Primary Care Coding Alert

Question: Our physician administered bilateral trigger point injections in three locations for a Medicare patient. I know that Medicare won’t accept the bilateral modifier 50, so should I include the left/right modifiers instead?

Washington Subscriber

Answer: Modifiers LT (Left side) or RT (Right side) won’t be necessary, even if Medicare doesn’t require modifier 50 (Bilateral procedure) for bilateral trigger point injections (TPIs).

Here’s why: You code TPIs based on the number of muscles treated, so left/right isn’t a factor, even for bilateral injections.  Your physician’s notes should clearly identify the exact muscles injected, so code according to the muscles that he documented injecting.

Based on the circumstances, you should report 20552 (Injection[s]; single or multiple trigger point[s], one or two muscle[s]) if the injections were in one or two muscles or 20553 (- single or multiple trigger point[s], three or more muscles) for three or more muscles.