Medicare is updating the coverage and billing requirements for Trigger Point Injections (TPI) billed under CPT 20552 and 20553, effective September 6, 2026, in New Jersey and Texas.
These changes are important for providers to help prevent claim denials and ensure compliance with the updated Medicare requirements.
Key Changes
1. Limited Diagnosis Codes
The updated policy identifies the following two ICD-10-CM diagnosis codes for TPI coverage:
- M79.12 – Myalgia of auxiliary muscles, head and neck
- M79.18 – Myalgia, other site
Providers should ensure the diagnosis submitted on the claim is supported by the patient’s medical record.
2. Drug Code Restrictions
Certain HCPCS drug codes are restricted when billed with CPT 20552 or 20553, including:
J0585, J0586, J0587, J0588, J0589, J0702, J1010, J1100, J2919, J3121, J3300, J3301, and J7040.
3. Four-Injection Limit in a Rolling 12-Month Period
Medicare allows up to four TPI sessions within a rolling 12-month period, subject to the applicable coverage requirements.
For the fourth session, modifier KX is required. The medical record should also support the medical necessity and therapeutic benefit of continued treatment.
The detailed Article find here: LCD Policy