Results 1 to 3 of 3

trigger point documentation

  1. #1
    Default trigger point documentation
    New Call-to-action
    Can some review this blurb and let me know what it is lacking for trigger point injection documentation?

    "Palpatory examination of the trapezius, temporalis, semispinalis cervicis, and supraspinatus revealed 6 active and 3 latent trigger points. Each point was marked and prepped with alcohol. A 27 gauge needle was then inserted and following negative aspiration, used to inject each point with 1ml of 0.5% Marcaine mixed with 0.5% lidocaine and 100mcg cyanocobalamin. Patient tolerated procedure well."

    This charge is being discarded as nonbillable because

    He told us which muscles he examined and that trigger points were found and injected, but didn't specify which of the muscles examined had the points/injections.

    I would like to discuss with the provider how to improve his documentation, but I need a resource that may further specify what he needs..... I, in my ignorance, thought he had a billable charge.

    Thanks so much
    Melissa Tescher, CPC, CPMA, CEMC Compliance and Coding Specialist
    Willamette Valley Professional Services member National Advisory Board 2013-2015

  2. #2
    I agree it is a little unclear. I would tell him to describe each muscle being injected. Like then muscle1, muscle 2, muscle 3 were injected using........But using the actual names of the muscles. This way you can review the documentation and say I can see where he is mentioning 3 or more muscles being injected so I can bill 20553 instead of 20552.

  3. #3
    Thank you, I appreciate your input
    Melissa Tescher, CPC, CPMA, CEMC Compliance and Coding Specialist
    Willamette Valley Professional Services member National Advisory Board 2013-2015

Similar Threads

  1. Trigger Point
    By mallorymartinelli in forum Billing/Reimbursement
    Replies: 1
    Last Post: 04-08-2015, 10:56 AM
  2. Trigger Point??????
    By graceroni13 in forum Diagnosis Coding
    Replies: 4
    Last Post: 08-26-2014, 01:43 PM
  3. Trigger Point - Trapezius region
    By missyah20 in forum Diagnosis Coding
    Replies: 2
    Last Post: 01-24-2013, 05:09 PM
  4. Trigger point
    By mamacase1 in forum Orthopaedics
    Replies: 3
    Last Post: 09-27-2011, 11:10 AM
  5. Trigger point
    By TrinaKnight123 in forum Billing/Reimbursement
    Replies: 1
    Last Post: 09-22-2010, 12:58 PM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?


Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.