Billing and Coding: Pain Management

This article contains coding and other guidelines that complement the Local
Coverage Determination (LCD) for Pain Management.  
  
 **  Coding Information:**  
  
Procedure codes may be subject to National Correct Coding Initiative (NCCI)
edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to
billing Medicare.  
  
For services requiring a referring/ordering physician, the name and NPI of the
referring/ordering physician must be reported on the claim.  
  
A claim submitted without a valid ICD-10-CM diagnosis code will be returned to
the provider as an incomplete claim under Section 1833(e) of the Social
Security Act.  
  
The diagnosis code(s) must best describe the patient's condition for which the
service was performed.  
  
All procedures related to pain management procedures performed by the
physician/provider performed on the same day must be billed on the same claim.  
  
Acupuncture, a non-covered service, prior to January 21, 2020, is reported
with CPT codes 97810 - 97814\. Effective January 21, 2020, Medicare will cover
all types of acupuncture including dry needling for chronic low back pain
within specific guidelines in accordance with NCD 30.3.3.  
  
 **TRIGGER POINT INJECTIONS AND INJECTIONS OF TENDON SHEATH, LIGAMENT,
GANGLION CYST, CARPAL AND TARSAL TUNNELS**  
  
For trigger point injections, use code 20552 for one or two muscle groups
injected, or 20553 for three or more muscle groups. The number of services for
either code is one (1), regardless of the number of injections at any
individual site, and regardless of the number of sites. Only 20552 or 20553
may be billed, not both. Trigger point injections must be billed on only one
line, regardless of the number of sites.  
  
For dates of service prior to 01/01/2020, dry needling should be reported with
CPT code 20999 (Unlisted procedure, musculoskeletal system, general).

For dates of service on or after 01/01/2020, dry needling should be reported
with CPT code 20560 and/or 20561. Effective January 21, 2020, Medicare will
cover all types of acupuncture including dry needling for chronic low back
pain within specific guidelines in accordance with NCD 30.3.3.  
  
CPT code 20551 should be used when the origin or insertion of a tendon is
injected, in contrast to an injection of the tendon sheath, CPT code 20550.  
  
CPT code 28899 (unilateral procedure, foot or toe) should be billed for the
injection of the tarsal tunnel.  
  
Injection of separate sites (tendon sheath, ligament or ganglion cyst) during
the same encounter should be reported on a separate line of coding and must
have the modifier 59 appended. Multiple surgical rules will apply. Modifier 50
should not be reported with CPT codes 20551, 20552, 20553 or 20612, but may be
reported, when appropriate, with CPT codes 20550 and 20526. For an Ambulatory
Surgical Center (ASC), the appropriate site modifier (RT and/or LT) should be
appended to indicate if the service was performed unilaterally or bilaterally.
Bilateral services must be reported on separate lines using an RT and LT
modifier (50 modifier should not be used).  
  
Multiple injections per day, at the same site, are considered one injection
and should be coded with one unit of service (NOS 001).  
  
Claims for prolotherapy must not be reported with the trigger point codes or
other injection codes.  
  
 **For claims submitted to the Part B MAC**  
  
 **HCPCS DRUG CODES**  
A claim for services rendered in the off-campus-outpatient hospital (19),
inpatient hospital (21), on campus-outpatient hospital (22) or emergency room,
hospital (23), ambulatory surgery center (24), skilled nursing facility for
patients in a part A stay (31), comprehensive inpatient rehabilitation
facility (61), and comprehensive outpatient rehabilitation facility (62) must
indicate the name of the drug and dosage in item 19 or the electronic
equivalent. The HCPCS drug code and dose is not required when CPT 20612 is
reported for aspiration and not for injection or when the ICD-10-CM codes
reported are M77.11 or M77.12 and there is no injection.  
  
The medication being injected, designated by an appropriate HCPCS drug code
must be submitted on the same claim, same day of service as the claim for the
procedure. Claims for local anesthetic should not be reported. The exceptions
to this guideline are:

  * When services are rendered in places of services 19, 21, 22, 23, 61, and 62 there should be no claim for the HCPCS drug code. In addition, drugs packaged in ASC payments should not be separately reported.

  
A claim for services rendered in the office or independent clinic, when the
physician does not bill for the injectables, must include the name of the drug
and dosage in item 19 or the electronic equivalent.

**Documentation Requirements:**

The patient's medical record must contain documentation that fully supports
the medical necessity for services included within the LCD. (See "Indications
and Limitations of Coverage.") This documentation includes, but is not limited
to, relevant medical history, physical examination, and results of pertinent
diagnostic tests or procedures.

A procedure note must be legible and include sufficient detail to allow
reconstruction of the procedure. Required elements of the note include a
description of the techniques employed, and sites(s) of injections, drugs and
doses with volumes and concentrations as well as pre- and post-procedural pain
assessments.

For the treatment of established **trigger point** , the patient's medical
record must clearly document:

  * The evaluation leading to the diagnosis of the trigger point in an individual muscle, as detailed in the "Indications and Limitations of Coverage and/or Medical Necessity" section of this LCD;
  * Identification of the affected muscle(s);
  * Reason for selecting the trigger point injection as a therapeutic option, and whether it is being used as an initial or subsequent treatment for myofascial pain.

For **injections of tendon sheaths, ligaments, ganglion cysts, carpal and
tarsal tunnels** , the medical record must include a procedural note
documenting the reason for the injection at any particular site. If multiple
sites are injected, documentation to substantiate that all the injections are
reasonable and necessary must be present.

**Utilization Guidelines:**

**Trigger Point Injections:**

  * Repeat **trigger point injections** may be necessary when there is evidence of persistent pain. Generally more than three injections of the same trigger point are not indicated. Evidence of partial improvements to the range of motion in any muscle area after an injection, but with persistent significant pain, would justify a repeat injection. The medical record must clearly reflect the medical necessity for repeated injections.

**Injection Tendon Sheath, Ligament, Ganglion Cyst, Carpal and Tarsal
Tunnel:**

  * Most conditions that require injections into the tendon sheaths, ligaments or ganglion cysts should be resolved with one to three injections.

Frequency and Number of Injections or Interventions:

  * In the diagnostic phase, a patient may receive injections at intervals of no sooner than one week or preferably, two weeks. 
  * The number of injections in the diagnostic phase should be limited to no more than two times. 
  * Once a structure is proven to be negative, no repeat interventions should be directed at that structure unless there is a new clinical presentation with symptoms, signs, and diagnostic studies of known reliability and validity that implicate the structure. 
  * The effect of injected corticosteroids may remain for several weeks. The benefit is attributed to a decrease of local inflammation and perhaps some local anesthetic effect. It is usually not necessary to repeat an injection if there has been a satisfactory response to the first injection. Patients who relapse after a satisfactory response may be candidates for another trial after an appropriate interval. Consideration should be given to the cumulative dose injected and limitations made to avoid steroid complications. 
  * In the therapeutic phase (after the diagnostic phase is completed), the frequency should be two months or longer between each injection, provided that there is initial pain relief with diagnostic injections of greater than or equal to (>/=) 75% - 100% with the ability to perform previously painful maneuvers, and a persistent pain relief of greater than or equal to (>/=) 50% with the continued ability to perform previously painful maneuvers is maintained for at least six weeks. The therapeutic frequency must remain at least two months or longer. 
  * In the treatment or therapeutic phase, the injections should be repeated only as medically necessary. No more than four per patient per year are anticipated for the majority of patients.