Injection Series: Part III – Trigger Points

women grabbing her neck in pain

Photo Credit: FreePik

Myofascial pain syndrome affects certain muscles and fascial tissues. Pain arises when pressure is applied to sensitive areas known as trigger points. These trigger points are persistent, highly irritable spots that can develop in any skeletal muscle due to acute or chronic stress. These points generate a specific referred pain pattern for the affected muscle. Each pattern is associated with a unique myofascial pain syndrome (MPS) of a single muscle.

Pain management treatment involves injections of a therapeutic agent:

  • Local anesthetics (e.g., lidocaine, and/or Marcaine)
  • Corticosteroids (e.g., triamcinolone or dexamethasone)
  • Non-steroidal anti-inflammatory medications (e.g., Toradol)
  • Botox (helps with muscle spasms by disrupting nerve signal)

Therapeutic injections can often be administered together. For instance, using lidocaine and Marcaine to anesthetize the area before a corticosteroid injection is quite common. At a minimum, basic procedural documentation is necessary to allocate the correct CPT/HCPCS codes.

Top TPE Errors:

Medical Necessity:
  • The documentation did not provide evidence that a trigger point injection was performed.
  • The documentation did not demonstrate that local coverage determination (LCD) requirements were satisfied.
Insufficient Documentation: 
  • Documentation was not submitted timely
  • Documentation did not support sufficient evidence of supervising physician (Incident to)
  • Documentation errors relating to the number of muscles injected
    • The LCD stipulates that when a specific site is injected, it is counted as a single injection service, irrespective of the number of injections given.

Frequency Limitation

The LCD policy stipulates that trigger point injections are typically not to be administered more than three times within a three-month period. Should trigger point injections exceed three sessions in a three-month span, the rationale for repeated procedures and the injected substances must be clearly documented in the medical record and accessible to the Contractor when requested.

For more information, please see the Novitas Trigger Point Injection documentation checklist and LCD policy links below.

Last in our series, Injection Series: Part IV – (ESI) Epidural Steroidal Injections

Novitas TPE:  Trigger Point Injections and Checklist

CDI Trigger Point Tip Sheet