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Internal Medicine Coding Alert

Trigger Point Injections Become More Precise

Published on Fri Feb 01, 2002 Print Friendly and PDF PDF

Changes in the 2002 CPT manual for trigger point injections mean that the days of billing for numerous injections with one code are over. These procedures were previously billed using either 20550 (injection tendon sheath, ligament, trigger points or ganglion cyst) or unlisted-procedure codes. Many muscle groups can be treated with trigger point injections, and therein lies the reason for the coding changes. In addition to more accurately representing the number of muscle groups treated, these new trigger point injection codes also eliminate the need for adding modifier -59 (distinct procedural service) to claims for more than one muscle group injected. Many carriers differed on whether modifier -59 or modifier -51 (multiple procedures) was appropriate, and practices often received denials by appending the incorrect modifier.
 
The revision to 20550 and the new codes are as follows:
  • 20526 injection, therapeutic (e.g., local anesthetic corticosteroid), carpal tunnel
  • 20550 injection; tendon sheath, ligament, or ganglion cyst
  • 20551 injection; tendon origin/insertion 
  • 20552 injection; single or multiple trigger point(s), one or two muscle group(s)
  • 20553 injection; single or multiple trigger point(s), three or more muscle groups.

    • Trigger Points Are Taken out of 20550

    While 20550 was always meant to be used broadly for trigger point injections, it was widely misinterpreted to be applicable for each trigger point injection. "This is going to change the coding procedures for a lot of physicians," says Jeri Harris, CPC, CPCH, MCS-P, practice administrator for Charleston Orthopedic Association, Charleston, S.C. "Some physicians give many injections, then try to bill individually for them. I knew one physician who injected a patient nine times, and wanted to bill each separate injection site, even though the documentation did not support that. The insurance carriers have long said that this practice is crazy, and that is one of the reasons why they added codes for trigger point injections."
     
    Linda Ensley, CPC, a senior coder with Professional Data Management in Maitland, Fla., who works with a group of more than 70 physicians, also thinks the changes in the codes will help clarify things for the billing department.
     
    "In the past, it has been difficult to get doctors to do the documentation needed to identify the muscle groups," Ensley continues. "They would say that a patient has neck and shoulder pain and that four trigger points were identified. They would say that injections were administered in a fan-like motion in the trapezius. Prior to this, we did not have much in writing to argue against them, but now unless they tell us where those injections are specifically, we must assume that only one muscle is hit and code for that."
     
    Prior to 2002, 20550 was used to describe injections of various anatomic sites. The code has since been revised to describe only injections of a tendon sheath, ligament or ganglion cyst, with the phrase "trigger points" removed from the descriptor. CPT 20550 is still used, for example, in the instance of a 26-year-old male patient who presents with a ganglion cyst. Although a few nerve fibers may be near the cyst, the local anesthetic agent injection will aspirate and massage the ganglion cyst to extrude the content.

    New Codes Offer Specificity

    To differentiate the techniques associated with multiple muscle group injections for trigger points, several new codes have been established, including 20551 to describe therapeutic injection of a tendon at its origin/insertion point. For example, a 50-year-old male patient comes in with complaints of pain at the base of his right wrist that is aggravated by his work as a gardener. The internist's exam turns up tenderness over the abductor pollicis brevis and extensor pollicis longus tendons, and a Finkelstein's test is positive, indicating de Quervain's disease. The treatment is a series of local tendon injections, coded using 20551 to indicate injection at the origin of the pain, which is a tendon but not a confirmed trigger point.
     
    Codes 20552 and 20553 were established because the procedure and the protocol for injections vary from specialty to specialty. Under these new changes, coders must know the muscle groups involved in treatment to properly code the procedures for billing.
     
    "We have to teach physicians that these codes are now derived by muscle groups and not by the number of injections," Harris says. "If you inject one or two groups, that's one code, and if you inject three or more groups, that is another code. It's up to the coders to educate the physicians and be mindful of what the correct code is. We have to let the physician know these are the options now, and that 20550 has a totally different meaning."
     
    For instance, a 45-year-old female patient has a history of pain in the left lower back above the posterior iliac crest, with radiation of pain into the left buttock. Conservative treatment with muscle relaxants, nonsteroidal anti-inflammatory drugs and physical therapy has failed. During examination, the physician discovers a distinct trigger point in the multifidus muscle to the left of the L5 spinous process. The physician's choice of treatment for the back pain is injection of the trigger point, with a proper coding of 20552 because only one muscle group received an injection. This is also the correct code if the documentation is incomplete.
     
    "We had a recent case where the physician did three injections into a hip scar, stipulating only that they were in the mid portion and mid-superior portion of the scar," Ensley says. "Since the doctor did not name the muscles, we are using 20552 because they are not separated out."
     
    When multiple muscle groups are involved, 20553 is the appropriate code. For example, a 35-year-old male patient comes into an internal medicine practice with right-side neck, shoulder and interior chest pain. Four trigger points are identified in the left sternocleidomastoid, the left middle scalene, the left trapezius, and the left deltoid muscles. The number of areas treated moves the payment category into the code for single or multiple trigger points, three or more muscle groups.
     
    "Sometimes we have patients from auto accidents who come in with neck and shoulder pain," Ensley says. "For example, in one recent case the physician identified three trigger points: one each in the right trapezius and the left trapezius muscle, and one in the right sacroiliac region. In this case, we used 20553 to bill because there are three or more muscle groups identified."
     
    Billing for the above cases a year ago would have necessitated the use of 20550, a code that will lead to reim-bursement denial in 2002 because it is now inappropriate.

    Code Created for Carpal Tunnel Injection

    In addition to the modification of 20550 and the creation of 20551-20553, 20526 was created to describe the technique required for therapeutic injection into the carpal tunnel. This code is appropriate for a 31-year-old female who presents with complaints of numbness involving the three radial digits of their right hand. The physician's examination determines a positive Tinel's sign of the median nerve at the right wrist and decreased sensation of the radial three digits in a median nerve distribution. Due to a failure of physical therapy and bracing for this case of confirmed carpal tunnel syndrome, the physician decides that the patient would benefit from right carpal canal injection. In this case, the code would clearly be 20526, as it specifically addresses this syndrome.

    Documentation Remains Crucial

    The key to successful billing, according to Harris, is  medical necessity and "documentation, documentation, documentation."
     
    "It is not normally medically indicated to have a surplus of injections anyway," she says. "Initially there will probably be some upcoding, but it is important to count your involved muscle groups. If you have nine trigger points and two muscle groups, the proper code is 20552, and that has nothing to do with the number of injections you did.
     
    "In addition, doctors have to be better at documenting which muscle groups are involved or the carrier will downgrade it," she adds. "In short, they have taken away how many as a definitive aspect, and now it only matters where you did it."
     
    "The code changes make it better for us as far as showing the doctor the way payment is made now," Ensley says. "We simply can't charge 12 trigger points for hitting three muscle groups. Trigger points are really hard to get paid for by insurance, anyway. "We have to identify them so that if the insurance starts to fight us, we can show documentation of where they were injected. This will help us get the correct payment for services rendered."

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