Trigger Point Injections – Know Payer Policies for Appropriate Reimbursement

by | Published on May 24, 2017 | Healthcare News

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Knowing Local Coverage Determination (LCD) policies is crucial for appropriate reimbursement for trigger point injections. The CPT codes for injections into trigger points for myofascial pain syndrome are based on the number of muscles treated:

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 muscle(s)

Trigger points or chronic myofascial pain syndrome are knots of muscle that form when the muscles do not relax. Trigger point injections are used to treat these painful knots of muscle that form when the muscles do not relax. Trigger points or may irritate the nerves around them and cause referred pain, or pain in another part of the body. Successful treatment of trigger points depends on identifying each single muscle syndrome along with every perpetuating factor.

According to the American Academy of Pain Medicine (AAPM), CPT 20552 was reported approximately 350,000 times and CPT 20553, approximately 295,000 times in 2015. High volume services are often assessed by Medicare payers to determine if medical coding is correct and if the services are suitable for the clinical indications. The clinical indications for trigger point injections are symptoms and examination findings consistent with active trigger points. It is also necessary that trigger points are limited in number and should be appropriate for injection.

According to an article in Medscape, treatment is indicated for endocrine diagnoses or fibromyalgia before trigger point injections are considered. As latent trigger points are clinically asymptomatic, they do not require treatment. Also, existence of tenderness alone is not an indication for trigger point injection, because patients with fibromyalgia may also have myofascial pain trigger points.

In some cases, national or local coverage determination policies are developed for trigger point injections. National coverage determinations (NCDs) are developed through an evidence-based process. When a national coverage policy is absent, an item or service may be covered by Medicare contractors based on a local coverage determination (LCD). Most of the policies of Medicare carriers’ LCD for trigger point injections include specific documentation requirements as well as a list of diagnostic codes.

As the AAPM points out, Noridian is one of the Medicare Administrative Contractors (MAC) to update its policies including LCD’s for trigger point injections, with effect from May 26, 2017. Noridian’s policy outlines coverage criteria inclusive of clinical indications which cover diagnostic criteria, medical necessity criteria, limitations on the number of injections, and documentation requirements. For instance, this MAC considers the following major criteria as necessary to establish the diagnosis:

  • Regional pain complaint
  • Pain complaint or altered sensation in the expected distribution of referred pain from a trigger point
  • Taut band palpable in an accessible muscle with exquisite tenderness at one point along the length of it
  • Some degree of restricted range of motion, when measurable.

Only one of four minor criteria is needed for the diagnosis, according to Noridan’s policy:

  • Reproduction of referred pain pattern by stimulating the trigger point
  • Altered sensation by pressure on the tender spot
  • Local response elicited by snapping palpation at the tender spot or by needle insertion into the tender spot
  • Pain alleviated by stretching or injecting the tender spot

This MAC provides coverage for trigger point injections which are medically necessary due to illness or injury and based on symptoms and signs. Examples of ICD-10 codes indicating trigger point injections that this Medicare carrier will reimburse include:

M46.01 Spinal enthesopathy, occipito-atlanto-axial region
M46.02 Spinal enthesopathy, cervical region
M46.05 Spinal enthesopathy, thoracolumbar region
M46.08 Spinal enthesopathy, sacral and sacrococcygeal region
M60.811 Other myositis, right shoulder
M60.812 Other myositis, left shoulder
M60.89 Other myositis, multiple sites
M76.01 Gluteal tendinitis, right hip
M76.02 Gluteal tendinitis, left hip
M76.61 Achilles tendinitis, right leg
M76.62 Achilles tendinitis, left leg
M76.821 Posterior tibial tendinitis, right leg
M76.822 Posterior tibial tendinitis, left leg
M79.1 Myalgia
M79.7 Fibromyalgia

Adhering to carriers’ documentation requirements is also critical for reimbursement. An article published by Medical Group Management Association (MGMA) in 2010 ncites a National Government Services (NGS) direction that cautions physicians against illegible documentation and “cookie cutter” physician notes which are a typical drawback of some electronic medical records systems, “where all patients are getting the same procedure, with the same complaint, the same findings and the provider is treating them all with the same exact plan of care.”

The NGS article recommends that injection documentation answers the following questions:

  • What was the medication and how much was injected?
  • How was the medication administered?
  • Where was it administered?
  • Who administered the medication?
  • Did the patient have a reaction to the medication?
  • Was any medication discarded?
  • Was it medically necessary?

All MACs have their own policies which may vary in terms of the frequency and/or limitation of injections and documentation requirements, and being aware of these is necessary to ensure appropriate reimbursement. Moreover, services with LCDs are often scrutinized by of payers. In these circumstances, outsourcing medical billing to an experienced service provider could be the best way to ensure accurate coding and documentation and avoid the risk of audits.

Meghann Drella

Meghann Drella possesses a profound understanding of ICD-10-CM and CPT requirements and procedures, actively participating in continuing education to stay abreast of any industry changes.

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