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Pulling the Trigger: New Policies and Impediments Involving Trigger Points

April 29, 2024

Last week, we published an article that explored the value that a chronic pain practice can bring to an anesthesia group. Today’s alert delves further into the chronic pain domain by focusing on one of the specialty’s go-to procedures: the trigger point injection (TPI).

Five of the seven Medicare administrative contractors (MACs) have recently adopted a new Local Coverage Determination (LCD)—Medicare’s designation for “medical policy”—that focusses on TPIs. The new LCDs, which became effective in April, contain several changes that will place a greater burden on chronic pain providers. Below, we have listed the main takeaways of these LCDs.

Medical Necessity Threshold

According to a presentation of the new LCD by Dr. Meredith Loveless, chief medical officer for Cigna Government Services (CGS), pain practitioners will have to meet a high bar before submitting a claim for TPI. Trigger point injections (TPI) will be considered medically reasonable and necessary to treat myofascial pain caused by trigger points only when all the following requirements are met:

  1. There is a focal area of pain in the skeletal muscle.
  2. There is clinical evidence of a trigger point defined as pain in a skeletal muscle that is associated with at least 2 of the following findings: the presence of a hyperirritable spot and/or taut band identified by palpation and possible referred pain, AND
  3. The physical examination identifies a focal hypersensitive bundle or nodule of muscle fiber harder than normal consistency with or without a local twitch response and referred pain, AND
  4. Non-invasive conservative therapy is not successful as first line treatment OR movement of a joint or limb is limited or blocked OR the TPI is necessary for diagnostic confirmation.

Providers should ensure their medical record reflects each of the above criteria in the event of an audit.

Follow-Up Treatments

According to the new LCD, repeat injections in previously injected trigger points will be considered medically reasonable and necessary to treat myofascial pain syndrome only when all the following requirements are met:

  1. There is a positive pain response from the most recent TPI, which is defined as providing a consistent minimum of 50-percent relief of primary (index) pain after the TPI, measured by the same pain scale at baseline and post-injection, AND
  2. Consistent pain relief from the most recent previous TPI lasting at least 6 weeks, AND
  3. The myofascial pain has reoccurred and is causing objective functional limitations measured by a functional scale obtained at baseline and after TPI, which demonstrated at least 50-percent improvement from the previous TPI.

Trigger point primary index pain must be measured prior to the injection at the beginning of the session. In addition, the post-procedure pain level must be measured after the TPI at the conclusion of the session using the same scale utilized at baseline. Accordingly, your documentation should record the above data for each subsequent TPI injection.

Session Limits

A patient can receive a maximum of three sessions during a rolling 12-month period, regardless of whether you are billing CPT 20552 or 20553. In addition, the new LCDs do not allow treatment of more than one anatomical group during the same treatment session. It is not considered medically reasonable and necessary to perform multiple blocks (ESI, sympathetic blocks, facet blocks etc.) during the same session as TPI.

Concurrent Conservative Treatment

Patients should be part of an ongoing conservative treatment program. The provider must document in the medical record the extent to which the patient is actively participating in a rehabilitation program, home exercise program or functional restoration program.

Other Considerations

Neither fluoroscopy nor MRI is considered reasonable or necessary, and the LCD deemed ultrasound guidance (USG) in conjunction with TPI to be “investigational.” Therefore, imaging is no longer billable. This is perhaps the biggest change that will affect pain providers from a billing and reimbursement perspective.

In addition to the documentation requirements listed above, the provider must denote the location of the trigger points and the muscles injected, as well as the name and amount of the drug injected.

The carriers adopting the new TPI LCDs are NGS, CGS, Palmetto, WPS, and Noridian. According to ASIPP, Novitas and First Coast did not participate with the other MACs in developing this multijurisdictional LCD and have not adopted their own TPI LCD. Chronic pain providers are encouraged to download and review their MAC’s TPI LCD and accompanying Billing Article to ensure they understand and follow all the requirements.

Finally, it should be noted that the Billing and Coding article that aligns with these new LCDs states the following: “No anesthesia codes should be billed in conjunction with 20552 or 20553.”

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