(continued) Harvard Pilgrim Health Care—Provider Manual H.298 December 2020

Payment Policies

Trigger Point InjectionsPolicy

Trigger Point Injections are used to treat painful areas of muscle that contain trigger points, or knots of muscle that form when muscles do not relax. trigger points may irritate the nerves around them and cause pain at the site of the trigger point or the pain can be felt in other parts of the body, including the back and neck. trigger point injections involve injection of local anesthetic, saline, dextrose, and/or cortisone into the trigger point.

Harvard Pilgrim reimburses contracted providers for trigger point injections when medically necessary and appropriate. Harvard Pilgrim Health care payment policy is consistent with cms lcD trigger Point injection policy, american academy of craniofacial Pain, agency for Healthcare Research and Quality (aHRQ) guidelines.

Prerequisite(s)

applicable Harvard Pilgrim referral, notification and authorization policies and procedures apply. Refer to Referral, Notification and Authorization for more information.

Open Access HMO and POSFor Open Access HMO and Open Access POS products, no referral is required to see a contracted specialist.

Harvard Pilgrim Reimburses1

HMO/POS/PPOtrigger point injections when billed with the cPt and icD codes listed under the “Provider Billing Guidelines and Docu-mentation” section of this policy. covered indications may include, but are not limited to:

• Central pain syndrome

• Other acute pain

• Other chronic pain

• Cervicalgia

• Other disorders of the back

• Rheumatism excluding the back

• Myalgia and myositis, unspecified

Harvard Pilgrim Does Not Reimbursetrigger point injections when billed with an icD code not listed below under the “Provider Billing Guidelines and Docu-mentation” section of this policy.

Member Cost-Sharingservices subject to applicable member out-of-pocket cost (e.g., co-payment, coinsurance, deductible).

Provider Billing Guidelines and Documentation

Coding2

Trigger Point Injections - CPT and ICD-10 Covered Indications

CPT Description

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 Covered Indications

Related Policies• Pain Management for Non-Anesthesiologists Payment Policy

Harvard Pilgrim Health Care—Provider Manual H.299 December 2020

PuBlication HistoRy 04/15/10 new policy—effective 07/01/1010/15/10 update to policy statement and added covered diags resulting from 10/1/10 ICD-9/ICD-10 release updates01/15/11 added new covered indications effective 1/15/2011 for annual coding and billing update01/01/12 removed First Seniority Freedom information from header12/15/12 annual review minor edits for clarity; bi-annual benchmark no updates12/15/13 annual review; no changes06/15/14 added Connecticut Open Access HMO referral information to prerequisites12/15/14 annual review; no changes07/30/15 ICD-10 coding update12/15/15 annual review; added related policies12/15/16 annual review; administrative edits01/15/17 ICD-10 coding update12/15/17 annual review; no changes02/01/18 updated Open Access Product referral information under Prerequisites10/01/18 ICD-10 coding update12/03/18 annual review; removed ICD-9 references; administrative edit11/01/19 ICD-10 coding update effective 10/01/1912/02/19 annual review; no changes12/01/20 annual review; no changes

1This policy applies to the products of Harvard Pilgrim Health Care and its affiliates—Harvard Pilgrim Health Care of Connecticut, Harvard Pilgrim Health Care of New England, and HPHC Insurance Company—for services performed by contracted providers. Payment is based on member benefits and eli-gibility, medical necessity review, where applicable, and provider contractual agreement. Payment for covered services rendered by contracted providers will be reimbursed at the lesser of charges or the contracted rate. (Does not apply to inpatient per diem, DRG, or case rates.) HPHC reserves the right to amend a payment policy at its discretion. CPT and HCPCS codes are updated annually. Always use the most recent CPT and HCPCS coding guidelines.2The table may not include all provider claim codes related to Trigger Point Injection services.

Payment Policiestrigger Point injections (cont.)