20553, single or multiple trigger point(s), three or more muscle(s). Diagnosis: 729.1, myalgia and myositis; fibromyositis NOS.
The CPT code 20553 is for the injection of three or more muscles. Trigger point injections are based on the number of muscles affected, not the number of injections performed. The code 20552 should be used for single or multiple trigger point injections involving one to two muscles.
This was a scheduled office visit for an injection, and the physician did not perform an examination. When a patient is scheduled for an office procedure, an E/M visit cannot be billed unless there is a significant, separately identifiable problem and the criteria are met for an E/M visit.
The CPT guidelines state that an office or other outpatient visit for the evaluation and management of an established patient requires two out of the three key components: history, examination, and medical decision making.