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Look sharp: Most states must follow a new trigger point LCD on April 1

A tough new policy for trigger point injections (20552-20553) will soon hit 38 states. Practices that don’t prepare will trigger denials that can’t be cured with an appeal.
Practices that perform this common pain treatment should make a point of studying the new local coverage determination (LCD) and companion billing and coding article before the new policy goes into effect.
All seven A/B Medicare administrative contractors (MAC) met April 27, 2023, to discuss trigger point injections (subscription required). Later that year CGS Administrators, National Government Services, Noridian, Palmetto GBA and WPS issued proposed uniform LCDs that included strict new guidelines.
The same five MACs have issued final versions of the policy with no substantial changes to the proposed versions. The following chart contains a link and effective date for each MAC’s new LCD.
New LCD #
Effective date
CGS Administrators
April 1
National Government Services
April 1
April 1
Palmetto GBA
March 31
April 1
First Coast Service Options and Novitas have not issued proposed LCDs, which would be the first step for updating a policy. Practices in those jurisdictions should watch their MAC for updates.
Share the new policy with staff
Make sure you share the new LCD and the companion billing and coding article with the appropriate members of the practice. You can find the article by scrolling down to “Related Documents” in the LCD.
Here are four highlights from the new policy:
  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).
Blog Tags: CMS, MACs
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