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CPT Code 20553 | Trigger Point Injections (TPIs) | 3 Or More Muscles

CPT code 20553 covers the injection of corticosteroids or anesthetics into multiple trigger points in three or more muscles, using palpation and assessment for referred pain and twitch response. The procedure may involve local anesthesia.

What Is CPT Code 20553?

CPT 20553 injects a corticosteroid or anesthetic into multiple trigger points in three or more muscles.

The provider will locate the trigger points through palpation, assess for referred pain and twitch response, and inject the medication into each point. The procedure may involve local anesthesia to numb the area.

Description

The CPT book describes CPT code 20553 as: “Injection(s); single or multiple trigger point(s), three or more muscles.”

Procedure

When the patient is appropriately prepped and the area anesthetized, the provider palpates the muscle to determine the location of a trigger point. 

Next, he applies firm pressure to the trigger point to assess the presence of referred pain and a twitch response. 

Then, after proper localization, he slowly injects the appropriate amount of corticosteroid or anesthetic into the trigger point of each muscle.

How To Use CPT 20553

Trigger point codes are based on the number of muscles treated, not the number of injections.

To report treatment of one or two muscles, use CPT code 20552. To report treatment of three or more muscles, use CPT code 20553.

These codes should not be used in conjunction with codes 20560 and 20561 for the same muscles.

If imaging guidance is utilized during the procedure, codes 76942, 77002, or 77021 should be used instead.”

Example

A patient comes in complaining of severe lower back pain. The provider performs a single TPI to the patient’s quadratus lumborum, and two injections each to the gluteus maximus and gluteus medius.

The correct code to report in this scenario would be CPT 20553 because the provider performed TPIs on three muscles.

Resources

CPT Professional 2022

https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=57114

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