The PT’s Guide to Trigger Point Injection CPT Codes

Myofascial pain can be treated with trigger point injections by pain management professionals such as physicians that work within a physical therapy practice. These are billable via trigger point injection CPT codes 20552 and 20553. 

A patient's range of motion and activity levels may be restricted due to localized muscle knots that cause myofascial pain. We will discuss trigger point injection Current Procedural Terminology (CPT) codes in this article, provide examples of their applications, and define the procedure in detail.

The Significance of Trigger Point Injections

Trigger points can be caused by a variety of factors, including muscle overuse, injury, and stress. These knots can cause local and referred pain. There are two main types of trigger points: active and latent.

Active trigger points can elicit pain at any time without a known cause, or they can elicit pain with movement. Active trigger points can cause pain at the area of the trigger point, or they may refer to pain elsewhere in the body. On the other hand, latent trigger points cause pain only in response to direct compression of the trigger point. 

Patients who have trigger point-induced myofascial pain may benefit from over-the-counter pain medications, anti-inflammatory medications, and massages. However, when a patient fails to respond to these interventions, involvement of a healthcare professional may be necessary.

Myofascial pain can oftentimes be managed effectively with trigger point injections. By injecting a numbing agent, steroid, or other substance into the trigger point(s), inflammation and the potential accompanying muscle knots may subside.

Understanding Trigger Point Injection CPT Codes

When it comes to medical billing and coding, assigning the correct CPT codes for various procedures, such as trigger point injections, is crucial.

Trigger point injection CPT codes include:

• 20552 CPT code: This code is used when one or two muscle groups are injected.
• 20553 CPT code: This code is used when three or more muscle groups are injected.

20552 and 20553 represent a single unit of the service, regardless of how many muscle groups were injected, so you should not use both, depending on the number of muscle groups injected. Additionally, multiple injections at the same site on the same day are coded with just one unit of service.

Examples of proper use of trigger point injection CPT codes:

Scenario #1: 

Four injections in the left gastrocnemius and two injections in the left soleus is one unit coded under 20552, as there are two involved muscle groups.

Scenario #2:

One injection in the right upper trapezius, one injection in the right posterior deltoid, and one injection in the right supraspinatus is one unit coded under 20553, as there are three involved muscle groups.

Modifiers and Units

Modifiers and units play a crucial role in medical coding. When it comes to the CPT code for trigger point injections, some specific rules apply:

Modifiers in Trigger Point Injection Codes

Accurately representing the CPT code for a trigger point injection within a physical therapy or pain management practice requires the correct use of modifiers. 

Trigger point injections are commonly used by trained physicians in addition to physical therapy interventions to relieve muscle tension and improve pain and function. Trigger point injections have CPT codes that include modifiers that provide additional information about the procedure. For example, CPT code 20552 is commonly used.

The following modifiers are the most used when it comes to trigger point injections: 

1. Modifier 25: This is necessary to use when there are other E/M (Evaluation/Management) services the patient receives that day. This modifier is needed when codes that are not typically billed alongside E/M services such as 20552 or 20553, are used, as it distinguishes the injection procedure as an appropriate service. The modifier should be attached to the E/M code, not the trigger point injection code. 
2. Modifier 59: This is used when there are other non-E/M services the patient receives the same day as the trigger point injection(s). It is needed if the non-EM service and the injections are not normally billed simultaneously. According to the Centers for Medicare & Medicaid Services at cms.gov, “Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual.” If there is another, more appropriate modifier, use this instead of modifier 59.

Units in Trigger Point Injection Codes

In the context of trigger point injection CPT codes, the number of muscles injected does not influence the number of billable units. 

For each distinct trigger point injection procedure represented by CPT code 20552 and 20553, the unit would be set to "1" to indicate that one injection was performed. The unit should be set to “1” regardless of how many injections are performed that visit and regardless of how many muscle sites are injected. The number of injection sites only determines whether to bill CPT code 20552 or CPT code 20553, not the number of units. 

Medicare does not consider more than three trigger point injection sessions in a 12-month period to be considered necessary and reasonable, so keep this in mind as well. 

This is essential for proper reimbursement and ensures accurate billing and coding of trigger point injection codes, especially if multiple injections are administered concurrently. Modifiers help specify the uniqueness of trigger point injection CPT codes. These components ensure accurate billing and fair compensation for physical therapy and pain management practices.

Clinical Documentation Improvement (CDI)

Accurate and detailed clinical documentation is essential when performing trigger point injections, as it helps to prevent claim denials. 

Your medical records should include:

• The name of the muscle(s) injected.
• The medication used.
• Needle size.
• The name of the agent (e.g., drug or substance), its strength, and the quantity injected.

Remember that the trigger point injection CPT code selection is primarily based on the number of muscle groups injected and not on the total number of injections given. 

Linking ICD-10-CM Codes to Trigger Point Injections

Assigning the correct International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) code to the procedure is essential. These codes support the medical necessity for trigger point injections. 

One can find the appropriate ICD-10-CM codes for trigger point injections by using resources like findacode.com or cms.gov, which lists Medicare-approved codes that support the procedure's medical necessity. 

Failure to include an approved diagnosis code identified within the medical record may result in claim denials.

Beyond the Codes: Additional Documentation Requirements

Comprehensive documentation is key to successful trigger point injection CPT coding. 

The patient's medical record should contain:

• Relevant medical history.
• A physical examination.
• Results of pertinent diagnostic tests or procedures.
• A detailed procedure note that includes a description of the techniques used, injection sites, drugs and doses with volumes and concentrations, and pre- and post-procedural pain assessments.

When treating established trigger points, the medical record should document:

• The evaluation leading to the diagnosis of the trigger point.
• Identification of the affected muscle(s).
• The reason for selecting trigger point injections as a therapeutic option.

Enhancing Trigger Point Injections with PT Management Software

PT management software is a game-changer for physical therapists and pain management practices offering trigger point injections. 

It simplifies the process in the following ways:

• Efficient Trigger Point Injection CPT Code Documentation: Structured templates ensure all critical details are documented, reducing errors.
• Improved Communication: Seamless interaction with referring physicians for quicker reimbursements.
• Coding Compliance: Accurate CPT and ICD-10-CM code selection prevents claim denials.
• Scheduling and Patient Management: Efficiently manage appointments and patient history, boosting engagement.

Incorporating PT management software streamlines the procedure, saves time, and enhances patient care and practice efficiency when it comes to CPT trigger point injection codes.