Pain Management Coding Alert

Question: A new patient reported to our physician complaining of pain in his right shoulder. After a level-two evaluation and management (E/M) service, the physician diagnosed soft tissue disorder related to overuse and performed a total of nine trigger point injections (TPIs) on three separate muscle groups. Notes indicate that the physician also used imaging guidance for the injections. What codes should I report for this encounter?

Kentucky Subscriber

Answer: You’ll report three codes, but you cannot choose the correct imaging guidance code without more information.

On the claim, you would report:

• 20553 (Injection[s]; single or multiple trigger point[s], 3 or more muscle[s]) once to account for all nine TPIs.
• 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; straightforward medical decision making…) for the E/M service.
• 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 99202 to show that the E/M and the injections were separate services.

Imaging guidance code: From your description of the encounter, we cannot settle on the correct imaging guidance code. Go back and check encounter notes, or ask the physician who performed the procedure which type of imaging she used. Then, select one of the following codes for the imaging guidance:

• 76942, Ultrasonic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device), imaging supervision and interpretation
• 77002, Fluoroscopic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device)
• 77021, Magnetic resonance guidance for needle placement (e.g., for biopsy, needle aspiration, injection, or placement of localization device) radiological supervision and interpretation

ICD-10 alert: No matter which code you choose for fluoroscopic guidance, be sure to append M70.911 (Unspecified soft tissue disorder related to use, overuse and pressure, right shoulder) to all of your CPT^® codes to represent the patient’s shoulder pain.