Local Coverage Article Billing and Coding

Billing and Coding: Piriformis Injections

A56028

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Contractor Information

Article Information

General Information

Article ID
A56028
Article Title
Billing and Coding: Piriformis Injections
Article Type
Billing and Coding
Original Effective Date
07/01/2018
Revision Effective Date
07/01/2018
Revision Ending Date
N/A
Retirement Date
N/A
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CMS National Coverage Policy

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Article Guidance

Article Text

This article replaces all prior instructions for billing and performing a piriformis muscle injection.

Piriformis syndrome may be a common cause of back, buttock and leg pain due to injury to the piriformis muscle. This clinical syndrome is due to compression of the sciatic nerve by the piriformis muscle and may be identical in clinical presentation to low back pain (LBP) with associated LS, S1 radiculopathy due to discogenic and/or lower lumbar facet arthropathy with foraminal narrowing. Patients may also demonstrate both of these clinical entities simultaneously. This diagnostic dilemma highlights the need for patients with LBP and associated radicular pain to undergo a complete history and physical examination. 

Noridian Healthcare Solutions (Noridian) has noted that CPT codes 72195-72197 (Magnetic resonance (e.g., proton) imaging, pelvis) are being used for mapping purposes prior to injection of the piriformis muscle and surrounding muscle groups (i.e., gemelli and obturator intemus muscles). However, there is no clear clinical evidence that doing an MRI, CT Scan or EMG for placement of the needle into the piriformis or to inject the sciatic nerve is of more benefit than using common land marks

 

Coding Clarification

For these reasons, the MRI CPT Codes 72195-72197 will be denied when billed in conjunction with injection of the piriformis muscle or surrounding muscle groups.

Noridian has also noted that providers have been using both CPT codes 64999 (unlisted procedure nervous system) and 64445 (Injection anesthetic agent; sciatic nerve, single) for the injection of the piriformis muscle and surrounding muscle groups. This is not the correct way to code. When the clinical notes reflect direct nerve block to the sciatic nerve, 64445 should be used. When the injection focus is in the piriformis muscle or surrounding muscle groups, 20552 should be used. Per CPT Assistant December 2011, Volume 21, Issue 12 page 8; There is a significant difference in the work and procedure, as well as intent, between an injection of the piriformis muscle and the perineural injection of the sciatic nerve. The sciatic nerve injection code (64445) should not be used to report a piriformis injection.

 

Source:

  • CPT Assistant December 2011, Volume 21, Issue 12 page 8.

Coding Information

CPT/HCPCS Codes

Group 1

(1 Code)
Group 1 Paragraph

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Group 1 Codes
CodeDescription
20552 INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)

CPT/HCPCS Modifiers

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ICD-10-CM Codes that Support Medical Necessity

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

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Additional ICD-10 Information

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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.

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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.

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Other Coding Information

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Revision History Information

Revision History DateRevision History NumberRevision History Explanation
07/01/2018 R1

Article converted to Billing and Coding, no change in coverage made.

Associated Documents

Related Local Coverage Documents
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Related National Coverage Documents
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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 Effective Dates Status
09/29/2020 07/01/2018 - N/A Currently in Effect You are here
06/14/2018 07/01/2018 - N/A Superseded View

Keywords

  • Piriformis injection,
  • 64999,
  • 20552.