Trigger point Injections, Coverage Indications, Documentation Requirements, Limitations and Coding TIPS

Trigger point injection is one of many modalities utilized in the management of chronic pain. Myofascial trigger points are self-sustaining hyperirritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic overload. Trigger point injections are indicated in symptomatic trigger points.

Myofascial trigger points are "small, circumscribed, hyperirritable foci in muscles and fascia, often found with a firm or taut band of skeletal muscle. These trigger points produce a referred pain patterned characteristic for that individual muscle. Each pattern becomes a single part of a single muscle syndrome. To successfully treat chronic myofascial pain syndrome (trigger points) each single muscle syndrome needs to be identified along with every perpetuating factor. These single muscle syndromes is responsive to appropriate treatment, which includes injection therapy.

The pain of active trigger points can begin as an acute single muscle syndrome resulting from stress overload or injury to the muscle, or can develop slowly because of chronic or repetitive muscle strain. The pain normally refers distal to the specific hypersensitive trigger point. Trigger point injections are used to alleviate this pain. Injection is achieved with needle insertion and the administration of agents, such as local anesthetics, steroids and/or local inflammatory drugs.

ü  As initial (diagnostic) or the only therapy when a joint movement is impaired, such as when a muscle cannot be stretched fully or is in fixed position and/or when joint movement is mechanically blocked as is the case of the coccygeus muscle.

ü  As treatment of trigger points that are unresponsive to non-invasive methods of treatment, e.g., exercise, use of medications, stretch and spray.

There is no laboratory or imaging test for establishing the diagnosis of trigger points; it depends therefore upon the detailed history and thorough examination. The following diagnostic criteria are needed:

Major criteria. All four must be present to establish the diagnosis.

A.    Regional pain complaint

B.    Pain complaint or altered sensation in the expected distribution of referred pain from a trigger point

C.    Taut band palpable in an accessible muscle with exquisite tenderness at one point along the length of it

D.    D. Some degree of restricted range of motion, when measurable.

Minor criteria. Only one of four needed for the diagnosis.

A.    Reproduction of referred pain pattern by stimulating the trigger point

B.    Altered sensation by pressure on the tender spot

C.    Local response elicited by snapping palpation at the tender spot or by needle insertion into the tender spot

D.    Pain alleviated by stretching or injecting the tender Spot

After making the diagnosis of myofascial pain syndrome and identifying the trigger point responsible for it, the treatment options are:

1.     Medical management, which may include consultation with a specialist in pain medicine.

2.     Medical management that may include the use of analgesics and adjunctive medications, including anti-depressant medications, shown to be effective in the management of chronic pain conditions.

3.     Passive physical therapy modalities, including "stretch and spray" heat and cold therapy, passive range of motion and deep muscle massage.

4.     Active physical therapy, including active range of motion, exercise therapy and physical conditioning. Application of low intensity ultrasound directed at the trigger point (this approach is used when the trigger point is otherwise inaccessible).

5.     Manipulation therapy.

6.     Psychiatric evaluation and therapy.

7.     A trial of oral non-steroid analgesic/anti-inflammatory drugs, if not contraindicated.

8.     Injection of local anesthetic, with or without corticosteroid, into the muscle trigger points.

Trigger point injections accompanied by appropriate adjunctive care should provide moderate-to-long term benefits.

An injection of a trigger point is considered medically necessary when it is currently causing tenderness and/or weakness, restricting motion and/or causing referred pain when compressed.

The goal is to treat the cause of the pain and not just the symptom of pain.

Documentation Requirements

All documentation must be maintained in the patient’s medical record and available 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 record must include the physician or non-physician practitioner responsible for and providing the care of the patient.

The submitted medical record should support the use of the selected ICD-9-CM code(s). The submitted CPT/HCPCS code should describe the service performed.

For the treatment of established trigger points, the patient’s medical record must have:

o    Documentation of the physical findings leading to diagnosis of the trigger point.

o    Documentation of the evaluation/ process of arriving at the diagnosis of the trigger point in an individual muscle should be clearly documented in the patient’s medical record 

o    The reason for the trigger point injection, and whether it is being used as an initial or subsequent treatment for myofascial pain, as well as the appropriate diagnosis code should be documented.

o    The involved muscle group(s) must be documented in the patient’s medical record as well as the number of trigger points injected. A diagram with an "X" or other similar annotation is not adequate documentation.

o    Documentation of the reason(s) for selecting this therapeutic option.

o    Diagnosis codes from the “ICD-9-CM Codes that Support Medical Necessity” must be used to support the specific muscles injected. Generalized diagnoses like low back pain, lumbago, etc. will not be covered.

o    If a patient requires more than four (4) procedures of either CPT codes 20552 or 20553 during one year, a report stating the unusual circumstances and medical necessity for giving the additional injections must be documented in the patient's medical record.

o    The health plan may request records when it is apparent that patients are requiring a significant number of injections to manage their pain.

o    Documentation in the medical record must support the medical necessity and frequency of the trigger point injection(s).

Limitations

Acupuncture is not covered by Medicare, even if provided for the treatment of an established trigger point. Use of acupuncture needles and/or the passage of electrical current through these needles is not covered (whether an acupuncturist or other provider renders the service). See your private health plan policy for coverage.

Providers of acupuncture services must inform the beneficiary that their services will not be covered as acupuncture is not a Medicare benefit.

Medicare does not cover Prolotherapy. Its billing under the trigger point injection code is a misrepresentation of the actual service rendered.

"Dry needling" of trigger points is a non-covered procedure since it is considered unproven and investigational.

Coding Tips

Only one code from 20552 or 20553 should be reported on any particular day, no matter how many sites or regions are injected.

The CPT codes for trigger point injections use the phrase "muscle group(s)" as a group of muscles that are contiguous and that share a common function, e.g., flexion, stabilization or extension of a joint. Trigger points that exist in muscles that are widely separated anatomically and that have different functions may be considered to be in separate muscle groups.

When a given site is injected, it will be considered one injection service, regardless of the number of injections administered.

Source: Centers for Medicare and Medicaid Services Local and National Coverage Determinations