Billing and Coding: Trigger Point Injections (TPI)

The information in this article contains billing, coding or other guidelines
that complement the Local Coverage Determination (LCD) for __ Trigger Point
Injections DL39671 _._

The Current Procedural Terminology (CPT) codes included in this article may
be subject to National Correct Coding Initiative (NCCI) edits or Outpatient
Prospective Payment System (OPPS) packaging edits. Please refer to the [NCCI
requirements](https://www.cms.gov/medicare-medicaid-coordination/national-
correct-coding-initiative-ncci/ncci-medicare/medicare-ncci-policy-manual).

**Coding Guidance**

Providers should refer to the applicable American Medical Association (AMA)
CPT Manual to assist with proper reporting of these services.

Notice: It is not appropriate to bill Medicare for services that are not
covered (as described by the entire LCD) as if they are covered. When billing
for non-covered services, use the appropriate modifier.

This policy applies only to TPIs and does not apply to dry needling or
acupuncture.

Modifier 50- bilateral should NOT be reported with CPT codes 20552 or 20553.

**Utilization Parameters**

No more than 3 TPI sessions in a rolling 12 months will be considered
reasonable and necessary, regardless of the code billed.

CPT 20552 limits to 1 or 2 muscles and 20553 is 3 or more muscles. The number
of injections into the muscle group are not billed separately. The code
includes all injections made into the muscle.

**Medication**

The drug used for the injection must be on the same claim as the trigger point
administration.

The medication used with the injection is reported with a HCPCS Drug code
"J-code" or a revenue code.

Unclassified drugs billed with J3490, J3590, J9999 or C9399* must also include
name of drug and dosage to Box 19 of the CMS-15000 paper form or electronic
equivalent.

*C3999 should only be used for Ambulatory Surgery Center (ASC) or outpatient facility claims.

**Documentation Requirements**

  1. All documentation must be maintained in the patient's medical record and made available to the contractor upon request.
  2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.
  3. The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.
  4. The procedural report should clearly document the indications and medical necessity for the injection(s), the name, and units of the injectant used, the location of the TPIs, along with the pre- and post- percent (%) pain relief achieved immediately post-injection.
  5. The patient's medical record should include, but is not limited to: 
    * The assessment of the patient by the performing provider as it relates to the complaint of the patient for that visit.
    * Relevant medical history.
    * Results of pertinent tests/procedures.
    * Signed and dated office visit record/operative report (Please note that all services ordered or rendered to Medicare beneficiaries must be signed.)
    * Documentation to support the medical necessity of the procedure(s).
  6. When documenting the TPI procedure, there must be specific information to indicate the location of trigger points treated, the muscles injected, medication injected, amount of medications used, and the post-procedure plan.

**Use of Biologicals**

There are currently no FDA approved biologicals for use as trigger point
injectable agents. The inclusion of biological and/or other non-FDA approved
substances in the injectant may result in denial of the entire claim based on
Medicare Benefit Policy Manual, Chapter 16, Section 180 Medicare Benefit
Policy Manual. Amniotic and placenta derived injectants, platelet rich plasma
and vitamins fall in this category.

**Use of Anesthesia**

No anesthesia codes should be billed in conjunction with 20552 or 20553.