Diagnosis 714.0
Incorrect Coding: 99213-25, 20552×5 or 99213-25, 20552, 20553×4, 73120-26
Coding for trigger-point injections continues to cause confusion. There are two CPT4 codes that can be used for trigger-point procedures:
- 20552: Injection(s); single or multiple trigger point(s), one or two muscle(s)
- 20553: Injection(s); single or multiple trigger point(s), three or more muscles
The CPT4 codes are based on the number of muscles affected, not the number of injections given to the patient.
Coders commonly (but mistakenly) bill according to the number of injections given when they should code by the number of muscles injected.
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 E/M visit is acceptable because the examination was expanded problem-focused and the medical decision-making complexity was low. An established patient visit only needs two out of the three elements—history, examination, and medical decision making—to determine the level of a visit.
Additionally, if you 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 ACR’s coding specialist, Melesia Tillman, CPC, CRHC, CHA, at [email protected] or (404) 633-3777, ext. 820.
