99213-25, 20552, J2001x2. Diagnosis 726.0, 729.1.
The E/M visit was a level three because the history and exam were expanded and problem focused. Office visits for the evaluation and management of an established patient require only two of three key components for a level-three designation. This visit met two of the key components; the medical decision-making was straightforward and was not a factor in the overall coding.
Although there were two injections, you would not code the 20552×2. Keep in mind that this code is based on the number of muscles, not injections. The CPT manual defines 20552 as, “Injection(s); single or multiple trigger point(s), one or two muscle(s).”
The modifier -25 is added because a separately identifiable E/M visit was performed on the same day as a procedure.