Primary Care Coding Alert

Question: Our FP recently performed trigger point injections to relieve muscle spasms. He performed two injections into one muscle group and another two injections into another muscle group. Should I count the muscle groups and report the TPI with 20552 or count the number of injections and report the TPI with 20553?

New Orleans Subscriber

Answer: When your FP performs trigger point injections (TPI), you report it with one of these two options:

• 20552 (Injection[s]; single or multiple trigger point[s], 1 or 2 muscle[s])
  
• 20553 (Injection[s]; single or multiple trigger point[s], 3 or more muscle[s])
  

You base the reporting of the TPI based on the number of muscles that your clinician performed the procedure in and not on the number of injections that he totally provided to relieve the spasm.

In the case scenario that you have described, your FP performed two TPI into one muscle group and another two TPI into another muscle group. Since he performed the procedure in two muscle groups, you’ll have to report the procedure with 20552 as this code caters to TPI provided into one or two muscle groups. If your FP provides the TPI into more than two muscle groups, you will have to report it with 20553.

Note: The CPT® code 20553 is not an add-on code and is a standalone code. So, you do not have to report 20552 for reporting TPI provided into two muscle groups and then report 20553 for the TPI provided into additional muscle groups. Instead, when the number of muscle groups into which the TPI was provided is more than two, you will just have to report one unit of 20553.