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Explore This IssueMay 2013
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The correct way to bill this visit is: 99213-25, 20553, 73120/LT Diagnosis 714.0
There continues to be a lot of confusion on the proper coding for trigger-point injections. Two CPT4 codes can be used for trigger-point procedures:
- 20552—Injection(s); single or multiple trigger point(s), one or two muscle(s); and
- 20553—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. Some practices mistakenly bill according to the number of injections given and not by the number of muscles injected. This is a very common mistake when billing trigger-point injections.
In this case, 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.
The encounter is coded as 99213 because it includes:
- History—Expanded-problem focused: history of present illness was brief, the review of system was extended, and the past family medical history was not documented.
- Examination—Expanded-problem focused: it was stated in the example.
- Medical decision making—Low complexity: the number of problems was limited (established problem worsening), amount of data was minimal for the X-ray, and the level of risk was moderate because of one or more chronic illnesses with mild exacerbation, progression, or side effect to treatment.
A level-three evaluation and management (E/M) visit is acceptable due to CPT and coding guidelines, the history was expanded-problem focused, 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 a radiological procedure is performed and interpreted in the physician’s office, then the procedure will have to be coded as a global service. No payment modifier is needed, i.e., 26 or TC, and this would simply be coded as 73120-LT. The LT modifier is appropriate to list because it identifies the anatomical site where the procedure was performed.
For questions or additional information on coding and documentation guidelines, contact Melesia Tillman, CPC-I, CRHC, CHA, specialist, coding and reimbursement, at [email protected] or (404) 633-3777, ext. 820.