Primary Care Coding Alert

Get the lowdown on when you should bill E/M, anesthetic or multiple injections with 20552-20553 Stop doubting whether you should grab office-visit or extra muscle-injection pay with your trigger point injection (TPI) encounters.

Because you should sometimes report an E/M service and/or additional injections, you may not know when to capture these charges. You can ethically maximize TPI-related reimbursement if you code based on three expert-approved guidelines: 1. Charge E/M With Unscheduled TPI Service You should submit an E/M code, such as 99201-99215 (Office or other outpatient visit for the evaluation and management of a new or established patient ...), when a patient presents for an unscheduled TPI as long as the FP's visit meets all the requirements of an E/M code. To separately charge $36 or more for the office visit (the approximate fee for 99201), the E/M must meet the criteria for modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service), says Amy S. McCreight, CPC, compliance research analyst at Ohio Health with 300-plus family physicians (FPs) in Columbus. This means that the visit must qualify as a significant, separately identifiable service from the injection. If the FP performs a history, examination and medical decision-making beyond that associated with the TPI administration, you should report both the TPI and the E/M service. Make sure you don't separately bill the minor E/M that the TPI includes. Right way: A female marathon runner presents with abdominal pain. After performing a full workup, the FP diagnosis a trigger point in the abdominal wall and gives the patient three TPIs in separate abdominal areas. In this case, you should bill an E/M visit, such as 99201-99215, in addition to the TPI code (20553, Injection[s]; single or multiple trigger point[s], three or more muscles), McCreight says. Append modifier -25 to the E/M code to indicate that the visit is significant and separately identifiable from the injection. In addition, the FP has to perform a history, evaluation and medical decision-making prior to administering the TPIs. Watch out: If the patient presents for a scheduled TPI, you typically shouldn't report an office visit. Suppose a patient with back pain presents for a single TPI. At a previous visit, the FP told the patient to return in a month for a TPI if his oral pain medication didn't work.

Because the FP already performed a preinjection workup at the prior visit, he does not document a significant, separately identifiable service at the TPI encounter. So submit only the procedure code (20552, Injection[s]; single or multiple trigger point[s], one or two muscle[s]), McCreight says. Exception: Bill an E/M when the FP treats an additional [...]