Effective May 22, 2017 Noridian has updated the Local Coverage Determination (LCD) coding guidelines for CPT procedures 20552, injection(s); single or multiple trigger point(s), 1 or 2 muscle(s) and 20553, injection(s); single or multiple trigger point(s), 3 or more used to affect therapy for a pathological condition.
Noridian states the goal of the updated diagnostic and utilization criteria is for providers to identify and treat the cause of the pain, not just the symptom. Practices should update coding and billing procedures for CPT codes 20552 and 20553 as the new guidelines will be applied to services performed on or after May 26, 2017
The updated criteria include the following:
Major criteria: All four must be present to establish the diagnosis.
A. Regional pain complaint
B. Pain complaint or altered sensation in the expected distribution of referred pain from a trigger point
C. Taut band palpable in an accessible muscle with exquisite tenderness at one point along the length of it
D. Some degree of restricted range of motion, when measurable.
Minor criteria: Only one of four needed for the diagnosis.
A. Reproduction of referred pain pattern by stimulating the trigger point
B. Altered sensation by pressure on the tender spot
C. Local response elicited by snapping palpation at the tender spot or by needle insertion into the tender spot
D. Pain alleviated by stretching or injecting the tender Spot
Additionally, the MAC has added utilization standards indicating that it is expected that trigger point injections would not usually be performed more often than three sessions in a three month period. If trigger point injections are performed more than three sessions in a three month period, the reason for repeated performance and the substances injected will need to be documented in the medical record and available to the Contractor upon request.
The Contractor indicates in the policy they may request records if they deem that patients are requiring a significant number of injections to manage their pain. Compliance with the provisions in this policy should be followed as the CPT codes are subject to monitoring by post payment data analysis and subsequent medical review.
Jurisdiction F includes Alaska, Arizona, Idaho, Montana, North Dakota, Oregon, South Dakota, Utah, Washington and Wyoming. Members can view the complete LCD update at https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=36859&ContrId=345
