Local Coverage Determination (LCD):
Injection of Trigger Points (L33912)
Contractor Information
Contractor Name
First Coast Service Options,
Inc.
LCD Information
Document Information
LCD ID
L33912
Original ICD-9 LCD ID
L29199
LCD Title
Injection of Trigger Points
Original Effective Date
For services performed on or after 10/01/2015
AMA CPT / ADA CDT / AHA NUBC
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CMS National Coverage Policy
Language quoted from CMS National Coverage Determination (NCDs) and coverage provisions
in interpretive manuals are italicized throughout the Local Coverage Determination (LCD).
NCDs and coverage provisions in interpretive manuals are not subject to the LCD Review
Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law
judge may not review an NCD. See §1869(f)(1)(A)(i) of the Social Security Act.
Unless otherwise specified, italicized text represents quotation from one or more of the following
CMS sources:
N/A
Coverage Guidance
Coverage Indications, Limitations, and/or Medical Necessity
Injection of a tendon sheath, ligament or trigger point consists of an anesthetic agent and/or
steroid agent injected into an area for the management of pain. This Local Coverage
Determination only addresses the injection of trigger points.
Trigger points are areas of taut muscle bands or palpable knots of the muscle, that are painful on
compression and can produce referred pain, referred tenderness, and/or motor dysfunction. A
trigger point may occur in any skeletal muscle/fascia in response to strain produced by acute or
chronic overload. Pain from trigger points can be mild to severe. When trigger point pain is
severe and unresponsive to non-invasive treatments (e.g., anti-inflammatory medications,
physical therapy, etc.), trigger point injections with local anesthetic and/or a steroid agent may be
helpful.
Besides injection into trigger points, local injections are useful in the treatment of pain or
dysfunction due to inflammation or other pathological changes of tendon sheaths, and ligaments.
Findings may include pain on motion or palpation, swelling, friction rubs and/or catches.
Injections; single or multiple trigger point(s), one or two muscle(s) (20552) or single or multiple
trigger point(s), three or more muscle(s) (20553)
The injection of trigger point(s) will be considered to be medically reasonable and necessary for
the treatment of trigger points that are unresponsive to non-invasive treatments or when noninvasive methods of treatment are contraindicated. The medical record should clearly reflect all
methods attempted and the results. If treatments are contraindicated, the medical record should
indicate why the trigger point(s) is not amenable to other therapeutic modalities.
Non-invasive treatments may include, but are not limited to:
•
Medications (non-steroidal anti-inflammatory drugs, muscle relaxants, etc.)
•
Physical therapy (massage, heat or ice, stretching, etc.)
•
Activity modification
•
Home exercise instruction
Repeat trigger point injections may be necessary when there is evidence of persistent pain or
inflammation. Evidence of partial improvements to the range of motion in any muscle area after
an injection would justify a repeat injection. Again, the medical record should clearly reflect the
medical necessity for repeated injections.
It is not recommended that trigger point injections be used on a routine basis for patients with
chronic non-malignant pain syndromes. In addition, several studies indicated that when
additional injections are required in a series, other therapies (e.g., medications, physical therapy)
in addition to the injections may be beneficial.
Coding Information
Bill Type Codes:
Contractors may specify Bill Types to help providers identify those Bill Types typically used to
report this service. Absence of a Bill Type does not guarantee that the policy does not apply to
that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by
Bill Type and the policy should be assumed to apply equally to all claims.
N/A
Revenue Codes:
Contractors may specify Revenue Codes to help providers identify those Revenue Codes
typically used to report this service. In most instances Revenue Codes are purely advisory; unless
specified in the policy services reported under other Revenue Codes are equally subject to this
coverage determination. Complete absence of all Revenue Codes indicates that coverage is not
influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue
Codes.
99999 Not Applicable
CPT/HCPCS Codes
Group 1 Paragraph: N/A
Group 1 Codes:
20552 INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)
INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 3 OR MORE
20553
MUSCLE(S)
ICD-10 Codes that Support Medical Necessity
Group 1 Paragraph: For Injections; single or multiple trigger point(s), one or two muscle(s)
(20552) single or multiple trigger point(s), three or more muscle(s) (20553), use the following
ICD-10 codes:
Group 1Codes
ICD-10 Code
D48.1
M25.721 - M25.729 Opens in a new window
M25.751 - M25.759 Opens in a new window
M25.771 - M25.776 Opens in a new window
M35.4
M46.00 - M46.09 Opens in a new window
M53.82
Description
Neoplasm of uncertain behavior of connective and other soft tissue
Osteophyte, right elbow - Osteophyte, unspecified elbow
Osteophyte, right hip - Osteophyte, unspecified hip
Osteophyte, right ankle - Osteophyte, unspecified foot
Diffuse (eosinophilic) fasciitis
Spinal enthesopathy, site unspecified - Spinal enthesopathy, multiple
sites in spine
Other specified dorsopathies, cervical region
M54.03 - M54.09 Opens in a new window
M54.89
M54.9
M60.10 - M60.19 Opens in a new window
M60.80 - M60.89 Opens in a new window
M60.9
M62.20 - M62.28 Opens in a new window
M62.40 - M62.49 Opens in a new window
M62.830 - M62.838 Opens in a new window
M62.89
M65.111 - M65.19 Opens in a new window
M65.311 - M65.359 Opens in a new window
M65.4
M65.80
M65.831 - M65.849 Opens in a new window
M65.871 - M65.879 Opens in a new window
M65.88
M65.89
M65.9
M67.30 - M67.39 Opens in a new window
M70.20 - M70.32 Opens in a new window
M70.60 - M70.72 Opens in a new window
M72.8
M72.9
M75.81
M75.82
M76.00 - M76.32 Opens in a new window
M76.60 - M76.829 Opens in a new window
Panniculitis affecting regions of neck and back, cervicothoracic region
- Panniculitis affecting regions, neck and back, multiple sites in spine
Other dorsalgia
Dorsalgia, unspecified
Interstitial myositis of unspecified site - Interstitial myositis, multiple
sites
Other myositis, unspecified site - Other myositis, multiple sites
Myositis, unspecified
Nontraumatic ischemic infarction of muscle, unspecified site Nontraumatic ischemic infarction of muscle, other site
Contracture of muscle, unspecified site - Contracture of muscle,
multiple sites
Muscle spasm of back - Other muscle spasm
Other specified disorders of muscle
Other infective (teno)synovitis, right shoulder - Other infective
(teno)synovitis, multiple sites
Trigger thumb, right thumb - Trigger finger, unspecified little finger
Radial styloid tenosynovitis [de Quervain]
Other synovitis and tenosynovitis, unspecified site
Other synovitis and tenosynovitis, right forearm - Other synovitis and
tenosynovitis, unspecified hand
Other synovitis and tenosynovitis, right ankle and foot - Other
synovitis and tenosynovitis, unspecified ankle and foot
Other synovitis and tenosynovitis, other site
Other synovitis and tenosynovitis, multiple sites
Synovitis and tenosynovitis, unspecified
Transient synovitis, unspecified site - Transient synovitis, multiple
sites
Olecranon bursitis, unspecified elbow - Other bursitis of elbow, left
elbow
Trochanteric bursitis, unspecified hip - Other bursitis of hip, left hip
Other fibroblastic disorders
Fibroblastic disorder, unspecified
Other shoulder lesions, right shoulder
Other shoulder lesions, left shoulder
Gluteal tendinitis, unspecified hip - Iliotibial band syndrome, left leg
Achilles tendinitis, unspecified leg - Posterior tibial tendinitis,
unspecified leg
Other specified enthesopathies of unspecified lower limb, excluding
foot
M77.00 - M77.12 Medial epicondylitis, unspecified elbow - Lateral epicondylitis, left
Opens in a new window elbow
M77.30 - M77.52 Calcaneal spur, unspecified foot - Other enthesopathy of left foot
Opens in a new window
M77.9
Enthesopathy, unspecified
M79.1
Myalgia
M79.601 - M79.676 Pain in right arm - Pain in unspecified toe(s)
Opens in a new window
M79.7
Fibromyalgia
M76.899
Showing 1 to 42 of 42 entries in Group 1
ICD-10 Codes that DO NOT Support Medical Necessity
Additional ICD-10 Information
N/A
General Information
Associated Information
Documentation Requirements
Medical record documentation must clearly indicate the medical necessity of the service being
billed. In addition, the documentation must support that the service was performed. This
information is normally found in the office/progress notes, hospital records, and test results.
The medical record must clearly indicate the number of injections given per session and the
site(s) injected. As stated in the “Indications and Limitations of Coverage” section for trigger
point injections, the medical record must clearly indicate all other methods of non-invasive
treatments attempted and the results. Furthermore, the medical record must clearly document the
medical necessity for repeated injections of trigger point(s). When frequent injections are
required, the medical record must reflect the reason for repeated injections.
Utilization Guidelines
The frequency at which trigger point injection(s) are performed is dependent on the clinical
presentation of the patient. However, it is generally expected that the patient’s response to the
previous injection is important in deciding whether to proceed with additional injections. If the
patient has achieved significant benefit after the first injection, an additional injection would be
appropriate for reoccurring symptoms. (Repeated injections may be justified by evidence of
improvement, such as reduction in pain, muscle tenderness, spasm; or improvement in the range
of motion.)
Multiple trigger points may be injected during any one session (see procedure codes 20552 and
20553). Some trigger points may need to be re-injected weekly or monthly for brief intervals
consisting of a few months, depending on the results of the injections and the relief of pain that
the injection provides. If therapeutic effect is achieved, medical literature supports that no more
than three sets (or sessions) of injections should be performed during one year.
If the patient experiences no symptom relief or functional improvement after two to three
injections into a muscle, repeated injections into that muscle are not recommended.
It is expected that these services would be performed as indicated by current medical literature
and/or standards of practice. When services are performed in excess of established parameters,
they may be subject to review for medical necessity.
Sources of Information and Basis for Decision
FCSO reference LCD number - L29351
American Medical Association (2001). CPT 2002 changes: An insider’s view. Chicago:
American Medical Association. This reference further explains procedure codes 20550, 20551,
20552, and 20553.
Alvarez, D.J. & Rockwell, P.G. (2002). Trigger points: Diagnosis and management. American
Family Physician. Retrieved July 24, 2002 from the World Wide Web: www.aafp.org. This
article supports the clinical presentation, evaluation, and management of trigger points.
Cardone, D.A. & Tallia, A.F. (2002). Joint and soft tissue injection. American Family Physician.
Retrieved July 24, 2002 from the World Wide Web: www.aafp.org. This article supports the
diagnostic and therapeutic indications for injections.
Ingber, R.S. (2002). Position paper on trigger point injections. New York, NY. Retrieved July
29, 2002 from the World Wide Web: www.drigber.com. This paper provided a definition of
trigger points. As well as a good overview of research on trigger points.
National Guideline Clearinghouse. Clinical practice guidelines for chronic non-malignant pain
syndrome patients II: An evidence-based approach. Journal of Back Musculoskeletal
Rehabilitation (1999) Jan 1; 13:47-58 [65 references]. Retrieved July 24, 2002 from the World
Wide Web: www.guideline.gov. This article recommended guidelines specific to adjunctive
treatment modalities for nerve blocks and trigger point injections.
VanTulder, M.W. & Koes, B.W. (2002). Low back pain American Family Physician. Retrieved
July 29, 2002 from the World Wide Web: www.aafp.org. This article supports the current
treatments used for low back pain.
Revision History Information
N/A
Associated Documents
Attachments
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Related Local Coverage Documents
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Related National Coverage Documents
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Public Version(s)
Updated on 07/01/2014 with effective dates 10/01/2015 - N/A
Updated on 03/23/2014 with effective dates 10/01/2015 - N/A
Keywords
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