Orthopedic Coding Alert

Here’s why the number of overall shots is irrelevant to your code choice.

When a patient reports to your practice with pain/sensitivity in their trigger point areas, the provider will often administer trigger point injections (TPIs) to alleviate the pain.

Coders need to be ready to leap into action with the appropriate CPT^®, ICD-10, and HCPCS codes in order to code the encounter correctly and completely.

Check out this advice on getting your TPI coding right the first time from a couple of experts.

Get to Know TPIs

To get the most out of each TPI encounter, it would help to start with a basic definition of trigger points.

“Trigger points are sensitive areas within the connective tissue — also known as fascia — and/or bands of muscle that has become hypersensitive with pain due to compression,” explains Yvonne Dillon, CPC, CEDC, manager of coding documentation at ZOTEC Partners in Carmel, Indiana. “When pressing on a trigger point referred pain can be caused. This helps identify the part of the body that is generating the pain.”

Trigger points are often identified during the course of an office/outpatient evaluation and management (E/M) service, which you’d code with the appropriate code from the 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 15-29 minutes of total time is spent on the date of the encounter.) through 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 40-54 minutes of total time is spent on the date of the encounter.) code set.

According to Dillon, trigger points can also be:

• “Local area pain, or a point as you will, from which pain can radiate throughout the connective tissue/fascia and/or the muscle.
• “Formed by acute or repetitive trauma to the muscle tissue, which puts too much stress on the fibers.
• “At different places in both skeletal muscles in the hip, neck, shoulder. They are usually in places where nerves connected the muscle fibers.”

Dillon says that the following conditions could necessitate a TPI:

• Spasms
• Tendonitis/Bursitis
• TMJ joint disorders
• Osteoarthritis or other joint dysfunction
• Non-myofascial tender points
• Myalgias
• Fibromyalgia
• Tension-type headaches
• Gout
• Psoriatic arthritis
• Rheumatoid arthritis
• Neuralgias
• Other soft tissue disorders related to overuse and pressure or the extremities.

There are too many ICD-10 codes to list under each of these broad diagnoses, but you should check your payer policy when you do settle on a diagnosis. They should have a list of ICD-10 codes that prove medical necessity for TPIs.

Remember: This is not a comprehensive list of all the conditions that could warrant a TPI. Always check with your payer for their policy on acceptable diagnoses for TPIs. There will be a core of commonality among all payers, but there might also be some differences as to which ICD-10 codes each payer accepts for TPIs.

Report TPIs With These Codes

When your provider decides to perform a TPI, coding is pretty straightforward — but don’t miss out on the details or you could end up miscoding.

Why? There’s a little trick to coding TPIs. The number of actual injections isn’t relevant; you’ll choose a TPI code based on the number of muscles injected, not the number of injections, says Jessica Miller, MHA, CPC, VP revenue cycle at Ortmann Healthcare Consulting Services in South Carolina.

Report TPIs with 20552 (Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s)) or 20553 (… single or multiple trigger point(s), 3 or more muscles).

Example 1: Encounter notes indicate that the provider performed TPIs on the longissimus and Iliocostalis muscles. They injected the longissimus four times and the iliocostalis five times. For this encounter, you’d report 20552.

Example 2: Encounter notes indicate that the provider performed TPIs on the longissimus, iliocostalis, multifidus, and quadratus muscles. They injected all the muscles once. For this encounter, you’d report 20553.

Report Other Services … Sometimes

In the notes beneath the 20552 and 20553 codes, there are some restrictions you need to observe when reporting.

According to CPT^®, you cannot report a TPI and the following codes for the same muscle(s):

• 20560 (Needle insertion(s) without injection(s); 1 or 2 muscle(s))
• 20561 (… 3 or more muscles)

In the notes beneath the 20552 and 20553 codes, there are also some exceptions that allow coding for certain services. If, the provider uses imaging guidance during the TPI, CPT^® allows coding for it in certain forms.

According to CPT^®, you can report these imaging guidance codes if the services are performed in conjunction with a TPI:

• 76942 (Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation)
• +77002 (Fluoroscopic guidance for needle placement (eg, biopsy, aspiration, injection, localization device) (List separately in addition to code for primary procedure))
• 77021 (Magnetic resonance imaging guidance for needle placement (eg, for biopsy, needle aspiration, injection, or placement of localization device) radiological supervision and interpretation)

Don’t Forget J Codes

Coders need to remember to check each TPI for any drugs that the provider might have injected, Miller reminds.

When the provider performs a TPI, they will inject a drug, typically a steroid or corticosteroid. To account for the drug supply, “the HCPCS J codes may be utilized to capture the steroid or corticosteroid medication,” explains Bouvier.

The drugs your provider might inject during a TPI and their corresponding J codes include:

• Betamethasone (Celestone): J0702 (Injection, betamethasone acetate 3 mg and betamethasone sodium phosphate 3 mg)
• Prednisolone (Prelone): J2650 (Injection, prednisolone acetate, up to 1 ml)
• Methylprednisolone (Medrol, Depo-Medrol, Solu-Medrol): J2920 (Injection, methylprednisolone sodium succinate, up to 40 mg)

Note: This is not a comprehensive list of all the J codes that could be associated with TPIs. Check with your payer to find out exactly what J codes and drugs you can code for.