New CMS Rules for Trigger Point Injections CPT 20552 and 20553 – Effective April 1st

CMS now has requirements, in 38 states, for providing trigger point injections, effective April 1^st, 2024.  Depending on your Medicare intermediary a highlight of the new rules are:

1. Initial and follow-up treatments. After an initial injection, subsequent treatments are medically necessary if the patient experiences a minimum of 50% pain relief that is consistent for at least six weeks.
2. Session limits. A patient can receive a maximum of three sessions during a rolling 12-month period. In addition, the new LCD does not allow treatment of more than one anatomical group during the same treatment session.
3. Concurrent conservative treatment. Patients must take part in an ongoing conservative treatment plan. The provider must document the patient’s participation.
4. Covered conditions restrictions. The new LCD will cover 10 ICD-10-CM codes for tension type headaches (G44.201-G44.229) and myalgia (M79.10-M79.18).

Be sure to read the full LCD policy for your region to fully understand the impact these rules will have on your practice.  Denials are possible, that cannot be appealed successfully.  Documentation is critical and may be requested by the payer.

Below is a list of the Medicare intermediaries and the new LCD’s, for your review.  Please note that Novitas and First Coast Service Options have not yet proposed changes but may implement similar guidelines soon.