Wiki MD refuses to document specific procedure

[Blackhorse]

One doctor did trigger point injection and wants to bill 20553. In his documentation, he says that he injected into "musculature" but didn't specify which muscles are involved. I emailed him to specify the muscles which are injected, he said that he always got paid for 20553 and has never had to specify the muscles, therefore he will not do it.

Without documentation, I don't really think 20553 is the correct code to bill. Most patients he sees are Medi-Cal, HMO patients. Any body has any suggestion what I should do, to bill 20553 or not to bill it?

 

[beulastella]

So then it can be coded as 96372 with the product j codes.

 

[Orthocoderpgu]

You are 100% correct. If your physician does trigger point injections the specific muscles have to be identified. If you injected the same muscle three times code 20553 would not be supported. You have to inject three different muscles and they must be identified. Just because it has been done incorrectly previously does not mean that it's OK not to properly document now. Your doctor is correct though, they don't have to document it. But without proper documentation it does not have to be billed either.

 

[SharonCollachi]

Why do doctors have to be such jackwagons sometimes? Whenever my boss pulls out the "everyone does it" card, I have to go online and found someone who "did it" that is now in prison or lost their license or got fined for whatever it was - overcoding, under-documenting, whatever.