Saturday, February 25, 2012

Trigger Point Injections

Coding never ceases to amaze me.  This week I had the opportunity to put this together for a physician that was wanting to do a trigger point injection for an OB patient that was having intense trigger point pain in a surgical scar location... so here's what I came up with. I hope it helps you out, as much as it did me!  Happy Coding...

Are you wondering how to code Trigger Point Injections?
Below I’ve outlined some of the basics for you to follow so that your provider can document appropriately, you can code correctly, and get paid.  

CPT  has designated 2 codes expressly as ‘trigger point’ injection codes.

CPT Code 20552
CPT Definition:  The physician injects a therapeutic agent into a single or multiple trigger points of one or two muscles

CPT Code 20553 
CPT Definition:  The physician injects a therapeutic agent into single or multiple trigger points for three or more muscles

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.

Trigger point Injection must be performed by the provider (not the nurse/MA etc), and Documentation must include:

  • Documentation of the evaluation (E&M code)  and the documentation of the diagnosis of the trigger point for a specific  individual muscle or muscle group needs to be clearly documented in the patients chart.
  • Documentation of the patients’ history of the specific pain, location and intensity of the pain should be noted.
  • If the physician has evaluated and examined palpable knots of muscle or taut muscle bands – this is also helpful to have documented in the patients chart

  • Another helpful notation, is if the patient has a range of motion restriction, referred pain and/or any motor dysfunction.
Once the physician has decided to proceed with the injection, this is what needs to be documented next…

o       The physician/provider need to document the specific muscle(s)  and how many injections in that particular muscle or muscle group they are going to do (such as 3 injection in  the trapezius,  2 injections in the deltoid muscle)

o       Next, the physician/provider  needs to notate the specific drug or therapeutic medication(s)  to be injected into the muscle sites (steroid, anti-inflammatory, anesthetic)

o       Provide a specific diagnosis to support the medical necessity of the injection (i.e.the diagnosis should support a 'pain' type code)

o       Once the physician has performed the injection, there needs to be a notation of the patient’s response to the injection. Such as ‘immediate relief,  redness/swelling at injection site, or a notation of a pain scale such as prior to the injection 8/10 on the pain scale,  post injection, pain is now 4 /10 on the pain scale  etc.)
For the coder: 
Review the documentation for
  1. E&M  Code – (If appropriate, and add 25 mod)
  2. CPT Procedure code for the injection (Code 20552/20553)
  3. HCPCS code for the therapeutic drug itself (such as a steroid, anti-inflammatory or anesthetic)
  4. ICD-9 diagnosis for medical necessity.


  1. can you share the references you used for this article, please?

  2. References used were CPT 4, and documentation guidelines from

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