Trigger Point Injections

Jurisdiction: JL MAC Part B. States: Delaware, District of Columbia, Maryland, New Jersey, Pennsylvania. Type: Active LCD

Compliance with the provisions in this LCD may be monitored and addressed through post payment data analysis and subsequent medical review audits. History/Background and/or General Information Trigger point injection is one of many modalities utilized in the management of chronic pain. Myofascial trigger points are self-sustaining hyperirritative foci that may occur in any skeletal muscle in response to strain produced by acute or chronic overload. These trigger points produce a referred pain pattern characteristic for that individual muscle. Each pattern becomes part of a single muscle myofascial pain syndrome (MPS) and each of these single muscle syndromes are responsive to appropriate treatment, which includes injection therapy. An injection is achieved with the insertion of a needle and the administration of agents, such as local anesthetics, steroids and/or local anti-inflammatory drugs. The diagnosis of trigger points requires a detailed history and thorough physical examination. The following clinical symptoms may be present when making the diagnosis: History of onset of the painful condition and its presumed cause (e.g., injury or sprain) Distribution pattern of pain consistent with the referral pattern of trigger points Range of motion restriction Muscular deconditioning in the affected area Focal tenderness of a trigger point Palpable taut band of muscle in which trigger point is located Local taut response to snapping palpation Reproduction of referred pain pattern upon stimulation of trigger point The goal is to treat the cause of the pain and not just the symptom of pain. Covered Indications After myofascial pain syndrome (MPS) is established, trigger point injection may be considered medically reasonable and necessary: When noninvasive medical management is unsuccessful (e.g., analgesics, passive physical therapy, ultrasound, range of motion and active exercises). As a bridging therapy to relieve pain while other treatments are also initiated, such as medication or physical therapy; or as a single therapeutic maneuver. The logic behind such therapeutic decision making should be obvious in the medical record and available upon Contractor request. When joint movement is mechanically blocked as is the case of the coccygeus muscle. Limitations The following are considered not medically reasonable and necessary: Medicare does not cover Prolotherapy. Its billing under the trigger point injection code is a misrepresentation of the actual service rendered. When a given site is injected, it will be considered one injection service, regardless of the number of injections administered. For frequency limitations, please refer to the Utilization Guidelines section below. Notice : Services performed for any given diagnosis must meet all of the indications and limitations stated in this LCD, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.