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Primary Care Coding Alert

Can You Find This TPI Scenario's Hidden $$$?

Published on Mon May 24, 2004

Test your 20552-20553 inclusion knowledge

If you think your TPI claims capture every cent of allowable reimbursement, test your coding savvy with the following example -- and expert answer -- to  make sure you're not leaving any money on the table.

A new patient vacationing in your town presents with pain in her left shoulder deltoid muscle and the sides of her thighs. Her regular family physician (FP) diagnosed her with chronic fatigue syndrome. To evaluate her condition, the FP performs a problem-focused history, problem-focused examination and  straightforward medical decision-making. The physician then injects her left deltoid muscle twice and her left and right thigh muscles once each.

Answer: You should submit:

  • 99201-25 -- Office or other outpatient visit for the evaluation and management of a new patient ...; significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service ($36.22, geographically unadjusted Medicare rate)
  • 20553 -- Injection(s); single or multiple trigger point(s), three or more muscles ($61.98).

    Rationale: Because the patient requires a full workup prior to receiving TPIs, you should separately report an office visit (99201-25). "You usually will bill an E/M service with a new patient," says Amy S. McCreight, CPC, compliance research analyst at Ohio Health with 300-plus FPs in Columbus.

    You should count TPIs per muscle. Because the FP injects three muscles (shoulder, left and right thigh), you should report 20553.

    If you omitted the office visit or miscounted the muscles injected, you'd cut $43.72 (99201 + 20553/20552 difference) from the claim.

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