Print Trigger Point Injections

Trigger Point Injections

 

DESCRIPTION

Trigger points are small, definite (confined to a limited space) abnormally sensitive areas in muscles, ligaments, joint capsules, tendons and related tissues that have a specific and typical area of referred pain. The trigger point is so called because its stimulation reproduces the pain complained of. Any kind of local injury to myofascial structures can induce trigger points. Other causes of trigger points are inflammation (myositis bursitis, fibrositis, arthritis, tendonitis, etc.) connective tissue disease and chronic infection.

Anesthetization of trigger points (also called myofascial or paravertebral muscle injections) relieves spasms and diminishes pain associated with myofascial pain (fibromyalgia, fibromyositis, myofascitis). Injections should generally be used with physical therapy so that the patient can take advantage of the pain relief from the injections and increase activity tolerance.

 

POLICY

Trigger point injection of abnormally sensitive areas in muscles, ligaments, joint capsules, tendons and related tissues may be considered medically necessary to relieve spasm and diminish myofascial pain.

One reimbursement will be made per site, per session, regardless of the number of trigger point injections.

Separate billing for the drug injected is not allowed. This is included in the administration of the injection.

Reimbursement for injections of tendon sheath, ligament, trigger points or ganglion cyst (CPT 20550) will be made up to a maximum of ten (10) sessions in a three (3) month period. Reimbursement for arthrocentesis, aspiration and/or injection of small and intermediate joints (CPT 20600 and 20605) will not exceed two (2) injections per joint within thirty (30) days. Reimbursement for arthrocentesis, aspiration and/or injection of major joint or bursa (e.g., shoulder, hip, knee joint, subacromial bursa), CPT 20610, will not exceed four (4) services per site within a thirty (30) day period.

 

POLICY EXCEPTIONS

None

 

POLICY GUIDELINES

Beyond the treatment limits specified, no coverage is allowed.

The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language

 

POLICY HISTORY

8/1997: Approved by Medical Policy Advisory Committee (MPAC)

11/2000: Reviewed by MPAC, no changes

7/11/2001: Code Reference section updated; ICD-9 diagnosis codes 098.50, 726.0, 726.12, 726.5, 726.61, 726.71, 726.79, 726.90, 728.85 added; ICD-9 diagnosis codes 040.0, 074.1, 478.29, 727.2, 729.1 deleted

3/13/2002: New 2002 codes added

5/8/2002: Type of Service and Place of Service deleted

8/21/2003: CPT codes 20600, 20605 listed separately, CPT codes 20550, 20551, 20552, 20553 descriptions revised to be consistent with AMA, ICD-9 procedure codes 81.92, 83.97 descriptions revised to be consistent with AMA, arthritis, bursitis, fibrositis, myalgia and myositis, tendonitis ICD-9 diagnosis code ranges listed separately

11/5/2004: Code Reference section updated, CPT code 20612 added covered codes, ICD-9 procedure code 05.39, 76.96, 82.94, 82.95, 83.96, 83.98 added covered codes, ICD-9 diagnosis code 727.00, 727.01, 727.04, 727.05, 727.06, 727.09, 727.9, 729.1, 730.10, 730.11, 730.12, 730.13, 730.14, 730.15, 730.16, 730.17, 730.18, 730.19, 730.20, 730.21, 730.22, 730.23, 730.24, 730.25, 730.26, 730.27, 730.28, 730.29, 730.80, 730.81, 730.82, 730.83, 730.84, 730.85, 730.86, 730.87, 730.88, 730.89, 730.90, 730.91, 730.92, 730.93, 730.94, 730.95, 730.96, 730.97, 730.98, 730.99 added covered codes

7/20/2006: Policy reviewed, prior authorization language removed.

03/27/2014: Policy statement updated to add the following for clarity purposes:  Trigger point injection of abnormally sensitive areas in muscles, ligaments, joint capsules, tendons and related tissues may be considered medically necessary to relieve spasm and diminish myofascial pain.

 

SOURCE(S)

Review of medical policy related to trigger point injections from Blue Cross & Blue Shield plans nationally.

Literature search through Grateful Med and MEDLINE databases focused on references containing the Medical Subject heading of arthrocentesis and trigger point.

Hayes Medical Technology Directory

 

CODE REFERENCE

This may not be a comprehensive list of procedure codes applicable to this policy.

The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.  

Covered Codes

Code Number

Description

CPT-4

20550

Injections(s); tendon sheath, ligament

20551Injection(s); tendon origin/insertion
20552
Injection(s); single or multiple trigger point(s), one or two muscle(s)
20553
Injection(s); single or multiple trigger point(s), three or more muscle(s)
20600Arthrocentesis, aspiration and/or injection; small joint or bursa (eg, fingers, toes)
20605

Arthrocentesis, aspiration and/or injection; intermediate joint or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa)

20610

Arthrocentesis, aspiration and/or injection of major joint or bursa; (e.g., shoulder, hip, knee joint, subacromial bursa)

20612Aspiration and/or injection of ganglion cyst(s) any location

ICD-9 Procedure

05.39Other injection into sympathetic nerve or ganglion
76.96Injection of therapeutic substance into temporomandibular joint

81.91

Arthrocentesis

81.92

Injection of therapeutic substance into tendon

82.94Injection of therapeutic substance into bursa of hand
82.95Injection of therapeutic substance into tendon of hand
83.96Injection of therapeutic substance into bursa

83.97

Injection of therapeutic substance into tendon

83.98

Injection of locally acting therapeutic substance into other soft tissue

ICD-9 Diagnosis

095.6

Syphilis of muscle

095.7

Syphilis of synovium, tendon, and bursa

098.50

Gonococcal arthritis

098.52

Gonococcal bursitis

376.12

Orbital myositis

711.00, 711.01, 711.02, 711.03, 711.04, 711.05, 711.06, 711.07, 711.08, 711.09,

Pyogenic arthritis code range

711.10, 711.11, 711.12, 711.13, 711.14, 711.15, 711.16, 711.17, 711.18, 711.19,Arthropathy associated with Reiter's disease and nonspecific urethritis code range
711.20, 711.21, 711.22, 711.23, 711.24, 711.25, 711.26, 711.27, 711.28, 711.29Arthropathy in Behcet's syndrome code range
711.30, 711.31, 711,32, 711.33, 711.34, 711.35, 711.36, 711.37, 711.38, 711.39Postdysenteric arthropathy code range
711.40, 711.41, 711.42, 711.43, 711.44, 711.45, 711.46, 711.47, 711.48, 711.49Arthropathy associated with other bacterial diseases code range
711.50, 711.51, 711.52, 711.53, 711.54, 711.55, 711.56, 711.57, 711.58, 711.59Arthropathy associated with other viral diseases code range
711.60, 711.61, 711.62, 711.63, 711.64, 711.65, 711.66, 711.67, 711.68, 711.69Arthropathy associated with mycoses code range
711.70, 711.71, 711.72, 711.73, 711.74, 711.75, 711.76, 711.77, 711.78, 711.79Arthropathy associated with helminthiasis code range
711.80, 711.81, 711.82, 711.83, 711.84, 711.85, 711.86, 711.87, 711.88, 711.89Arthropathy associated with other infectious and parasitic diseases code range
711.90, 711.91, 711.92, 711.93, 711.94, 711.95, 711.96, 711.97, 711.98, 711.99Unspecified infective arthritis code range
712.10, 712.11, 712.12, 712.13, 712.14, 712.15, 712.16, 712.17, 712.18, 712.19Chondrocalcinosis due to dicalcium phosphate crystals code range
712.20, 712.21, 712.22, 712.23, 712.24, 712.25, 712.26, 712.27, 712.28, 712.29Chondrocalcinosis due to pyrophosphate crystals code range
712.30, 712.31, 712.32, 712.33, 712.34, 712.35, 712.36, 712.37, 712.38, 712.39Chondrocalcinosis, cause unspecified, involving unspecified code range
712.80, 712.81, 712.82, 712.83, 712.84, 712.85, 712.86, 712.87, 712.88, 712.89Other specified crystal arthropathies code range
712.90, 712.91, 712.92, 712.93, 712.94, 712.95, 712.96, 712.97, 712.98, 712.99Unspecified crystal arthropathy code range
713.0, 713.1, 713.2, 713.3, 713.4, 713.5, 713.6, 713.7, 713.8Arthropathy code range
714.0Rheumatoid arthritis
714.1Felty's syndrome
714.2Other rheumatoid arthritis with visceral or systemic involvement
714.30, 714.31, 714.32Polyarticular juvenile rheumatoid arthritis code range
714.33Monoarticular juvenile rheumatoid arthritis
714.4Chronic postrheumatic arthropathy
714.81Rheumatoid lung
714.89Other specified inflammatory polyarthropathies
714.9Unspecified inflammatory polyarthropathy
715.00, 715.04, 715.09Generalized osteoarthrosis code range
715.10, 715.11, 715.12, 715.13, 715.14, 715.15, 715.16, 715.17, 715.18, 715.19Primary localized osteoarthrosis code range
715.20, 715.21, 715.22, 715.23, 715.24, 715.25, 715.26, 715.27,
715.28
Secondary localized osteoarthrosis code range
715.30, 715.31, 715.32, 715.33, 715.34, 715.35, 715.36, 715.37, 715.38Localized osteoarthrosis not specified whether primary or secondary code range
715.80Osteoarthrosis involving more than one site, but not specified as generalized, unspecified site
715.89Osteoarthrosis involving multiple sites, but not specified as generalized
715.90, 715.91, 715.92, 715.93, 715.94, 715.95, 715.96, 715.97,
715.98
Osteoarthrosis, unspecified whether generalized or localized code range
716.00, 716.01, 716.02, 716.03, 716.04, 716.05, 716.06, 716.07, 716.08, 716.09Kaschin-Beck disease code range
716.10, 716.11, 716.12, 716.13, 716.14, 716.15, 716.16, 716.17, 716.18, 716.19Traumatic arthropathy code range
716.20, 716.21, 716.22, 716.23, 716.24, 716.25, 716.26, 716.27, 716.28, 716.29Allergic arthritis code range
716.30, 716.31, 716.32, 716.33, 716.34, 716.35, 716.36, 716.37, 716.38, 716.39Climacteric arthritis code range
716.40, 716.41, 716.42, 716.43, 716.44, 716.45, 716.46, 716.47, 716.48, 716.49Transient arthropathy code range
716.50, 716.51, 716.52, 716.53, 716.54, 716.55, 716.56, 716.57, 716.58, 716.59Unspecified polyarthropathy or polyarthritis code range
716.60, 716.61, 716.62, 716.63, 716.64, 716.65, 716.66, 716.67,
716.68
Unspecified monoarthritis code range
716.80, 716.81, 716.82, 716.83, 716.84, 716.85, 716.86, 716.87, 716.88, 716.89Other specified arthropathy code range
716.90, 716.91, 716.92, 716.93, 716.94, 716.95, 716.96, 716.97, 716.98, 716.99Unspecified arthropathy code range
726.0Adhesive capsulitis of shoulder
726.10Unspecified disorders of bursae and tendons in shoulder region
726.11Calcifying tendinitis of shoulder
726.12Bicipital tenosynovitis
726.19Other specified disorders of rotator cuff syndrome of shoulder and allied disorders
726.2Other affections of shoulder region, not elsewhere classified
726.33Olecranon bursitis
726.4Enthesopathy of wrist and carpus
726.5Enthesopathy of hip region
726.60Unspecified enthesopathy of knee
726.61Pes anserinus tendinitis or bursitis
726.62Tibial collateral ligament bursitis
726.63Fibular collateral ligament bursitis
726.64Patellar tendinitis
726.65Prepatellar bursitis
726.69Other enthesopathy of knee
726.71Achilles bursitis or tendinitis
726.72Tibialis tendinitis
726.79Other enthesopathy of ankle and tarsus
726.8Other peripheral enthesopathies
726.90Enthesopathy of unspecified site
727.00, 727.01, 727.04, 727.05, 727.06, 727.09Synovitis and tenosynovitis code range
727.3Other bursitis disorders
727.51Synovial cyst of popliteal space
727.82Calcium deposits in tendon and bursa
727.9Unspecified disorder of synovium, tendon, and bursa
728.0Infective myositis
728.11Progressive myositis ossificans
728.12Traumatic myositis ossificans
728.2Muscular wasting and disuse atrophy, not elsewhere classified
728.81Interstitial myositis
728.85Muscle Spasm
729.0Rheumatism, unspecified and fibrositis
729.1Unspecified myalgia and myositis
730.10, 730.11, 730.12, 730.13, 730.14, 730.15, 730.16, 730.17, 730.18, 730.19Chronic osteomyelitis code range
730.20, 730.21, 730.22, 730.23, 730.24, 730.25, 730.26, 730.27, 730.28, 730.29Unspecified osteomyelitis code range
730.80, 730.81, 730.82, 730.83, 730.84, 730.85, 730.86, 730.87, 730.88, 730.89Other infections involving bone in diseases classified elsewhere code range 
730.90, 730.91, 730.92, 730.93, 730.94, 730.95, 730.96, 730.97, 730.98, 730.99Unspecified infection of bone code range

958.6

Volkmann's ischemic contracture

HCPCS

 

 

 

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