Injection Procedures code 20600 and 20550

Procedure code and description 

20550 Injection(s); single tendon sheath, or ligament, aponeurosis (eg, plantar “fascia’’)


20551 Injection(s); single tendon origin/insertion

20600 - Arthrocentesis, aspiration and/or injection, small joint or bursa (eg, fingers, toes); without ultrasound guidance - average fee payment - $50 - $60


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 non-invasive 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.

Injection Procedures 20600 and 20550

How to code multiple injections. So my hand surgeon is doing injections of the tendon sheath for tigger finger of the Middle finger and ring finger CPT 20550 x 1, than he does injections on the same fingers but in the PIP joint of each finger CPT 20600 x2. Per CCI the 20550 is bundled into 20600 yet a modifer is allowed. In this case would you bill both with a 59 modifer or the 20600 only. Also there is differnt diagnosis for each procedure.

 We cannot report these two codes together,only 20660 reportable. As per CCI edit these codes are considered as "Misuse of colum two code with column one code" but there are limited circumstances when the column two code may be reported on the same date of service as the column one code with a 59 modifier. E.g 83721 and 80061.

Injection therapies for tarsal tunnel syndromes (which include any socalled “Baxter’s injections”) and for Morton’s neuroma do not involve the structures described by CPT code 20550 and 20551 or direct injection into other peripheral nerves but rather the focal injection of tissue surrounding a specific focus of inflammation on the foot. These therapies are not to be coded using 20550, 20551, 64450, 64640 or other assigned CPT codes. Rather, the provider of these therapies must bill with CPT code 28899 (Unlisted procedure, foot or toes), since there is not yet a CPT code that specifically addresses either Morton’s neuroma injection or tarsal tunnel injection. Most specifically, the provider must not bill CPT codes 64450 or 64640 for these injections, since those codes respectively address the additional work of an injection of an anesthetic agent (nerve block), neurolytic or sclerosing agent into relatively more difficult peripheral nerves, rather than that involved in an injection of relatively easily localized areas such as a carpal tunnel, tarsal tunnel or Morton’s neuroma



New Edit #780 -- Injection(s), Different Types of Radiologic Services (Ultrasound, Fluoroscopic, CT, MRI) and Pooling of Platelets with Injection(s) Platelet Rich Plasma, Any Skin, Including Major Guidance for Harvesting and Preparation. Rationale:  Codes 20550, 20551, 20600-20610, 20926, 76942, 77002, 77012, 77021 or 86965 bundle with 0232T.  Based on the 2013 Current Procedural Terminology manual, page 588, which states in parenthesis below code 0232T, (Do not report 0232T in conjunction with 20550, 20551, 20600-20610, 20926, 76942, 77002, 77012, 77021, 86965).  The bundling of these services follows the National Correct Coding Initiative Edits-Version 19.0.

Rationale:  Anthem Central Region bundles J2001 into 20526-20527, 20550-20555, 20600-20615, 27096, 64479, 6448064484, 64490-64495.  Based on the National Correct Coding Initiative Edits (Version 19.1), code J2001 is listed as a component code to codes 20526-20527, 20550-20553, 20600-20615, 27096, 64479, 64483, 64490-64495.  Therefore, if J2001 is submitted with 20526-20527, 20550-20553, 20600-20615, 27096, 64479, 64483, 64490-64495—only 20526-20527, 20550-20553, 20600-20615, 27096, 64479, 64483, 64490-64495 reimburses


Medicare is establishing the following limited coverage for CPT/HCPCS codes 20526, 20550, 20551 and 20612:


ICD-10 Codes that Support Medical Necessity
   
    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:
 
    D48.1 Neoplasm of uncertain behavior of connective and other soft tissue
    M25.721 Osteophyte, right elbow
    M25.722 Osteophyte, left elbow
    M25.729 Osteophyte, unspecified elbow
    M25.751 Osteophyte, right hip
    M25.752 Osteophyte, left hip
    M25.759 Osteophyte, unspecified hip
    M25.771 Osteophyte, right ankle
    M25.772 Osteophyte, left ankle
    M25.773 Osteophyte, unspecified ankle
    M25.774 Osteophyte, right foot
    M25.775 Osteophyte, left foot
    M25.776 Osteophyte, unspecified foot
    M35.4 Diffuse (eosinophilic) fasciitis
    M46.00 Spinal enthesopathy, site unspecified
    M46.01 Spinal enthesopathy, occipito-atlanto-axial region
    M46.02 Spinal enthesopathy, cervical region
    M46.03 Spinal enthesopathy, cervicothoracic region
    M46.04 Spinal enthesopathy, thoracic region
    M46.05 Spinal enthesopathy, thoracolumbar region
    M46.06 Spinal enthesopathy, lumbar region
    M46.07 Spinal enthesopathy, lumbosacral region
    M46.08 Spinal enthesopathy, sacral and sacrococcygeal region
    M46.09 Spinal enthesopathy, multiple sites in spine
    M53.82 Other specified dorsopathies, cervical region
    M54.03 Panniculitis affecting regions of neck and back, cervicothoracic region
    M54.04 Panniculitis affecting regions of neck and back, thoracic region
    M54.05 Panniculitis affecting regions of neck and back, thoracolumbar region
    M54.06 Panniculitis affecting regions of neck and back, lumbar region
    M54.07 Panniculitis affecting regions of neck and back, lumbosacral region
    M54.08 Panniculitis affecting regions of neck and back, sacral and sacrococcygeal region
    M54.09 Panniculitis affecting regions, neck and back, multiple sites in spine
    M54.89 Other dorsalgia
    M54.9 Dorsalgia, unspecified
    M60.10 Interstitial myositis of unspecified site
    M60.111 Interstitial myositis, right shoulder
    M60.112 Interstitial myositis, left shoulder
    M60.119 Interstitial myositis, unspecified shoulder
    M60.121 Interstitial myositis, right upper arm
    M60.122 Interstitial myositis, left upper arm
    M60.129 Interstitial myositis, unspecified upper arm
    M60.131 Interstitial myositis, right forearm
    M60.132 Interstitial myositis, left forearm
    M60.139 Interstitial myositis, unspecified forearm
    M60.141 Interstitial myositis, right hand
    M60.142 Interstitial myositis, left hand
    M60.149 Interstitial myositis, unspecified hand
    M60.151 Interstitial myositis, right thigh
    M60.152 Interstitial myositis, left thigh
    M60.159 Interstitial myositis, unspecified thigh
    M60.161 Interstitial myositis, right lower leg
    M60.162 Interstitial myositis, left lower leg
    M60.169 Interstitial myositis, unspecified lower leg
    M60.171 Interstitial myositis, right ankle and foot
    M60.172 Interstitial myositis, left ankle and foot
    M60.179 Interstitial myositis, unspecified ankle and foot
    M60.18 Interstitial myositis, other site
    M60.19 Interstitial myositis, multiple sites
    M60.80 Other myositis, unspecified site
    M60.811 Other myositis, right shoulder
    M60.812 Other myositis, left shoulder
    M60.819 Other myositis, unspecified shoulder
    M60.821 Other myositis, right upper arm
    M60.822 Other myositis, left upper arm
    M60.829 Other myositis, unspecified upper arm
    M60.831 Other myositis, right forearm
    M60.832 Other myositis, left forearm
    M60.839 Other myositis, unspecified forearm
    M60.841 Other myositis, right hand
    M60.842 Other myositis, left hand
    M60.849 Other myositis, unspecified hand
    M60.851 Other myositis, right thigh
    M60.852 Other myositis, left thigh
    M60.859 Other myositis, unspecified thigh
    M60.861 Other myositis, right lower leg
    M60.862 Other myositis, left lower leg
    M60.869 Other myositis, unspecified lower leg
    M60.871 Other myositis, right ankle and foot
    M60.872 Other myositis, left ankle and foot
    M60.879 Other myositis, unspecified ankle and foot
    M60.88 Other myositis, other site
    M60.89 Other myositis, multiple sites
    M60.9 Myositis, unspecified
    M62.20 Nontraumatic ischemic infarction of muscle, unspecified site
    M62.211 Nontraumatic ischemic infarction of muscle, right shoulder
    M62.212 Nontraumatic ischemic infarction of muscle, left shoulder
    M62.219 Nontraumatic ischemic infarction of muscle, unspecified shoulder
    M62.221 Nontraumatic ischemic infarction of muscle, right upper arm
    M62.222 Nontraumatic ischemic infarction of muscle, left upper arm
    M62.229 Nontraumatic ischemic infarction of muscle, unspecified upper arm
    M62.231 Nontraumatic ischemic infarction of muscle, right forearm
    M62.232 Nontraumatic ischemic infarction of muscle, left forearm
    M62.239 Nontraumatic ischemic infarction of muscle, unspecified forearm
    M62.241 Nontraumatic ischemic infarction of muscle, right hand
    M62.242 Nontraumatic ischemic infarction of muscle, left hand
    M62.249 Nontraumatic ischemic infarction of muscle, unspecified hand
    M62.251 Nontraumatic ischemic infarction of muscle, right thigh
    M62.252 Nontraumatic ischemic infarction of muscle, left thigh
    M62.259 Nontraumatic ischemic infarction of muscle, unspecified thigh
    M62.261 Nontraumatic ischemic infarction of muscle, right lower leg
    M62.262 Nontraumatic ischemic infarction of muscle, left lower leg
    M62.269 Nontraumatic ischemic infarction of muscle, unspecified lower leg
    M62.271 Nontraumatic ischemic infarction of muscle, right ankle and foot
    M62.272 Nontraumatic ischemic infarction of muscle, left ankle and foot
    M62.279 Nontraumatic ischemic infarction of muscle, unspecified ankle and foot
    M62.28 Nontraumatic ischemic infarction of muscle, other site
    M62.40 Contracture of muscle, unspecified site
    M62.411 Contracture of muscle, right shoulder
    M62.412 Contracture of muscle, left shoulder
    M62.419 Contracture of muscle, unspecified shoulder
    M62.421 Contracture of muscle, right upper arm
    M62.422 Contracture of muscle, left upper arm
    M62.429 Contracture of muscle, unspecified upper arm
    M62.431 Contracture of muscle, right forearm
    M62.432 Contracture of muscle, left forearm
    M62.439 Contracture of muscle, unspecified forearm
    M62.441 Contracture of muscle, right hand
    M62.442 Contracture of muscle, left hand
    M62.449 Contracture of muscle, unspecified hand
    M62.451 Contracture of muscle, right thigh
    M62.452 Contracture of muscle, left thigh
    M62.459 Contracture of muscle, unspecified thigh
    M62.461 Contracture of muscle, right lower leg
    M62.462 Contracture of muscle, left lower leg
    M62.469 Contracture of muscle, unspecified lower leg
    M62.471 Contracture of muscle, right ankle and foot
    M62.472 Contracture of muscle, left ankle and foot
    M62.479 Contracture of muscle, unspecified ankle and foot
    M62.48 Contracture of muscle, other site
    M62.49 Contracture of muscle, multiple sites
    M62.830 Muscle spasm of back
.....

Covered ICD codes

354.0 Carpal tunnel syndrome 355.5 Tarsal tunnel syndrome 355.6* Lesion of plantar nerve  Note: Use 355.6 for Morton’s metatarsalgia, neuralgia, or neuroma 720.0-720.2 Ankylosing spondylopathies and other inflammatory spondylopathies 720.81 Inflammatory spondylopathies in diseases classified elsewhere 720.89 Other inflammatory spondylopathies 720.9 Unspecified inflammatory spondylopathy 723.7 Ossification of posterior longitudinal ligament in cervical region 724.71 Hypermobility of coccyx 724.79 Other disorders of coccyx 726.0 Adhesive capsulitis of shoulder 726.10-726.12 Rotator cuff syndrome of shoulder and allied disorders 726.19 Other specified disorders of bursae and tendons in shoulder region 726.2 Other affections of shoulder region not elsewhere classified 726.30-726.33 Enthesopathy of elbow region 726.39 Other enthesopathy of elbow region 726.4-726.5 Enthesopathy of wrist and carpus 726.60-726.65 Enthesopathy of knee 726.69 Other enthesopathy of knee 726.70-726.73 Enthesopathy of ankle and tarus 726.79 Other enthesopathy of ankle and tarsus 726.8 Other peripheral enthesopathies 726.90-726.91 Unspecified enthesopathy 727.00-727.06 Synovium and tenosynovitis 727.09 Other synovium and tenosynovitis 727.1 - 727.3 Other disorders of synovium, tendon and bursa 727.40-727.43 Ganglion and cyst of synovium, tendon and bursa 727.49 Other ganglion and cyst of synovium, tendon and  bursa 727.50 -727.51 Rpture of synovium 727.59 Other rupture of synovium 727.60-727.69 Rupture of tendon, nontraumatic 727.81-727.83 Other disorders of synovium, tendon and bursa 727.89 Other disorders of synovium tendon and bursa 727.9 Unspecified disorder of synovium tendon and bursa 728.4-728.6 Disorders of muscle, ligament and fascia 728.71 Plantar fascial fibromatosis 728.79 Other fibromatoses of muscle ligament and fascia 729.0-729.1 Other disorders of soft tissues 729.4 Fasciitis unspecified 733.6 Tietze’s disease 840.0-840.9 Sprains and strains of shoulder and upper arm 841.0-841.3 Sprains and strains of elbow and forearm 841.8-841.9 Sprains and strains of elbow and forearm 842.00-842.02 Sprains and strains of wrist 842.09 Other wrist sprain 842.10-842.13 Sprains and strains of hand 842.19 Other hand sprain 843.0-843.1 Sprains and strains of hip and thigh 843.8-843.9 Sprains and strains of hip and thigh 844.0-844.3 Sprains and strains of knee and leg 844.8-844.9 Sprains and strains of knee and leg 845.00-845.03 Sprains and strains of ankle 845.09 Other sprains and strains of ankle 845.10 - 845.13 Sprains and strains of foot 845.19 Other foot sprain 846.0-846.3 Sprains and strains of sacroiliac region 846.8-846.9 Sprains and strains of sacroiliac region 847.0-847.4 Sprains and strains of other and unspecified parts of back 847.9 Sprain of unspecified site of back 848.0-848.3 Other and ill-defined sprains and strains 848.40-848.42 Other and ill-defined sprains and strains of sternum 848.49 Other sprain of sternum 848.5 Pelvic sprain 848.8-848.9 Other and ill-defined sprains and strains

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