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CPT code for Trigger point injection periscapular area

Bonnie Posted Sun 15th of September, 2013 17:19:41 PM

Hi:
How would you code trigger point injection x6 (thoracolumbar region- three on left, three on right) around the periscapular area in fanlike distribution. How would you determine how many muscles were injected based on this documentation?
Thanks so much

SuperCoder Answered Mon 16th of September, 2013 20:16:33 PM

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. Bilateral muscles that have separate origin and insertion sites typically are considered to be separate muscles. For example, trigger point injections into separate and distinct bilateral muscles would be considered to be two muscles for coding purposes.

Bonnie Posted Mon 16th of September, 2013 20:41:26 PM

Thank you- so then would you code it to the lower level code 20552 since the number of muscles are undetermined?

SuperCoder Answered Mon 16th of September, 2013 20:55:59 PM

No. I would go with 20553 here. We do have the documentation of (thoracolumbar region- three on left, three on right)

Compare it with above "Bilateral muscles that have separate origin and insertion sites typically are considered to be separate muscles."

Total 6 muscles leads to 20553

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