LCD/NCD Portal

L29199 INJECTION OF TRIGGER POINTS

 

 

03/17/2009

 

 

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.

• Injections;

o single or multiple trigger point(s), one or two muscle(s) (20552)

Or

o 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.

o The medical record should clearly reflect all methods attempted and the results.

o 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:

o Medications:

 Non-steroidal anti-inflammatory drugs.

 Muscle relaxants.

 Other medications.

o Physical therapy:

 Massage.

 Heat.

 Ice.

 Stretching.

o Activity modification.

o Home exercise instruction.

• Repeat trigger point injections may be necessary when there is evidence of persistent pain or inflammation.

o Evidence of partial improvements to the range of motion in any muscle area after an injection would justify a repeat injection.

o 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.

o 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.

 

 

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 ENTHESOPATHY OF ELBOW UNSPECIFIED

726.31 MEDIAL EPICONDYLITIS

726.32 LATERAL EPICONDYLITIS

726.33 OLECRANON BURSITIS

726.39 OTHER ENTHESOPATHY OF ELBOW REGION

726.5 ENTHESOPATHY OF HIP REGION

726.70 ENTHESOPATHY OF ANKLE AND TARSUS UNSPECIFIED

726.71 ACHILLES BURSITIS OR TENDINITIS

726.72 TIBIALIS TENDINITIS

726.73 CALCANEAL SPUR

726.79 OTHER ENTHESOPATHY OF ANKLE AND TARSUS

726.90 ENTHESOPATHY OF UNSPECIFIED SITE

727.00 SYNOVITIS AND TENOSYNOVITIS UNSPECIFIED

727.01 SYNOVITIS AND TENOSYNOVITIS IN DISEASES CLASSIFIED ELSEWHERE

727.02 GIANT CELL TUMOR OF TENDON SHEATH

727.03 TRIGGER FINGER (ACQUIRED)

727.04 RADIAL STYLOID TENOSYNOVITIS

727.05 OTHER TENOSYNOVITIS OF HAND AND WRIST

727.06 TENOSYNOVITIS OF FOOT AND ANKLE

727.09 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

 

 

Documentation Requirements

• Medical record documentation must clearly indicate the medical necessity of the service being billed.

o In addition, the documentation must support that the service was performed.

o 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.

o 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.

o Furthermore, the medical record must clearly document the medical necessity for repeated injections of trigger point(s).

o When frequent injections are required, the medical record must reflect the reason for repeated injections.

Utilization Guidelines

• The frequency at which trigger point injection(s) are performed is dependent on the clinical presentation of the patient.

o However, it is generally expected that the patient’s response to the previous injection is important in deciding whether to proceed with additional injections.

o 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:

o Pain.

o Muscle tenderness.

o 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.

o 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.

o When services are performed in excess of established parameters, they may be subject to review for medical necessity.

Treatment Logic

• 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.

o Findings may include pain on motion or palpation, swelling, friction rubs and/or catches.

 

 

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.

 

FCSO LCD 29199, Injection of Trigger Points, 03/17/2009. The official local coverage determination (LCD) is the version on the Medicare coverage database at www.cms.gov/medicare-coverage-database/.

 

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.

 

 

AMA CPT / ADA CDT Copyright Statement

CPT codes, descriptions and other data only are copyright 2012 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply.

 

 

CMS LCD INJECTION OF TRIGGER POINTS