Pain Management Coding Alert

Question: Our physician dictated the following: “patient has irritation of the soft tissues over the left rib area due to scoliosis; I have injected the painful rib area, a 25 gauge needle was placed along the rib itself and 40 mg of Depo-Medrol was injected.” How should we code this?

Ohio Subscriber

Answer: The physician’s dictation is not complete. Ask him to elaborate in an addendum to the injection note and specify the injected site (tendon, tendon sheath, muscle, or fascia) so you can code appropriately. Once you have this information, report the service based on the injection site: 

• 20550 – Injection(s); single tendon sheath, or ligament, aponeurosis (e.g., plantar “fascia”) 

• 20551 – Injection(s); single tendon origin/insertion 

• 20552 – Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s) 

• 20553 – Injection(s); single or multiple trigger point(s), 3 or more muscle(s).

For 40 mg of Depo-Medrol, use HCPCS code J1030 (Injection, methylprednisolone acetate, 40 mg).