LCD Clarification

Question:

Does the LCD L33622 Pain Management - Injection of tendon sheaths, ligaments, ganglion cysts, carpal and tarsal tunnels apply to trigger finger injections? I am reading the LCD and the title but not seeing where it applies specifically to trigger finger questions. 

Answer:

Yes, the LCD does apply to trigger finger injections. You are correct, that in the actual LCD there is not a specific reference to this diagnosis, including the title.  

Look at the links in the Associated Diagnosis section of the LCD. You will find the following link which takes you to the coding and billing requirements. CPT code 20550 and the diagnosis codes for trigger finger are listed in this document. 

 A52863 - Billing and Coding: Pain Management - injection of tendon sheaths, ligaments, ganglion cysts, carpal and tarsal tunnels. 

https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=52863&ver=51 

*This response is based on the best information available as of 10/23/25.

Modifier 59 vs Modifier 51

Question:

Can you clarify when to use modifiers 59 vs 51?

Answer:

Modifier 59 (or X modifiers) should only be used for a bundling edit to unbundle two codes that are not usually reported together but are appropriate under specific circumstances. If there is no bundling edit between two codes, then modifier 51 is appended to the second code to indicate an additional procedure.

*This response is based on the best information available as of 10/09/25.

Reporting Modifiers with Unlisted Codes

Question:

Can modifiers be reported with unlisted CPT codes?

Answer:

Yes, modifiers can be appended to unlisted CPT codes.

In 2024, CPT clarified this by updating the introduction guidelines for unlisted procedures and services. These updates were further explained in the January 2024 issue of CPT Assistant, which addressed the new and revised text and the standardization of reporting unlisted CPT codes across the CPT code set.

Illustration of modifiers that may be appropriately applied includes:

• Laterality modifiers – e.g., RT (right), LT (left)

• Bilateral procedure modifier – 50

• Role-based modifiers – e.g., 62 (two surgeons), 80 (assistant surgeon), 82 (assistant surgeon when qualified resident not available), AS (non-physician surgical assistant)

• Multiple or distinct procedure modifiers – e.g., 51 (multiple procedures), 59 (distinct procedural service)

• Global modifiers – e.g., 58 (staged or related procedure), 78 (return to operating room for related procedure), 79 (unrelated procedure or service)

This is not an all-inclusive list of modifiers that may be appropriately applied to unlisted CPT codes. For complete and up-to-date information, one should refer to current CPT guidelines and payer-specific policies.

Please note: Modifiers that describe an alteration of a service or procedure, such as modifier 52 (reduced services), are not appropriate for use with unlisted codes. The same applied to modifier 22 (increased procedural services).

*This response is based on the best information available as of 9/22/25.

J3301 Triamcinolone Billing

Question:

When billing HCPCS code J3301 Triamcinolone acetonide injectable suspension (Kenelog), if 40 mgs are injected, do I bill J3301 x 4 units or J3301 x 40 units?

Answer:

HCPCS code J3301 triamcinolone acetonide injectable suspension, not otherwise specified, (Kenalog) is billed based on 10mg dosage. If 40 mgs are injected, it would be coded with J3301 x 4 units.

Do not confuse this with HCPCS J1030 Depo Medrol which changed in 2024 and is now coded for 40 mg as J1010 x 40 units.

*This response is based on the best information available as of 9/25/25.

Cryoablation of Genicular Nerve

Question:

I'm new to coding pain management procedures. My provider plans to begin performing cryoablation of the genicular nerve under ultrasound guidance. What is the correct way to code this procedure?

Answer:

Great question! The appropriate CPT code for this procedure is 64624 Destruction by neurolytic agent, genicular nerve branches including imaging guidance, when performed. This code encompasses all methods of nerve destruction, including cryoablation, as well as radiofrequency, thermal, chemical, and electric techniques.

To report CPT 64624 correctly, documentation must reflect destruction of all three key genicular nerve branches:

• Superolateral

• Superomedial

• Inferomedial

If the provider does not treat all three branches, you must append modifier 52 to indicate reduced services. Also, while imaging guidance is included in the code, make sure the medical record documents its use to support the procedure.

*This response is based on the best information available as of 8/28/25.

Sacroiliac Joint Injections (SI Joint)

Question:

We are receiving denials from NGS Medicare for CPT code 20552 when we do SI joint injections using ultrasound guidance. Our typical diagnosis is sacroiliac dysfunction.

Does KZA have an insight into what may be causing the denial?

Answer:

Thank you for your inquiry.

You are correct that CPT code 20552 is appropriate for SI joint injections performed with ultrasound, following AMA CPT guidance. However, some Medicare Contractors and private payors are denying this code when used for the SI joint injection.

Without access to specific notes, Explanation of Benefits (EOB), or details about the specific MAC, the issue may stem from the following limitations listed in the LCD:

Trigger Point Limitations Excerpt: LCD 39662 Trigger Point Injections

• #4. Trigger points injections for treatment of headache, neck pain or low back pain in absence of actual trigger points, diffuse muscle pain, a chronic pain syndrome, lumbosacral canal stenosis, fibromyalgia, non-malignant multifocal musculoskeletal pain, complex regional pain syndrome, sexual dysfunction/ pelvic pain, whiplash, neuropathic pain, and hemiplegic shoulder pain are considered investigational and therefore are not considered medically reasonable and necessary.

• #5. Use of fluoroscopy or MRI guidance for performance of TPI is not considered reasonable and necessary.

• #6. The use of ultrasound guidance for the performance of TPI is considered investigational.

  • Limitation #6 specifically identifies "ultrasound guidance" as investigational, which could partially account for the denial.

Additionally, the NGS Medicare Billing and Coding Article (A59847) specifies the covered "sacral" diagnoses as follows:

• M48.00 - M48.08 Spinal stenosis, site unspecified - Spinal stenosis, sacral and sacrococcygeal region

It is important to note that sacroiliac dysfunction is not listed as a covered diagnosis under this article.

Sacroiliac dysfunction is not identified as a covered diagnosis.

Sources:

Billing and Coding: Trigger Point Injections (TPI), A45897

https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=59487&ver=8

Trigger Point Injections (TPI), L39622

https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdid=39662&ver=5

*This response is based on the best information available as of 7/31/25.