Question: Anesthesia was given when a patient had a trigger point injection because the patient had a great fear of needles and was highly anxious about the procedure. Would either 00300 or 00400 be appropriate with 20552?
Answer: The trigger point injection itself includes a local anesthetic and normally doesn’t require anesthesia in conjunction with administration. In such case, only report 20552 (Injection[s]; single or multiple trigger point[s], 1 or 2 muscle[s]) for the therapeutic injection.
A possible exception would be if the provider who plans to administer the injection requests anesthesia from a different provider. In that situation, clear documentation of the request for anesthesia is required, and the codes mentioned above (00300—Anesthesia for all procedures on the integumentary system, muscles and nerves of head, neck, and posterior trunk, not otherwise specified; 00400—Anesthesia for procedures on the integumentary system on the extremities, anterior trunk and perineum; not otherwise specified) might be appropriate depending on the circumstances. Unfortunately, payors are reluctant to pay this combination and it can be difficult to get properly paid.