Article Detail - JE Part B

Effective April 2024, Noridian updated the LCD and Local Coverage Article (LCA) for trigger point injections policy. Some of the updates are highlighted below. This is a general overview and not an exhaustive list of the policy changes and coverage article. It is covered for refractory pain associated with trigger points that do not respond to conservative therapy.

As the treating provider and medical record author, review the requirements included in the updated LCD to verify Medicare coverage, or possibly obtaining an Advance Beneficiary Notice of Non-coverage (ABN) from the beneficiary if a denial is expected. Make sure the billing and coding staff are aware to avoid unnecessary denials.

Medically necessary and reasonable requirements for initial trigger point injections:

1. There is a focal area of pain in the skeletal muscle.
2. There is clinical evidence of a trigger point defined as pain in a skeletal muscle that is associated with at least two of the following findings: the presence of a hyperirritable spot and/or taut band identified by palpation and possible referred pain AND
3. The physical examination identifies a focal hypersensitive bundle or nodule of muscle fiber harder than normal consistency with or without a local twitch response and referred pain AND
4. Non-invasive conservative therapy is not successful as first line treatment OR movement of a joint or limb is limited or blocked OR the TPI is necessary for diagnostic confirmation.

Please review the LCD for subsequent trigger point injection requirements.

Utilization

• No more than three trigger point injection sessions in a rolling 12 months
• 20552 – Injection(s); single or multiple trigger point(s); 1 or 2 muscles
• 20553 – Single or multiple trigger point(s); 3 or more muscles
• Pre- and post-injection pain scales must be indicated in the medical record

Medication

• Medication used is reported with a HCPCS drug code "J-code" or a revenue code
• Unclassified drugs (J3490, J9999, or C9399) must report the drug and dosage in Box 19 or its electronic equivalent
• C3999 is only for use in an Ambulatory Surgical Center (ASC)
• There are no current FDA approved biologicals for use as a trigger point injectable agent and billing these may result in a claim denial based on Internet Only Manual (IOM) Medicare Benefit Policy Manual 100-02 Chapter 16 Section 180
• No anesthesia codes should be billed in conjunction with 20552 or 20553

Resources

• Article - Billing and Coding: Trigger Point Injections (TPI) (A57701)
• LCD - Trigger Point Injections (TPI) (L34211)