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trigger point documentation

  1. #1
    Default trigger point documentation
    Medical Coding Books
    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
    Default
    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
    Default
    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

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