Trigger Point Injections

This LCD supplements but does not replace, modify or supersede existing Medicare applicable National Coverage Determinations (NCDs) or payment policy rules and regulations for trigger point injections. Federal statute and subsequent Medicare regulations regarding provision and payment for medical services are lengthy. They are not repeated in this LCD. Neither Medicare payment policy rules nor this LCD replace, modify or supersede applicable state statutes regarding medical practice or other health practice professions acts, definitions and/or scopes of practice. All providers who report services for Medicare payment must fully understand and follow all existing laws, regulations and rules for Medicare payment for trigger point injections and must properly submit only valid claims for them. Please review and understand them and apply the medical necessity provisions in the policy within the context of the manual rules. Relevant CMS manual instructions and policies may be found in the following Internet-Only Manuals (IOMs) published on the CMS Web site:

IOM Citations:

• CMS IOM Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, 
  • Chapter 1, Part 1, Section 30.3 Acupuncture 
  • Chapter 1, Part 2, Section 150.7 Prolotherapy, Joint Sclerotherapy, and Ligamentous Injections with Sclerosing Agents
• CMS IOM Publication 100-08, Medicare Program Integrity Manual,
  • Chapter 13, Section 13.5.4 Reasonable and Necessary Provision in an LCD

Social Security Act (Title XVIII) Standard References:

• Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no Medicare payment may be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.
• Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations.

Compliance with the provisions in this LCD may be monitored and addressed through post payment data analysis and subsequent medical review audits.

History/Background and/or General Information

Trigger point injection is one of many modalities utilized in the management of chronic pain. Myofascial trigger points are self-sustaining hyperirritative 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) and each of these single muscle syndromes are responsive to appropriate treatment, which includes injection therapy. An injection is achieved with the insertion of a needle and the administration of agents, such as local anesthetics, steroids and/or local anti-inflammatory drugs.

The diagnosis of trigger points requires a detailed history and thorough physical examination. The following clinical symptoms may be present when making the diagnosis:

• History of onset of the painful condition and its presumed cause (e.g., injury or sprain)
• Distribution pattern of pain consistent with the referral pattern of trigger points
• Range of motion restriction
• Muscular deconditioning in the affected area
• Focal tenderness of a trigger point
• Palpable taut band of muscle in which trigger point is located
• Local taut response to snapping palpation
• Reproduction of referred pain pattern upon stimulation of trigger point

The goal is to treat the cause of the pain and not just the symptom of pain.

Covered Indications

After myofascial pain syndrome (MPS) is established, trigger point injection may be considered medically reasonable and necessary:

1. When noninvasive medical management is unsuccessful (e.g., analgesics, passive physical therapy, ultrasound, range of motion and active exercises).
2. As a bridging therapy to relieve pain while other treatments are also initiated, such as medication or physical therapy; or as a single therapeutic maneuver. The logic behind such therapeutic decision making should be obvious in the medical record and available upon Contractor request.
3. When joint movement is mechanically blocked as is the case of the coccygeus muscle.

 Limitations

The following are considered not medically reasonable and necessary:

1. Medicare does not cover Prolotherapy. Its billing under the trigger point injection code is a misrepresentation of the actual service rendered.
2. When a given site is injected, it will be considered one injection service, regardless of the number of injections administered.

For frequency limitations, please refer to the Utilization Guidelines section below.

Notice: Services performed for any given diagnosis must meet all of the indications and limitations stated in this LCD, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.

N/A

N/A

Please refer to the related Local Coverage Article: Billing and Coding: Trigger Point Injections, A57751 for all coding information as applicable.

Documentation Requirements

1. All documentation must be maintained in the patient’s medical record and available to the contractor upon request.
2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.
3. The medical record documentation must support the medical necessity of the services as stated in this policy.
4. For the treatment of established trigger points, the patient’s medical record must have:
   
   • Documentation of the evaluation/process of arriving at the diagnosis of the trigger point in an individual muscle or muscle group should be clearly documented in the patient’s medical record.
   • The reason for the trigger point injection, and whether it is being used as an initial or subsequent treatment for myofascial pain, as well as the appropriate diagnosis code should be documented.

Utilization Guidelines

In accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice.

It is expected that trigger point injections would not usually be performed more often than three sessions in a three month period. If trigger point injections are performed more than three sessions in a three month period, the reason for repeated performance and the substances injected should be evident in the medical record and available to the Contractor upon request.

This contractor may request records when it is apparent that patients are requiring a significant number of injections to manage their pain.

Documentation in the medical record must support the medical necessity and frequency of the trigger point injection(s).

Contractor is not responsible for the continued viability of websites listed.

Other Contractor Policies

Contractor Medical Directors

Original JH ICD-9 Source LCD L33648, Trigger Point Injections

This bibliography presents those sources that were obtained during the development of this policy. The Contractor is not responsible for the continuing viability of Website addresses listed below.

1. Borg-Stein J, Stein J. Trigger Points and Tender Points: One and the Same? Does Injection Treatment Help? Rheum Dis Clin North Am 1996 May;22(2):305-22.
2. Ferrante FM, Kaufman AG, Dunbar SA et al. Sphenopalatine Ganglion Block For The Treatment Of Myofascial Pain Of The Head, Neck, and Shoulders: Reg Anesth Pain Med 1998 Jan-Feb;23(1):30-6.
3. Hameroff SR, Crago BR, Blitt CD, et al. Comparison of Bupivacaine, Etidocaine, and Saline for Trigger-Point Therapy: Anesth Analg 1981 Oct;60(10):752-5.
4. Hans SC, Harrison P. Myofascial Pain Syndrome and Trigger-Point Management. Reg Anesth 1997 Jan-Feb;22(1):89-101.
5. Harden RN, Bruehl SP, Gass S, et al. Signs and Symptoms of the Myofascial Pain Syndrome; A National Survey of Pain Management Providers: Clin J Pain 2000 Mar;16(1):64-72.
6. Hong CZ, Hsueh TC. Difference in Pain Relief after Trigger Point Injections in Myofascial Pain Patients with and Without Fibromyalgia: Arch Phys Med Rehabil 1996 Nov;77(11):1161-6.
7. Hong CZ.; Lidocaine Injection Versus Dry Needling To Myofascial Trigger Point. The Importance of the Local Twitch Response: Am J Phys Med Rehabil 1994 Jul-Aug;73(4):256.63.
8. Hopwood MB, Abram SE. Factors Associated With Failure Of Trigger Point Injections. Clin J Pain 1994 Sep;10(3):227-34
9. Pongratz DE, Sievers M. Fibromyalgia-Symptom or Diagnosis: A Definition Of The Position. Scand J Rheumatol Suppl; 200;113:3-7.
10. Sist T, Miner M, Lema M. Characteristics Of Postradical Neck Pain Syndrome: A Report Of 25 Cases. J Pain Symptom Manage 1999 Aug;18(2):95-102
11. Wittenberg RH, Steffen R, Ludwig J.; Injection Treatment Of Non-Radicular Lumbalgia: Orthopade 1997 Jun; 26(6):544-52.
12. Wolfe F, Simons DG, Fricton J, et al. The Fibromyalgia And Myofascial Pain Syndromes: A Preliminary Study Of Tender Points And Trigger Points In Persons With Fibromyalgia, Myofascial Pain Syndrome And No Disease: J Rheumatol 1992 Jun; 19(6):944-51.
13. Wyant GM. Chronic Pain Syndromes and Their Treatment. II Trigger Points: Can Anaesth Soc J 1979 May; 26(3):216-9.