CMS states TPI should only have local. No steroid.

[thecgrblue]

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New CMS rule Sept 2026, only two covered codes 20552 and 20553. No steroid or any other inject are to be utilized, local only.

Also specific limits on frequency to 3 in 12 month period unless you’re essentially putting a disclaimer in the chart. Big change from “treatment” and “maintenance” wording.

 

[Orin]

Article - Billing and Coding: Trigger Point Injections (A57114)

Use this page to view details for the Local Coverage Article for Billing and Coding: Trigger Point Injections.

www.cms.gov

Utilization Parameters

Per the LCD, no more than 3 TPI sessions are expected within a rolling 12‑month period. However, in select circumstances, there may be a therapeutic benefit to an additional session. Consistent with the LCD, reporting 4 TPI sessions in a rolling 12-month period will require attestation; however, 5 or more sessions will be denied.

Documentation Requirements

1. All documentation must be maintained in the patient's medical record and made available to the contractor upon request.
2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.
3. The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.
4. For the treatment of established trigger points, the patient’s medical record must have:
   1. The evaluation/process of arriving at the diagnosis of the trigger point in an individual muscle or muscle group must be clearly documented in the patient’s medical record.
   2. The reason for the trigger point injection, and whether it is being used as an initial or subsequent treatment for myofascial pain, as well as the appropriate diagnosis code, must be clearly documented in the patient's medical records.
5. Attestation for extended services (e.g., above 3 TPI sessions per rolling 12 months) must be supported by documentation that validates the therapeutic benefit of additional TPIs beyond what is typically expected, including:
   1. Clinical indications for continued treatment,
   2. Documentation of adherence to multi-modal therapy,
   3. Evidence of prior response and ongoing medical necessity,
   4. Compliance with frequency and duration limits,
   5. All required elements specified in the LCD.

 

[Dr. Ice]

Are people routinely dumping steroid in their trigger points..think I stopped doing that in residency

 

[Painologist]

I still add steroid when I do TPs. That being said, I rarely do them. Mostly a sham procedure with limited benefit in my mind

 

[Dr. Ice]

Def no benefit with the steroids either..

 

[nvrsumr]

The micromanaging is ridiculous . I have not done a tpi in a decade but if u graduated med school im ok with them adding whatever. Sarapin was still I thing when I stopped tpi

 

[drusso]

New CMS rule Sept 2026, only two covered codes 20552 and 20553. No steroid or any other inject are to be utilized, local only.

Also specific limits on frequency to 3 in 12 month period unless you’re essentially putting a disclaimer in the chart. Big change from “treatment” and “maintenance” wording.

Most of the time, the people getting TPI's for myofascial pain actually have PMR or other "rheumatism" and feel great with a little steroid in their TPI. I'll have to start charging them cash for that.

 

[Dr. Ice]

They feel great for 24 hours and then ask for it every week..that’s the problem. It’s sham and def shouldn’t have steroid in it

 

[Agast]

I do them a lot for people who have cervical radicular pain and rotator cuff/shoulder arthritis. The shooting sensation won’t stop until the knots go away.

 

[buddababa]

New CMS rule Sept 2026, only two covered codes 20552 and 20553. No steroid or any other inject are to be utilized, local only.

Also specific limits on frequency to 3 in 12 month period unless you’re essentially putting a disclaimer in the chart. Big change from “treatment” and “maintenance” wording.

This has been the case for over a year

 

[Ferrismonk]

I rarely, if ever, will do a TPI and bill for it. Usually just a freebee added to another procedure. IF I do TPI, local only or maybe add toradol. Basically a fancy IM injection at that point.

 

[Dr. Ice]

The sham docs are the ones doing tpi with steroid and med management..”keeps em coming back for more”

 

[painfree23]

Most of the time, the people getting TPI's for myofascial pain actually have PMR or other "rheumatism" and feel great with a little steroid in their TPI. I'll have to start charging them cash for that.

if they have Medicare how can u charge cash?

 

[callmeanesthesia]

if they have Medicare how can u charge cash?

Not covered by Medicare if you’re using steroid so you have them sign an ABN and bill with modifier GA. Juice probably not worth the squeeze.

 

[drusso]

They feel great for 24 hours and then ask for it every week..that’s the problem. It’s sham and def shouldn’t have steroid in it

How is it a sham if it works for 24 hours?

 

[powermd]

Been doing fascia hydrodissection with ultrasound for years instead of TPs. Way more effective and satisfying to do. I charge $185 per region/side. $195 if dextrose 50% used. F Medicare and their rules. I haven't done a "trigger point" based on their covered methodology in a decade.

 

[FSQT]

As a utilizer of 5% dextrose, how do you feel about this on concert with anesthetic? E.g., 1 mL 50% dextrose mixed with 9 mL 1% lidocaine.

What fascial planes are you typically going after? Between trap and rhomboid minor where the SAN lives? Rhomboid and serratus posterior?

Thanks!

 

[powermd]

As a utilizer of 5% dextrose, how do you feel about this on concert with anesthetic? E.g., 1 mL 50% dextrose mixed with 9 mL 1% lidocaine.

What fascial planes are you typically going after? Between trap and rhomboid minor where the SAN lives? Rhomboid and serratus posterior?

Thanks!

I do straight up dilute 0.125% bupi in patients with "catching" points in their traps, or elsewhere. Also for specific nerve hydrodissections. When the issue is closer to a chronic muscle strain/tear I'll lean toward prolo with 50% dextrose 15 mL mixed with 0.5% bupi 5 mL, like a poor man's PRP but with local.

As to what fascia plans... that's a long answer. Most common would be the superficial trap fascia, the thoracic erector/trap/lat fascia, and the lumbar erector/lat fascia. Pain relief is usually achieved with the more superficial rather than deep layers.

 

[Welcome123]

I will use steroid in tpi and may follow it with medrol dose pak to cool a patient down if they are coming in with a lot of pain before setting up potential interventional spine procedure esi/si/facet. Insurance auths significantly delay setting up the more appropriate procedures and i would prefer to have the patients feel better sooner rather than waiting for me to argue with a pediatrician in the peer review about the appropriate nature of an esi. On a side note. It seems like medicare wants to phase out tpi

 

[painfree23]

I will use steroid in tpi and may follow it with medrol dose pak to cool a patient down if they are coming in with a lot of pain before setting up potential interventional spine procedure esi/si/facet. Insurance auths significantly delay setting up the more appropriate procedures and i would prefer to have the patients feel better sooner rather than waiting for me to argue with a pediatrician in the peer review about the appropriate nature of an esi. On a side note. It seems like medicare wants to phase out tpi

How much steroid are your patients exposed to in a month??

 

[Dr. Ice]

How is it a sham if it works for 24 hours?

Not sure your boy centeno would approve of you putting steroids in anywhere let alone a TPI

 

[Welcome123]

How much steroid are your patients exposed to in a month??

4mg dex and medrol dose pak until esi is scheduled which may have delays up to 2-3weeks

 

[Welcome123]

4mg dex and medrol dose pak until esi is scheduled which may have delays up to 2-3weeks

This is in the setting of a patient in severe pain not likely to get scheduled quickly. -oh wait, was that meant as a dig? Curious as to what your management would be advil and PT? LOL

 

[bedrock]

New CMS rule Sept 2026, only two covered codes 20552 and 20553. No steroid or any other inject are to be utilized, local only.

Also specific limits on frequency to 3 in 12 month period unless you’re essentially putting a disclaimer in the chart. Big change from “treatment” and “maintenance” wording.

The official rules say they won’t pay for the J code of a steroid not that they won’t pay the CPT codes 20553 or 20552 if you do it with a steroid.

Won’t affect me as I use toradol + lido, lido only if toradol contraindicated, or do cash TPI with PRP.

I find TPI with toradol often helpful during the 1 month f/u after cervical RFA.

I hate the cms micromanaging the number of TPI that can be done each year but I agree with them not paying for steroid in TPI. No one should be using steroid in TPI.

 

[clubdeac]

The official rules say they won’t pay for the J code of a steroid not that they won’t pay the CPT codes 20553 or 20552 if you do it with a steroid.

Won’t affect me as I use toradol + lido, lido only if toradol contraindicated, or do cash TPI with PRP.

I find TPI with toradol often helpful during the 1 month f/u after cervical RFA.

I hate the cms micromanaging the number of TPI that can be done each year but I agree with them not paying for steroid in TPI. No one should be using steroid in TPI.

How much Toradol are you injecting per site? Might start doing this as well. Any risk injecting it around the neck with increased vasculature?

 

[bedrock]

How much Toradol are you injecting per site? Might start doing this as well. Any risk injecting it around the neck with increased vasculature?

I use 30mg total. No issues doing cervical TPI.

 

[painfree23]

The official rules say they won’t pay for the J code of a steroid not that they won’t pay the CPT codes 20553 or 20552 if you do it with a steroid.

Won’t affect me as I use toradol + lido, lido only if toradol contraindicated, or do cash TPI with PRP.

I find TPI with toradol often helpful during the 1 month f/u after cervical RFA.

I hate the cms micromanaging the number of TPI that can be done each year but I agree with them not paying for steroid in TPI. No one should be using steroid in TPI.

PRP in a tpi?? How long do these last?

 

[lobelsteve]

PRP in a tpi?? How long do these last?

Hopefully not long so you can charge more money for the next one.
How is the literature for anything other than the needle, or lido for comfort?

 

[clubdeac]

The official rules say they won’t pay for the J code of a steroid not that they won’t pay the CPT codes 20553 or 20552 if you do it with a steroid.

Won’t affect me as I use toradol + lido, lido only if toradol contraindicated, or do cash TPI with PRP.

I find TPI with toradol often helpful during the 1 month f/u after cervical RFA.

I hate the cms micromanaging the number of TPI that can be done each year but I agree with them not paying for steroid in TPI. No one should be using steroid in TPI.

Just saw a post RF patient today and did some paraspinal lumbar TPIs with Lido and Toradol. We’ll see how it does.

 

[bedrock]

PRP in a tpi?? How long do these last?

I‘ve had several patients achieve a full year of 80% relief after PRP TPI. It doesn’t work for everyone, and I don’t offer this frequently, but I’ve seen some home runs.

 

[lobelsteve]

I‘ve had several patients achieve a full year of 80% relief after PRP TPI. It doesn’t work for everyone, and I don’t offer this frequently, but I’ve seen some home runs.

Magical thinking. RF and kypho can be due to our procedures. Everything else is 8-12 weeks or less. And if they are better then it is for other reasons.

 

[bedrock]

Magical thinking. RF and kypho can be due to our procedures. Everything else is 8-12 weeks or less. And if they are better then it is for other reasons.

Lol. You haven’t changed.

 

[BobBarker]

Lol. You haven’t changed.

But yet he is putting pearls of bone graft into compression fractures. The duality of Steve will be studied by our AI overlords for generations to come.

 

[lobelsteve]

But yet he is putting pearls of bone graft into compression fractures. The duality of Steve will be studied by our AI overlords for generations to come.

I'm sorry, Dave. I'm afraid I can't do that"

 

[Laryngospasm]

Well there’s always stim..

 

[BobBarker]

Yes. It is so funny, they basically removed all the guard rails from scs the most expensive procedure we can do with the ncd shrinking to a paragraph and are targeting the cheapest thing we can do. Thanks big stim. They are better at this game than us.

 

[potcake76]

New CMS rule Sept 2026, only two covered codes 20552 and 20553. No steroid or any other inject are to be utilized, local only.

Also specific limits on frequency to 3 in 12 month period unless you’re essentially putting a disclaimer in the chart. Big change from “treatment” and “maintenance” wording.

Remember, this new policy was published only by FCSO and Novitas, so it only applies to states in those jurisdictions.

 

[painfree23]

How much Toradol are you injecting per site? Might start doing this as well. Any risk injecting it around the neck with increased vasculature?

Do you not inject for ckd or if anticoagulated?

 

[lobelsteve]

Do you not inject for ckd or if anticoagulated?

What is your concern with a single shot of 15mg?

 

[clubdeac]

Do you not inject for ckd or if anticoagulated?

I guess I probably would leave toradol out in those situations