Ob-Gyn Coding Alert

Question: My office note reads: "About 3-4 cm into the vagina, the patient has a U-shaped ridge made of muscle that seems to prevent her from having intercourse. I injected Botox into the perineal muscles to relax them and help her have sexual intercourse. I injected this  muscle with 20 Botox units total, 4 equally spaced injections of 5 units each." Should I use 20552 for this or another code?

Texas Subscriber

Answer: Read more into your physician's documentation before billing.

A trigger point is a specific spot in a muscle that is hypersensitive. The physician must first identify each trigger point by palpation or imaging and mark those points to do each injection. So if your documentation describes this, you should use 20552 (Injection[s]; single or multiple trigger points[s], 1 or 2 muscle[s]) or 20553 (... single or multiple trigger point[s], three or more muscles).

If the documentation does not describe any identification going on, no marking of the sites prior to the injection, and the Botox is simply put anywhere into the muscle, you should consider this an IM injection, 96372 (Therapeutic, prophylactic, or diagnostic injection [specify substance or drug]; subcutaneous or intramuscular), not a trigger point injection.