L29199-LCD

LCD/NCD Portal

Automated World Health

Local Coverage Determination (LCD) for Injection of Trigger Points (L29199)

Contractor Information

Contractor Name

First Coast Service Options, Inc.

Contractor Number 09102

Contractor Type MAC - Part B

LCD Information

Document Information

LCD ID Number L29199

LCD Title Injection of Trigger Points

Contractor's Determination Number 20552

Primary Geographic Jurisdiction Florida

Oversight Region Region IV

AMA CPT/ADA CDT Copyright Statement

CPT only copyright 2002-2011 American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright © American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association.

Original Determination Effective Date

For services performed on or after 02/02/2009

Original Determination Ending Date

Revision Effective Date

For services performed on or after 03/17/2009

Revision Ending Date

CMS National Coverage Policy N/A

Indications and Limitations of Coverage and/or Medical Necessity

Injection of a tendon sheath, ligament or trigger point consists of an anesthetic agent and/or steroid agent injected into an area for the management of pain. This Local Coverage Determination only addresses the injection of trigger points.

Trigger points are areas of taut muscle bands or palpable knots of the muscle, that are painful on compression and can produce referred pain, referred tenderness, and/or motor dysfunction. A trigger point may occur in any skeletal muscle/fascia in response to strain produced by acute or chronic overload. Pain from trigger points can be mild to severe. When trigger point pain is severe and unresponsive to non-invasive treatments (e.g., anti- inflammatory medications, physical therapy, etc.), trigger point injections with local anesthetic and/or a steroid agent may be helpful.

Besides injection into trigger points, local injections are useful in the treatment of pain or dysfunction due to inflammation or other pathological changes of tendon sheaths, and ligaments. Findings may include pain on motion or palpation, swelling, friction rubs and/or catches.

Injections; single or multiple trigger point(s), one or two muscle(s) (20552) or single or multiple trigger point(s), three or more muscle(s) (20553)

Medicare will consider the injection of trigger point(s) to be medically reasonable and necessary for the treatment of trigger points that are unresponsive to non-invasive treatments or when non-invasive methods of treatment are contraindicated. The medical record should clearly reflect all methods attempted and the results. If treatments are contraindicated, the medical record should indicate why the trigger point(s) is not amenable to other therapeutic modalities.

Non-invasive treatments may include, but are not limited to:

• Medications (non-steroidal anti-inflammatory drugs, muscle relaxants, etc.)

• Physical therapy (massage, heat or ice, stretching, etc.)

• Activity modification

• Home exercise instruction

Repeat trigger point injections may be necessary when there is evidence of persistent pain or inflammation. Evidence of partial improvements to the range of motion in any muscle area after an injection would justify a repeat injection. Again, the medical record should clearly reflect the medical necessity for repeated injections.

It is not recommended that trigger point injections be used on a routine basis for patients with chronic non- malignant pain syndromes. In addition, several studies indicated that when additional injections are required in a series, other therapies (e.g., medications, physical therapy) in addition to the injections may be beneficial.

Coding Information

Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

99999 Not Applicable

CPT/HCPCS Codes

20552 INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)

20553 INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 3 OR MORE MUSCLE(S)

ICD-9 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-9 codes:

720.1 SPINAL ENTHESOPATHY

723.9 UNSPECIFIED MUSCULOSKELETAL DISORDERS AND SYMPTOMS REFERABLE TO NECK

724.5 BACKACHE UNSPECIFIED

724.8 OTHER SYMPTOMS REFERABLE TO BACK

726.19 OTHER SPECIFIED DISORDERS OF BURSAE AND TENDONS IN SHOULDER REGION

726.30 - 726.39 ENTHESOPATHY OF ELBOW UNSPECIFIED - OTHER ENTHESOPATHY OF ELBOW REGION

726.5 ENTHESOPATHY OF HIP REGION

726.70 - 726.79 ENTHESOPATHY OF ANKLE AND TARSUS UNSPECIFIED - OTHER ENTHESOPATHY OF ANKLE AND TARSUS

726.90 ENTHESOPATHY OF UNSPECIFIED SITE

727.00 - 727.09 SYNOVITIS AND TENOSYNOVITIS UNSPECIFIED - OTHER SYNOVITIS AND TENOSYNOVITIS

728.81 INTERSTITIAL MYOSITIS

728.85 SPASM OF MUSCLE

728.89 OTHER DISORDERS OF MUSCLE LIGAMENT AND FASCIA

729.1 MYALGIA AND MYOSITIS UNSPECIFIED

729.4 FASCIITIS UNSPECIFIED

729.5 PAIN IN LIMB

Diagnoses that Support Medical Necessity N/A

ICD-9 Codes that DO NOT Support Medical Necessity N/A

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation

Diagnoses that DO NOT Support Medical Necessity N/A

General Information

Documentations Requirements

Medical record documentation must clearly indicate the medical necessity of the service being billed. In addition, the documentation must support that the service was performed. This information is normally found in the office/progress notes, hospital records, and test results.

The medical record must clearly indicate the number of injections given per session and the site(s) injected. As stated in the “Indications and Limitations of Coverage” section for trigger point injections, the medical record must clearly indicate all other methods of non-invasive treatments attempted and the results. Furthermore, the medical record must clearly document the medical necessity for repeated injections of trigger point(s). When frequent injections are required, the medical record must reflect the reason for repeated injections.

Appendices

Utilization Guidelines The frequency at which trigger point injection(s) are performed is dependent on the clinical presentation of the patient. However, it is generally expected that the patient’s response to the previous injection is important in deciding whether to proceed with additional injections. If the patient has achieved significant benefit after the first injection, an additional injection would be appropriate for reoccurring symptoms. (Repeated injections may be justified by evidence of improvement, such as reduction in pain, muscle tenderness, spasm; or improvement in the range of motion.)

Multiple trigger points may be injected during any one session (see procedure codes 20552 and 20553). Some trigger points may need to be re-injected weekly or monthly for brief intervals consisting of a few months, depending on the results of the injections and the relief of pain that the injection provides. If therapeutic effect is achieved, medical literature supports that no more than three sets (or sessions) of injections should be performed during one year.

If the patient experiences no symptom relief or functional improvement after two to three injections into a muscle, repeated injections into that muscle are not recommended.

It is expected that these services would be performed as indicated by current medical literature and/or standards of practice. When services are performed in excess of established parameters, they may be subject to review for medical necessity.

Sources of Information and Basis for Decision

American Medical Association (2001). CPT 2002 changes: An insider’s view. Chicago: American Medical Association. This reference further explains procedure codes 20550, 20551, 20552, and 20553.

Alvarez, D.J. & Rockwell, P.G. (2002). Trigger points: Diagnosis and management. American Family Physician. Retrieved July 24, 2002 from the World Wide Web: www.aafp.org. This article supports the clinical presentation, evaluation, and management of trigger points.

Cardone, D.A. & Tallia, A.F. (2002). Joint and soft tissue injection. American Family Physician. Retrieved July 24, 2002 from the World Wide Web: www.aafp.org. This article supports the diagnostic and therapeutic indications for injections.

Ingber, R.S. (2002). Position paper on trigger point injections. New York, NY. Retrieved July 29, 2002 from the World Wide Web: www.drigber.com. This paper provided a definition of trigger points. As well as a good overview of research on trigger points.

National Guideline Clearinghouse. Clinical practice guidelines for chronic non-malignant pain syndrome patients II: An evidence-based approach. Journal of Back Musculoskeletal Rehabilitation (1999) Jan 1; 13:47-58 [65 references]. Retrieved July 24, 2002 from the World Wide Web: www.guideline.gov. This article recommended guidelines specific to adjunctive treatment modalities for nerve blocks and trigger point injections.

VanTulder, M.W. & Koes, B.W. (2002). Low back pain American Family Physician. Retrieved July 29, 2002 from the World Wide Web: www.aafp.org. This article supports the current treatments used for low back pain.

Advisory Committee Meeting Notes This Local Coverage Determination (LCD) does not reflect the sole opinion of the contractor or Contractor Medical Director. Although the final decision rests with the contractor, this LCD was

developed in cooperation with advisory groups, which includes representatives from numerous societies.

Start Date of Comment Period

End Date of Comment Period

Start Date of Notice Period 03/01/2009

Revision History Number 1

Revision History Explanation Revision Number:1 Start Date of Comment Period:N/A

Start Date of Notice Period:03/01/2009 Revised Effective Date: 03/17/2009

LCD B2009-046

March 2009 Update

Explanation of Revision: This LCD was revised to remove procedure codes 20550 and 20551. All language related to codes 20550 and 20551 was removed from the “Indications and Limitations of Coverage and/or Medical Necessity”, “ICD-9 Codes that Support Medical Necessity”, and “Documentation Requirements” sections of the LCD. The LCD title was change to “Injection of Trigger Points” and the Contractor’s Determination Number was changed to 20552. The effective date of this revision is based on dates of service.

Revision Number:Original

Start Date of Comment Period:N/A Start Date of Notice Period:12/04/2008 Revised Effective Date:02/02/2009

LCR B2009-044FL LCR B2009-045PR/VI

December 2008 Bulletin

This LCD consolidates and replaces all previous policies and publications on this subject by the carrier predecessors of First Coast Service Options, Inc. (Triple S and FCSO).

For Florida (00590) this LCD (L29199) replaces LCD L5687 as the policy in notice. This document (L29199) is effective on 02/02/2009.

11/21/2010 - For the following CPT/HCPCS codes either the short description and/or the long description was changed. Depending on which description is used in this LCD, there may not be any change in how the code displays in the document:

20552 descriptor was changed in Group 1

20553 descriptor was changed in Group 1

Reason for Change