Coding Trigger Point Injections for Pain Management

Review your payer policies when performing these services.

Pain management coding can be tricky.  Trigger point injection therapy is a common procedure performed by pain management specialists, orthopedic surgeons, physical medicine and rehab and other specialties. Trigger point injection therapy is used for the treatment of myofascial pain syndrome (MPS).

According to the American Society of Regional Anesthesia and Pain Medicine. Myofascial pain is a common, non-articular musculoskeletal disorder characterized by symptomatic myofascial trigger points – hard, palpable, localized nodules within taut bands of skeletal muscle that are painful upon compression. MPS is a chronic condition affecting the connective tissue (i.e., fascia) surrounding the muscles; sensitive points in your muscles (trigger points) cause referred pain in seemingly unrelated parts of the body. MPS typically occurs after a muscle has been contracted repetitively. The large upper back muscles are prone to developing myofascial pain, as well as the neck, shoulders, heel and temporomandibular joint.

There are two CPT^® codes for Trigger point injections:

• 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

Local anesthesia is included in these services.  However, imaging guidance can be billed in addition to the injection if necessary using the following CPT Codes:

• 76942-Ultrasonic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device), imaging supervision and interpretation
• 77002-Fluoroscopic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device) (List separately in addition to code for primary procedure)
• 77021-Magnetic resonance guidance for needle placement (e.g., for biopsy, needle aspiration, injection, or placement of localization device) radiological supervision and interpretation

Don’t forget to report a HCPC J code for the medication injected. 

Most payers consider dry needling of trigger point investigational and not covered by all payers.

These codes are under many insurance companies radar including Medicare and Medicaid because of the high volume of frequency. payers are auditing and monitoring pain management services more closely now so crossing your t’s and dotting you I’s is very important to validate medical necessity for trigger point injections.

Centers for Medicare & Medicaid Services (CMS) does not have a National Carrier Determination (NCD), but many of the CMS Medicare contractors have LCDs (Local Carrier Determination) as well as many commercial carriers have medical policies for trigger point injections.  It is important to review your payer policies when performing these services as it is not only the coding, but documentation and clinical indicators.

There are three key areas that are important to validate medical necessity

1. Conservative Treatment
2. Documentation
3. Frequency

Conservative Treatment

The first issue to address is conservative management.  payers expect to see more conservative/noninvasive treatment before giving a trigger point injection. The first step is the evaluation to determine the site and level of pain along with the cause of pain if known.  I always recommend to my clients that a separate treatment plan is developed at the initial evaluation and updated during every visit or treatment.

 Conservative treatment includes:

Medications including the use of analgesics and adjunctive medications, including anti-depressants shown to be effective in management of chronic pain.

• Physical therapy modalities, heat and cold therapy, passive range of motion, and deep muscle massage
• Activity modification
• Home exercise

Most payers consider that trigger point injections as the initial therapy is used only when joint movement is impaired, the muscle cannot be stretched fully, or is in a fixed position.  Trigger point injections are accepted if the patient is unresponsive to non-invasive treatment methods as listed above.

Documentation

Documentation must include the site of the injection and number of injections and number of muscles.  Documentation must also support that conservative therapies has been tried and failed and in many cases payers what documentation that indicates the symptoms have persisted more than thee months and the trigger points have been identified by palpation.

Frequency

Frequency should be dependent on clinical judgement, but payment and frequency limitations are defined by the payer. 

For example, Aetna’s Medical policy states “It is not medically necessary to repeat injections more frequently than every seven days.  Up to 4 sets of injections are considered medically necessary to diagnose the origin of the patient’s pain and to achieve a therapeutic effect; additional sets of trigger point injections are not considered medically necessary if not clinical response is achieved.  Once therapeutic effect is achieved, it is rarely considered medically necessary to repeat trigger point injections more frequently than once every 2 months.”

According to First Coast (Medicare Administrative Contractor), LCD 37635 indicates that “Trigger point injections accompanied by appropriate adjunctive care should provide moderate-to-long term benefits. There is no peer-reviewed literature to substantiate more than four trigger point injections in a year”.

Typically, frequency is:

• Dependent not only based on clinical judgement but also payer policy
• Repeat injections if previous injection successful
• Medical necessity must be documented
• Pain should resolve in 2-3 injections
• No more than 2 sites per session
• Limitations are dependent on payer policy

Summary

Make certain when coding for trigger point injections that documentations supports evidence of conservative therapy, documentation supports the site and number of injections and number of muscles.  Make certain that you reference the patient’s medical policy for details on limitations of frequency along with the diagnosis codes that support medical necessity for the trigger point injection(s).  I recommend that during the initial evaluation for management, the practitioner develop a separate pain management care plan that can be updated during every visit. And always when billing for trigger point injections make certain you report the trigger point, drug injected (J code) and if ultrasound, fluoroscopic guidance, or MRI is used to perform the injection you report it on the claim.

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