March’s coding answer: During a follow-up visit for a diagnosis of fibromyalgia, the physician performs an examination including a review of symptoms and a history, and makes a medical decision of moderate complexity. The physician performs an appropriate level of an E/M visit. During the visit, the patient complains of pain in the neck trapezius muscle, shoulders, and hips. Because of the severity of the pain, the physician gives the patient three trigger-point injections. What is the proper code for this scenario?
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Many coders and billers have coded this scenario incorrectly in one of three ways:
- As 99213-25: Mid-level evaluation and management with modifier -25; significant, separately identifiable evaluation and management service by the same physician on the same day;
- As 20552X3 or 99213-25: Injections; single or multiple trigger points, three or more muscles; or
- As 99213-25, 20552, 20553×2, and 20052: Injections; single or multiple trigger points, one or two muscles.
The correct answer is 99213-25 for the E/M and 20553 for the injections. Trigger-point injections are billed according to number of muscles injected, not how many injections are given. For example, if you gave four injections to two muscles, it would be coded as 20552.