CPT® code 20552 is used to report trigger point injections administered into one or two muscles, for pain management and musculoskeletal dysfunction. These injections are typically performed in outpatient settings by pain management specialists, physiatrists, chiropractors, and integrative or sports medicine providers.
Description of Procedure
CPT 20552 represents the injection of anesthetic and/or corticosteroid agents into trigger points—hyperirritable spots within skeletal muscle that are associated with palpable nodules in taut bands of muscle fibers.
The procedure involves:
- Identifying one or more trigger points in one or two muscles
- Sterilizing the injection site
- Inserting a needle into the taut muscle band
- Injecting medication to relieve pain, reduce inflammation, and improve function
These injections may be performed for a variety of clinical conditions, including myofascial pain syndrome, fibromyalgia, neck and back pain, and sports-related muscular tightness.
When to Report CPT Code 20552
Report CPT code 20552 when administering trigger point injections in one or two muscles, regardless of how many trigger points are treated within those muscles.
If more than two muscles are injected during the same session, CPT code 20553 (injection(s); single or multiple trigger point(s), three or more muscles) should be reported instead.
Documentation must include:
- Medical necessity (e.g., failed conservative therapy, functional limitation)
- Muscles treated
- Medications used (e.g., lidocaine, bupivacaine, corticosteroids)
- Response to prior treatment, if applicable
Coding Tips
- Do not report CPT 20552 in conjunction with dry needling (CPT 20560 or 20561) unless both are distinct and separately identifiable procedures.
- Use the appropriate ICD-10 diagnosis code that supports the medical necessity of trigger point injection (e.g., M79.1 – Myalgia).
- Modifier -59 may be required when multiple injection procedures are billed together on the same day.
Streamline Pain Management Workflows with OptiMantra
For integrative, physical medicine, or pain management clinics that routinely perform trigger point injections, clear documentation and accurate coding are vital for proper reimbursement. OptiMantra helps providers streamline this process with:
- Custom chart note templates for injection-based services
- Integrated CPT + ICD-10 pairing to prevent claim denials
- One-click superbill creation for rapid coding and billing
- Real-time inventory tracking for injectable supplies
With OptiMantra, providers can spend less time navigating paperwork and more time focusing on patient recovery—ensuring every injection is properly documented, coded, and reimbursed.
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