Proposed trigger point LCD contains tough limits, could become uniform across MACs

by: Julia Kyles, CPC Aug 22, 2023

Practices that perform trigger point injections (20552-20553) should read Noridian’s proposed local coverage determination (LCD) for the service and submit comments if they’re in Noridian’s jurisdiction. The LCD could be the model for a uniform LCD that several Medicare administrative contractors (MAC) adopt, and it includes some strict limits on the service.

Noridian published the proposed LCD on Aug. 11, a few months after it participated in a multi-jurisdictional contractor advisory committee meeting on April 27. Previous multi-jurisdictional meetings have resulted in a uniform LCD for services such as epidural steroid injections that all MACs use. More recently, five MACs have issued a proposed uniform LCD for urine drug testing.

During the meeting on trigger points, which was attended by representatives from all seven MACs, subject matter experts discussed a variety of issues related to the service (PBN 7/10/23, subscription required).

The proposed LCD refers to and reflects some of the subject matter experts’ input. For example, the experts agreed that the patient should receive at least 50% pain relief from a treatment before the provider repeats an injection, that there should be at least six weeks between treatments of the same area and that patients should also participate in some sort of conservative therapy.

However, Noridian’s proposed policy also includes features that do not reflect the discussion during the meeting. For example, the experts believed that ultrasound image guidance was necessary for injections in certain regions of the body, such as the thoracic area. But the proposed LCD declares ultrasound guidance is investigational for trigger points. In addition, the companion billing and coding article proposes a utilization limit of no more than three trigger point injection sessions in a rolling 12-month period. The experts did not discuss utilization limits during the meeting.

The article includes a list of 10 covered diagnosis codes for tension headaches and myalgia and 134 non-covered codes.

If you aren’t in Noridian’s jurisdiction, sign up for notifications from your MAC so you’ll know if it issues a proposed LCD for trigger points.

Practices in Noridian’s jurisdiction can submit comments directly from the LCD until Sept. 30.

Blog Tags: CMS, MACs

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