Properly Coding Trigger Point Injections (20552 and 20553)

Have you ever had a knot in your back where the muscles simply cannot relax? Those knots are referred to as trigger points and they can be very painful. As a matter of fact, a trigger point (TP) in one area can cause surrounding muscles to tighten or spasm, increasing pain and discomfort for the patient. Over-the-counter pain medications, anti-inflammatories, or even a good massage, may help to alleviate some symptoms, but when these don't work, the assistance of a healthcare professional may be required. Once the provider has palpated to identify the location of the TPs and their severity, a decision to perform a trigger point injection(s). The injection is an outpatient, 0-day global period procedure that is most often performed in the provider's office. The TPs are injected with either a numbing agent, steroid, or another substance used to relax or decrease inflammation within the knotted muscle. 

Coding: Because TPs are considered 0-day global procedures, when performed the same day as an E/M service, the E/M service will be bundled into the TP injection and be denied unless the documentation supports the application of modifier 25 as a separate service.

The codes for reporting TPs include: 

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

Modifiers and Units

• Modifiers: Although it may seem logical to report modifiers RT, LT, or 59, the code descriptions clearly identify the codes for 1-2 muscles injected or 3 or more muscles injected, making these modifiers inappropriate to report, and doing so may cause claim denials. 
• Units: These codes have only a single (1) medically unlikely edit (MUE), indicating multiple units would be inappropriate to report for a single date of service.

Clinical documentation improvement (CDI): Documentation in the medical record should include:

• Muscle(s) injected (name them)
• Medication 
• Needle size
• Agent (eg, drug, substance), strength, and quantity injected

Code selection is based on the number of muscles injected and not how many injections were given.

Examples:

1. Three injections were given into the right shoulder (no specific muscle noted). This is counted as 1 unit of 20552.
2. Four injections into the right gluteus maximus and two into the right biceps femoris were administered is counted as two muscles or 20552.
3. Trigger point injections were administered as follows: left deltoid x 4, left trapezius x3, and rhomboid minor x4 = three muscles or 20553. 

Be sure to link the appropriate ICD-10-CM code to the procedure performed. For a list of ICD-10-CM codes that may support medical necessity for trigger point injections, be sure to look up 20552 or 20553 in findacode.com and on the code page click on the tab titled "Cross-A-Code" for a list of Medicare-approved ICD-10-CM codes that support medical necessity for these codes. Failure to apply an approved diagnosis code that is identified within the medical record may result in claim denial. 

For more information on how to access the Local Coverage Determinations (LCDs) specific to your Medicare Administrative Carrier (MAC) to identify codes supporting medical necessity for a specific procedure, contact our wonderful customer success managers by clicking on the "HELP" button in the upper right corner of the findacode.com screen.

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