What CPT (Current Procedural Terminology) code(s) are reported for trigger point injections with 0.25% bupivacaine into the rhomboid major, rhomboid minor, and levator scapular muscles?

CPT Coding for Trigger Point Injections

The correct CPT code for this procedure is 20553, which represents trigger point injections of 3 or more muscles.

Understanding Trigger Point Injection Coding

When coding for trigger point injections, the selection of the appropriate CPT code depends on the number of muscles injected, not the number of trigger points or injections:

• 20552: Used for trigger point injections of 1-2 muscles
• 20553: Used for trigger point injections of 3 or more muscles

Analysis of the Case

In this case, the procedure involved:

• Injections into the rhomboid major, rhomboid minor, and levator scapular muscles
• A total of 4 trigger points were injected
• Each trigger point received 2 cc of 0.25% bupivacaine
• Total volume used: 8 cc

Since three distinct muscles were injected (rhomboid major, rhomboid minor, and levator scapular), regardless of the number of trigger points (4), the correct code is 20553.

Common Coding Errors to Avoid

1. Counting trigger points instead of muscles: The code is based on the number of muscles injected, not the number of trigger points or injections.

2. Using multiple units of 20550: Code 20550 is for tendon sheath, ligament, or ganglion cyst injections, not trigger point injections.

3. Reporting 20552 x 4: This would incorrectly suggest four separate procedures of 1-2 muscle injections each, rather than a single procedure involving 3 muscles.

4. Using 20552,20553-51: This combination would be incorrect as it suggests both a 1-2 muscle injection and a separate 3+ muscle injection with a multiple procedure modifier. Since this was a single procedure involving 3 muscles, only 20553 is appropriate.

Proper Documentation Tips

For accurate coding of trigger point injections, documentation should clearly specify:

• The specific muscles injected (not just the number of trigger points)
• The medication and volume used
• The technique used for injection
• Negative aspiration (as documented in this case)
• The indication for the procedure

By focusing on the number of muscles (3) rather than the number of trigger points (4), the correct CPT code for this procedure is 20553.