There are two CPT4 codes used for this procedure:
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- 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.
These CPT4 codes are based on the number of muscles affected, not the number of injections given.
Example: Mary, age 51, comes in for a follow-up visit for her diagnosis of rheumatoid arthritis. The physician or practitioner does an examination, including a review of symptoms, takes a history of present illness, and makes a medical decision of moderate complexity. The physician or practitioner performs an appropriate level of an E/M visit. During the visit, the patient complains of stiffness and swelling in the hands, elbows, and neck. Also, an X-ray of the left hand (two views) is taken and read during the visit. Because of the severity of the swelling, the physician or practitioner decides to give the patient six trigger-point injections.
Correct Coding: 99213-25, 20553, 73120/LT
Incorrect Coding: 99213-25, 20552×6 or 99213-25, 20552, 20553×5, 73120
These are common mistakes when billing for trigger-point injections, but correct coding will help reimbursement.
If you have any questions about this or other coding and reimbursement issues, contact the ACR’s certified professional coders Melesia Tillman at firstname.lastname@example.org or Resaee Freeman at email@example.com or by phone at (404) 633-3777.