Local Coverage Determination (LCD):

Trigger Point Injections (L34211)

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Contractor Information

Contractor Name Contract Type Contract Number Jurisdiction State(s)

Noridian Healthcare Solutions, LLC A and B MAC 01111 - MAC A J-E California - Entire State
Noridian Healthcare Solutions, LLC A and B MAC 01112 - MAC B J-E California - Northern
Noridian Healthcare Solutions, LLC A and B MAC 01182 - MAC B J-E California - Southern
American Samoa
Guam
Noridian Healthcare Solutions, LLC A and B MAC 01211 - MAC A J-E
Hawaii
Northern Mariana Islands
American Samoa
Guam
Noridian Healthcare Solutions, LLC A and B MAC 01212 - MAC B J-E
Hawaii
Northern Mariana Islands
Noridian Healthcare Solutions, LLC A and B MAC 01311 - MAC A J-E Nevada
Noridian Healthcare Solutions, LLC A and B MAC 01312 - MAC B J-E Nevada
American Samoa
California - Entire State
Guam
Noridian Healthcare Solutions, LLC A and B MAC 01911 - MAC A J-E
Hawaii
Nevada
Northern Mariana Islands
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LCD Information
Document Information

LCD ID Original Effective Date

L34211 For services performed on or after 10/01/2015

Original ICD-9 LCD ID Revision Effective Date

L33498 For services performed on or after 10/01/2018

Revision Ending Date

LCD Title N/A
Trigger Point Injections
Retirement Date
Proposed LCD in Comment Period N/A
N/A
Notice Period Start Date
Source Proposed LCD 04/10/2017
DL34211
Notice Period End Date
05/25/2017
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

Printed on 10/9/2018. Page 1 of 7

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CMS National Coverage Policy

Title XVIII of the Social Security Act, §1862(a)(1)(A). Allows coverage and payment for only those services that
are considered to be medically reasonable and necessary.

Title XVIII of the Social Security Act, §1833(e). Prohibits Medicare payment for any claim which lacks the
necessary information to process the claim.

Coverage Guidance
Coverage Indications, Limitations, and/or Medical Necessity

Myofascial trigger points are small, circumscribed, hyperirritable foci in muscles and fascia, often found with a
firm or taut band of skeletal muscle.2 These trigger points produce a referred pain patterned characteristic for
that individual muscle. Each pattern becomes a single part of a single muscle syndrome. To successfully treat
chronic myofascial pain syndrome (trigger points) each single muscle syndrome needs to be identified along with
every perpetuating factor.

The pain of active trigger points can begin as an acute single muscle syndrome resulting from stress overload or
injury to the muscle, or can develop slowly because of chronic or repetitive muscle strain. The pain normally
refers distal to the specific hypersensitive trigger point. Trigger point injections are used to alleviate this pain.

There is no laboratory or imaging test for establishing the diagnosis of trigger points; it depends therefore upon
the detailed history and thorough examination. The following diagnostic criteria are adopted by this A/B MAC from
Simons.3

Major criteria. All four must be present to establish the diagnosis.

A. Regional pain complaint

B. Pain complaint or altered sensation in the expected distribution of referred pain from a trigger point
C. Taut band palpable in an accessible muscle with exquisite tenderness at one point along the length of it
D. Some degree of restricted range of motion, when measurable.

Minor criteria. Only one of four needed for the diagnosis.

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A. Reproduction of referred pain pattern by stimulating the trigger point
B. Altered sensation by pressure on the tender spot
C. Local response elicited by snapping palpation at the tender spot or by needle insertion into the tender spot
D. Pain alleviated by stretching or injecting the tender Spot

The goal is to identify and treat the cause of the pain, not just the symptom. After making the diagnosis of
myofascial pain syndrome and identifying the trigger point responsible for it, the treatment options are:

1. Medical management, which may include consultation with a specialist in pain medicine
2. Medical management that may include the use of analgesics and adjunctive medications, including anti-
depressant medications, shown to be effective in the management of chronic pain conditions.
3. Passive physical therapy modalities, including "stretch and spray" heat and cold therapy, passive range of
motion and deep muscle massage.
4. Active physical therapy, including active range of motion, exercise therapy and physical conditioning.
Application of low intensity ultrasound directed at the trigger point (this approach is used when the trigger
point is otherwise inaccessible).
5. Manipulation therapy.
6. Injection of local anesthetic, with or without corticosteroid, into the muscle trigger points.
7.
a. as initial or the only therapy when a joint movement is impaired, such as when a muscle cannot be
stretched fully or is in fixed position.

b. as treatment of trigger points that are unresponsive to non-invasive methods of treatment, e.g.,
exercise, use of medications, stretch and spray.

The CPT codes for trigger point injections use the phrase "muscle group(s)". For the purpose of this policy, this
A/B MAC defines "muscle group" as a group of muscles that are contiguous and that share a common function,
e.g., flexion, stabilization or extension of a joint. Trigger points that exist in muscles that are widely separated
anatomically and that have different functions may be considered to be in separate muscle groups.

To treat established trigger points, after identification, of the muscle or muscle group where the trigger point is
located and documenting that in the patient's medical record.

Coverage is provided for injections which are medically necessary due to illness or injury and based on symptoms
and signs. An injection of a trigger point is considered medically necessary when it is currently causing
tenderness and/or weakness, restricting motion and/or causing referred pain when compressed.

Use of injections should be done as part of an overall management (usually short term) plan including one or
more of the following:

1. Diagnostic evaluation to clearly identify the primary cause, if possible.

2. Physical and occupational therapy.
3. Psychiatric evaluation and therapy.
4. A trial of oral non-steroid analgesic/anti-inflammatory drugs, if not contraindicated.

Acupuncture is not a covered service, even if provided for treatment of an established trigger point.

Use of acupuncture needles and/or the passage of electrical current through these needles is not a covered
service, whether the service is rendered by an acupuncturist or any other provider.

Providers of acupuncture services must inform the beneficiary that their services will not be covered as
acupuncture is not a Medicare benefit.

Prolotherapy, the injection into a damaged tissue of an irritant to induce inflammation, is not covered by
Medicare. Billing this under the trigger point injection codes is misrepresentation.

"Dry needling" of trigger points is a non-covered procedure since it is considered unproven and investigational.

Screening diagnoses will be denied as routine services.

Compliance with the provisions in this policy is subject to monitoring by post payment data analysis and
subsequent medical review.
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Summary of Evidence

N/A

Analysis of Evidence
(Rationale for Determination)

N/A

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Coding Information
Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service.
Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all
Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally
to all claims.

999x Not Applicable

Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report
this service. In most instances Revenue Codes are purely advisory. Unless specified in the policy, services
reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all
Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to
apply equally to all Revenue Codes.

99999 Not Applicable

CPT/HCPCS Codes
Group 1 Paragraph: N/A

Group 1 Codes:
20552 INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 1 OR 2 MUSCLE(S)
20553 INJECTION(S); SINGLE OR MULTIPLE TRIGGER POINT(S), 3 OR MORE MUSCLES

ICD-10 Codes that Support Medical Necessity

Group 1 Paragraph:
These are the only covered ICD-10-CM codes that support medical necessity.

This A/B MAC will assign the following ICD-10-CM codes to indicate the diagnosis of a trigger point. Claims
without one of these diagnoses will always be denied.

Group 1 Codes:
ICD-10 Codes Description
M53.82 Other specified dorsopathies, cervical region
M53.83 Other specified dorsopathies, cervicothoracic region
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ICD-10 Codes Description
M53.84 Other specified dorsopathies, thoracic region
M53.85 Other specified dorsopathies, thoracolumbar region
M53.86 Other specified dorsopathies, lumbar region
M53.87 Other specified dorsopathies, lumbosacral region
M53.88 Other specified dorsopathies, sacral and sacrococcygeal region
M54.2 Cervicalgia
M54.5 Low back pain
M54.6 Pain in thoracic spine
M60.811 Other myositis, right shoulder
M60.812 Other myositis, left shoulder
M60.821 Other myositis, right upper arm
M60.822 Other myositis, left upper arm
M60.831 Other myositis, right forearm
M60.832 Other myositis, left forearm
M60.841 Other myositis, right hand
M60.842 Other myositis, left hand
M60.851 Other myositis, right thigh
M60.852 Other myositis, left thigh
M60.861 Other myositis, right lower leg
M60.862 Other myositis, left lower leg
M60.871 Other myositis, right ankle and foot
M60.872 Other myositis, left ankle and foot
M60.88 Other myositis, other site
M60.89 Other myositis, multiple sites
M79.18 Myalgia, other site
M79.7 Fibromyalgia

ICD-10 Codes that DO NOT Support Medical Necessity

Group 1 Paragraph:

All ICD-10-CM codes not listed in this policy under ICD-10-CM Codes That Support Medical Necessity above.

Group 1 Codes: N/A

ICD-10 Additional Information Back to Top

General Information
Associated Information
It is expected that trigger point injections would not usually be performed more often than three sessions in a
three month period. If trigger point injections are performed more than three sessions in a three month period,
the reason for repeated performance and the substances injected should be evident in the medical record and
available to the Contractor upon request.

This contractor may request records when it is apparent that patients are requiring a significant number of
injections to manage their pain.

Sources of Information

Local Medical Review Policy from Iowa, Aug 1999

1. Manchikanti L, Singh V, Kloth D, et al. Interventional Techniques in the Management of Chronic Pain: Part
2.0. Pain Physician. 2001;4(1):24-96
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 2. Simons DG. Muscular Pain Syndromes. In: JR Friction. Awad EA, JR. eds. Advances in Pain Research and
Therapy. Lippincott-Raven. Philadelphia. 1990;17:1-41.
3. Travell JG, Simons DG. Myofascial Pain and Dysfunction, The Trigger Point Manual. Baltimore. Lippincott
Williams & Wilkins. 1983.

The following sources of information were cited in the Iowa LMRP:

1. Other Carrier Policies (Kansas/Nebraska/Western Missouri, North Dakota, GHI of New York)
2. Satterthwaite, Dollison. Handbook of Pain Management. Williams and Wilkins. 1994;2 ed
3. Yale University School of Medicine, Department of Pain Management
4. Connecticut Society of Anesthesiology
5. Local Medical Policy from Nationwide Insurance Company
6. Medicare Operations Spine Five: 1980;193-200.
7. Journal of Neurosurgery. 1975;43:448-51.

Bibliography

N/A

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Revision History Information

Revision
Revision Reason(s) for
History Revision History Explanation
History Date Change
Number
09/28/2018: At this time 21st Century Cures Act will apply to
new and revised LCDs that restrict coverage which requires
comment and notice. This revision is not a restriction to the
coverage determination; and, therefore not all the fields
included on the LCD are applicable as noted in this policy. • Typographical
10/01/2018 R5
Error
Typographical error in revision history was corrected to read:
Effective 10/1/2018, LCD is revised per the annual ICD-10-CM
codes to add ICD-10-CM code M79.18
08/30/2018: At this time 21st Century Cures Act will apply to
new and revised LCDs that restrict coverage which requires
comment and notice. This revision is not a restriction to the
coverage determination; and, therefore not all the fields
included on the LCD are applicable as noted in this policy. • Revisions Due
10/01/2018 R4 To ICD-10-CM
Code Changes
Effective 10/1/2017, LCD is revised per the annual ICD-10-CM
code update to:

Add ICD-10-CM codes: M79.18

DATE (08/28/2017): At this time 21st Century Cures Act will apply to
new and revised LCDs that restrict coverage which requires comment
and notice. This revision is not a restriction to the coverage
determination; and, therefore not all the fields included on the LCD are • Revisions Due
10/01/2017 R3 applicable as noted in this policy. To ICD-10-CM
Code Changes
Effective 10/1/2017, LCD is revised per the annual ICD-
10-CM code update to: Add ICD-10-CM codes: M53.83; M583.84;
M53.85; M53.86; M53.87; M53.88
10/01/2017 R2

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 Revision
Revision Reason(s) for
History Revision History Explanation
History Date Change
Number
DATE (08/28/2017): At this time 21st Century Cures Act will • Revisions Due
apply to new and revised LCDs that restrict coverage which To ICD-10-CM
requires comment and notice. This revision is not a restriction Code Changes
to the coverage determination; and, therefore not all the fields
included on the LCD are applicable as noted in this policy.

Effective 10/1/2017, LCD is revised per the annual ICD-10-CM

code update to: Add ICD-10-CM codes: M53.83; M583.84;
M53.85; M53.86; M53.87; M53.88

• Creation of
03/15/2017 - This LCD version was created as a result of
Uniform LCDs
05/26/2017 R1 DL34211 being released to a Final LCD for creation of uniform
Within a MAC
LCDs within a MAC Jurisdiction.
Jurisdiction
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Associated Documents
Attachments N/A

Related Local Coverage Documents Article(s) A55472 - Response to Comments: Trigger Point Injections LCD(s)
DL34211 - (MCD Archive Site)

Related National Coverage Documents N/A

Public Version(s) Updated on 09/28/2018 with effective dates 10/01/2018 - N/A Updated on 08/30/2018 with
effective dates 10/01/2018 - N/A Updated on 08/28/2017 with effective dates 10/01/2017 - 09/30/2018 Updated
on 08/28/2017 with effective dates 10/01/2017 - N/A Some older versions have been archived. Please visit the
MCD Archive Site to retrieve them. Back to Top

Keywords

• Trigger
• Point
• Injections
• 20552
• 20553

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Printed on 10/9/2018. Page 7 of 7