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.

Limitations

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:

Prerequisite(s)

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


ICD-10 CODE DESCRIPTION

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