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.

Ten for 10: Top Ten Reasons We Need ICD-10 Now

In light of CMS looking at a possible delay for ICD-10...  AHIMA put this out -  GREAT info!

Ten for 10: Top Ten Reasons We Need ICD-10 Now




1. It Enhances Quality Measures. Without ICD-10 data, serious gaps will remain in the healthcare community’s ability to extract important patient health information needed for physicians and others to measure quality care.



2. Research Capabilities Will Improve Patient Care. Data could be used in a more meaningful way to enable better understanding of complications, better design of clinically robust algorithms, and better tracking of the outcomes of care. Greater detail offers the ability to discover previously-unrecognized relationships or uncover phenomenon such as incipient epidemics early.



3. Significant Progress Has Already Been Made. For several years, hospitals and healthcare systems, health plans, vendors and academic institutions have been preparing in good faith to put systems in place to transition to ICD-10. A delay would cause an unnecessary setback.



4. Education Programs Are Underway. To ready the next generation of HIM professionals, academic institutions have set their curriculum for two-year, four-year, and graduate programs to include ICD-10.



5. Other Healthcare Initiatives Need ICD-10. ICD-10 is the foundation needed to support other national healthcare initiatives such as meaningful use, value-based purchasing, payment reform, quality reporting and accountable care organizations. Electronic health record systems being adopted today are ICD-10 compatible. Without ICD-10, the value of these other efforts is greatly diminished.



6. It Reduces Fraud. With ICD-10, the detail of health procedures will be easier to track, reducing opportunities for unscrupulous practitioners to cheat the system.



7. It Promotes Cost Effectiveness. More accurate information will reduce waste, lead to more accurate reimbursement and help ensure that healthcare dollars are used efficiently.



If ICD-10 Is Delayed:



8. Resources Will Be Lost. For the last three years, the healthcare community has invested millions of dollars analyzing their systems, aligning resources and training staff for the ICD-10 transition.



9. Costs Will Increase. A delay will cause increased implementation costs, as many healthcare providers and health plans will need to maintain two systems (ICD-9 and ICD-10). Delaying ICD-10 increases the cost of keeping personnel trained and prepared for the transition. Other systems, business processes, and operational elements also will need upgrading. More resources will be needed to repeat some implementation activities if ICD-10 is delayed.



10. Jobs Will Be Lost. To prepare for the transition, many hospitals and healthcare providers have hired additional staff whose jobs will be affected if ICD-10 is delayed.



And Finally…



We Can’t Wait for ICD-11. The foundations of ICD-11 rest on ICD-10 and the foundation must be laid before a solid structure can be built. ICD-11 will require the development and integration of a new clinical modification system. Even under ideal circumstances, ICD-11 is still several years away from being ready for implementation in the United States.

Outpatient CDI efforts offer documentation opportunities - justcoding.com

Outpatient CDI efforts offer documentation opportunities - justcoding.com

Great article - something to consider as we try and align our physician office and inpatient billing.... hmmmmmm and I have been informed that CDI wasn't important for physican office billing. Geeeez.... we really need to have the 'suits' re-look at what CDI is and how it really can benefit us all. L :