Primary Care Coding Alert

The challenge of coding trigger point injections is two-fold: calculating the number of injections versus the number of muscle groups and combining those two factors. Aiming for the number of muscle groups targeted, not the number of injections, will bring you a bull's-eye.

In years past, FP coders used to report trigger point injections with a single code, 20550, but in 2002 CPT revised it and added new codes (20551-20553; see box on next page). Now that CPT has removed the words "trigger point" from the 20550 definition, coders cannot use it to bill for trigger point injections. "A trigger point is a muscle or fascia," says Joan Hubball, FNP, nurse practitioner at the Fernald Center in Waltham, Mass. "It is not a tendon or ligament, as described in 20550."

Now you should use only the new codes (20552-20553) for trigger point injections.

Coders may become puzzled when the doctor performs more than one injection and/or targets more than one muscle group. The part of the descriptor in 20552-20553 that says "single or multiple trigger point(s)" refers to the injection itself, says Rose Lemarie, office manager and biller for Pamela Wansker, MD, in Greene, Maine. Because both 20552 and 20553 include "single or multiple trigger point(s)," you can report either one regardless of the number of times the doctor actually injects. "Choosing 20552 or 20553 depends on the amount of muscle groups targeted," Lemarie says.

If the FP injects into one or two muscle group(s), use 20552. For example, a female marathon runner presents with abdominal pain. After a full workup, the FP diagnosis a trigger point in the abdominal wall. The physician gives her three trigger point injections in separate parts of her abdomen. Report 20552. Because the abdomen counts as only one muscle group, the number of injections does not matter for coding purposes.

"Physicians should include the muscle group injected in their documentation," Hubball says. "For example, instead of documenting 'Three injections into trigger points,' write 'Three injections into rectus muscle.' "

When the physician injects three or more different muscle groups, use 20553. For example, suppose a patient with chronic fatigue syndrome has pain in her shoulder muscles, abdomen and the backs of her thighs. The physician injects her once in each area. Use 20553 because three different muscle groups were targeted. Even if the doctor injected each of the three areas more than once, you still report 20553 only once.

In addition to more accurately representing the number of muscle groups treated, the new trigger point injection codes eliminate the need for adding modifier -59 (Distinct procedural service) to claims for more than one muscle group injected. Many carriers differed on whether modifier -59 or modifier -51 (Multiple procedures) was appropriate, and practices often received denials because they appended what carriers thought was the incorrect modifier.

You can also code for an E/M visit with the trigger point injection code as long as you append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service).

Often "a patient comes in for a regular office visit and the doctor finds a trigger point that needs an injection," Lemarie says. For example, a patient comes in to have his diabetes checked. During the visit he complains of back pain, and the FP gives him a trigger point injection. Report 20552 and an E/M office visit code with modifier -25.

If, however, the patient comes in solely for the trigger point injection, you cannot code for an office visit. For example, the FP instructs the diabetes patient to take oral medication for his pain, saying if it doesn't work he should come back in one month for a trigger point injection. When the patient returns in a month, the muscle is still tender, and the FP gives him a trigger point injection. For the initial visit, just an E/M is used. For a second visit, you bill 20552 only.