Overview
CPT® Code 20551 is used to report the injection of a therapeutic substance into a single tendon origin or insertion. This procedure is typically performed by a physician, physiatrist, or other qualified healthcare provider for the treatment of pain, inflammation, or tendon-related disorders.
The code includes all preparation, localization, and injection of the tendon, but does not include evaluation, imaging guidance, or additional injections unless separately reported.
Key Facts About CPT® 20551
- Service type: Therapeutic injection
- Provider type: Physicians, orthopedists, physiatrists, or qualified clinicians
- Medical services included: Yes—single tendon origin/insertion injection with or without anesthetic
- Common clinical indications:
- Tendinitis (e.g., Achilles, patellar, biceps)
- Tenosynovitis or overuse injuries
- Pain or inflammation at tendon attachment sites
- Trigger points at tendon insertions
- Injection sites: Single tendon origin or insertion per session
When to Use CPT® 20551
CPT 20551 is appropriate when:
- A therapeutic injection is performed at a single tendon origin or insertion
- The procedure is medically necessary to reduce pain, inflammation, or improve function
- Documentation supports the site, diagnosis, and clinical indication
Example:
- Corticosteroid injection into the lateral epicondyle tendon origin for tennis elbow
Documentation Requirements
To properly support CPT 20551 billing, documentation should include:
- Patient identifiers and date of service
- Tendon origin or insertion treated
- Substance injected and dosage
- Indication for injection (e.g., tendinitis, inflammation)
- Technique and approach used
- Patient response and post-procedure instructions
Accurate documentation ensures compliance, reimbursement, and continuity of care.
Reimbursement and Coding Considerations
- CPT 20551 is typically covered by commercial insurers, Medicare, and Medicaid when medically necessary
- Report one code per tendon injected; use 20552 for each additional tendon during the same session
- Use appropriate modifiers when performed bilaterally or with other procedures
- Follow payer-specific rules for injections combined with imaging guidance
How OptiMantra Supports Tendon Injections
OptiMantra’s integrated EMR and practice management system streamlines documentation, coding, and billing for procedures like CPT 20551:
With OptiMantra, providers can:
- Document injection sites, techniques, and substances in structured templates
- Track patient outcomes and responses over time
- Automatically generate clean, audit-ready billing codes
- Integrate procedure notes with broader care plans and follow-up treatments
- Streamline follow-up reminders and patient education
By centralizing procedure documentation and billing, OptiMantra ensures accuracy, compliance, and optimal reimbursement for therapeutic tendon injections.
Try OptiMantra for free here!
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