Modifier for trigger point injection 20553

chrislcz

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I have been getting denials from Blue care network for CPT 20553 saying that it is missing a modifier. Everything I am reading says that you do not use a modifier for this code. Anyone else have any input on whether you need one or not? I do see on the internet that some people are using a RT or LT modifier for this code. Any help would be greatly appreciated.

Thanks,
Chris
 

jeskla

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Hi,
I work for an ortho office and we bill this code quite often. We do not bill this code with any modifier and make sure the qualifying diagnosis per the LCD is added.The doc documents the specific muscles he injects in the medical record. As far as I am aware, we have not received any denials. Is this code being billed alone or with other charges? Is is denied after the note are reviewed or before?
 

chrislcz

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We are a physical medicine office and this charge is usually billed with other codes such as PT and sometimes DME. I have not seen this deny for a modifier until just now and it is Blue Care Network that is denying. There is an appropriate diagnosis code attached to the TPI service. I am wondering if this is somehow a fluke that it denied? Any suggestions on if I should contact the insurance company for further information?
 

KMCFADYEN

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Have you checked NCCI edits?
Make sure there are no bundling issues with other codes submitted same day and same session.
 

chrislcz

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Typical visit billing out consists of TPI (20553), therapeutic exercises (97110) and sometimes a piece of DME. It is only Blue care network that is sending it back with a rejection saying either the procedure is inconsistent with the modifier used or a required modifier is missing. I do not use a modifier when billing the 20553. Would it be appropriate to use a modifier 25 in this situation?
 
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I may have figured out the problem... the denial you're getting "the procedure is inconsistent with the modifier used or a required modifier is missing" doesn't seem to make sense because 20553 doesn't bundle with 97710. But when I searched that denial reason, I came across a listing of denial types (from my local MAC).

The denial stating "the procedure is inconsistent with the modifier used or a required modifier is missing" falls under a denial reason/category/umbrella of "Not covered when performed during the same session/date as a previously processed service for the patient." SO, that's perhaps what they're actually trying to relay.

20553 is a surgical procedure, so mod 25 wouldn't be an option as it's only applicable to E/M services. Are the TPIs given prior to the PT? What is the purpose for them? I assume if they are done prior to the PT, the intent is to help minimize pain that would be cause by the therapy itself. If that's the case, I'd add a 59 to 20553 and appeal with documentation; you need to prove the injections were required, for medically necessary reasons. For example, if the PT wouldn't be able to be carried out without the injections because the pain would be too great and cause unnecessary suffering to the patient, that more than proves the TPIs were necessary and separates them from the procedure, if that makes sense. The documentation would have to specifically state that's the case though.

If they're being done after the PT... you could do the same thing, add the 59 and appeal, but building the medical necessity case will be more challenging. The documentation would have to state that the pain post-PT would be so intense that it would cause undue harm to the patient, or something similar.

I could be totally wrong, but it's the only thing I've found that seems to be the most logical.
 
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