Refer to the draft Local Coverage Determination (LCD) Trigger Point Injections (TPI) reasonable and necessary requirements and frequency limitations.
The Current Procedural Terminology (CPT) codes included in this article may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Please refer to the NCCI requirements.
Coding Guidance
Providers should refer to the applicable AMA CPT Manual to assist with proper reporting of these services.
Notice: It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.
This policy applies only to trigger point injections and does not apply to dry needling or acupuncture.
Modifier 50- bilateral should not be reported with CPT codes 20552 or 20553.
Utilization Parameters
No more than 3 Trigger point injection sessions in a rolling 12 months will be considered reasonable and necessary, regardless of the code billed.
CPT 20552 limits to 1 or 2 muscles and 20553 is 3 or more muscles. The number of injections into the muscle group are not billed separately. The code includes all injections made into the muscle.
Medication
The drug used for the injection must be on the same claim as the trigger point administration.
The medication used with the injection is reported with a HCPCS Drug code “J-code” or a revenue code.
Unclassified drugs billed with J3490, J3590, J9999 or C9399* must also include name of drug and dosage to Box 19 of the CMS-15000 paper form or electronic equivalent.
*C3999 should only be used for ASC outpatient facility claims.
Documentation Requirements
- All documentation must be maintained in the patient's medical record and made available to the contractor upon request.
- Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.
- The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.
- The procedural report should clearly document the indications and medical necessity for the injections, the name, and units of the injectant used, the location of the TPIs, along with the pre and post percent (%) pain relief achieved immediately post-
- The patient’s medical record should include, but is not limited to:
- The assessment of the patient by the performing provider as it relates to the complaint of the patient for that visit.
- Relevant medical history
- Results of pertinent tests/procedures
- Signed and dated office visit record/operative report (Please note that all services ordered or rendered to Medicare beneficiaries must be signed.)
- Documentation to support the medical necessity of the procedure(s).
- When documenting the TPI procedure, there must be specific information to indicate the location of trigger points treated, the muscles injected, medication injected, amount of medications used, and the post-procedure plan.
Use of Biologicals
There are currently no FDA approved biologicals for use as trigger point injectable agents. The inclusion of biological and/or other non-FDA approved substances in the injectant may result in denial of the entire claim based on Medicare Benefit Policy Manual, Chapter 16, Section 180 Medicare Benefit Policy Manual (cms.gov). Amniotic and placenta derived injectants, and platelet rich plasma and vitamins fall in this category.
Use of Anesthesia
No anesthesia codes should be billed in conjunction with 20552 or 20553.
