Part B Insider (Multispecialty) Coding Alert

Understand the difference between trigger points and tendon sheaths

It used to be that you could bill for every single trigger point injection your physician performed, using CPT code 20550. Now you can only bill one code for all trigger point injections, and some physicians seem to suffer from nostalgia.
 
Part B carrier Cigna says in a new Medical Review frequently asked questions list that many physicians have started improperly billing multiple units of 20551, a code for tendon origin/insertions. Cigna notes that these physicians used to bill for multiple trigger point injections, back when you could still do that, so it appears they're confused or trying to game the system.
 
The 2002 version of the CPT redefined 20550* as Injection; tendon sheath, ligament, ganglion cyst (CPT 2003 deleted "ganglion cyst") and created two new codes for trigger point injections. You could use CPT 20552 to bill for TPI administered to one or two muscle groups, and 20553 to bill for TPI for three or more muscle groups.
 
The good news is that the 2003 CPT revised the definitions of 20552 and 20553 to allow you to bill 20553 if you injected three or more muscles, not muscle groups, says Carla Thibodeaux of Excel Practice Management in San Antonio. That makes it much easier to get to the higher-paying 20553 if the doctor injected multiple muscles in one muscle group. The bad news is you can only bill one code for all TPIs.
 
So it appears that some coders are attempting to bill 20551 instead, because you can bill that code as many times as you like. But Cigna states that it's highly unlikely that a patient would ever need injections in multiple tendon sheaths. It would be "extraordinarily rare" for a patient to need more than one such injection, without a "systemic underlying illness (autoimmune or the like)" causing multiple inflammations, Cigna states.
 
"I would venture to say they're not doing it to gain more reimbursement, but because they are confused how to code this," Thibodeaux says. But the multiple instances of 20551 that Cigna mentions are almost certainly "incorrect coding," she adds. Back when doctors could bill 20550 for TPI, they would bill the same code 10 or 12 times, so it's frustrating to be able to bill for TPI only once. "Even if eight muscles were injected, only one unit of 20553 should be billed," says Alison Waxler with the American Academy of Physical Medicine & Rehab in Chicago.
 
The main diagnosis for TPI will be 729.1 (Myalgia and myositis, unspecified), Thibodeaux says.