Primary Care Coding Alert

Stop doubting whether you should grab office-visit or extra muscle-injection pay with your trigger point injection (TPI) encounters.

Because you should sometimes report an E/M service and/or additional injections, you may not know when to capture these charges. You can ethically maximize TPI-related reimbursement if you code based on three expert-approved guidelines:

You should submit an E/M code, such as 99201-99215 (Office or other outpatient visit for the evaluation and management of a new or established patient ...), when a patient presents for an unscheduled TPI as long as the FP's visit meets all the requirements of an E/M code. To separately charge $36 or more for the office visit (the approximate fee for 99201), the E/M must meet the criteria for modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service), says Amy S. McCreight, CPC, compliance research analyst at Ohio Health with 300-plus family physicians (FPs) in Columbus.

This means that the visit must qualify as a significant, separately identifiable service from the injection. If the FP performs a history, examination and medical decision-making beyond that associated with the TPI administration, you should report both the TPI and the E/M service. Make sure you don't separately bill the minor E/M that the TPI includes.

Right way: A female marathon runner presents with abdominal pain. After performing a full workup, the FP diagnosis a trigger point in the abdominal wall and gives the patient three TPIs in separate abdominal areas.

In this case, you should bill an E/M visit, such as 99201-99215, in addition to the TPI code (20553, Injection[s]; single or multiple trigger point[s], three or more muscles), McCreight says. Append modifier -25 to the E/M code to indicate that the visit is significant and separately identifiable from the injection. In addition, the FP has to perform a history, evaluation and medical decision-making prior to administering the TPIs.

Watch out: If the patient presents for a scheduled TPI, you typically shouldn't report an office visit.

Suppose a patient with back pain presents for a single TPI. At a previous visit, the FP told the patient to return in a month for a TPI if his oral pain medication didn't work.

Because the FP already performed a preinjection workup at the prior visit, he does not document a significant, separately identifiable service at the TPI encounter. So submit only the procedure code (20552, Injection[s]; single or multiple trigger point[s], one or two muscle[s]), McCreight says.

Exception: Bill an E/M when the FP treats an additional problem during a scheduled TPI visit.

Suppose the back-pain patient returns for his scheduled injection and also complains of sneezing, congestion and watery eyes. To assess the patient's rhinitis symptoms, the FP performs a significant, separately identifiable service from the scheduled TPI. You should submit the office visit, for example 99213-25, in addition to 20552. Link the injection (20552) to back pain (for instance, 724.5, Other and unspecified disorders of back; backache, unspecified), and link the office visit (99201-99215-25) to allergic rhinitis (such as 477.0, Allergic rhinitis; due to pollen).

If you're not sure what 20552-20553's surgical packages contain, you're not alone. "I never know if I should report a topical anesthetic with a TPI," says Rita Michelek, practice operations director at Partners in Primary Care in Berlin, N.J.

You shouldn't separately report a numbing anesthetic that an FP administers prior to a TPI. "The TPI cost includes the anesthetic," McCreight says.

Proof: The surgical package always includes "local infiltration, metacarpal/metatarsal/digital block or topical anesthesia," according to CPT.

About $7.50 is at stake when you choose between 20552 and 20553. You should submit the higher-paying code 20553 ($61.98, Medicare's geographically unadjusted rate) when your FP injects three or more muscles. Reserve 20552 ($54.51) for TPIs into one or two muscles.

In the above female runner example, you should submit 20553. The FP administers three TPIs in three separate abdominal areas or muscles, McCreight says.

Be careful: Make sure you report 20552 or 20553 only once per session, regardless of the number of injections. The parenthetical "s" on "Injection(s)" means each code includes one or more injections.

For instance, your FP twice injects a patient's deltoid muscle. You should report 20552 because the FP injects one muscle. The number of injections doesn't matter.