Billing and Coding: Trigger Point Injections

Refer to the draft Local Coverage Determination (LCD) DL37913 **Trigger Point
Injections** reasonable and necessary requirements and frequency limitations.

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

**Coding Guidance**

Providers should refer to the applicable 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 trigger point injections 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 Trigger point injection 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.

*C9399 should only be used for ASC, inpatient 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 injections, 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 (cms.gov)](https://www.cms.gov/Regulations-and-
Guidance/Guidance/Manuals/Downloads/bp102c16.pdf). Amniotic and placenta
derived injectants, and platelet rich plasma and vitamins fall in this
category.

**Use of Anesthesia**

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