Pain Management Coding Alert

Published on Mon May 02, 2016 PDF

Any muscle group is a potential TPI candidate. 

Pain management providers often perform trigger point injections (TPIs) for patients, which means coders need to keep count of the muscles and injections involved in the procedure.

Without this knowledge, you could misfire on your TPI claims.

Check this out: We asked Judith Blaszczyk, RN, CPC, ACS-PM, medical compliance auditor at Auditing for Compliance and Education, Inc. in Overland Park, Kan., a couple of quick questions on how to submit spot-on TPI claims each time. Check out her expert advice on TPIs.

Choose Code After Counting TPI Muscles

According to CPT^® rules, you should code 20552 (Injection[s]; single or multiple trigger point[s], 1 or 2 muscle[s]) when the provider injects one or two muscles; when she injects three or more muscles, opt for 20553 (... single or multiple trigger point[s], 3 or more muscle[s]), Blaszczyk reports. These rules hold regardless of the number of injections the provider performs on each muscle group.

These codes make it clear how to report TPIs, and "it's very important that the physician document each muscle that is injected, so the coder can select the correct code," Blaszczyk continues.

Your provider can perform TPIs on any muscle, so it's difficult to come up with a list of top TPI injection sites. TPIs are, however, often used to ease pain in the neck, shoulder, and back area.

Here's a list of muscles that Blaszczyk often sees on TPI claims:

• trapezius
• scalene
• sternocleidomastoid
• levator scapulae
• quadratus lumborum
• gluteus maximus
• gluteus medius
• gluteus minimus.

Ensure TPI Claim Success With Documentation

On your TPI claims, experts recommend that you not only include a list of muscles the provider injected, but also "documentation of the medical necessity for the [TPI] procedure should be clear," Blaszczyk says. This documentation could include:

• a brief pain history
• the location of the pain
• the pre-injection intensity of the pain and
• prior treatment and responses to treat the pain. 

Blaszczyk also recommends including these procedure-specific details to solidify your TPI coding:

• Method or technique used for injection
• Equipment used
• Location of injection
• Substance and amount injected
• The patient's tolerance of the procedure
• The patient's post-procedure pain rating.