RETIRED LCD: Centers for Medicare & Medicaid Services

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Contractor Information

Contractor Name ^{back to top}

Noridian Administrative Services, LLC
Contractor Number ^{back to top}
00820
Contractor Type ^{back to top}
Carrier

LCD Information

LCD ID Number ^{back to top}

L23773

LCD Title ^{back to top}
Trigger Point Injections

Contractor's Determination Number ^{back to top}
B2007.103

AMA CPT / ADA CDT Copyright Statement ^{back to top}
CPT codes, descriptions and other data only are copyright 2009 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

CMS National Coverage Policy ^{back to top}
Title XVIII of the Social Security Act, Section 1862(a)(1)(A). This section allows coverage and payment for only those services that are considered to be medically reasonable and necessary. Title XVIII of the Social Security Act, Section 1833(e). This section prohibits Medicare payment for any claim which lacks the necessary information to process the claim.

Primary Geographic Jurisdiction ^{back to top}
Colorado

Oversight Region ^{back to top}
Region X

Original Determination Effective Date ^{back to top}
For services performed on or after 03/15/2007

Original Determination Ending Date ^{back to top}
06/15/2009

Revision Effective Date ^{back to top}


Revision Ending Date ^{back to top}


Indications and Limitations of Coverage and/or Medical Necessity ^{back to top}
Myofascial trigger points are "small, circumscribed, hyperirritable foci in muscles and fascia, often found with a firm or taut band of skeletal muscle." (See Item 2 under "Sources of Information and Basis for Decision.") These trigger points produce a referred pain patterned characteristic for that individual muscle. Each pattern becomes a single part of a single muscle syndrome. To successfully treat chronic myofascial pain syndrome (trigger points) each single muscle syndrome needs to be identified along with every perpetuating factor. The pain of active trigger points can begin as an acute single muscle syndrome resulting from stress overload or injury to the muscle, or can develop slowly because of chronic or repetitive muscle strain. The pain normally refers distal to the specific hypersensitive trigger point. Trigger point injections are used to alleviate this pain. There is no laboratory or imaging test for establishing the diagnosis of trigger points; it depends therefore upon the detailed history and thorough examination. The following diagnostic criteria are adopted by Noridian from Simons (See Item 3 under Sources of Information and Basis for Decision."): Major criteria. All four must be present to establish the diagnosis. A. Regional pain complaint B. Pain complaint or altered sensation in the expected distribution of referred pain from a trigger point C. Taut band palpable in an accessible muscle with exquisite tenderness at one point along the length of it D. Some degree of restricted range of motion, when measurable Minor criteria. Only one of four needed for the diagnosis. A. Reproduction of referred pain pattern by stimulating the trigger point B. Altered sensation by pressure on the tender spot C. Local response elicited by snapping palpation at the tender spot or by needle insertion into the tender spot D. Pain alleviated by stretching or injecting the tender Spot The goal is to identify and treat the cause of the pain, not just the symptom. After making the diagnosis of myofascial pain syndrome and identifying the trigger point responsible for it, the treatment options are: 1. Medical management, which may include consultation with a specialist in pain medicine 2. Medical management that may include the use of analgesics and adjunctive medications, including anti-depressant medications, shown to be effective in the management of chronic pain conditions. 3. Passive physical therapy modalities, including "stretch and spray" heat and cold therapy, passive range of motion and deep muscle massage. 4. Active physical therapy, including active range of motion, exercise therapy and physical conditioning. Application of low intensity ultrasound directed at the trigger point (this approach is used when the trigger point is otherwise inaccessible). 5. Manipulation therapy. 6. Injection of local anesthetic, with or without corticosteroid, into the muscle trigger points. a. as initial or the only therapy when a joint movement is impaired, such as when a muscle cannot be stretched fully or is in fixed position. b. as treatment of trigger points that are unresponsive to non-invasive methods of treatment, e.g., exercise, use of medications, stretch and spray. The CPT codes for trigger point injections use the phrase "muscle group(s)". For the purpose of this policy, NAS defines "muscle group" as a group of muscles that are contiguous and that share a common function, e.g., flexion, stabilization or extension of a joint. Trigger points that exist in muscles that are widely separated anatomically and that have different functions may be considered to be in separate muscle groups. To treat established trigger points after identification of the muscle or muscle group where the trigger point is located and documenting that in the patient's medical record. Coverage is provided for injections which are medically necessary due to illness or injury and based on symptoms and signs. An injection of a trigger point is considered medically necessary when it is currently causing tenderness and/or weakness, restricting motion and/or causing referred pain when compressed. Use of injections should be done as part of an overall management (usually short term) plan including one or more of the following: 1. Diagnostic evaluation to clearly identify the primary cause, if possible. 2. Physical and occupational therapy. 3. Psychiatric evaluation and therapy. 4. A trial of oral non-steroid analgesic/anti-inflammatory drugs, if not contraindicated. Acupuncture is not a covered service, even if provided for treatment of an established trigger point. Use of acupuncture needles and/or the passage of electrical current through these needles is not a covered service, whether the service is rendered by an acupuncturist or any other provider. Providers of acupuncture services must inform the beneficiary that their services will not be covered as acupuncture is not a Medicare benefit. Prolotherapy, the injection into a damaged tissue of an irritant to induce inflammation, is not covered by Medicare. Billing this under the trigger point injection codes is misrepresentation. "Dry needling" of trigger points is a non-covered procedure since it is considered unproven and investigational. Screening diagnoses will be denied as routine services. Compliance with the provisions in this policy is subject to monitoring by post payment data analysis and subsequent medical review.

Coding Information

Bill Type Codes: ^{back to top}

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.

999x	Not Applicable

Revenue Codes: ^{back to top}

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 ^{back to top}

20552	INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)
20553	INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 3 OR MORE MUSCLE(S)

ICD-9 Codes that Support Medical Necessity ^{back to top}

Note: Diagnosis codes are based on the current ICD-9-CM codes that are effective at the time of LCD publication. Any updates to ICD-9-CM codes will be reviewed by NAS, and coverage should not be presumed until the results of such review have been published/posted.

These are the only covered ICD-9-CM codes that support medical necessity:

Neither "trigger points" nor "myofascial pain syndrome" appear in the 2005 ICD-9-CM. Accordingly, NAS will assign the following three ICD-9-CM codes to indicate the diagnosis of a trigger point. Claims without one of these diagnoses will always be denied.

729.0	RHEUMATISM UNSPECIFIED AND FIBROSITIS
729.1	MYALGIA AND MYOSITIS UNSPECIFIED
729.4	FASCIITIS UNSPECIFIED

Diagnoses that Support Medical Necessity ^{back to top}

All ICD-9-CM codes listed in this policy under ICD-9-CM Codes that Support Medical Necessity above.

ICD-9 Codes that DO NOT Support Medical Necessity ^{back to top}

All ICD-9-CM codes not listed in this policy under ICD-9-CM Codes that Support Medical Necessity above.

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation ^{back to top}

Diagnoses that DO NOT Support Medical Necessity ^{back to top}

All ICD-9-CM codes not listed in this policy under ICD-9-CM Codes that Support Medical Necessity above.

General Information

Documentation Requirements ^{back to top}

The patient's medical record must have:

1. Documentation of proper evaluation leading to diagnosis of the trigger point. This must include the patient's history, extenuating circumstances (i.e. level of pain, interruption of activities of daily living), specific diagnosis codes, drugs injected, dosage of the drug,

2. The specific site of each injection, including identification of the affected muscle(s).

3. Documentation of reasons for selecting this therapeutic option, including the medical necessity for giving the injection, and the expected outcome of the treatment.

4. Precise diagnosis code(s) must be used. Generalized diagnoses like low back pain, lumbago, etc., will not be covered.

5. Multiple trigger points may be injected during any session.

6. If a patient requires more than three sets of injections during one year, a report stating the unusual circumstances and medical necessity for giving the additional injections may be requested for review and individual consideration.

Documentation must reflect the medical necessity of providing the service. The major and minor criteria (listed above under Indications and Limitations of Coverage and/or Medical Necessity) must be documented in the medical record and the record must be made available to Medicare upon request. The need for repeated injections (see Utilization Guidelines below) must be documented in the medical record.

The HCPCS/CPT code(s) may be subject to Correct Coding Initiative (CCI) edits. This policy does not take precedence over CCI edits. Please refer to the CCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare.

When the documentation does not meet the criteria for the service rendered or the documentation does not establish the medical necessity for the services, such services will be denied as not reasonable and necessary under Section 1862(a)(1) of the Social Security Act.

When requesting a written redetermination (formerly appeal), providers must include all relevant documentation with the request.

Appendices ^{back to top}

Utilization Guidelines ^{back to top}

NAS has adopted the following guidelines from Manchikanti et al (2).

1. In the diagnostic or stabilization phase, a patient may receive trigger point injections at intervals of no more frequently than every two weeks.

2. In the treatment or therapeutic phase (after stabilization is completed), the frequency should be two months or longer between each injection provided that at least >50% relief is obtained for six weeks.

3. In the diagnostic or stabilization phase, the number of trigger point injections should be limited to no more than four times per year.

4. In the treatment or therapeutic phase, the trigger point injections should be repeated only as reasonable and medically necessary, and these should be limited to a maximum of six times for local anesthetic and steroid injections.

5. Only one Trigger Point Injection CPT code can be billed per date of service.

6. Because the ICD-9-CM manual does not list "trigger point" or "myofascial pain syndrome," this LCD lists related diagnoses that can reasonably include trigger points and uses "myofascial pain syndrome" to refer to trigger points.

Sources of Information and Basis for Decision ^{back to top}

1. Local Medical Review Policy from Iowa, August 1999

2. Manchikanti L et al, Interventional Techniques in the Management of Chronic Pain, Pain Physician, Volume 4, Number 1, 2001

3. Simons DG. Muscular Pain Syndromes. In Friction JR, Awad EA (eds). Advances in Pain Research and Therapy. Lippincott-Raven, Philadelphia, 1990, Vol 17

4. Travell JG and Simons DG, Myofascial Pain and Dysfunction, The Trigger Point Manual, Baltimore, Williams and Wilkins, 1983

5. The following sources of information were cited in the Iowa LMRP:

● Other Carrier Policies (Kansas/Nebraska/Western Missouri, North Dakota, GHI of New York)
● Satterthwaite, Dollison. Handbook of Pain Management, 2nd Edition, 1994, Williams and Wilkins
● Yale University School of Medicine, Department of Pain Management
Connecticut Society of Anesthesiology
● Local Medical Policy from Nationwide Insurance Company
● Medicare Operations Spine Five: 193-200, 1980
● Journal of Neurosurgery 43:448-451, 1975

6. Other carriers’ LCDs

7. NAS Carrier Advisory Committee Members

Advisory Committee Meeting Notes ^{back to top}

This medical policy was presented at the Medicare Part B Open Public Meeting held on September 12, 2006 and discussed at the following Carrier Advisory Committee meetings:

Alaska - September 28, 2006
Colorado - October 19, 2006
Hawaii - October 20, 2006
Iowa - October 5, 2006
Nevada - October 19, 2006
Oregon - October 14, 2006
Washington - October 10, 2006

This policy does not reflect the sole opinion of the contractor or the Contractor Medical Director(s). Although the final decision rests with the contractor, this policy was developed in cooperation with the Carrier Advisory Committee(s), which include representatives of various medical specialty societies.

The Section titled "Does the ‘CPT 30% Rule' apply?" needs clarification. This rule comes from the AMA (American Medical Association), the organization that holds the copyrights for all CPT codes. The rule states that if, in a given section (e.g., surgery) or subsection (e.g., surgery, integumentary) of the CPT Manual, more than 30% of the codes are listed in the LCD, then the short descriptors must be used rather than the long descriptors found in the CPT Manual.

This policy is subject to the reasonable and necessary guidelines and the limitation of liability provision.

This medical policy consolidates and replaces all previous policies and publications on this subject by NAS and its predecessors for Medicare Part B.

Start Date of Comment Period ^{back to top}

08/30/2006

End Date of Comment Period ^{back to top}

12/05/2006

Start Date of Notice Period ^{back to top}

01/25/2007

Revision History Number ^{back to top}

N/A

Revision History Explanation ^{back to top}

11/09/2008 - The description for CPT/HCPCS code 20552 was changed in group 1
11/09/2008 - The description for CPT/HCPCS code 20553 was changed in group 1

This LCD is retired effective 06/15/2009.

Reason for Change ^{back to top}

Last Reviewed On Date ^{back to top}

01/18/2007

Medicare Coverage Database

LCD for Trigger Point Injections (L23773)