Wiki Trigger Point Injections-Can we assign

[melissaannsmith]

Can we assign procedure codes ICD-9/CPT based on a drawing by the physician in place of written words?

My issue: patient had three trigger point injections. Instead of writing out the sites the physician drew a picture of a head and torso, labeled it as back, marked an “x” for each of the tree injection sites.

 

[aaron.lucas]

You might be able to get away with billing 20552, but probably not. Because the description for trigger point injections specifically states either "1 or 2 muscles" or "3 or more muscles", unless the provider lists the muscles injected or has them marked on the diagram, the documentation is incomplete, because with just a bunch of x's you can't tell how many muscles were injected.