ED Coding and Reimbursement Alert

Question: A patient reported to the ED complaining of spasming pain in her left calf. After performing a level-three E/M service, the physician diagnosed muscle spasms in the left calf. The ED physician administered two trigger point injections (TPIs) into the patient's calf muscle, and then instructed her on aftercare. Which TPI code applies?

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Answer: When reading through CPT^®'s trigger point injection options, you'll note that the codes differ based on the number of muscles treated. Therefore, since your physician injected only one muscle, your coding would appear as follows:

• 20552 (Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s)) for the TPI.
• 99283 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Medical decision making of moderate complexity...) for the E/M
• Modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) appended to 99283 to show that the E/M and TPI were significant and separate services
• M62.831 (Muscle spasm of calf) linked to 20552 and 99213 to represent the patient's injury.

Potential problem: Even if you knew every ICD-10 code in the book, you could still have problems linking a diagnosis to your TPI code if the provider isn't specific. Frequently, physicians will document only the location of the pain, such as neck pain, low back pain, or headache, but in the case of trigger point injections, they should really indicate more specifically the etiology of the pain. If you have trouble discerning the appropriate ICD-10 code on your TPI claims, go back and ask the provider for more information so you can get the coding right the first time.