Wiki Trigger Point Injection

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Trigger Point Inj (3 muscles)

In office procedure determined by the Diagnosis and clinical condition of the patient. At this point the patient has FAILED all conservative measures to improve and will require an injection in order to help them alleviate their pain.
Pt is here for a TRIGGER point injection to areas that are painful due to a POSITIVE jump sign and point tenderness at the muscle groups involved. The injection given today is warranted in order to provide relief of the acute pain.
Consent was obtained of a fully coherent patient.
The area was prepped using aseptic technique. First Ethyl Chloride x 6 sec was sprayed over the injection site. 10 mg dexamethasone with 8 cc 0.25% bupivicane is divided between the three areas listed in CC

The patient remained calm and alert throughout the procedure, no sequelae developed and immediate pain relief was experienced by the patient. Immediate pain relief was experienced by the patient. The area was cleaned and a band aid was applied. Patient given wound care instructions and encouraged to apply ice to area today.

A follow up appointment will be made upon leaving the office today.


Note:
Trigger points listed in CC ==== BASE OF NECK BILATERALLY AND PARA SPINAL RIGHT MEDIAL SCAPULA



I new coder to pain management. I'm leaning towards procedure code 20553.


Thanks in advance.

 

[talitha82]

I might be considered a little picky in saying this, but I think the provider would have to document that a little more specifically in order to be confident in choosing 20553. I know it sounds like 3 different muscles, or at least you could 'assume' it, but as a coder, assumptions should be avoided. The 'base of the neck' isn't specific enough, in my humble opinion. You are onto the right code, but I would probably talk to your provider about documenting a more specific thing, ie. muscle that was specifically injected, etc.