CPT codes: 99213-25, 20553, 73120/LT
Diagnosis: ICD-9 7291
ICD-10 M79.7
Coding for trigger-point injections continues to create a lot of confusion on proper coding guidelines. Keep in mind, 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. Billing for the number of injections given and not by the number of muscles injected is a common mistake.
Also, the E/M service is allowed for this office visit and should be billed with the modifier -25, since the decision to give the injections was made after the examination.
This encounter is coded as 99213 because it included:
- 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 E/M visit is acceptable because the history was expanded problem focused, the examination was expanded problem focused and the medical decision making complexity was moderate. 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 an office performs diagnostic imaging, the procedure should be billed as a global service, which includes the imaging and interpretation.
The ICD-10 code M79.7 is for fibromyalgia; it is one of the few codes that crosswalks as a one-to-one match from ICD-9 to ICD-10.
For more information on coding, billing or ICD-10 training, contact Melesia Tillman, CPC, CPC-I, CRHC, CHA at mtillman@rheumatology.org or 404-633-3777 x820.