Radiology Coding Alert

Question: If a patient presents for multiple trigger-point injections with image guidance, will we report multiple units of the image guidance code?

West Virginia Subscriber

Answer: No, you’ll report the image guidance code only once for the trigger-point injection session. Regardless of whether the provider performs one, two, three, or more injections, the image guidance applies to that specific operative session.

For example, the patient presents for trigger-point injections of their trapezius muscle. The provider uses ultrasonic guidance to perform four injections in the trapezius muscle. You’ll assign 20552 (Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s)) and 76942 (Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation) to report the procedures. Even though the provider injected the patient six times, the physician targeted only one muscle group and the injections took place during one encounter.