Eli's Rehab Report

Question: If a physiatrist does trigger point injections in the trapezius, right and left, would that count as only one muscle?

New Mexico Subscriber

Answer: No. The right trapezius is a different muscle from the left trapezius. They each have separate and distinct insertion and origin (mirror image). Just like if a patient had a sprain/strain in their left biceps and additionally a sprain/strain in their right biceps, it is easy to "see" that those are two different muscles. Multiple injections into the same muscle would NOT be counted as separate trigger points.
 
So if a provider has clear documentation of separate trigger points in the right trapezius, right levator scapulae, left trapezius, and left levator scapulae, you should report one unit of 20553 (Injection[s]; single or multiple trigger point[s], three or more muscles) and indicate the physiatrist injected the trigger points of three or more muscles.