Trigger point injection CPT code list - 20552, 20553

Procedure Code Description

10022 Fine needle aspiration; with imaging guidance

20552 Injection(s); single or multiple trigger point(s), one or two muscle(s) - average fee payment - $50 - $60

20553 Injection(s); single or multiple trigger point(s), three or more muscle(s) - average fee payment - $50 - $60

20600 Arthrocentesis, aspiration and/or injection; small joint or bursa (eg, fingers, toes)

20605 Arthrocentesis, aspiration and/or injection; intermediate joint or bursa (eg, temporomandibular, acromicoclavicular, wrist, elbow or ankle, olecranon bursa)


20610 Arthrocentesis, aspiration and/or injection; major joint or bursa (eg, shoulder, hip, knee joint, subacromial bursa)

Trigger Point Injections (CPT codes 20552 and 20553)

* Medicare does not have a National Coverage Determination (NCD) for trigger point injections.

* Local Coverage Determinations (LCDs) which address these injections exist and compliance with these LCDs is required where applicable. For state-specific LCD, refer to the LCD Availability Grid (Attachment E).

* For states with no LCDs, see the Wisconsin Physicians Services LCD for Trigger Points, Local Injections LCD (L34588) for coverage guidelines. (IMPORTANT NOTE: After searching the Medicare Coverage Database, if no state LCD or Local Article is found, then use the above referenced policy.)

Patient controlled analgesia – The postoperative insertion of an intravenous catheter and preprogramming of a patient-activated delivery system to control the first several days of postoperative pain.
Epidural anesthesia – The insertion of a catheter allowing access to the epidural space for the purpose of injecting anesthetic or narcotic medication.

Trigger point injections

  • Trigger point injection refers to the injection of local anesthetics or anti-inflammatory medications into myofascial trigger points. Trigger points are self-sustaining irritative foci that occur in skeletal muscle in response to strain, as well as mechanical overload phenomena. These trigger points produce a referred pain pattern characteristic for the individual involved muscle.
  • Trigger point injections are an integral part of comprehensive pain management, and may be used concurrently in support of other conservative modalities. Conservative therapy may include analgesics, passive physical therapy, ultrasound, range of motion, chiropractic intervention (within the defined limits of the Medicare benefit) and active exercises. Additionally, trigger point injections may be indicated when joint movement is mechanically limited, as in the case of the coccygeus muscle. The diagnosis of trigger points requires a detailed history and thorough physical examination.
  • The following clinical features are consistently present and are helpful in making the diagnosis:
    • History of onset of the painful condition and its presumed cause (e.g., injury or sprain).
    • Distribution pattern of pain consistent with the referral pattern of trigger points.
    • Range of motion restriction.
    • Muscular deconditioning in the affected area.
    • Focal tenderness of a trigger point.
    • Palpable taut band of muscle in which trigger point is located.
    • Local taut response to snapping palpation.
    • Reproduction of referred pain pattern upon stimulation of trigger point.
  • The goal is to treat the cause of pain, not just the symptoms. With this intent, it is expected that trigger point injections may be performed as frequently as a monthly interval from the time of onset of illness or injury for the first three sets of injections of a treatment course, and as frequently as every two months thereafter for an additional three sets of injections. At that point, the patient should be re-evaluated regarding the etiology of the complaint, and the available treatment options reconsidered. Medicare will consider payment for additional trigger point injections upon review.
Nerve blocks– Nerve blocks are temporary interruptions of conduction in peripheral nerves or nerve trunks created by the injection of local anesthetic solutions. Somatic and sympathetic nerves may be injected. In the diagnostic mode, this procedure can help differentiate a nerve that is a pathway for the conduction of pain impulses, to determine the type of nerve conducting the pain, to distinguish between central and peripheral origins of pain, and to evaluate the potential benefit of other neurolytic procedures or surgical lysis of a nerve. In a therapeutic mode, the procedure may be used for the treatment of painful conditions that respond to this modality (i.e., celiac block for the treatment of pain related to GI neoplasms), or to prevent pain following procedures.

Limitations
Endoscopic lysis of adhesions by use of an epiduroscope is a relatively new technique in the treatment of back pain. Approved by the Food and Drug Administration (FDA) in 1996 and marketed by several centers, there is insufficient evidence in peer-reviewed medical literature to support its use at this time.
Pain examination under anesthesia a two-step procedure to reproduce pain before and after the administration of IV Pentothal, is considered non-covered as it has not been shown to be safe or effective at present. Medicare will consider re-review at a later time if additional peer-reviewed literature is presented.
Pharmacologic challenges for sympathetically maintained pain using IV medications such as lidocaine, phentolamine, carbamazepine or imipramine are considered to be investigational and currently not supported by peer-reviewed literature.
Notice: This LCD imposes diagnosis limitations that support diagnosis to procedure code automated denials. However, services performed for any given diagnosis must meet all of the indications and limitations stated in this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.
Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is:
  • Safe and effective.
  • Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000, which meet the requirements of the clinical trials NCD are considered reasonable and necessary).
  • Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:
    • Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient’s condition or to improve the function of a malformed body member.
    • Furnished in a setting appropriate to the patient’s medical needs and condition.
    • Ordered and furnished by qualified personnel.
    • One that meets, but does not exceed, the patient’s medical need.
    • At least as beneficial as an existing and available medically appropriate alternative.

Revenue Codes
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

CPT/HCPCS Codes
Note:
Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book. The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) require the use of short CPT descriptors in policies published on the Web.
20552©
Inject trigger point, 1 or 2
20553©
Inject trigger points, =/> 3
62263©
Epidural lysis mult sessions
62264©
Epidural lysis on single day
62280©
Treat spinal cord lesion
62281©
Treat spinal cord lesion
62282©
Treat spinal cord lesion
62310©
Inject spine c/t
62311©
Inject spine l/s (cd)
62318©
Inject spine w/cath, c/t
62319©
Inject spine w/cath l/s (cd)
64400©
N block inj, trigeminal
64402©
N block inj, facial
64405©
N block inj, occipital
64408©
N block inj, vagus
64410©
N block inj, phrenic
64412©
N block inj, spinal accessor
64413©
N block inj, cervical plexus
64415©
N block inj, brachial plexus
64417©
N block inj, axillary
64418©
N block inj, suprascapular
64420©
N block inj, intercost, sng
64421©
N block inj, intercost, mlt
64425©
N block inj, ilio-ing/hypogi
64430©
N block inj, pudendal
64435©
N block inj, paracervical
64445©
N block inj, sciatic, sng
64450©
N block, other peripheral
64483©
Inj foramen epidural
64484©
Inj foramen epidural add-on
64505©
N block, spenopalatine gangl
64508©
N block, carotid sinus s/p
64510©
N block, stellate ganglion
64520©
N block, lumbar/thoracic
64530©
N block inj, celiac pelus
64622©
Destr paravertebrl nerve l/s
64623©
Destr paravertebral n add-on
64626©
Destr paravertebrl nerve c/t
64627©
Destr paravertebral n add-on
77003©
Fluoroguide for spine inject
Billing and Coding Guideliens


Trigger Point Injections  Policy

Trigger Point Injections are used to treat painful areas of muscle that contain trigger points, or knots of muscle that form when muscles do not relax. Trigger points may irritate the nerves around them and cause pain at the site of the
trigger point or the pain can be felt in other parts of the body, including the back and neck. Trigger point injections involve injection of local anesthetic, saline, dextrose, and/or cortisone into the trigger point.

Harvard Pilgrim reimburses contracted providers for trigger point injections when medically necessary and appropriate. Harvard Pilgrim Health Care payment policy is consistent with CMS LCD Trigger Point Injection policy, American Academy of Craniofacial Pain, Agency for Healthcare Research and Quality (AHRQ) guidelines.



Prerequisite(s)

Applicable Harvard Pilgrim referral, notification and authorization policies and procedures apply. Refer to Referral, Notification and Authorization for more information.


Connecticut Open Access HMO For the Connecticut Open Access HMO product, no referral is required to see a contracted specialist.


Harvard Pilgrim Reimburses

HMO/POS/PPO

Trigger point injections when billed with the CPT and ICD codes listed under the “Provider Billing Guidelines and  documentation”

section of this policy. Covered indications may include, but are not limited to:

• Central pain syndrome

• Other acute pain

• Other chronic pain

• Cervicalgia

• Other disorders of the back

• Rheumatism excluding the back

• Myalgia and myositis, unspecified



Harvard Pilgrim Does Not Reimburse

Trigger point injections when billed with an ICD code not listed below under the “Provider Billing Guidelines and  documentation” section of this policy.



Member Cost-Sharing


Services subject to applicable member out-of-pocket cost (e.g., co-payment, coinsurance, deductible).


Example # :

27506 = Open treatment of femoral shaft fracture, with or without external fixation, with insertion of intramedullary implant, with or without cerclage and/or locking screws Modifiers LT or RT would be valid for 27506 because there is a Right femur and a Left femur. 





20552 = Injection(s); single or multiple trigger point(s), one or two muscle(s) Modifiers LT or RT are not valid for 20552 because trigger points and muscles exist throughout the body, not in only two paied locations.


Current Policy Statement

Health Net, Inc. considers Trigger Point Injections (TPIs) of local anesthetics, alone or in combination with corticosteroids, medically necessary when any of the following is met:

1. For treatment of myofascial pain syndrome when all of the following are met:

? The patient’s medical record must contain documentation that fully supports the medical necessity for trigger point injections. Documentation must also support the frequency and the medical necessity of this procedure, as opposed to alternate forms of therapy; and ? Patient has local pain symptoms that have persisted for more than 3 months causing tenderness and/or weakness, restricting motion and/or causing referred pain when compressed; and

? A taut band is palpable in an accessible muscle with exquisite tenderness at one point along its length; and

? Patient has been refractory or intolerant of conservative therapies such as bed rest, active exercises, ultrasound, range of motion, heating or cooling modalities, massage, and pharmacotherapies (e.g. NSAIDS), muscle relaxants, non-narcotic analgesics, and anti-depressants for a period of at least 1 month; and

? The TPIs are being given as part of an overall management (usually short term) plan including other modalities of therapy (e.g., physical therapy, occupational therapy).




2. As initial or the only therapy when a joint movement is mechanically blocked as is the case of coccygeus muscle or when a muscle cannot be stretched as fully as is the case of the lateral pterygoid muscle.  


ICD-10 Codes that Support Medical Necessity
    
    For Injections; single or multiple trigger point(s), one or two muscle(s) (20552) single or multiple trigger point(s), three or more muscle(s) (20553), use the following ICD-10 codes:
    
    D48.1 Neoplasm of uncertain behavior of connective and other soft tissue
    M25.721 Osteophyte, right elbow
    M25.722 Osteophyte, left elbow
    M25.729 Osteophyte, unspecified elbow
    M25.751 Osteophyte, right hip
    M25.752 Osteophyte, left hip
    M25.759 Osteophyte, unspecified hip
    M25.771 Osteophyte, right ankle
    M25.772 Osteophyte, left ankle
    M25.773 Osteophyte, unspecified ankle
    M25.774 Osteophyte, right foot
    M25.775 Osteophyte, left foot
    M25.776 Osteophyte, unspecified foot
    M35.4 Diffuse (eosinophilic) fasciitis
    M46.00 Spinal enthesopathy, site unspecified
    M46.01 Spinal enthesopathy, occipito-atlanto-axial region
    M46.02 Spinal enthesopathy, cervical region
    M46.03 Spinal enthesopathy, cervicothoracic region
    M46.04 Spinal enthesopathy, thoracic region
    M46.05 Spinal enthesopathy, thoracolumbar region
    M46.06 Spinal enthesopathy, lumbar region
    M46.07 Spinal enthesopathy, lumbosacral region
    M46.08 Spinal enthesopathy, sacral and sacrococcygeal region
    M46.09 Spinal enthesopathy, multiple sites in spine
    M53.82 Other specified dorsopathies, cervical region
    M54.03 Panniculitis affecting regions of neck and back, cervicothoracic region
    M54.04 Panniculitis affecting regions of neck and back, thoracic region
    M54.05 Panniculitis affecting regions of neck and back, thoracolumbar region
    M54.06 Panniculitis affecting regions of neck and back, lumbar region
    M54.07 Panniculitis affecting regions of neck and back, lumbosacral region
    M54.08 Panniculitis affecting regions of neck and back, sacral and sacrococcygeal region
    M54.09 Panniculitis affecting regions, neck and back, multiple sites in spine
    M54.89 Other dorsalgia
    M54.9 Dorsalgia, unspecified
    M60.10 Interstitial myositis of unspecified site
    M60.111 Interstitial myositis, right shoulder
    M60.112 Interstitial myositis, left shoulder
    M60.119 Interstitial myositis, unspecified shoulder
    M60.121 Interstitial myositis, right upper arm
    M60.122 Interstitial myositis, left upper arm
    M60.129 Interstitial myositis, unspecified upper arm
    M60.131 Interstitial myositis, right forearm
    M60.132 Interstitial myositis, left forearm
    M60.139 Interstitial myositis, unspecified forearm
    M60.141 Interstitial myositis, right hand
    M60.142 Interstitial myositis, left hand
    M60.149 Interstitial myositis, unspecified hand
    M60.151 Interstitial myositis, right thigh
    M60.152 Interstitial myositis, left thigh
    M60.159 Interstitial myositis, unspecified thigh
    M60.161 Interstitial myositis, right lower leg
    M60.162 Interstitial myositis, left lower leg
    M60.169 Interstitial myositis, unspecified lower leg
    M60.171 Interstitial myositis, right ankle and foot
    M60.172 Interstitial myositis, left ankle and foot
    M60.179 Interstitial myositis, unspecified ankle and foot
    M60.18 Interstitial myositis, other site
    M60.19 Interstitial myositis, multiple sites
    M60.80 Other myositis, unspecified site
    M60.811 Other myositis, right shoulder
    M60.812 Other myositis, left shoulder
    M60.819 Other myositis, unspecified shoulder
    M60.821 Other myositis, right upper arm
    M60.822 Other myositis, left upper arm
    M60.829 Other myositis, unspecified upper arm
    M60.831 Other myositis, right forearm
    M60.832 Other myositis, left forearm
    M60.839 Other myositis, unspecified forearm
    M60.841 Other myositis, right hand
    M60.842 Other myositis, left hand
    M60.849 Other myositis, unspecified hand
    M60.851 Other myositis, right thigh
    M60.852 Other myositis, left thigh
    M60.859 Other myositis, unspecified thigh
    M60.861 Other myositis, right lower leg
    M60.862 Other myositis, left lower leg
    M60.869 Other myositis, unspecified lower leg
    M60.871 Other myositis, right ankle and foot
    M60.872 Other myositis, left ankle and foot
    M60.879 Other myositis, unspecified ankle and foot
    M60.88 Other myositis, other site
    M60.89 Other myositis, multiple sites
    M60.9 Myositis, unspecified
    M62.20 Nontraumatic ischemic infarction of muscle, unspecified site
    M62.211 Nontraumatic ischemic infarction of muscle, right shoulder
    M62.212 Nontraumatic ischemic infarction of muscle, left shoulder
    M62.219 Nontraumatic ischemic infarction of muscle, unspecified shoulder
    M62.221 Nontraumatic ischemic infarction of muscle, right upper arm
    M62.222 Nontraumatic ischemic infarction of muscle, left upper arm
    M62.229 Nontraumatic ischemic infarction of muscle, unspecified upper arm
    M62.231 Nontraumatic ischemic infarction of muscle, right forearm
    M62.232 Nontraumatic ischemic infarction of muscle, left forearm
    M62.239 Nontraumatic ischemic infarction of muscle, unspecified forearm
    M62.241 Nontraumatic ischemic infarction of muscle, right hand
    M62.242 Nontraumatic ischemic infarction of muscle, left hand
    M62.249 Nontraumatic ischemic infarction of muscle, unspecified hand
    M62.251 Nontraumatic ischemic infarction of muscle, right thigh
    M62.252 Nontraumatic ischemic infarction of muscle, left thigh
    M62.259 Nontraumatic ischemic infarction of muscle, unspecified thigh
    M62.261 Nontraumatic ischemic infarction of muscle, right lower leg
    M62.262 Nontraumatic ischemic infarction of muscle, left lower leg
    M62.269 Nontraumatic ischemic infarction of muscle, unspecified lower leg
    M62.271 Nontraumatic ischemic infarction of muscle, right ankle and foot
    M62.272 Nontraumatic ischemic infarction of muscle, left ankle and foot
    M62.279 Nontraumatic ischemic infarction of muscle, unspecified ankle and foot
    M62.28 Nontraumatic ischemic infarction of muscle, other site
    M62.40 Contracture of muscle, unspecified site
    M62.411 Contracture of muscle, right shoulder
    M62.412 Contracture of muscle, left shoulder
    M62.419 Contracture of muscle, unspecified shoulder
    M62.421 Contracture of muscle, right upper arm
    M62.422 Contracture of muscle, left upper arm
    M62.429 Contracture of muscle, unspecified upper arm

    M62.431 Contracture of muscle, right forearm
Many more ..


ICD-9-CM Codes that Support Medical Necessity
The CPT/HCPCS codes included in this LCD will be subjected to “procedure to diagnosis” editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary.
Medicare is establishing the following limited coverage for CPT/HCPCS codes 20552 and 20553 (trigger point injections):
Covered for:
720.1
Ankylosing spondylitis and other inflammatory spondylopathies, spinal enthesopathy
Note: Spinal enthesopathy Serratus anterior and posterior, quadratus lumborum, longissimus thoracis, lower thoracic iliocostalis, rectus abdominalis, upper lumbar iliocostalis, multifidus, external oblique, McBurney’s Point
723.9
Unspecified musculoskeletal disorders and symptoms referable to the neck
Note: Unspecified musculoskeletal disorders and symptoms referable to the neck –Trapezius, sternocleidomastoid, masseter, temporalis, lateral pterygoid, splenii, posterior cervical, suboccipital
726.19
Peripheral enthesopathies and allied syndromes, other specified disorders (shoulder)
Note: Peripheral enthesopathies and allied syndromes, other specified disorders (shoulder) – Scaleni subscapularis, levator scapulae-brachialis, deltoid, middle finger extensor, infraspinatus/supraspinatus, first dorsal interosseous, pectoralis major and minor
726.32
Peripheral enthesopathies and allied syndromes, lateral epicondylitis
726.39
Peripheral enthesopathies and allied syndromes, other enthesopathy of elbow region
Note: Other enthesopathy of elbow region - Biceps, triceps, extensor carpi radialis, middle finger flexor
726.5
Peripheral enthesopathies and allied syndromes, enthesopathy of hip region
Note: Enthesopathy of hip region – Glutei, piriformis, adductor longus, brevis
726.71
Peripheral enthesopathies and allied syndromes, Achilles bursitis or tendonitis
Note: Achilles bursitis or tendonitis – Soleus, gastrocnemius
726.72
Peripheral enthesopathies and allied syndromes, tibialis tendonitis
Note: Tibialis tendonitis – Tibialis anterior
726.79
Peripheral enthesopathies and allied syndromes, other enthesopathy of ankle and tarsus
Note: Other enthesopathy of ankle and tarsus – Peroneus longus and brevis, extensor digitorum, hallucis longus, third dorsal interosseous
726.90
Peripheral enthesopathies and allied syndromes, enthesopathy of unspecified site
Note: Enthesopathy of unspecified site – Rectus femoris, vastus intermedius, vastus medialis, vastus lateralis (anterior, posterior), biceps femoral
729.0–729.1
Other disorders of soft tissue
729.4
Fasciitis unspecified
Medicare is establishing the following limited coverage for CPT/HCPCS codes 64622, 64623, 64626 and 64627.
Covered for:
721.0–721.3
Spondylosis and allied disorders
721.41–721.42
Thoracic or lumbar spondylosis with myelopathy
721.90–721.91
Spondylosis of unspecified site
722.4
Degeneration of cervical intervertebral disc
722.51–722.52
Degeneration of thoracic or lumbar intervertebral disc
722.6
Degeneration of intervertebral disc, site unspecified
722.70–722.73
Intervertebral disc disorder with myelopathy
722.81–722.83
Postlaminectomy syndrome
733.13
Pathological fracture of vertebrae
738.4
Acquired spondylolisthesis
Note: Medicare is only establishing limited coverage for CPT codes 20552, 20553, 64622, 64623, 64626 and 64627 as listed above. All other CPT codes included in this policy will not be subject to limited coverage at this time because there are numerous reasonable and necessary conditions that warrant their application. An appropriate ICD-9-CM code must be submitted with each claim, coded to the highest level of specificity for that date of service.
Note: For coverage related to facet joint injections (CPT Codes 64490, 64491, 64492, 64493, 64494 and 64495) see LCD “Facet Joint Injections 4S-158AB”.
Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims.

Diagnoses that DO NOT Support Medical Necessity
All diagnoses not listed in the “ICD-9-CM Codes that Support Medical Necessity” section of this LCD.
Documentation Requirements
Documentation supporting medical necessity should be legible, maintained in the patient’s medical record and made available to Medicare upon request.
When using code 729.1 with CPT codes 20552 and 20553 for trigger point injection, medical documentation must be clearly maintained noting the anatomic location of the injection site(s).
Appendices
N/A
Utilization Guidelines
Medicare would not expect to see trigger point injections (codes 20552 and 20553) performed beyond eight months after the initiation of treatment without a documented re-evaluation of the patients’ complaint, and without consideration of alternative treatment modalities.
Notice: This LCD imposes utilization guideline limitations. Despite Medicare’s allowing up to these maximums, each patient’s condition and response to treatment must medically warrant the number of services reported for payment. Medicare requires the medical necessity for each service reported to be clearly demonstrated in the patient’s medical record. Medicare expects that patients will not routinely require the maximum allowable number of services.
Sources of Information and Basis for Decision
J4 (CO, NM, OK, TX) MAC Consolidation
TrailBlazer adopted, with inclusion of diagnosis and CPT codes, the TrailBlazer LCD, “Pain Management,” for theJurisdiction 4 (J4) MAC transition.
Full disclosure of the sources of information is found with original contractor LCD.


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