Trigger Point Injections Coding: Muscle or Muscle Group

Trigger Point Injections Coding: Muscle or Muscle Group

December 19, 2019

Question:
One of our Providers recently completed Trigger Point injections to Bilateral Thoracic Paraspinals and Bilateral Trapezius in the same setting for a patient. When we bill for this procedure do we count each side (Left and Right) of these procedures as a muscle group to be billed out as 20553 OR each area (Bilateral or unilateral) of these procedures as a muscle group to be billed out as 20552?

Answer:
Trigger points are by muscle(s) injected; 20552 is 1-2 muscles, 20553 is more than 3 or more muscles.  He injected 4 muscles (2 paraspinal and 2 trapezius) so the code billed is 20553. Additionally, these codes are not reported bilaterally with a 50 modifier or with an RT/LT. Report by the number of muscles injected.

*This response is based on the best information available as of 12/19/19.

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