Neurology & Pain Management Coding Alert

Question: My understanding is that the paraspinal muscle is a group of individual muscles that combine and run along the spine. Our provider administered bilateral trigger point injections in the cervical paraspinal area. From a coding perspective, should I consider these two injections into two separate muscles? Answer: Coding for trigger point injections is based on the total number of individual muscles. Injections of trigger points into one or two muscles would be billed with 20552 (Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s)) whereas trigger point injections into three or more muscles would be reported with 20553 (Injection(s); single or multiple trigger point(s), 3 or more muscle(s)). Compliant documentation for trigger point injections would include the specific muscles injected rather than use of a broad term such as paraspinal. Anatomy: The deep muscles (sometimes referred to collectively as paraspinal muscles) form a thick mass on each side [...]