Wednesday, August 31, 2016

CPT CODE 20552, 20553 - Trigger point injection

CPT Description

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)

Trigger Point Injections are used to treat painful areas of muscle that contain trigger points, or knots of muscle that form when muscles do not relax. Trigger points may irritate the nerves around them and cause pain at the site of the  trigger point or the pain can be felt in other parts of the body, including the back and neck. Trigger point injections involve injection of local anesthetic, saline, dextrose, and/or cortisone into the trigger point.

Harvard Pilgrim reimburses contracted providers for trigger point injections when medically necessary and appropriate.

Harvard Pilgrim Health Care payment policy is consistent with CMS LCD Trigger Point Injection policy, American Academy of Craniofacial Pain, Agency for Healthcare Research and Quality (AHRQ) guidelines.


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

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

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

Covered for 20552 and 20553:


Applicable Harvard Pilgrim referral, notification and authorization policies and procedures apply. Refer to Referral, Notification and  authorization for more information.

covered indications may include, but are not limited to:

• Central pain syndrome

• Other acute pain

• Other chronic pain

• Cervicalgia

• Other disorders of the back

• Rheumatism excluding the back

• Myalgia and myositis, unspecified

Member Cost-Sharing

Services subject to applicable member out-of-pocket cost (e.g., co-payment, coinsurance, deductible).

Coverage Indications, Limitations, and/or Medical Necessity

Myofascial trigger points are self-sustaining hyper-irritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic overload. These trigger points produce a referred pain pattern characteristic for that individual muscle. Each pattern becomes part of a single muscle myofascial pain syndrome (MPS); each of these single muscle syndromes is responsive to appropriate treatment. To successfully treat chronic myofascial pain syndrome, each single muscle syndrome needs to be identified along with every perpetuating factor.

There is no laboratory or imaging test for establishing the diagnosis of trigger points; it depends therefore, upon the detailed history and thorough directed examination. The following clinical features are present most consistently and are helpful in making the diagnosis:
history of onset and its cause (injury, sprain, etc.);

distribution of pain;

restriction of movement;

mild muscle specific weakness;

focal tenderness of a trigger point;

palpable taut band of muscle in which trigger point is located;

local taut response to snapping palpitation; and

reproduction of referred pain pattern upon most sustained mechanical stimulation of the trigger point.

The goal is to identify and treat the cause of the pain and not just the symptom of pain.
After making the diagnosis of myofascial pain syndrome and identifying the trigger point responsible for it, the treatment options are:
medical management, including the use of anti-inflammatory agents, tricyclics, etc.;

stretch and use of coolant spray followed by hot packs and/or aerobic exercises;

application of low intensity ultrasound directed at the trigger point (this approach is used when the trigger point is otherwise inaccessible);

deep muscle massage;

injection of local anesthetic into the muscle trigger points:
as the initial or the only therapy when a joint movement is mechanically blocked, as is the case of coccygeus muscle, or when a muscle cannot be stretched fully, as is the case of the lateral pterygoid muscle;

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

NOTE: For all conditions, the actual area must be reported specifically and must be documented in the medical record. Using a non-specific diagnosis code to support injections of multiple areas of the body, rather than more specific diagnosis codes, may result in denial of payment.
Known trigger points may be treated at frequencies necessitated by the nature and the severity of associated symptoms and signs.

Per national Medicare regulations acupuncture is not a covered service, even if provided for treatment of established trigger point:
Use of acupuncture needles and/or the passage of electrical current through these needles is not a covered service whether the service is rendered by an acupuncturist or any other provider;

providers of acupuncture services should inform the beneficiary that such services will not be covered; and

prolotherapy is not covered by Medicare and cannot be billed under the trigger point injection code.

If the service has been provided for a diagnosis that is not listed in the covered diagnosis codes section, the provider must thoroughly document the medical necessity and rationale for providing the service for the unlisted diagnosis in the patient's medical records and this must be provided at the review level for consideration.

The diagnosis codes listed as covered should only be used for purposes of this policy when a trigger point is injected.

Documentation must be maintained noting the anatomic location of the injection site(s).

Group 1 Codes


M46.01 Spinal enthesopathy, occipito-atlanto-axial region

M46.02 Spinal enthesopathy, cervical region

M46.03 Spinal enthesopathy, cervicothoracic region

M46.04 Spinal enthesopathy, thoracic region

M46.05 Spinal enthesopathy, thoracolumbar region

M46.06 Spinal enthesopathy, lumbar region

M46.07 Spinal enthesopathy, lumbosacral region

M46.08 Spinal enthesopathy, sacral and sacrococcygeal region

M46.09 Spinal enthesopathy, multiple sites in spine

M53.82 Other specified dorsopathies, cervical region

M60.811 Other myositis, right shoulder

M60.812 Other myositis, left shoulder

M60.821 Other myositis, right upper arm

M60.822 Other myositis, left upper arm

M60.831 Other myositis, right forearm

M60.832 Other myositis, left forearm

M60.841 Other myositis, right hand

M60.842 Other myositis, left hand

M60.851 Other myositis, right thigh

M60.852 Other myositis, left thigh

M60.861 Other myositis, right lower leg

M60.862 Other myositis, left lower leg

M60.871 Other myositis, right ankle and foot

M60.872 Other myositis, left ankle and foot

M60.88 Other myositis, other site

M60.89 Other myositis, multiple sites

M75.81 Other shoulder lesions, right shoulder

M75.82 Other shoulder lesions, left shoulder

M76.31 Iliotibial band syndrome, right leg

M76.32 Iliotibial band syndrome, left leg

M76.811 Anterior tibial syndrome, right leg

M76.812 Anterior tibial syndrome, left leg

M77.51 Other enthesopathy of right foot

M77.52 Other enthesopathy of left foot

M77.9 Enthesopathy, unspecified

M79.0 Rheumatism, unspecified

M79.1 Myalgia

M79.7 Fibromyalgia

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)

The injection of trigger point(s) will be considered 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.


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

20553 single or multiple trigger point(s), three or more muscle(s)

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.


  1. how many unit do we use to bill code 20553 (only one or 3 )?

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