Hit the Bulls Eye With Trigger Point Coding

By Susan Dooley

Triamcinolone acetonide, a corticosteroid medication often sold under the brand name Kenalog, can be
used both as a topical ointment and as an injectable. This popular medication has many uses, including
trigger point injection.

What Are Trigger Points?

Physicians often use Kenalog for trigger point injections to treat conditions like myofascial pain
syndrome. Trigger points, or painful knots in muscles and fascia, the sheaths that surround muscle,
produce pain in both local and referred patterns. Often caused by repetitive motion activities,
myofascial pain may occur after a muscle has been contracted repeatedly.

The Coding Institute LLC, 2222 Sedwick Road, Durham, NC 27713, Eenterprise Contact: Sam Nair, Direct: 704 303 8150,
shyamn@codinginstitute.com

Review This Scenario to Hone Your Trigger Point Injection Reporting

How do you report trigger point injections? First, make sure the clinicians documentation clearly
delineates the names of the medications used in the injection and the dosage and amount injected.
Lets say your physician sees a patient with acute myofascial pain syndrome with severe pain in the neck
and shoulder region. The physician performs three injections of Kenalog in the trapezius muscle of the
neck and two injections of the same drug in the levator scapulae muscles of the shoulder. Each injection
of Kenalog consists of a 10 mg dosage, for a total of 50 mg.

To report this treatment, you must code for both the procedure, using a CPT code, and for the drug
supply of Kenalog, using a HCPCS code. First, lets consider our CPT code.

20552, Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s)

Because this code specifies a number of muscles injected, not a particular amount of medication or
number of injections, youll report 20552 because only two muscles (trapezius and levator scapulae)
were injected. Yes, the physician gave a total of five injections, but we dont capture the number of
injections with this CPT code. Instead, well use the following HCPCS code to get reimbursement for the
drug supply.

J3301, Injection, triamcinolone acetonide, not otherwise specified, 10 mg

Remember, in our scenario our physician made a total of 5 intramuscular injections of 10 mg of Kenalog
(triamcinolone acetonide) each. J3301 covers a single unit of 10 mg, so we will report 5 units of J3301 in
this case.

Brand Name or Generic Name Does It Matter for Reporting J3300 and J3301?
What if your providers documentation specifies the drug name Kenalog can you still report J3300
and J3301, which cover triamcinolone acetonide, the generic name of the drug?
The answer is yes in fact, you must use these codes for Kenalog. The HCPCS tabular listing is arranged
by generic drug name. When you look Kenalog up, it refers you to triamcinolone acetonide, which is the
generic name for Kenalog.

What About You?

Does your practice deal with trigger point injections? Let us know your questions or tips for success. Just
drop us a note.
The Coding Institute LLC, 2222 Sedwick Road, Durham, NC 27713, Eenterprise Contact: Sam Nair, Direct: 704 303 8150,
shyamn@codinginstitute.com

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Contact Us:
Name: Sam Nair
Title: Associate Director
Email: shyamn@codinginstitute.com
Direct: 704 303 8150

Desk: 866 228 9252, Ext: 4813

The Coding Institute LLC, 2222 Sedwick Road, Durham, NC 27713

The Coding Institute LLC, 2222 Sedwick Road, Durham, NC 27713, Eenterprise Contact: Sam Nair, Direct: 704 303 8150,
shyamn@codinginstitute.com