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.

12/31/2014: Added the following new 2015 CPT codes to the Code Reference section: 20604, 20606, and 20611. Revised the description of the following CPT codes: 20600, 20605, and 20610. Effective 1/1/15.

08/31/2015: Medical policy revised to add ICD-10 codes. Removed ICD-9 procedure code 81.91 from the Code Reference section.

  

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

20551

Injection(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)

20600

Arthrocentesis, aspiration and/or injection, small joint or bursa (eg, fingers, toes); without ultrasound guidance (Revised 01-01-2015)

20604

Arthrocentesis, aspiration and/or injection, small joint or bursa (eg, fingers, toes); with ultrasound guidance, with permanent recording and reporting (New 01-01-2015)

20605

Arthrocentesis, aspiration and/or injection, intermediate joint or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa); without ultrasound guidance (Revised 01-01-2015)

20606

Arthrocentesis, aspiration and/or injection, intermediate joint or bursa (eg, temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa); with ultrasound guidance, with permanent recording and reporting (New 01-01-2015)

20610

Arthrocentesis, aspiration and/or injection, major joint or bursa (e.g., shoulder, hip, knee, subacromial bursa); without ultrasound guidance (Revised 01-01-2015)

20611

Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording and reporting (New 01-01-2015)

20612

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

HCPCS

  

ICD-9 Procedure

ICD-10 Procedure

05.39

Other injection into sympathetic nerve or ganglion

3E0T33Z

Introduction of Anti-inflammatory into Peripheral Nerve and Plexi, Percutaneous Approach

76.96

 

 

 

 

83.96

Injection of therapeutic substance into temporomandibular joint

 

Injection of therapeutic substance into bursa

3E0U33Z

Introduction of Anti-inflammatory into Joints, Percutaneous Approach

81.92

Injection of therapeutic substance into tendon

3E0U3BZ , 3E0U3GC, 3E0U3NZ

Introduction of Local Anesthetic, Analgesics or Other Therapeutic Substance into the Joints, Percutaneous Approach

82.94

Injection of therapeutic substance into bursa of hand

3E0U33Z, 3E0U3BZ, 3E0U3NZ

(See description above)

82.95

Injection of therapeutic substance into tendon of hand

3E0233Z, 3E023BZ, 3E023GC

Introduction of Anti-inflammatory, Local Anesthetic or Other Therapeutic Substance into Muscle, Percutaneous Approach

83.97

Injection of therapeutic substance into tendon

3E0233Z

Introduction of Anti-inflammatory into Muscle, Percutaneous Approach

83.98

Injection of locally acting therapeutic substance into other soft tissue

3E0133Z, 3E013BZ

Introduction of Anti-inflammatory or Local Anesthetic into Subcutaneous Tissue, Percutaneous Approach

  

3E023JZ, 3E023NZ

Introduction of Analgesics, Hypnotics, Sedatives into Muscle, Percutaneous Approach

ICD-9 Diagnosis

ICD-10 Diagnosis

095.6

 

095.7

Syphilis of muscle

 

Syphilis of synovium, tendon, and bursa

A52.78

Syphilis of other musculoskeletal tissue (syphilis of bursa, muscle, synovium, tendon)

098.50

Gonococcal arthritis

A54.42

Gonococcal arthritis

098.52

Gonococcal bursitis

A54.49

Gonococcal infection of other musculoskeletal tissue (gonococcal bursitis, myositis, synovitis, tenosynovitis)

376.12

Orbital myositis

H05.121 - H05.129

Orbital myositis (code range)

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

Pyogenic arthritis code range

M00.00 - M00.9

Staphylococcal arthritis and polyarthritis (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

M02.30 - M02.39

Reiter's disease (code range)

711.20, 711.21, 711.22, 711.23, 711.24, 711.25, 711.26, 711.27, 711.28, 711.29

Arthropathy in Behcet's syndrome code range

M35.2

Behcet's disease

711.30, 711.31, 711,32, 711.33, 711.34, 711.35, 711.36, 711.37, 711.38, 711.39

Postdysenteric arthropathy code range

M02.10 - M02.19

Postdysenteric arthropathy (code range)

711.40, 711.41, 711.42, 711.43, 711.44, 711.45, 711.46, 711.47, 711.48, 711.49

Arthropathy associated with other bacterial diseases code range

A18.01 - A18.02

Tuberculosis of bones and joints (spine, hip, knee) (code range)

711.50, 711.51, 711.52, 711.53, 711.54, 711.55, 711.56, 711.57, 711.58, 711.59

 

711.60, 711.61, 711.62, 711.63, 711.64, 711.65, 711.66, 711.67, 711.68, 711.69

 

711.70, 711.71, 711.72, 711.73, 711.74, 711.75, 711.76, 711.77, 711.78, 711.79

 

711.90, 711.91, 711.92, 711.93, 711.94, 711.95, 711.96, 711.97, 711.98, 711.99

Arthropathy associated with other viral diseases code range

 

 

 

 

 

 

 

 

 

Arthropathy associated with mycoses code range

 

 

 

 

 

 

 

 

 

Arthropathy associated with helminthiasis code range

 

 

 

 

 

 

 

 

 

Unspecified infective arthritis code range

M01.X0 - M01.X9

Direct infections of joints in infectious and parasitic diseases classified elsewhere (code range)

  

M02.80 - M02.9

Other reactive arthropathies (code range)

711.80, 711.81, 711.82, 711.83, 711.84, 711.85, 711.86, 711.87, 711.88, 711.89

Arthropathy associated with other infectious and parasitic diseases code range

M02.80 - M02.89

(See description above)

712.10, 712.11, 712.12, 712.13, 712.14, 712.15, 712.16, 712.17, 712.18, 712.19

 

712.20, 712.21, 712.22, 712.23, 712.24, 712.25, 712.26, 712.27, 712.28, 712.29

 

712.90, 712.91, 712.92, 712.93, 712.94, 712.95, 712.96, 712.97, 712.98, 712.99

Chondrocalcinosis due to dicalcium phosphate crystals code range

 

 

 

 

 

 

 

 

Chondrocalcinosis due to pyrophosphate crystals code range

 

 

 

 

 

 

 

 

Unspecified crystal arthropathy code range

M11.80 - M11.89

Other specified crystal arthropathy (code range)

712.30, 712.31, 712.32, 712.33, 712.34, 712.35, 712.36, 712.37, 712.38, 712.39

Chondrocalcinosis, cause unspecified, involving unspecified code range

M11.10 - M11.29

Familial chondrocalcinosis (code range)

712.80, 712.81, 712.82, 712.83, 712.84, 712.85, 712.86, 712.87, 712.88, 712.89

Other specified crystal arthropathies code range

M11.00 - M11.09

Hydroxyapatite deposition disease (code range)

713.0, 713.1, 713.2, 713.3, 713.4, 713.5, 713.6, 713.7, 713.8

Arthropathy code range

A52.16

Charcot's arthropathy (tabetic)

  

E08.610

Diabetes mellitus with diabetic neuropathic arthropathy

  

M02.00 - M02.09

Arthropathy following intestinal bypass (code range)

  

M02.20 - M02.29

Postimmunization arthropathy (code range)

  

M07.60 - M07.69

Enteropathic arthropathies (code range)

  

M12.80 - M12.9

Other specified arthropathies, NEC (code range)

  

M14.60 - M14.69

Charcot's joint (neuropathic arthropathy) (code range)

  

M14.80 - M14.89

Arthropathies in other specified diseases classified elsewhere (code range)

  

M36.1 - M36.4

Systemic disorders of connective tissue in diseases classifed elsewhere (arthropathy) (code range)

714.0

Rheumatoid arthritis

M05.40 - M05.59

Rheumatoid myopathy with rheumatoid arthritis(code range)

  

M05.70 - M05.9

Rheumatoid arthritis with rheumatoid factor (code range)

  

M06.00 - M06.09

Rheumatoid arthritis without rheumatoid factor (code range)

  

M06.1

Adult-onset Still's disease

  

M06.20 - M06.29

Rheumatoid bursitis (code range)

  

M06.30 - M06.39

Rheumatoid nodule (code range)

  

M06.80 - M06.9

Other specified rheumatoid arthritis (code range)

714.1

Felty's syndrome

M05.00 - M05.09

Felty's syndrome (code range)

714.2

Other rheumatoid arthritis with visceral or systemic involvement

M05.20 - M05.29

Rheumatoid vasculitis with rheumatoid arthritis (code range)

  

M05.30 - M05.39

Rheumatoid heart disease with rheumatoid arthritis (code range)

  

M05.60 - M05.69

Rheumatoid arthritis with involvement of other organs and systems (code range)

714.30, 714.31, 714.32

 

 

714.33

Polyarticular juvenile rheumatoid arthritis code range

 

 

Monoarticular juvenile rheumatoid arthritis

M08.00 - M08.99

Juvenile arthritis (code range)

714.4

Chronic postrheumatic arthropathy

M12.00 - M12.09

Chronic posrheumatic arthropathy (code range)

714.81

Rheumatoid lung

M05.10 - M05.19

Rheumatoid lung (code range)

714.89

 

 

 

714.9

Other specified inflammatory polyarthropathies

 

Unspecified inflammatory polyarthropathy

M06.4

Inflammatory polyarthropathy

715.00, 715.04, 715.09

Generalized osteoarthrosis code range

M15.0 - M15.9

Polyosteoarthritis (code range)

715.10, 715.11, 715.12, 715.13, 715.14, 715.15, 715.16, 715.17, 715.18, 715.19

Primary localized osteoarthrosis code range

M16.0 - M16.12, M17.0 - M17.12, M18.0 - M18.12, M19.011 - M19.079, M19.91 - M19.91

Primary localized osteoarthritis (code ranges)

715.20, 715.21, 715.22, 715.23, 715.24, 715.25, 715.26, 715.27,

715.28

Secondary localized osteoarthrosis code range

M16.2 - M16.9

Osteoarthritis of hip (code range)

  

M17.2 - M17.9

Osteoarthritis of knee (code range)

  

M18.2 - M18.9

Osteoarthritis of first carpometacarpal joint (code range)

  

M19.111 - M19.279

Post-traumatic osteoarthritis of other joints (code range)

  

M19.90 - M19.93

Osteoarthritis, unspecified site (code range)

715.30, 715.31, 715.32, 715.33, 715.34, 715.35, 715.36, 715.37, 715.38

Localized osteoarthrosis not specified whether primary or secondary code range

M16.9, M17.9, M19.90

(See description above)

715.80

Osteoarthrosis involving more than one site, but not specified as generalized, unspecified site

M15.4, M15.8

Polyosteoarthritis

715.89

Osteoarthrosis involving multiple sites, but not specified as generalized

M15.3, M15.8

Polyosteoarthritis

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

M15.9, M16.9, M19.90

(See description above)

716.00, 716.01, 716.02, 716.03, 716.04, 716.05, 716.06, 716.07, 716.08, 716.09

Kaschin-Beck disease code range

M12.10 - M12.19

Kaschin-Beck disease (osteochondroarthrosis deformans endemica) (code range)

716.10, 716.11, 716.12, 716.13, 716.14, 716.15, 716.16, 716.17, 716.18, 716.19

Traumatic arthropathy code range

M12.50 - M12.59

Traumatic arthropathy (code range)

716.20, 716.21, 716.22, 716.23, 716.24, 716.25, 716.26, 716.27, 716.28, 716.29

 

716.30, 716.31, 716.32, 716.33, 716.34, 716.35, 716.36, 716.37, 716.38, 716.39

Allergic arthritis code range

 

 

 

 

 

 

 

 

 

 

Climacteric arthritis code range

M13.80 - M13.89

Other specified arthritis (code range)

716.40, 716.41, 716.42, 716.43, 716.44, 716.45, 716.46, 716.47, 716.48, 716.49

Transient arthropathy code range

M12.80 - M12.89

Other specified arthropathies, NEC (code range)

716.50, 716.51, 716.52, 716.53, 716.54, 716.55, 716.56, 716.57, 716.58, 716.59

Unspecified polyarthropathy or polyarthritis code range

M13.0

Polyarthritis, unspecified

716.60, 716.61, 716.62, 716.63, 716.64, 716.65, 716.66, 716.67,

716.68

Unspecified monoarthritis code range

M13.10 - M13.179

Monoarthritis (code range)

716.80, 716.81, 716.82, 716.83, 716.84, 716.85, 716.86, 716.87, 716.88, 716.89

Other specified arthropathy code range

E08.618, E09.618, E10.618, E13.618

Diabetes mellitus with diabetic arthropathy

716.90, 716.91, 716.92, 716.93, 716.94, 716.95, 716.96, 716.97, 716.98, 716.99

Unspecified arthropathy code range

M12.9

Arthropathy, unspecified

726.0

Adhesive capsulitis of shoulder

M75.00 - M75.02

Adhesive capsulitis of shoulder (code range)

726.10

Unspecified disorders of bursae and tendons in shoulder region

M66.211 - M66.219

Spontaneous rupture of extensor tendons, shoulder (code range)

  

M66.811 - M66.819

Spontaneous rupture of other tendons, shoulder (code range)

  

M75.100 - M75.122

Rotator cuff tear or rupture, not specified as traumatic

  

M75.50 - M75.52

Patellar tendinitis (code range)

726.11

Calcifying tendinitis of shoulder

M75.30 - M75.32

Calcific tendinitis of shoulder (code range)

726.12

Bicipital tenosynovitis

M75.20 - M75.22

Bicipital tendinitis (code range)

726.19

Other specified disorders of rotator cuff syndrome of shoulder and allied disorders

M75.80 - M75.82

Other shoulder lesions (code range)

726.2

Other affections of shoulder region, not elsewhere classified

M25.711 - M25.719

Osteophyte, shoulder (code range)

  

M75.40 - M75.42

Impingement syndrome of shoulder (code range)

  

M75.90 - M75.92

Shoulder lesion, unspecified (code range)

726.33

Olecranon bursitis

M70.20 - M70.22

Olecranon bursitis (code range)

726.4

Enthesopathy of wrist and carpus

M25.731 - M25.749

Osteophyte, wrist and hand (code range)

  

M70.10 - M70.12

Bursitis of hand , olecranon bursitis (code range)

  

M77.20 - M77.22

Periarthritis of wrist (code range)

726.5

Enthesopathy of hip region

M25.751 - M25.759

Osteophyte, hip (code range)

  

M70.60 - M70.72

Trochanteric bursitis, other bursitis of hip

  

M76.00 - M76.32

Enthesopathies, lower limb, excluding foot (code range)

726.60

Unspecified enthesopathy of knee

M25.761 - M25.769

Osteophyte, knee (code range)

  

M70.50 - M70.52

Other bursitis of knee (code range)

726.61

 

 

726.63

 

 

726.69

Pes anserinus tendinitis or bursitis

 

Fibular collateral ligament bursitis

 

Other enthesopathy of knee

M76.899

Other specified enthesopathies of unspecified lower limb, excluding foot

726.62

Tibial collateral ligament bursitis

M76.40 - M76.42

Tibial collateral bursitis ) Pellegrini-Stieda) (code range)

726.64

Patellar tendinitis

M76.50 - M76.52

Patella tendonitis (code range)

726.65

Prepatellar bursitis

M70.40 - M70.42

Prepatellar bursitis (code range)

726.71

Achilles bursitis or tendinitis

M76.60 - M76.62

Achilles tendinitis (code range)

726.72

Tibialis tendinitis

M76.811 - M76.829

Anterior and posterior tibial syndrome (code range)

726.79

Other enthesopathy of ankle and tarsus

M76.70 - M76.72

Peroneal tendinitis (code range)

  

M77.50 - M77.52

Other enthesopathy of foot

726.8

Other peripheral enthesopathies

M76.891 - M76.9

Other and unspecified enthesopathies of lower limb, excluding foot (code range)

726.90

Enthesopathy of unspecified site

M77.8 - M7709

Other and unspecified enthesopathies, NEC (code range)

727.00, 727.01, 727.04, 727.05, 727.06, 727.09

Synovitis and tenosynovitis code range

M65.10 - M65.19

Other infective (teno)synivutus (code range)

  

M65.80 - M65.9

Other synovitis and tenosynovitis (code range)

  

M67.30 - M67.39

Transient synovitis (code range)

727.3

Other bursitis disorders

M71.10 - M71.19

Other infective bursitis (code range)

  

M71.50 - M71.58

Other bursitis, NEC (code range)

727.51

Synovial cyst of popliteal space

M66.0,                       M71.50 - M71.22

Synovial cyst of popliteal space (code range)

727.82

Calcium deposits in tendon and bursa

M65.20 - M65.29

Calcific tendinitis (code range)

  

M71.40 - M71.49

Calcium deposit in bursa (code range)

727.9

Unspecified disorder of synovium, tendon, and bursa

M67.90 - M67.99

Unspecified disorders of synovium and tendon (code range)

728.0

Infective myositis

M60.000 - M60.09

Infective myositis (code range)

728.11

Progressive myositis ossificans

M61.10 - M61.19

Myositis ossificans progressiva (code range)

728.12

Traumatic myositis ossificans

M61.00 - M61.09

Myositis ossificans traumatica (code range)

728.2

Muscular wasting and disuse atrophy, not elsewhere classified

M62.50 - M62.59

Muscle wasting and atrophy, NEC (code range)

728.81

Interstitial myositis

M60.10 - M60.19

Interstitial myositis (code range)

728.85

Muscle Spasm

M62.40 - M62.49, M62.830 - M62.838

Contracture of muscle (muscle spasm) (code ranges)

729.0

Rheumatism, unspecified and fibrositis

M79.0

Rheumatism, unspecified

729.1

Unspecified myalgia and myositis

M60.80 - M60.9, M79.1, M79.7

Other myositis, including myalagia and fibromyalgia (code range)

730.10, 730.11, 730.12, 730.13, 730.14, 730.15, 730.16, 730.17, 730.18, 730.19

Chronic osteomyelitis code range

M86.30 - M86.8x9

Chronic multifocal osteomyelitis, unspecified site (code range)

730.20, 730.21, 730.22, 730.23, 730.24, 730.25, 730.26, 730.27, 730.28, 730.29

Unspecified osteomyelitis code range

M46.20 - M46.28, M86.9

Osteomyelitis of vertebra (code range)

730.80, 730.81, 730.82, 730.83, 730.84, 730.85, 730.86, 730.87, 730.88, 730.89

Other infections involving bone in diseases classified elsewhere code range

A18.01, A18.03, M90.80 - M90.89

Osteopathy in diseases classified elsewhere (code range)

730.90, 730.91, 730.92, 730.93, 730.94, 730.95, 730.96, 730.97, 730.98, 730.99

Unspecified infection of bone code range

M46.30 - M46.39, M86.9

Infection of intervertebral disc (pyogenic) (code range)

958.6

Volkmann's ischemic contracture

T79.6XXA

Traumatic ischemia of muscle, initial encounter

 

 

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