How To Use CPT Code 20552

CPT 20552 refers to the injection procedure for single or multiple trigger points in one or two muscles. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, similar codes, and examples of CPT 20552.

1. What is CPT 20552?

CPT 20552 is a medical procedure code that describes the injection of an anesthetic or corticosteroid substance into single or multiple trigger points in one or two muscles. This procedure is performed to relieve pain and discomfort caused by trigger points, which are painful knots or areas within a muscle.

2. 20552 CPT code description

The official description of CPT code 20552 is: “Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s)”.

3. Procedure

The 20552 procedure involves the following steps:

1. The patient is appropriately prepped and the area to be treated is anesthetized.
2. The provider palpates the muscle to determine the location of the trigger point.
3. Firm pressure is applied to the trigger point to assess for referred pain and a twitch response.
4. The appropriate amount of corticosteroid or anesthetic is slowly injected into the trigger point.

4. Qualifying circumstances

Patients who are eligible to receive CPT code 20552 services are those experiencing pain and discomfort due to trigger points in one or two muscles. These trigger points may cause localized pain or referred pain to other areas of the body. The provider must determine that the trigger point injection is medically necessary and appropriate for the patient’s condition.

5. When to use CPT code 20552

It is appropriate to bill the 20552 CPT code when a provider performs a trigger point injection procedure on one or two muscles, regardless of the number of injections given. If the provider treats three or more muscles with injections, CPT code 20553 should be used instead.

6. Documentation requirements

To support a claim for CPT 20552, the following information should be documented:

• Patient’s medical history and physical examination findings
• Diagnosis and indication for the trigger point injection
• Location and number of trigger points treated
• Type and dosage of medication used for the injection
• Provider’s assessment of the patient’s response to the treatment

7. Billing guidelines

When billing for CPT code 20552, it is important to follow the appropriate guidelines and rules. Some tips and codes that apply to CPT code 20552 include:

• Ensure that the documentation supports the medical necessity of the procedure
• Use the appropriate ICD-10 diagnosis code(s) to indicate the reason for the trigger point injection
• Bill for the medication used in the injection separately using the appropriate HCPCS code
• Do not bill for more than one unit of CPT 20552, as the code covers the treatment of one or two muscles, regardless of the number of injections

8. Historical information

CPT 20552 was added to the Current Procedural Terminology system on January 1, 2002. There have been updates to the code since its addition:

• Code Changed on 01-01-2003: Injection; single or multiple trigger point(s), one or two muscle group(s)
• Code Changed on 01-01-2009: Injection(s); single or multiple trigger point(s), one or two muscle(s)

9. Similar codes to CPT 20552

Five similar codes to CPT 20552 and how they differentiate are:

• CPT 20553: This code is used for trigger point injections in three or more muscles.
• CPT 64400-64450: These codes describe nerve block injections for specific nerves.
• CPT 20600-20611: These codes cover arthrocentesis, aspiration, and/or injection procedures for different joint sizes.
• CPT 27096: This code is for sacroiliac joint injections.
• CPT 62320-62323: These codes describe epidural injections for the cervical, thoracic, lumbar, and sacral regions.

10. Examples

Here are 10 detailed examples of CPT code 20552 procedures:

1. A patient presents with neck pain. The provider performs four injections on the patient’s sternocleidomastoid muscle. Report CPT 20552.
2. A patient complains of shoulder pain. The provider performs two injections on the patient’s deltoid muscle and one on the infraspinatus muscle. Report CPT 20552.
3. A patient experiences pain in the forearm. The provider performs three injections on the patient’s extensor carpi radialis brevis muscle. Report CPT 20552.
4. A patient has pain in the lower back. The provider performs one injection on the patient’s iliopsoas muscle and two on the piriformis muscle. Report CPT 20552.
5. A patient presents with pain in the thigh. The provider performs two injections on the patient’s rectus femoris muscle and one on the vastus lateralis muscle. Report CPT 20552.
6. A patient complains of calf pain. The provider performs three injections on the patient’s gastrocnemius muscle. Report CPT 20552.
7. A patient experiences pain in the upper arm. The provider performs two injections on the patient’s biceps brachii muscle and one on the triceps brachii muscle. Report CPT 20552.
8. A patient has pain in the buttocks. The provider performs one injection on the patient’s gluteus maximus muscle and two on the gluteus medius muscle. Report CPT 20552.
9. A patient presents with pain in the wrist. The provider performs two injections on the patient’s flexor carpi ulnaris muscle. Report CPT 20552.
10. A patient complains of pain in the ankle. The provider performs one injection on the patient’s tibialis anterior muscle and two on the peroneus longus muscle. Report CPT 20552.