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Anesthesia Coding Alert

Reader Questions:

20552, 20553: Base TPI Code on Muscles

Question: My understanding is that the paraspinal muscle is a group of individual muscles that combine and run along the spine. Our provider administered bilateral trigger point injections in the cervical paraspinal area. From a coding perspective, should I consider these two injections into two separate muscles?Answer: Coding for trigger point injections is based on the total number of individual muscles. Injections of trigger points into one or two muscles would be billed with 20552 (Injection[s]; single or multiple trigger point[s], 1 or 2 muscle[s]) whereas trigger point injections into three or more muscles would be reported with 20553 (Injection[s]; single or multiple trigger point[s], 3 or more muscle[s]). Compliant documentation for trigger point injections would include the specific muscles injected rather than use of a broad term such as paraspinal.Anatomy: The deep muscles (sometimes referred to collectively as paraspinal muscles) form a thick mass on each side of the [...]

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