Hit the Bull’s Eye With Trigger Point Coding

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  • June 3, 2016
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Hit the Bull’s Eye With Trigger Point Coding

Triamcinolone acetonide, a corticosteroid medication often sold under the brand name Kenalog, can be used both as a topical ointment and as an injectable. This popular medication has many uses, including trigger point injection.

What Are Trigger Points?

Physicians often use Kenalog for trigger point injections to treat conditions like myofascial pain syndrome. Trigger points, or painful knots in muscles and fascia, the sheaths that surround muscle, produce pain in both local and referred patterns. Often caused by repetitive motion activities, myofascial pain may occur after a muscle has been contracted repeatedly.

Review This Scenario to Hone Your Trigger Point Injection Reporting

How do you report trigger point injections? First, make sure the clinician’s documentation clearly delineates the names of the medications used in the injection and the dosage and amount injected.

Let’s say your physician sees a patient with acute myofascial pain syndrome with severe pain in the neck and shoulder region. The physician performs three injections of Kenalog in the trapezius muscle of the neck and two injections of the same drug in the levator scapulae muscles of the shoulder. Each injection of Kenalog consists of a 10 mg dosage, for a total of 50 mg.

To report this treatment, you must code for both the procedure, using a CPT® code, and for the drug supply of Kenalog, using a HCPCS code. First, let’s consider our CPT® code.

  • 20552Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s)

Because this code specifies a number of muscles injected, not a particular amount of medication or number of injections, you’ll report 20552 because only two muscles (trapezius and levator scapulae) were injected. Yes, the physician gave a total of five injections, but we don’t capture the number of injections with this CPT® code. Instead, we’ll use the following HCPCS code to get reimbursement for the drug supply.

  • J3301, Injection, triamcinolone acetonide, not otherwise specified, 10 mg

Remember, in our scenario our physician made a total of 5 intramuscular injections of 10 mg of Kenalog (triamcinolone acetonide) each. J3301 covers a single unit of 10 mg, so we will report 5 units of J3301 in this case.

Brand Name or Generic Name — Does It Matter for Reporting J3300 and J3301?

What if your provider’s documentation specifies the drug name Kenalog — can you still report J3300 and J3301, which cover triamcinolone acetonide, the generic name of the drug?

The answer is yes — in fact, you must use these codes for Kenalog. The HCPCS Level II tabular listing is arranged by generic drug name. When you look Kenalog up, it refers you to triamcinolone acetonide, which is the generic name for Kenalog.

What About You?

Does your practice deal with trigger point injections? Let us know your questions or tips for success. Just drop us a note in the comment box below.

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Susan Dooley taught health information and healthcare documentation at the community college level for more than 20 years. She has a special love for medical language and terminology. She is passionate about ensuring accurate patient healthcare documentation through education. She has a master's degree in healthcare administration, is a certified healthcare documentation specialist, and serves as immediate past president for the Association for Healthcare Documentation Integrity (AHDI).

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