This Billing and Coding Article provides billing and coding guidance for Proposed Local Coverage Determination (LCD) DL33912, Trigger Point Injections (TPI). Please refer to the LCD for reasonable and necessary requirements.
Coding Guidance
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.
Pursuant to the provisions of the applicable LCD, CPT code 76942 is not eligible for separate payment and will be denied when billed on the same date of service with CPT codes 20552 or 20553.
When a beneficiary receives four (4) TPI sessions within the same rolling 12-month period, the claim for the fourth session must include the KX modifier to attest that the service complies with all coverage requirements outlined in the LCD and all other applicable Medicare regulations.
Utilization Parameters
Per the LCD, no more than 3 TPI sessions are expected within a rolling 12‑month period. However, in select circumstances, there may be a therapeutic benefit to an additional session. Consistent with the LCD, reporting 4 TPI sessions in a rolling 12-month period will require attestation; however, 5 or more sessions will be denied.
Documentation Requirements
- All documentation must be maintained in the patient's medical record and made available to the contractor upon request.
- 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.
- 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.
- For the treatment of established trigger points, the patient’s medical record must have:
- The evaluation/process of arriving at the diagnosis of the trigger point in an individual muscle or muscle group must 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, must be clearly documented in the patient's medical records.
- Attestation for extended services (e.g., above 3 TPI sessions per rolling 12 months) must be supported by documentation that validates the therapeutic benefit of additional TPIs beyond what is typically expected, including:
- Clinical indications for continued treatment,
- Documentation of adherence to multi-modal therapy,
- Evidence of prior response and ongoing medical necessity,
- Compliance with frequency and duration limits,
- All required elements specified in the LCD.
