Medicare Compliance & Reimbursement

Remember to document the drug that the physician injected. Question: A patient reported to the ED for treatment of severe back spasms. After a level-three E/M, the physician ordered four Trigger Point Injections (TPIs): two in the patient's multifidis, and one each in the longissimus and psoas major. How should I code for this encounter? Answer: You should first check that the patient's insurer covers TPIs for muscle spasms as acceptable ICD-9s for this service. Covered diagnoses depend entirely on the payer. Provided the payer accepts the diagnosis, report the following: • 20553 -- Injection[s]; single or multiple trigger point[s], 3 or more muscle[s] for all four TPIs; • 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 -- [...]