There continues to be a lot of confusion on proper coding for trigger-point injections. Two CPT4 codes can be used:
- 20552—Injection(s); single or multiple trigger point(s), one or two muscle(s); and
- 20553—Injection(s); single or multiple trigger point(s), three or more muscle(s).
The CPT4 codes are based on the number of muscles affected, not the number of injections given to the patient.
These are very common mistakes when billing trigger-point injections. Some practices mistakenly bill according to the number of injections given and not by the number of muscles injected.
The office visit is allowed and should be billed with the modifier -25 because the decision to give the injections was made after the examination.
This encounter is coded as 99213 because it included:
- History—Expanded problem focused: history of present illness was brief, the review of systems was extended and the past family medical history was not documented.
- Examination—Problem focused: it was stated in the example.
- Medical decision making—Low complexity: the number of problems was limited (established problem worsening), amount of data was none or minimal and the level of risk was moderate because of one or more chronic illnesses with mild exacerbation, progression or side effect to treatment.
A level three E/M visit is acceptable because the history was expanded problem focused, the examination was expanded problem focused and the MDM complexity was moderate. An established patient visit only needs two out of the three elements—history, examination and medical decision making—to determine the level of a visit.
For more information on coding and documentation guidelines, contact Melesia Tillman, CPC-I, CRHC, CHA, via email or 404-633-3777 x820.
