Radiology Coding Alert

Question: Which CPT code should I report if the radiologist performed six trigger point injections on a patient's trapezius and three on her levator scapulae under ultrasound guidance?

Arizona Subscriber

Answer: The radiologist performed trigger point injections (TPIs) on two separate muscles in your scenario, so you should report 20552 (Injection[s]; single or multiple trigger point[s], 1 or 2 muscle[s]) for the injections.

A parenthetical note under 20552 and 20553 (... single or multiple trigger points, 3 or more muscle[s]) in the CPT manual instructs you to see 76942 (Ultrasonic guidance for needle placement ...), 77002 (Fluoroscopic guidance for needle placement ...), or 77021 (Magnetic resonance guidance for needle placement ...) for imaging guidance.

Because your radiologist performed and documented ultrasound guidance, you should report 76942 for the guidance in your case.