Question

A 27 year-old presents with right-sided thoracic myofascial pain. a 25-gauge 1.5-inch needle on a 10 cc controlled syringe with 0.25% bupivacaine was used. after negative aspiration, 2 cc were injected into each trigger point. a total of four trigger points were injected. a total of 8 cc of bupivacaine was used on the rhomboid major, rhomboid minor, and levator scapular muscles. what cpt® code(s) is/are reported for this procedure? answer

Answer 1

This is a case of a patient with right sided thoracic myofascial (involving the muscles and the overlying fascia) pain involving 3 muscle groups that was injected with a local anesthetic (Bupivacaine) which are rhomboid major, rhomboid minor, and levator scapular muscles. The CPT code involving trigger point injections of 3 or more muscle groups is CPT 20553.