LCD Reference Article Billing and Coding Article

Billing and Coding: Trigger Point Injections (TPI)

A59487

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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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Contractor Information

Article Information

General Information

Source Article ID
N/A
Article ID
A59487
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Trigger Point Injections (TPI)
Article Type
Billing and Coding
Original Effective Date
04/01/2024
Revision Effective Date
N/A
Revision Ending Date
N/A
Retirement 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.

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CMS National Coverage Policy

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Article Guidance

Article Text

Refer to the Local Coverage Determination (LCD) 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-15000 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-
  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 - G44.229 Tension-type headache, unspecified, intractable - Chronic tension-type headache, not intractable
M79.10 - M79.18 Myalgia, unspecified site - 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 - G81.94 Hemiplegia, unspecified affecting unspecified side - Hemiplegia, unspecified affecting left nondominant side
G89.0 Central pain syndrome
G89.11 - G89.18 Acute pain due to trauma - Other acute postprocedural pain
G89.21 - G89.29 Chronic pain due to trauma - Other chronic pain
G89.4 Chronic pain syndrome
M25.50 - M25.59 Pain in unspecified joint - Pain in other specified joint
M26.621 - M26.629 Arthralgia of right temporomandibular joint - Arthralgia of temporomandibular joint, unspecified side
M48.00 - M48.08 Spinal stenosis, site unspecified - Spinal stenosis, sacral and sacrococcygeal region
M54.2 Cervicalgia
M54.50 - M54.59 Low back pain, unspecified - Other low back pain
M70.80 - M70.99 Other soft tissue disorders related to use, overuse and pressure of unspecified site - 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

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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.

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
L39662 - 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 Effective Dates Status
02/05/2024 04/01/2024 - N/A Currently in Effect You are here

Keywords

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