Trigger point injections are injections of a tendon sheath, ligament, trigger point(s) or ganglion cyst which consists of an anesthetic agent and/or therapeutic agent injected into the area to relax the intense muscles.
In case of TPI’s, one must really indicate more specifically the etiology of the pain. Since Medical Necessity is the main criteria for TPI’s, it is always advisable to keep your documention in a certain way:
- Documentation of any evaluation/process of arriving at the diagnosis of the trigger point for an individual muscle or muscles should be clearly documentated in the patient’s chart.
- History of pain, location and intensity of pain should be noted.
- Palpable knots of muscle or taut muscle bands should be recorded
- Range of motion restriction, production of referred pain and/or any motor dysfunction should be duly noted in patient’s chart.
Once the medical necessity is established, use the appropriate ICD-9 code as your diagnosis. Always keep a record of the muscles you are injecting. Since TPI’s are per session codes and not per injection codes, no modifiers can be used. Select the appropriate code by the no. of muscles injected. For example: If a patient presents with pain in abdominal area and physician injects 6 injections on patient’s Transverse Abdominus and 4 injections on patients Rectus Abdominus, you would report CPT 20552 [Injection(s);single or multiple trigger point(s), 1 or 2 muscle(s)]. Also report the appropriate J code from the HCPCS if any therapeutic drug is used.
When repeat Trigger Point Injections are necessary, the medical record must reflect the reason for repeated injections. Patient’s response to the previous injection is an important factor in deciding any subsequent treatments. Evidence of any improvment to the range of motion in any muscle area after an injection would justify a repeat injection.
When services are performed in excess of establised parameters, they may be subject to a review for medical necessity.