Trigger Point Injections Coding: Muscle or Muscle Group

Question:

One of our Providers recently completed Trigger Point injections toBilateralThoracic ParaspinalsandBilateralTrapeziusin the same setting for a patient. When we bill for this procedure do we counteachside(Left and Right) of these procedures as a muscle group to be billed out as 20553 OReacharea(Bilateral or unilateral) of these procedures as a muscle group to be billed out as 20552?

Answer:

Trigger points are by muscle(s) injected; 20552 is 1-2 muscles, 20553 is more than 3 or more muscles.  He injected 4 muscles (2 paraspinal and 2 trapezius) so the code billed is 20553. Additionally, these codes are not reported bilaterally with a 50 modifier or with an RT/LT. Report by the number ofmusclesinjected.

*This response is based on the best information available as of 12/19/19.