Primary Care Coding Alert

Question: A 39-year-old new male patient reports to the FP for treatment of severe back spasms. After a levelthree E/M, the physician orders four trigger point injections (TPIs): two in the patient's multifidus, and one each in the longissimus and psoas major. How should I code for this encounter?

North Dakota Subscriber

Answer: You should first check that the patient's insurer covers TPIs for muscle spasms as acceptable ICD-9s for this service. Covered diagnoses depend entirely on the payer. Provided the payer accepts the diagnosis, report the following:

• 20553 (Injection[s]; single or multiple trigger point[s], 3 or more muscle[s]) for all four TPIs,

• 99203 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: a detailed history; a detailed examination; and medical decision making of low complexity ...) for the E/M,

• modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to 99203 to show that the TPIs and E/M were separate services, and

• 728.85 (Spasm of muscle) appended to 20553 and 99203 to represent the patient's condition.

Documentation tip: If your physician doesn't list each muscle that the physician injects during the TPI, your claim might get knocked down to 20552 (... single or multiple trigger point[s], 1 or 2 muscles). Since you should base your coding on the number of muscles, insurers want proof of three-plus separate areas for 20553.

Also, you should document the drug(s) the provider injects to clarify that the procedure was an injection and not "dry-needling," which some payers do not cover. Drugs the physician could use during TPI will vary by practice.

-- Information for and answers to You Be the Coder and Reader Questions reviewed by Kent Moore, manager of health care financing and delivery systems for the American Academy of Family Physicians in Leawood, Kan.