Neurology & Pain Management Coding Alert

Question: How should I code a visit that included a trigger point injection and epidurography?


Michigan Subscriber
Answer: Report the trigger point injection with either 20552 (Injection[s]; single or multiple trigger point[s], one or two muscle[s]) or 20553 (... single or multiple trigger point[s], three or more muscles). You-ll choose the code that corresponds to the number of muscles injected.

The code for epidurography is 72275 (Epidurography, radiological supervision and interpretation). However, CPT also includes a note about this code: -Use 72275 only when an epidurogram is performed, images documented, and a formal radiological report is issued.- Review your  documentation to verify that it meets these criteria.

Option: If it doesn-t, many coders instead report 76005 (Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures [epidural, transforaminal epidural, subarachnoid, paravertebral facet joint, paravertebral facet joint nerve or sacroiliac joint], including neurolytic agent destruction).