As an experienced medical billing company, we handle claims submission for all specialties including pain management. Just as other medical specialties, billing and coding for pain management is challenging as there are several applicable government and private payer rules and regulations. Trigger point injections (TPI) are commonly practiced pain intervention techniques. Trigger point injection (TPI) therapy involves injection of medications directly into the trigger points or knots that form when muscles do not relax. Commonly performed by pain management specialists, orthopedic surgeons, and physical medicine and rehabilitation specialists, this therapy can improve pain and function by making changes in soft tissues such as muscle and fascia. As pain management medical coding and billing can be complex, relying on the services of a reliable medical billing company is an option worth considering. Medical billing and coding companies provide the service of medical coders well-versed in the correct diagnostic and procedure codes that are to be used to ensure appropriate reimbursement for the medical services.

Coding Trigger Point Injections

Trigger point injections (TPI) are used to treat a wide variety of pain syndromes and other painful conditions including myofascial pain syndrome (MPS), fibromyalgia and tension headache. The injections may often include a corticosteroid, with which the trigger point is made inactive and the pain is alleviated. Generally, pain arises from multiple trigger points in our soft tissues which can be located anywhere in the body. Trigger points are focal areas of muscle spasm, (often located in the upper back and shoulder areas) that develops when a small portion of myofascia (the tissue covering the muscle) tightly contracts to itself by cutting off its blood supply and preventing the underlying muscle from working properly.

There are several lifestyle factors that can contribute to the development of trigger points in the neck, middle back or lower back area which include injury to the muscles, joint disorders, poor posture, vitamin deficiencies, sleep disturbances and repeated stress on the muscles.

What Are The Symptoms Associated With Trigger Points?

A person living with trigger points may experience the following symptoms –

  • Pain (including headache, neck pain and back pain)
  • Decreased range of motion
  • Fatigue
  • Muscle stiffness/tightness
  • Muscle tenderness
  • Numbness

What Happens During a TPI?

As part of the TPI procedure, a nerve block will be directly administered by an orthopedist or pain management specialist to numb the treatment area and to keep the patient comfortable during the procedure. Further, a small needle containing a local anesthetic (lidocaine, procaine) or saline, which may include a corticosteroid is directly injected into the trigger point, which makes it inactive and the pain is relieved. However, a dry needle technique (without medications) will be used if the patient is allergic to the local anesthetic medication.

The procedure is of short duration and may take only a few minutes. The injection may cause mild pain and numbness for some time. In some cases, a bruise may form at the site of injection. Applying moist heat and ice alternatively to the area of injection may help in sustained relief. In some cases, the orthopedist may also recommend stretching exercises and physical therapy for better pain relief.

Documentation Guidelines

Medical coding for trigger point injections involves following several documentation guidelines. Knowing Local Coverage Determination (LCD) policies is important for appropriate reimbursement for trigger point injections. The documentation must include –

  • The site of the injection
  • The total number of injections made
  • The number and type of muscles involved

The documentation must also support the various therapies that have been repeatedly tried and failed. In many cases, payers want documentation that indicates the symptoms have persisted for more than three months and that the trigger points have been identified by palpation.

Frequency of injections administered is another important factor. Generally, frequency of injections will be dependent on the following factors –

  • Based on clinical judgment, 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

Medical Codes to Use

The CPT codes for injections into trigger points (which are based on the number of muscles treated) include –

  • 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

However, only a single code from 20552 or 20553 should be reported on any particular day, no matter how many sites are injected. Whenever a given site is injected, it will be considered as one injection service, regardless of the number of injections administered.

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

In addition to the above CPT codes, it is important to report a HCPC J code for the type of medication injected.

ICD-10 Codes to Use

M79 – Other and unspecified soft tissue disorders, not elsewhere classified

  • M79.0 – Rheumatism, unspecified
  • M79.1 – Myalgia
  • 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

M79.6 – Pain in limb, hand, foot, fingers and toes

  • M79.60 – Pain in limb, unspecified
  • M79.601 – Pain in right arm
  • M79.602 – Pain in left arm
  • M79.603 – Pain in arm, unspecified
  • M79.604 – Pain in right leg
  • M79.605 – Pain in left leg
  • M79.606 – Pain in leg, unspecified
  • M79.609 – Pain in unspecified limb

M79.62 – Pain in upper arm

  • M79.621 – Pain in right upper arm
  • M79.622 – Pain in left upper arm
  • M79.629 – Pain in unspecified upper arm

M79.63 – Pain in forearm

  • M79.631 – Pain in right forearm
  • M79.632 – Pain in left forearm
  • M79.639 – Pain in unspecified forearm

M79.64 – Pain in hand and fingers

  • M79.641 – Pain in right hand
  • M79.642 – Pain in left hand
  • M79.643 – Pain in unspecified hand
  • M79.644 – Pain in right finger(s)
  • M79.645 – Pain in left finger(s)
  • M79.646 – Pain in unspecified finger(s)

M79.65 – Pain in thigh

  • M79.651 – Pain in right thigh
  • M79.652 – Pain in left thigh
  • M79.659 – Pain in unspecified thigh

M79.66 – Pain in lower leg

  • M79.661 – Pain in right lower leg
  • M79.662 – Pain in left lower leg
  • M79.669 – Pain in unspecified lower leg

M79.67 – Pain in foot and toes

  • M79.671 – Pain in right foot
  • M79.672 – Pain in left foot
  • M79.673 – Pain in unspecified foot
  • M79.674 – Pain in right toe(s)
  • M79.675 – Pain in left toe(s)
  • M79.676 – Pain in unspecified toe(s)

M79.7-Fibromyalgia

Partnering with an experienced medical billing and coding outsourcing company can ensure accurate reporting of pain management procedures. Such companies have experienced AAPC-certified coders who are knowledgeable in the coding and billing guidelines for this specialty and can ensure accurate claims for optimal reimbursement.