60606
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Patients should be part of an ongoing conservative treatment program and documentation to support the patient is actively participating in a rehabilitation program, home exercise program or functional restoration program is in the medical record.
- Trigger point primary index pain must be measured prior to the injection at the beginning of the session (baseline measurement on a documented pain scale).
- The post procedure pain level must be measured after the TPI at the conclusion of the session using the same pain scale utilized at baseline.
- When documenting the percentage of pain relief from the primary (index) pain compared to the post-injection pain levels, it is insufficient to report only a percentage of pain relief and/or a nonspecific statement of the duration of pain relief. The documentation should include a specific assessment of the duration of relief being consistent or inconsistent with the agent used for the injection and the specific dates the measurements were obtained using the SAME pain scale used at baseline.
Key Coverage Criteria
- Initial Trigger Point Injection: Trigger point injections (TPI) will be considered medically reasonable and necessary to treat myofascial pain caused by trigger points when all the following requirements are met: 1) There is a focal area of pain in the skeletal muscle.
- Initial Trigger Point Injection: 2) There is clinical evidence of a trigger point defined as pain in a skeletal muscle that is associated with at least 2 of the following findings: the presence of a hyperirritable spot and/or taut band identified by palpation and possible referred pain.
- Initial Trigger Point Injection: 3) The physical examination identifies a focal hypersensitive bundle or nodule of muscle fiber harder than normal consistency with or without a local twitch response and referred pain.
- Initial Trigger Point Injection: 4) Non-invasive conservative therapy is not successful as first line treatment OR movement of a joint or limb is limited or blocked OR the TPI is necessary for diagnostic confirmation.
- Subsequent TPI: Repeat trigger point injections of previously injected trigger points will be considered medically reasonable and necessary to treat myofascial pain syndrome when all of the following requirements are met: 1) There is a positive pain response from the most recent TPI defined as providing consistent minimum of 50% relief of primary (index) pain after the TPI measured by the SAME pain scale at baseline and post-injection.
- Subsequent TPI: 2) Consistent pain relief from the most recent previous TPI lasting at least 6 weeks.
3 Active Policies
L40003 — Molecular Pathology Procedures
J06
L36859 — Trigger Point Injections (TPI)
L39755 — Skin Substitute Grafts/Cellular and Tissue-Based Products for the Treatment of Diabetic Foot Ulcers and Venous Leg Ulcers
Related Codes
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