Pain Management Coding Alert

Q&A:

Stay Sharp With Trigger Point Documentation Smarts

Published on Fri Mar 08, 2019

PDF

Take this expert advice on what to include to cement your TPI claims.

Coding for trigger point injections (TPIs) seems, superficially, pretty simple.

The basics: The PM physician performs a TPI or TPIs; you count the number of muscles the PM physician injected, and choose one of the following codes:

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

As is often the case with CPT^® coding, the devil’s in the details — the details in the encounter notes, which you’ll need to pore over in order to ensure the proper documentation accompanies your TPI claims.

We picked the brains of Deborah Pellon, RHIT, CCS, CPC, CPMA, coding manager, Surgery & Anesthesia Team at Massachusetts General Physicians Organization/Professional Billing Office in Charlestown, Massachusetts; Judith L. Blaszczyk, RN, CPC, ACS-PM, ICDCT-CM, compliance auditor at ACE, Inc. in Overland Park, Kansas; and Joanne Mehmert, CPC, CCS-P, president of Joanne Mehmert and Associates in Kansas City, Missouri.

Check out what these experts had to say on TPI documentation:

I’ve heard some coders say that documentation for TPI should include a list of the muscles injected. Would you recommend this? And do you have any other documentation advice for TPIs?

Mehmert

“Absolutely I agree that the physician should document the muscles s/he injects from a record of patients’ condition and treatment to a risk management. Physicians need to document how they arrived at the conclusion that the patient required the injection. History of condition, exam, supporting documentation etc.”

Blaszczyk

“I completely agree that the muscle(s) injected must be documented. In addition, documentation of the medical necessity for the procedure should be clear. Included in this would be documentation of a brief

pain history, the location of the pain, the pre-injection intensity of the pain, prior treatment, and responses.”

Pellon

“I agree that identification of muscles injected should be documented, as well as indications, description of injection, type and amount of infiltrate and description of infiltration, and cleaning bandaging, if applicable, of injection areas post-procedure, based on CPT^® Assistant September 2003.

Could you provide an example of solid documentation for a TPI encounter?

Blaszczyk

“A 43-year-old male presents with a three-week history of occipital and cervical neck pain unrelieved by over the counter pain medications, heat, or muscle relaxers. He describes the pain as sharp, unrelenting and 8 out of 10 on the pain scale. Palpable trigger points are found in the trapezius and quadratus lumborum muscles.”

“In documenting the actual procedure the following should be included: Method or technique; equipment used; location of injection; substance and amount injected; the patient’s tolerance of the procedure; and the patient’s post-procedure pain rating.