Primary Care Coding Alert

Question: A 39-year-old new male patient reports to the FP for treatment of severe back spasms. After a levelthree E/M, the physician orders four trigger point injections (TPIs): two in the patient's multifidus, and one each in the longissimus and psoas major. How should I code for this encounter? North Dakota Subscriber Answer: You should first check that the patient's insurer covers TPIs for muscle spasms as acceptable ICD-9s for this service. Covered diagnoses depend entirely on the payer. Provided the payer accepts the diagnosis, report the following: • 20553 (Injection[s]; single or multiple trigger point[s], 3 or more muscle[s]) for all four TPIs, • 99203 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: a detailed history; a detailed examination; and medical decision making of low complexity ...) for the E/M, • modifier 25 (Significant, separately identifiable evaluation [...]