Draft Article - Billing and Coding: Trigger Point Injections (TPI) (DA59498)

CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.CMSInternet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 16,180 Services Related to and Required as a Result of Services Which Are Not Covered Under MedicareArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) forTrigger 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 theNCCI requirements.Coding GuidanceProviders should refer to the applicable American Medical Association (AMA) CPTManual 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 CPTcodes 20552 or 20553.Utilization ParametersNo more than 3 TPI sessions in a rolling 12 months will be considered reasonable and necessary, regardless of the code billed.CPT20552 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.MedicationThe 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 RequirementsAll documentation must be maintained in the patient's medical record and made available to the contractor upon request.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.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.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.The patients 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).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 BiologicalsThere 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 AnesthesiaNo anesthesia codes should be billed in conjunction with 20552 or 20553.