Wiki Implant removed, billing 20553 to document the injection of lidocaine to numb the area. Is Trigger point injection necessary?

[jaylene1990@gmail.com]

Hi there, provider is billing for removal of retained hardware in the foot. The left foot was injected with 10cc of Lidocaine 1% as a local anesthesia. Under sterile condition provider then used a 15 blade scalpel and an incision was made directly over the most distal first metatarsal screw. Retained screw was made visible and an Arthrex 3.0 screw driver was used to remove without complications.

The provider is billing for 20553 trigger point injection and 10cc Lidocaine as well as 20680 Removal of implant.

I am questioning the 20553 trigger point injection code. If the patient is undergoing removal of Implant 20680 wouldn't the injection of the lidocaine be inclusive to the Removal of the implant, therefore would not code a trigger point injection code? also the doctor does not document the muscles receiving the injection.

Thanks in advance.

 

[thomas7331]

You are correct, the injection of local anesthesia is inclusive to the procedure and can't be billed separately. A trigger point procedure is also not supported by any of the documentation you've included here so it would be inappropriate to bill that code in any case.