Pain Management Coding Alert

Question: Our provider performed significant, separately identifiable level-three evaluation and management service for a patient with upper back pain, and then made the decision to perform trigger point injections (TPIs). The provider injected the patient’s rhomboid and trapeziusmuscles with one injection each. How should I code this encounter? Can I report the drug supply separately from the TPI?

Connecticut Subscriber

Answer: On TPIs, “you can code separately for the drug, any drug, that is therapeutic such as corticosteroids,” confirms Deborah Messinger, RHIT, CCS, CPC, CPMA, coding manager for the surgery & anesthesia team at Massachusetts General Physicians Organization/Professional Billing Office in Charlestown.

As long as the drug was therapeutic, you should report it along with the TPI. On the claim, report the following:

• 20552 (Injection[s]; single or multiple trigger point[s], 1 or 2 muscle[s]) for the TPIs
• 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity …) for the E/M
• 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 99213 to show that the E/M was a significant, separately identifiable service from the E/M.
• M54.89 (Other dorsalgia) Appended to 20552 and 99213 to represent the patient’s back pain. 
• the appropriate J code for the drug the provider used during the TPI.

Potential drug codes: Since you didn’t specify the drug the provider injected during the TPI, here is a list of potential drugs that your provider might use during a TPI:

• J3301 (Injection, triamcinolone acetonide, not otherwise specified, 10 mg)
• J1020 (Injection, methylprednisolone acetate, 20 mg), J1030 (... 40 mg), or J1040 (... 80 mg)
• J1100 (Injection, dexamethasone sodium phosphate, 1 mg)

Anesthetic conundrum: Although Medicare will not provide you any separate reimbursement for local anesthetics that the provider uses during the TPIs, some private payers might. If you are filling a TPI claim with a local anesthetic to a non-Medicare provider, check your contract to see if you can separately report theanesthetic.