Anesthesia Coding Alert

Trigger point injections (20550, injection, tendon sheath, ligament, trigger points or ganglion cyst) should be coded according to the muscle groups targeted, not the number of injections administered. Although multiple injections are often performed at the same site, they are considered a single injection for coding purposes.

Many physicians charge every time they perform a pressure point injection, which is inappropriate, says Patricia Bukauskas, CMM, CPC, a pain management coding and reimbursement specialist in Aliquippa, Pa. If you administer three injections into the trapezius muscle, that counts as only one injection. However, three injections into the trapezius muscle and two more into the supraspinal muscle count as two injections because two different muscle groups were targeted.

Note: Noncovered procedures such as acupuncture should not be billed using 20550.

Billing and Modifiers

Carriers limit the number of injections that may be billed even when different muscle groups are treated, Bukauskas says. Some Medicare carriers may pay for as many as eight injections during the same session, but most reimburse a maximum of five. Medicare carriers in some states, such as Alaska, Arizona, Hawaii, Nevada, Oregon and Washington, only pay for one injection regardless of the number of muscle groups treated. The Medicare limit in Utah, however, is seven injections, says Deanna Clark, a coder with the University of Utahs Pain Management Center in Salt Lake City. She notes that at least one private carrier she deals with doesnt cover trigger point injections at all.

In most states, Medicare carriers want to see modifier -59 (distinct procedural service) attached to additional 20550 claims. By appending this modifier, the physician indicates the injections were performed on different muscle groups and overrides any software edit bundling multiple trigger point injections. Most Medicare carriers also want claims involving 20550-59 on separate lines. For example, if the physician treated three muscle groups with trigger point injections, the session should be coded:

20550
20550-59
20550-59

Note: A few Medicare carriers require modifier -51 (multiple procedures), not -59. Contact your payer if you are uncertain of its policy. Remember also that the multiple procedure reduction applies and therefore the payments for subsequent injection will be reduced by 50 percent.

Documentation and Diagnosis

Because trigger point injections are relatively straightforward and fairly well reimbursed (2.88 relative value units), 20550 is carefully watched for abuse, and documentation guidelines covering its use are stringent. Claims for multiple injections (and in some cases claims for individual injections) will be denied unless medical necessity is indicated. Documentation should include the following:

An appropriate diagnosis. Many carriers only pay for trigger point injections linked to specific diagnoses, such as 726.5 (enthesopathy of hip region); 726.71 (achilles bursitis or tendinitis); 726.72 (tibialis tendinitis); 729.1 (myalgia and [...]