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RETIRED Local Coverage Determination (LCD)

Trigger Points, Local Injections

L34588

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Proposed LCD
Proposed LCDs are works in progress that are available on the Medicare Coverage Database site for public review. Proposed LCDs are not necessarily a reflection of the current policies or practices of the contractor.
Retired

Document Note

Note History

Contractor Information

LCD Information

Document Information

Source LCD ID
N/A
LCD ID
L34588
Original ICD-9 LCD ID
Not Applicable
LCD Title
Trigger Points, Local Injections
Proposed LCD in Comment Period
N/A
Source Proposed LCD
N/A
Original Effective Date
For services performed on or after 10/01/2015
Revision Effective Date
For services performed on or after 08/31/2023
Revision Ending Date
03/31/2024
Retirement Date
03/31/2024
Notice Period Start Date
N/A
Notice Period End Date
N/A
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

CPT codes, descriptions and other data only are copyright 2023 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

Current Dental Terminology © 2023 American Dental Association. All rights reserved.

Copyright © 2023, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB‐04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312‐893‐6816.

Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB‐04 Manual and/or codes and descriptions; and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.

Issue

Issue Description

This LCD outlines limited coverage for this service with specific details under Coverage Indications, Limitations and/or Medical Necessity.
Issue - Explanation of Change Between Proposed LCD and Final LCD

CMS National Coverage Policy

Title XVIII of the Social Security Act, section 1862(a)(1)(A). This section allows coverage and payment for only those services that are considered to be medically reasonable and necessary.

Title XVIII of the Social Security Act, section 1833(e). This section prohibits Medicare payment for any claim which lacks the necessary information to process the claim.

Title XVIII of the Social Security Act, section 1862 (a)(7) excludes routine physical evaluations.

PUB 100-03 Medicare National Coverage Determinations (NCD) Manual-
Part 1 Section 30.3 – Acupuncture, 30.3.1 Acupuncture for Fibromyalgia, 30.3.2 Acupuncture for Osteoarthritis.
Part 2 Section 150.7 - Prolotherapy, Joint Sclerotherapy, and Ligamentous Injections with Sclerosing Agents.

Change Request 10901, Local Coverage Determinations (LCDs)

CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 13, Section 13.5.4 - Reasonable and Necessary Provisions in an LCD.

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

Myofascial trigger points are self-sustaining hyper-irritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic overload. These trigger points produce a referred pain pattern characteristic for that individual muscle. Each pattern becomes part of a single muscle myofascial pain syndrome (MPS); each of these single muscle syndromes is responsive to appropriate treatment. To successfully treat chronic myofascial pain syndrome, each single muscle syndrome needs to be identified along with every perpetuating factor.

There is no laboratory or imaging test for establishing the diagnosis of trigger points; it depends therefore, upon the detailed history and thorough directed examination. The following clinical features are present most consistently and are helpful in making the diagnosis:

  1. history of onset and its cause (injury, sprain, etc.);

  2. distribution of pain;

  3. restriction of movement;

  4. mild muscle specific weakness;

  5. focal tenderness of a trigger point;

  6. palpable taut band of muscle in which trigger point is located;

  7. local taut response to snapping palpitation; and

  8. reproduction of referred pain pattern upon most sustained mechanical stimulation of the trigger point.

The goal is to identify and treat the cause of the pain and not just the symptom of pain.
After making the diagnosis of myofascial pain syndrome and identifying the trigger point responsible for it, the treatment options are:

  1. medical management, including the use of anti-inflammatory agents, tricyclics, etc.;

  2. stretch and use of coolant spray followed by hot packs and/or aerobic exercises;

  3. application of low intensity ultrasound directed at the trigger point (this approach is used when the trigger point is otherwise inaccessible);

  4. deep muscle massage;

  5. injection of local anesthetic into the muscle trigger points:

    1. as the initial or the only therapy when a joint movement is mechanically blocked, as is the case of coccygeus muscle, or when a muscle cannot be stretched fully, as is the case of the lateral pterygoid muscle;

    2. as treatment of trigger points that are unresponsive to non-invasive methods of treatment, e.g., use of medications, spray and stretch.

NOTE: For all conditions, the actual area must be reported specifically, and must be documented in the medical record. Using a non-specific diagnosis code to support injections of multiple areas of the body, rather than more specific diagnosis codes, may result in denial of payment.

    1. Known trigger points may be treated at frequencies necessitated by the nature and the severity of associated symptoms and signs.
    2. Per national Medicare regulations, acupuncture is not a covered service for the treatment of trigger points.
      1. Use of acupuncture needles and/or the passage of electrical current through these needles is not a covered service whether the service is rendered by an acupuncturist or any other provider;
      2. providers of acupuncture services should inform the beneficiary that such services will not be covered; and
      3. prolotherapy is not covered by Medicare and cannot be billed under the trigger point injection code.

    3. If the service has been provided for a diagnosis that is not listed in the covered diagnosis codes section, the provider must thoroughly document the medical necessity and rationale for providing the service for the unlisted diagnosis in the patient's medical records, and this must be provided at the review level for consideration.

The diagnosis codes listed as covered should only be used for purposes of this policy when a trigger point is injected.

Documentation must be maintained noting the anatomic location of the injection site(s).
Summary of Evidence

N/A
Analysis of Evidence (Rationale for Determination)

N/A

Proposed Process Information

Synopsis of Changes
Changes Fields Changed
N/A
Associated Information
Sources of Information
Bibliography
Open Meetings
Meeting Date Meeting States Meeting Information
N/A
Contractor Advisory Committee (CAC) Meetings
Meeting Date Meeting States Meeting Information
N/A
MAC Meeting Information URLs
N/A
Proposed LCD Posting Date
Comment Period Start Date
Comment Period End Date
Reason for Proposed LCD
Requestor Information
This request was MAC initiated.
Requestor Name Requestor Letter
N/A
Contact for Comments on Proposed LCD

Coding Information

Bill Type Codes

Code Description
N/A

Revenue Codes

Code Description
N/A

CPT/HCPCS Codes

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Group 1

Group 1 Paragraph

N/A

 Group 1 Codes

N/A

N/A

ICD-10-CM Codes that Support Medical Necessity

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Group 1

Group 1 Paragraph:

N/A

 Group 1 Codes:

N/A

N/A

ICD-10-CM Codes that DO NOT Support Medical Necessity

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Group 1

Group 1 Paragraph:

N/A

 Group 1 Codes:

N/A

N/A

Additional ICD-10 Information

General Information

Associated Information

Documentation Requirements

  1. Documentation of proper evaluation leading to diagnosis of the trigger point.

  2. Identification of the affected muscle(s).

  3. Documentation of reasons for selecting this therapeutic option.

  4. Precise diagnosis code must be used: generalized diagnoses like low back pain, lumbago, etc. will not be covered.

  5. Documentation which includes the frequency of injections.

  6. Documentation must reflect the medical necessity of providing the service. In a post payment review, the process of making the diagnosis of the trigger point in an individual muscle as detailed in the description section must be documented.

  7. If a patient requires more than 4 sets/series of injections during 1 year, (trigger points in different anatomical locations), a report stating the unusual circumstances and medical necessity for giving the additional injections must accompany the claim for review and individual consideration.


Utilization Guidelines
Repeat trigger point injections may be necessary when there is evidence of persistent pain. Generally, more than 3 injections of the same trigger point are not indicated. Evidence of partial improvement to the range of motion in any muscle area after an injection, but with persistent significant pain, would justify a repeat injection. The medical record must clearly reflect the medical necessity of the repeat injections.

Only 1 Trigger Point Injection CPT code can be billed per date of service.

Because the diagnosis code manual does not list "trigger point" or "myofascial pain syndrome," this LCD lists related diagnoses that can reasonably include trigger points and uses "myofascial pain syndrome" to refer to trigger points.
Sources of Information

Other Medicare Contractors’ Local Coverage Determinations
Bibliography
  1. Alvarez DJ, Rockwell PG. Trigger points: diagnosis and management. American Family Physician. 2002;65(4)653-660.
  2. Dommerholt J, Grieve R, Layton M, Hooks T. An evidence-informed review of the current myofascial pain literature. Journal of Bodywork & Movement Therapies. 2015;19(1)126-137.
    doi: 10.1016/j.jbmt.2014.11.006
  3. Wong CSM, Wong SHS. A new look at trigger point injections. Anesthesiology Research and
    Practice. 2012;1-5. doi:10.1155/2012/492452.

Revision History Information

Revision History Date Revision History Number Revision History Explanation Reasons for Change
03/31/2024 R12

Posted 02/15/2024- This LCD is being retired effective 03/31/2024 and is being replaced with L39713 Trigger Point Injections.
  • LCD Being Retired
08/31/2023 R11

Posted 08/31/2023 Minor grammatical changes made throughout. Review completed 07/20/2023 with no change in coverage.
  • Other (Review)
09/30/2021 R10

09/30/2021 Review completed 08/26/2021 with no change in coverage. Grammar and punctuation corrections made throughout the LCD. Relocated references listed under “Sources of Information” to “Bibliography”, and corrected AMA formatting.
  • Other (Review)
11/01/2019 R9

Content has been moved to the new template.
  • Revisions Due To Code Removal
08/29/2019 R8

08/29/2019 Change Request 10901 Local Coverage Determinations (LCDs): it will no longer be appropriate to include Current Procedure Terminology (CPT)/Health Care Procedure Coding System (HCPCS) codes or International Classification of Diseases Tenth Revision-Clinical Modification (ICD-10-CM) codes in the LCDs. All CPT/HCPCS and ICD-10 codes have been removed from this LCD and placed in Billing and Coding: Trigger Points, Local Injections linked to this LCD. The applicable manual/regulation has been referenced in CMS National Coverage Policy Section. Review completed 08/08/2019. There will not be a lapse in coverage and there has been no change to the coverage content of this LCD.
  • Other (Changes in response to CMS Change Request 10901. Review completed.)
10/01/2018 R7

10/01/2018 ICD-10 Codes updates: deleted code M79.1 and added codes M79.11, M79.12, and M79.18 in Group One.
  • Revisions Due To ICD-10-CM Code Changes
02/01/2018 R6

02/01/2018 Annual review completed 01/10/2018 with no change in coverage. At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.
  • Other (- Annual review)
03/01/2017 R5 03/01/2017 Annual review done 02/02/2017. No change in coverage, reformatting, and typographical corrections made.

  • Other (Annual review)
03/01/2016 R4 03/01/2016 Annual review no change in coverage, removed CAC information.
  • Other (Maintenance annual review)
10/01/2015 R3 10/06/2015 - Due to CMS guidance, we have removed the Jurisdiction 8 Notice and corresponding table from the CMS National Coverage Policy section. No other changes to policy or coverage.
  • Other
10/01/2015 R2 05/29/2015 – Annual updates to the Bill Type Codes and Revenue Codes have been reviewed by the Policy Department and are being Approved for public display. No other changes to policy or coverage.
  • Other (Annual Bill Type Code and Revenue Code updates.)
10/01/2015 R1 04/01/2015 Annual review no change in coverage updated references.
  • Other (Maintenance annual review)
N/A

Associated Documents

Attachments
N/A
Related Local Coverage Documents
Articles
A56909 - Billing and Coding: Trigger Points, Local Injections
Public Versions
Updated On Effective Dates Status
03/31/2024 08/31/2023 - 03/31/2024 Retired You are here
08/23/2023 08/31/2023 - N/A Superseded View
09/20/2021 09/30/2021 - 08/30/2023 Superseded View
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

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