Part B Insider (Multispecialty) Coding Alert

Question: My understanding is that the paraspinal muscle is a group of individual muscles that combine and run along the spine. Our provider administered bilateral trigger point injections in the cervical paraspinal area. From a coding perspective, should I consider these two injections into two separate muscles?

Answer: Coding for trigger point injections is based on the total number of individual muscles. Injections of trigger points into one or two muscles would be billed with 20552 (Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s)) whereas trigger point injections into three or more muscles would be reported with 20553 (Injection(s); single or multiple trigger point(s), 3 or more muscle(s)). Compliant documentation for trigger point injections would include the specific muscles injected rather than use of a broad term such as paraspinal.

Anatomy: The deep muscles (sometimes referred to collectively as paraspinal muscles) form a thick mass on each side of the spine, extending from the base of the skull to the sacrum. This muscle mass consists of many separate, overlapping muscles of different lengths, attached to the spinous or transverse processes of different vertebrae. The semispinalis capitis, the splenius capitis and the multifidus muscles are some of the deep paraspinal muscles of the neck region.

Bilateral muscles that have separate origin and insertion sites typically are considered to be separate muscles. For example, separate trigger point injections into both the right and left splenius capitis muscles could be considered to be two muscles for coding purposes.