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.)
- 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.
- 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.
|
|
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.
Coverage Indications, Limitations, and/or Medical Necessity
Myofascial trigger points are self-sustaining hyper-irritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic overload. These trigger points produce a referred pain pattern characteristic for that individual muscle. Each pattern becomes part of a single muscle myofascial pain syndrome (MPS); each of these single muscle syndromes is responsive to appropriate treatment. To successfully treat chronic myofascial pain syndrome, each single muscle syndrome needs to be identified along with every perpetuating factor.
There is no laboratory or imaging test for establishing the diagnosis of trigger points; it depends therefore, upon the detailed history and thorough directed examination. The following clinical features are present most consistently and are helpful in making the diagnosis:
history of onset and its cause (injury, sprain, etc.);
distribution of pain;
restriction of movement;
mild muscle specific weakness;
focal tenderness of a trigger point;
palpable taut band of muscle in which trigger point is located;
local taut response to snapping palpitation; and
reproduction of referred pain pattern upon most sustained mechanical stimulation of the trigger point.
The goal is to identify and treat the cause of the pain and not just the symptom of pain.
After making the diagnosis of myofascial pain syndrome and identifying the trigger point responsible for it, the treatment options are:
medical management, including the use of anti-inflammatory agents, tricyclics, etc.;
stretch and use of coolant spray followed by hot packs and/or aerobic exercises;
application of low intensity ultrasound directed at the trigger point (this approach is used when the trigger point is otherwise inaccessible);
deep muscle massage;
injection of local anesthetic into the muscle trigger points:
as the 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 fully, as is the case of the lateral pterygoid muscle;
as treatment of trigger points that are unresponsive to non-invasive methods of treatment, e.g., use of medications, stretch and spray.
NOTE: For all conditions, the actual area must be reported specifically and must be documented in the medical record. Using a non-specific diagnosis code to support injections of multiple areas of the body, rather than more specific diagnosis codes, may result in denial of payment.
Known trigger points may be treated at frequencies necessitated by the nature and the severity of associated symptoms and signs.
Per national Medicare regulations acupuncture is not a covered service, even if provided for treatment of established trigger point:
Use of acupuncture needles and/or the passage of electrical current through these needles is not a covered service whether the service is rendered by an acupuncturist or any other provider;
providers of acupuncture services should inform the beneficiary that such services will not be covered; and
prolotherapy is not covered by Medicare and cannot be billed under the trigger point injection code.
If the service has been provided for a diagnosis that is not listed in the covered diagnosis codes section, the provider must thoroughly document the medical necessity and rationale for providing the service for the unlisted diagnosis in the patient’s medical records and this must be provided at the review level for consideration.
The diagnosis codes listed as covered should only be used for purposes of this policy when a trigger point is injected.
Documentation must be maintained noting the anatomic location of the injection site(s).
Botulinum Toxin Injection
• headaches, except as noted above for prevention (treatment) of chronic migraine headache
• chronic low back pain
• joint pain
• mechanical neck disorders
• neuropathic pain after neck dissection
• myofascial pain syndrome
• temperomandibular joint disorders
• trigeminal neuralgia
• pain after hemorrhoidectomy or lumpectomy
• tremors such as benign essential tremor (upper extremity)
• tinnitus
• sialorrhea (drooling) except that associated with Parkinson disease
• chronic motor tic disorder, and tics associated with Tourette syndrome (motor tics)
• lateral epicondylitis
• benign prostatic hyperplasia
• interstitial cystitis
• detrusor sphincteric dyssynergia (after spinal cord injury)
• piriformis
• prevention of pain associated with breast reconstruction after mastectomy
• Hirschsprung’s disease
• gastroparesis
• facial wound healing
• internal anal sphincter (IAS) achalasia
• depression
The use of botulinum toxin is not medically necessary as a treatment of wrinkles or other cosmetic indications.
The use of assays to detect antibodies to botulinum toxin is considered investigational.
Piriformis Syndrome
Piriformis myofascial pain is a potential cause of buttock and posterior leg pain which typically presents as an aching sensation over the infero-lateral gluteal region [37]. In addition, a tight piriformis muscle may cause nerve entrapment due to the anatomic association of the muscle and the sciatic nerve [37]. The piriformis muscle originates on the anterior wall of the sacrum, travels through the greater sciatic foramen and inserts on the greater trochanter of the femur [38]. The primary action of this muscle is external rotation of the femur. A constellation of symptoms consisting of buttock pain, with or without posterior thigh pain, is typically made worse with prolonged sitting [38]. When this occurs, the piriformis can become tight and focal point tenderness will reproduce these symptoms. Injection of anesthetic with or without steroid can provide a safe and effective way to offer both diagnostic and therapeutic intervention.
If using only local anesthetic, 1cc of either 1% lidocaine or 0.25% bupivacaine can provide diagnostic utility. When injecting a steroid mixture, the authors suggest 1cc of local anesthetic (1% lidocaine or 0.25% bupivacaine) with 1 cc of corticosteroid (betamethasone (6mg/ ml) or triamcinolone (40mg/ml)). Some recent data has advocated the use of botulinum toxin (onabotulinumtoxin A) in patients with diagnosed piriformis syndrome. In 2007, Yoon et al. [39] injected 20 patients with 50 units of botulinum toxin (onabotulinumtoxin A) using CT guidance. This group was compared to nine control patients receiving corticosteroid. Pain intensity scores were significantly lower in the botulinum group at all follow-up time-points.
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
|
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
|
|
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
|
