Diagnosis ICD-9: 714.0
ICD-10: M05.49
Incorrect Coding: 99213-25, 20552×5 or 99213-25, 20552, 20553×4, 73120-26
Proper coding for trigger-point injections continues to confuse coders. There are two CPT codes that can be used for trigger-point procedures:
- 20552–Injection(s); single or multiple trigger point(s), one or two muscle(s)
- 20553–Single or multiple trigger point(s), three or more muscles
These CPT codes are based on the number of muscles affected, not the number of injections given to the patient.
The office visit is allowed, and should be billed with a modifier -25 because the decision to give the injections was made after the examination. A level-three Evaluation and Management visit is acceptable because the examination was expanded, problem focused and the medical decision-making complexity was low. Remember, an established patient visit only needs two out of the three elements—history, examination, and medical decision making—to determine its level.
Additionally, if an office is to perform any diagnostic imaging, the procedure should be billed as a global fee, which includes the imaging and interpretation.
For questions or additional information on coding and documentation guidelines, contact Melesia Tillman, CPC, CRHC, CHA, at [email protected] or (404) 633-3777, ext. 820.
