculoskeletal diseases;
• Spasms;
• Tendonitis/bursitis;
• TMJ joint disorders;
• Osteoarthritis or other joint dysfunction;
• Non-myofascial tender points;
• Myalgias;
• Fibromyalgia;
• Tension-type headaches;
• Gout;
• Psoriatic arthritis;
• Rheumatoid arthritis; and
• Other soft tissue disorders related to overuse and pressure or the extremities.

Note: This is not an exhaustive list of conditions that could lead to a TPI; patients could have different injuries that require TPIs, and a diagnosis from one of those listed above won’t guarantee that the payer will accept the TPI claim. You have to go case-by-case, and, payer-by-payer.

“Some carriers ask for a more specific code, and they list the ICD-10 codes according to muscle group,” Mehmert explains. “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.”

Count Muscles, not Injections

Once you get past identifying the condition and diagnosing it, coding for TPIs isn’t too laborious; there’s only two TPI codes, and when to use them is fairly straightforward.

According to Judith L. Blaszczyk, RN, CPC, ACS-PM, ICDCT-CM, compliance auditor at ACE, Inc. in Overland Park, Kansas, you should report 20552 (Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s)) for TPIs of one or two muscles — not the number of injections. If the provider injects three or more muscles, report 20553 (… single or multiple trigger point(s), 3 or more muscles).

As you can imagine, you’ll need very specific info in the encounter notes to correctly code TPIs.

Last word: “It is very important that the physician document each muscle that is injected so the coder can select the correct code,” Blaszczyk relays.

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