DRAFT LCD Reference Article Billing and Coding Article

Billing and Coding: Trigger Point Injections (TPI)

DA57701

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Draft Article
Draft Articles are works in progress and not necessarily a reflection of the current billing and coding practices. Revisions to codes are carefully and thoroughly reviewed and are not intended to change the original intent of the LCD.

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Note History

Contractor Information

Draft Article Information

General Information

Source Article ID
A57701
Draft Article ID
DA57701
Original ICD-9 Article ID
Not Applicable
Draft Article Title
Billing and Coding: Trigger Point Injections (TPI)
Article Type
Billing and Coding
Original Effective Date
N/A
Revision Effective Date
N/A
Revision Ending Date
N/A
Retirement Date
ANTICIPATED 02/05/2025

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

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CMS National Coverage Policy

N/A

Article Guidance

Article Text

Refer to the draft Local Coverage Determination (LCD) DL34211-Trigger Point Injections (TPI) reasonable and necessary requirements and frequency limitations.

The Current Procedural Terminology (CPT) codes included in this article may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Please refer to the NCCI requirements.

Coding Guidance

Providers should refer to the applicable AMA CPT Manual to assist with proper reporting of these services.

Notice: It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.

This policy applies only to trigger point injections and does not apply to dry needling or acupuncture.

Modifier 50- bilateral should not be reported with CPT codes 20552 or 20553.

Utilization Parameters

No more than 3 Trigger point injection sessions in a rolling 12 months will be considered reasonable and necessary, regardless of the code billed.

CPT 20552 limits to 1 or 2 muscles and 20553 is 3 or more muscles. The number of injections into the muscle group are not billed separately. The code includes all injections made into the muscle.

Medication

The drug used for the injection must be on the same claim as the trigger point administration.

The medication used with the injection is reported with a HCPCS Drug code “J-code” or a revenue code.

Unclassified drugs billed with J3490, J3590, J9999 or C9399* must also include name of drug and dosage to Box 19 of the CMS-1500 paper form or electronic equivalent.

*C3999 should only be used for ASC outpatient facility claims.

Documentation Requirements

  1. All documentation must be maintained in the patient's medical record and made 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 submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.
  4. The procedural report should clearly document the indications and medical necessity for the injections, the name, and units of the injectant used, the location of the TPIs, along with the pre and post percent (%) pain relief achieved immediately post injection.
  5. The patient’s medical record should include, but is not limited to:
    • The assessment of the patient by the performing provider as it relates to the complaint of the patient for that visit.
    • Relevant medical history
    • Results of pertinent tests/procedures
    • Signed and dated office visit record/operative report (Please note that all services ordered or rendered to Medicare beneficiaries must be signed.)
    • Documentation to support the medical necessity of the procedure(s).
  6. When documenting the TPI procedure, there must be specific information to indicate the location of trigger points treated, the muscles injected, medication injected, amount of medications used, and the post-procedure plan.

Use of Biologicals

There are currently no FDA approved biologicals for use as trigger point injectable agents. The inclusion of biological and/or other non-FDA approved substances in the injectant may result in denial of the entire claim based on Medicare Benefit Policy Manual, Chapter 16, Section 180 Medicare Benefit Policy Manual (cms.gov). Amniotic and placenta derived injectants, and platelet rich plasma and vitamins fall in this category.

Use of Anesthesia

No anesthesia codes should be billed in conjunction with 20552 or 20553.

Response To Comments

Number Comment Response
1
N/A

Coding Information

Bill Type Codes

Code Description
012x Hospital Inpatient (Medicare Part B only)
013x Hospital Outpatient
071x Clinic - Rural Health
073x Clinic - Freestanding
083x Ambulatory Surgery Center
085x Critical Access Hospital
N/A

Revenue Codes

Code Description
032X Radiology - Diagnostic - General Classification
036X Operating Room Services - General Classification
045X Emergency Room - General Classification
049X Ambulatory Surgical Care - General Classification
051X Clinic - General Classification
052X Freestanding Clinic - General Classification
076X Specialty Services - General Classification
N/A

CPT/HCPCS Codes

Group 1

(2 Codes)
Group 1 Paragraph

N/A

Group 1 Codes
Code Description
20552 INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)
20553 INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 3 OR MORE MUSCLES
N/A

CPT/HCPCS Modifiers

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

(10 Codes)
Group 1 Paragraph

N/A

Group 1 Codes
Code Description
G44.201 Tension-type headache, unspecified, intractable
G44.209 Tension-type headache, unspecified, not intractable
G44.211 Episodic tension-type headache, intractable
G44.219 Episodic tension-type headache, not intractable
G44.221 Chronic tension-type headache, intractable
G44.229 Chronic tension-type headache, not intractable
M79.10 Myalgia, unspecified site
M79.11 Myalgia of mastication muscle
M79.12 Myalgia of auxiliary muscles, head and neck
M79.18 Myalgia, other site
N/A

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

Group 1

(134 Codes)
Group 1 Paragraph

N/A

Group 1 Codes
Code Description
F52.5 Vaginismus not due to a substance or known physiological condition
F52.9 Unspecified sexual dysfunction not due to a substance or known physiological condition
G81.90 Hemiplegia, unspecified affecting unspecified side
G81.91 Hemiplegia, unspecified affecting right dominant side
G81.92 Hemiplegia, unspecified affecting left dominant side
G81.93 Hemiplegia, unspecified affecting right nondominant side
G81.94 Hemiplegia, unspecified affecting left nondominant side
G89.0 Central pain syndrome
G89.11 Acute pain due to trauma
G89.12 Acute post-thoracotomy pain
G89.18 Other acute postprocedural pain
G89.21 Chronic pain due to trauma
G89.22 Chronic post-thoracotomy pain
G89.28 Other chronic postprocedural pain
G89.29 Other chronic pain
G89.4 Chronic pain syndrome
M25.50 Pain in unspecified joint
M25.511 Pain in right shoulder
M25.512 Pain in left shoulder
M25.519 Pain in unspecified shoulder
M25.521 Pain in right elbow
M25.522 Pain in left elbow
M25.529 Pain in unspecified elbow
M25.531 Pain in right wrist
M25.532 Pain in left wrist
M25.539 Pain in unspecified wrist
M25.541 Pain in joints of right hand
M25.542 Pain in joints of left hand
M25.549 Pain in joints of unspecified hand
M25.551 Pain in right hip
M25.552 Pain in left hip
M25.559 Pain in unspecified hip
M25.561 Pain in right knee
M25.562 Pain in left knee
M25.569 Pain in unspecified knee
M25.571 Pain in right ankle and joints of right foot
M25.572 Pain in left ankle and joints of left foot
M25.579 Pain in unspecified ankle and joints of unspecified foot
M25.59 Pain in other specified joint
M26.621 Arthralgia of right temporomandibular joint
M26.622 Arthralgia of left temporomandibular joint
M26.623 Arthralgia of bilateral temporomandibular joint
M26.629 Arthralgia of temporomandibular joint, unspecified side
M48.00 Spinal stenosis, site unspecified
M48.01 Spinal stenosis, occipito-atlanto-axial region
M48.02 Spinal stenosis, cervical region
M48.03 Spinal stenosis, cervicothoracic region
M48.04 Spinal stenosis, thoracic region
M48.05 Spinal stenosis, thoracolumbar region
M48.061 Spinal stenosis, lumbar region without neurogenic claudication
M48.062 Spinal stenosis, lumbar region with neurogenic claudication
M48.07 Spinal stenosis, lumbosacral region
M48.08 Spinal stenosis, sacral and sacrococcygeal region
M54.2 Cervicalgia
M54.50 Low back pain, unspecified
M54.51 Vertebrogenic low back pain
M54.59 Other low back pain
M70.80 Other soft tissue disorders related to use, overuse and pressure of unspecified site
M70.811 Other soft tissue disorders related to use, overuse and pressure, right shoulder
M70.812 Other soft tissue disorders related to use, overuse and pressure, left shoulder
M70.819 Other soft tissue disorders related to use, overuse and pressure, unspecified shoulder
M70.821 Other soft tissue disorders related to use, overuse and pressure, right upper arm
M70.822 Other soft tissue disorders related to use, overuse and pressure, left upper arm
M70.829 Other soft tissue disorders related to use, overuse and pressure, unspecified upper arms
M70.831 Other soft tissue disorders related to use, overuse and pressure, right forearm
M70.832 Other soft tissue disorders related to use, overuse and pressure, left forearm
M70.839 Other soft tissue disorders related to use, overuse and pressure, unspecified forearm
M70.841 Other soft tissue disorders related to use, overuse and pressure, right hand
M70.842 Other soft tissue disorders related to use, overuse and pressure, left hand
M70.849 Other soft tissue disorders related to use, overuse and pressure, unspecified hand
M70.851 Other soft tissue disorders related to use, overuse and pressure, right thigh
M70.852 Other soft tissue disorders related to use, overuse and pressure, left thigh
M70.859 Other soft tissue disorders related to use, overuse and pressure, unspecified thigh
M70.861 Other soft tissue disorders related to use, overuse and pressure, right lower leg
M70.862 Other soft tissue disorders related to use, overuse and pressure, left lower leg
M70.869 Other soft tissue disorders related to use, overuse and pressure, unspecified leg
M70.871 Other soft tissue disorders related to use, overuse and pressure, right ankle and foot
M70.872 Other soft tissue disorders related to use, overuse and pressure, left ankle and foot
M70.879 Other soft tissue disorders related to use, overuse and pressure, unspecified ankle and foot
M70.88 Other soft tissue disorders related to use, overuse and pressure other site
M70.89 Other soft tissue disorders related to use, overuse and pressure multiple sites
M70.90 Unspecified soft tissue disorder related to use, overuse and pressure of unspecified site
M70.911 Unspecified soft tissue disorder related to use, overuse and pressure, right shoulder
M70.912 Unspecified soft tissue disorder related to use, overuse and pressure, left shoulder
M70.919 Unspecified soft tissue disorder related to use, overuse and pressure, unspecified shoulder
M70.921 Unspecified soft tissue disorder related to use, overuse and pressure, right upper arm
M70.922 Unspecified soft tissue disorder related to use, overuse and pressure, left upper arm
M70.929 Unspecified soft tissue disorder related to use, overuse and pressure, unspecified upper arm
M70.931 Unspecified soft tissue disorder related to use, overuse and pressure, right forearm
M70.932 Unspecified soft tissue disorder related to use, overuse and pressure, left forearm
M70.939 Unspecified soft tissue disorder related to use, overuse and pressure, unspecified forearm
M70.941 Unspecified soft tissue disorder related to use, overuse and pressure, right hand
M70.942 Unspecified soft tissue disorder related to use, overuse and pressure, left hand
M70.949 Unspecified soft tissue disorder related to use, overuse and pressure, unspecified hand
M70.951 Unspecified soft tissue disorder related to use, overuse and pressure, right thigh
M70.952 Unspecified soft tissue disorder related to use, overuse and pressure, left thigh
M70.959 Unspecified soft tissue disorder related to use, overuse and pressure, unspecified thigh
M70.961 Unspecified soft tissue disorder related to use, overuse and pressure, right lower leg
M70.962 Unspecified soft tissue disorder related to use, overuse and pressure, left lower leg
M70.969 Unspecified soft tissue disorder related to use, overuse and pressure, unspecified lower leg
M70.971 Unspecified soft tissue disorder related to use, overuse and pressure, right ankle and foot
M70.972 Unspecified soft tissue disorder related to use, overuse and pressure, left ankle and foot
M70.979 Unspecified soft tissue disorder related to use, overuse and pressure, unspecified ankle and foot
M70.98 Unspecified soft tissue disorder related to use, overuse and pressure other
M70.99 Unspecified soft tissue disorder related to use, overuse and pressure multiple sites
M79.0 Rheumatism, unspecified
M79.2 Neuralgia and neuritis, unspecified
M79.3 Panniculitis, unspecified
M79.4 Hypertrophy of (infrapatellar) fat pad
M79.5 Residual foreign body in soft tissue
M79.601 Pain in right arm
M79.602 Pain in left arm
M79.604 Pain in right leg
M79.605 Pain in left leg
M79.621 Pain in right upper arm
M79.622 Pain in left upper arm
M79.631 Pain in right forearm
M79.632 Pain in left forearm
M79.641 Pain in right hand
M79.642 Pain in left hand
M79.644 Pain in right finger(s)
M79.645 Pain in left finger(s)
M79.651 Pain in right thigh
M79.652 Pain in left thigh
M79.661 Pain in right lower leg
M79.662 Pain in left lower leg
M79.671 Pain in right foot
M79.672 Pain in left foot
M79.674 Pain in right toe(s)
M79.675 Pain in left toe(s)
M79.7 Fibromyalgia
M79.9 Soft tissue disorder, unspecified
R10.2 Pelvic and perineal pain
S13.4XXA Sprain of ligaments of cervical spine, initial encounter
N/A

ICD-10-PCS Codes

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

Additional ICD-10 Information

N/A

Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

Code Description
012x Hospital Inpatient (Medicare Part B only)
013x Hospital Outpatient
071x Clinic - Rural Health
073x Clinic - Freestanding
083x Ambulatory Surgery Center
085x Critical Access Hospital
N/A

Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

Code Description
032X Radiology - Diagnostic - General Classification
036X Operating Room Services - General Classification
045X Emergency Room - General Classification
049X Ambulatory Surgical Care - General Classification
051X Clinic - General Classification
052X Freestanding Clinic - General Classification
076X Specialty Services - General Classification
N/A

Other Coding Information

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

Coding Table Information

Excluded CPT/HCPCS Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
N/A N/A
N/A
Non-Excluded CPT/HCPCS Ended Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
N/A

Revision History Information

Revision History Date Revision History Number Revision History Explanation
N/A

Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
Related Local Coverage Documents
LCDs
DL34211 - Trigger Point Injections (TPI)
Related National Coverage Documents
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SAD Process URL 1
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SAD Process URL 2
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Statutory Requirements URLs
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Rules and Regulations URLs
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CMS Manual Explanations URLs
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Other URLs
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Public Versions
Updated On Archived Date Status
08/11/2023 N/A N/A You are here

Keywords

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