Neurology & Pain Management Coding Alert

Question: What is the best way to code for trigger point injections to receive the maximum reimbursement (diagnosis: cervicalgia (723.1), lumbar strain (847.2); CPT code 20550)?

Howard D. Chazin, MD
Olney, Md.

Answer: Arnold J. Weil, MD, a pain management expert in Atlanta who served on his states Medicare carrier advisory committee and was instrumental in the formation of Georgias Medicare policy for trigger point injections says that the first consideration in coding for trigger point injections must be state-to-state carrier variations.

Weil says that although the correct code for a trigger point injection is 20550 (injection, tendon sheath, ligament, trigger points or ganglion cyst) the number of reimbursable injections per site, per visit, and per patient per year varies greatly from one state to another. The neurologist should check with his or her state Medicare carrier regarding this issue and verify with major third-party payers whether they follow Medicares guidelines.

In Georgia, for example, Medicare has a set list of reimbursable diagnoses and sites for trigger point injections, which include muscle spasm (728.85) and myofascial pain (729.1). Weir says that a muscle group such as the trapeziae would be viewed by Medicare in Georgia as an acceptable site. Some states and some carriers within different states may have different lists of reimbursable sites and diagnoses, and some may not have such a list at all.

Weir adds that in Georgia, it is not necessary to denote the particular muscle that receives each injection on the claim (it is common for a single site to receive multiple injections). He would bill for cervical injections times six for lower lumbar paravertebral or trigger point injections times eight for upper trapeziae.

Whether a claim may be billed electronically or whether documentation will be required is another state and carrier specific issue. In Georgia, as many as eight injections given to a patient in a single session may be billed electronically. But if more than eight are billed, the claim must be submitted on paper with documentation. Bart W. Balint, MD, DABA, an associate of the American Pain Society and primary physician and owner of Balint Pain Management Center in Weyers Cave, Va., says that Medicare and most third-party payers in his state require the identification of the individual muscles being injected. Reimbursement also may vary greatly. From my experience, payers in Virginia only reimburse for two to two and a half trigger point injections per visit.

Myofascial pain and chronic headache pain are the primary reasons Balint performs trigger point injections. Other conditions that medically might require the pain relief provided by this procedure include injuries stemming from sports activities, automobile accidents, falls, twists, strains, carpal tunnel and even incorrect [...]