Part B Insider (Multispecialty) Coding Alert

Remember to document the drug that the physician injected.

Question: A patient reports to the ED for treatment of severe back spasms. After a level-three E/M, the physician orders four trigger point injections (TPIs): two in the patient's multifidis, and one each in the longissimus and psoas major. How should I code for this encounter?

Answer: You should first check that the patient's insurer covers TPIs for muscle spasms as acceptable ICD-9s for this service. Covered diagnoses depend entirely on the payer. Provided the payer accepts the diagnosis, report the following:

• 20553 (Injection[s]; single or multiple trigger point[s], 3 or more muscle[s]) for all four TPIs

• 99283 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; and medical decision making of moderate complexity ...) for the E/M

• modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to 99283 to show that the TPIs and E/M were separate services

• 728.85 (Spasm of muscle) appended to 20553 and 99283 to represent the patient's condition.

Documentation tip: If your physician doesn't list each muscle that the physician injects during the TPI, your claim might get knocked down to 20552 (... single or multiple trigger point[s], 1 or 2 muscles).

Since the coding is based on number of muscles, insurers want proof of three-plus separate areas for 20553.

Also, you should document the drug(s) the provider injects to clarify that the procedure was an injection and not "dry-needling," which some payers do not cover. Drugs the provider could use during TPI, and might be reported by the facility, include:

• Depo-Medrol (J1020, Injection, methylprednisoloneacetate, 20 mg)

• DepoMedalone40, Depo-Medrol, Sano-Drol (J1030, Injection, methylprednisolone acetate, 40 mg)

• Cortimed, DepMedalone, DepoMedalone80, Depo-Medrol, Duro Cort, Methylcotolone, Pri- Methylate, Sano-Drol (J1040, Injection, methylprednisolone acetate, 80 mg).