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This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

02-20000-28

Original Effective Date: 11/15/00

Reviewed: 07/25/13

Revised: 01/01/16

Next Review: No Longer Scheduled for Routine Review (NLR)

Subject: Tendon Sheath, Ligament, and Trigger Point Injections

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

           
Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
           
Other References Updates  
           

DESCRIPTION:

Pain is defined as an unpleasant sensory and emotional experience, which may be associated with actual or potential tissue damage. The condition is considered as “chronic pain” when it has been present continuously or intermittently for three months or more.

Myofascial pain may develop from a muscle injury or from excessive strain on a particular muscle or muscle group, ligament or tendon. Injection of a tendon sheath, ligament, or trigger point with an anesthetic agent and/or steroid agent may be indicated for the management of pain.

NOTE: When zinc sulfate, psyllium seed oil, combinations of dextrose, glycerine, and phenol, or dextrose alone (D50) is injected into the ligament or surrounding structures, this is Prolotherapy. Prolotherapy is considered experimental or investigational. (See MCG 02-20000-08 Prolotherapy).

POSITION STATEMENT:

Tendon sheath and ligament injections (20550, 20551) meet the definition of medical necessity to relieve pain or dysfunction due to inflammation or pathological changes in the tendon sheath or ligament (e.g. fasciitis, tenosynovitis) when ALL of the following are met:

The initial set of injections may include up to 4 separate dates of service with injections are given no sooner than 1 week apart, AND

For continued injection therapy beyond the initial set of injections (up to 4 separate dates of service), subsequent injection requires that pain reduction of ≥ 50% for 6 weeks was achieved, AND

Injection therapy has not exceeded 1 year (Medical Director review required after one year of injection therapy).

Trigger point injections (20552, 20553) meet the definition of medical necessity to treat trigger points when ALL of the following criteria are met:

• Pain after 6 weeks with ALL of the following treatments:

o NSAIDS ≥ 4 weeks (if not contraindicated); AND

o Activity modification ≥ 6 weeks; AND

o Physical therapy, chiropractic therapy or home exercise program ≥ 6 weeks; OR

• Worsening pain after 2 weeks with ALL of the following treatments:

o NSAIDS (if not contraindicated); AND

o Activity modification; AND

o Physical therapy, chiropractic therapy or home exercise program; AND

• No associated neurological deficit; AND

The initial set of injections may include up to 4 separate dates of service with injections given no sooner than 1 week apart; AND

• For continued injection therapy beyond the initial set of injections (up to 4 separate dates of service), each subsequent injection requires that prior injection provided 50% pain reduction for 6 weeks; AND

Injection therapy has not exceeded 1 year (Medical Director review is required after one year)

Imaging guidance (ultrasound or fluoroscopic) performed with tendon sheath injection and ligament injection (20550, 20551) meets the definition of medical necessity.

Imaging guidance (ultrasound or fluoroscopic) performed with trigger point injection (20552, 20553) is considered experimental or investigational, as there is insufficient clinical evidence to permit scientific conclusions on net health outcomes.

Dry-needling of trigger points is considered experimental or investigational, as there is insufficient clinical evidence to permit scientific conclusions on net health outcomes.

BILLING/CODING INFORMATION:

CPT Coding:

20550

Injection(s); single tendon sheath, or ligament, aponeurosis (e.g., plantar “fascia”)

20551

Injection(s); single tendon origin/insertion

20552

Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s)

20553

Injection(s); single or multiple trigger point(s), 3 or more muscles

ICD-10 Diagnoses Codes That Support Medical Necessity for 20550 – 20551: (Effective 10/01/15)

D48.1

Neoplasm of uncertain behavior of connective and other soft tissue

M25.711 – M25.719

Osteophyte, shoulder

M25.721 – M25.729

Osteophyte, elbow

M25.731 – M25.739

Osteophyte, wrist

M25.741 – M25.749

Osteophyte, hand

M25.751 – M25.759

Osteophyte, hip

M25.761 – M25.769

Osteophyte, knee

M25.771 – M25.776

Osteophyte, ankle or foot

M46.00 – M46.09

Spinal enthesopathy

M46.1

Sacroiliitis, not elsewhere classified

M54.09

Panniculitis affecting regions of neck and back

M54.2

Cervicalgia

M54.5

Low back pain

M54.6

Pain in thoracic spine

M54.89

Other dorsalgia

M54.9

Dorsalgia, unspecified

M60.10 – M60.19

Interstitial myositis

M60.80 – M60.9

Other myositis

M62.40 – M62.49

Contracture of muscle

M62.830 – M62.838

Muscle spasm

M65.311 – M65.359

Trigger finger

M65.4

Radial styloid tenosynovitis [de Quervain]

M65.80

Other synovitis and tenosynovitis, unspecified site

M65.811 – M65.9

Other synovitis and tenosynovitis

M65.841 – M65.849

Other synovitis and tenosynovitis, hand

M65.88

Other synovitis and tenosynovitis, other site

M65.89

Other synovitis and tenosynovitis, multiple sites

M65.9

Synovitis and tenosynovitis, unspecified

M67.30 – M67.39

Transient synovitis

M70.10 – M70.12

Bursitis, hand

M70.20 – M70.22

Olecranon bursitis, elbow

M70.30 – M70.32

Other bursitis of elbow

M70.40 – M70.42

Prepatellar bursitis

M70.50 – M70.52

Other bursitis of knee

M70.60 – M70.62

Trochanteric bursitis, hip

M70.70 – M70.72

Other bursitis of hip

M72.1

Knuckle pads

M72.2

Plantar fascial fibromatosis

M72.4

Pseudosarcomatous fibromatosis

M72.9

Fibroblastic disorders

M75.00 – M75.02

Adhesive capsulitis of shoulder

M75.100 – M75.102
M75.111 - M75.112
M75.121 – M75.122

Unspecified, incomplete or complete rotator cuff tear, not specified as traumatic

M75.20 – M75.22

Bicipital tendinitis

M75.30 – M75.32

Calcific tendinitis of unspecified shoulder

M75.40 – M75.42

Impingement syndrome of shoulder

M75.50 – M75.52

Bursitis of shoulder

M75.80 – M75.92

Other shoulder lesions and shoulder lesion, unspecified

M76.01 – M76.02

Gluteal tendinitis hip

M76.00 – M76.12

Psoas tendinitis, side

M76.20 – M76.22

Iliac crest spur, hip

M76.30 – M76.32

Iliotibial band syndrome

M76.40 – M76.42

Tibial collateral bursitis [Pellegrini-Stieda]

M76.50 – M76.52

Patellar tendinitis

M76.60 – M76.62

Achilles tendinitis

M76.70 – M76.72

Peroneal tendinitis

M76.811 – M76.9

Other specified enthesopathies of the lower limb, except foot

M77.00 – M77.02

Medial epicondylitis, elbow

M77.10 – M77.12

Lateral epicondylitis, elbow

M77.20 – M77.22

Periarthritis, wrist

M77.30 – M77.32

Calcaneal spur

M77.40 – M77.42

Metatarsalgia,foot

M77.50 – M77.52

Other enthesopathy, foot

M77.8

Other enthesopathies, not elsewhere classified

M77.9

Enthesopathy, unspecified

ICD-10 Diagnoses Codes That Support Medical Necessity for 20552 – 20553: (Effective 10/01/15)

C49.9

Malignant neoplasm of connective and soft tissue, unspecified

M25.721 – M25.729

Osteophyte, elbow

M25.751 – M25.759

Osteophyte, hip

M25.771 – M25.776

Osteophyte, ankle or foot

M35.4

Diffuse (eosinophilic) fasciitis

M46.00 – M46.09

Spinal enthesopathy

M53.82

Other specified dorsopathies, cervical region

M53.9

Dorsopathy, unspecified

M54.00 – M54.09

Panniculitis affecting regions of neck and back,

M54.89

Other dorsalgia

M54.9

Dorsalgia, unspecified

M60.10

Interstitial myositis of unspecified site

M60.111 – M60.179

Interstitial myositis

M60.80 – M60.9

Other myositis

M60.9

Myositis, unspecified

M62.4

Contracture of muscle, unspecified site

M62.411 – M62.49

Contracture of muscle

M62.830 – M62.838

Muscle spasm

M62.89

Other specified disorders of muscle

M65.30

Trigger finger, unspecified finger

M65.311 – M65.359

Trigger finger

M65.4

Radial styloid tenosynovitis [de Quervain]

M65.80

Other synovitis and tenosynovitis, unspecified site

M65.811 – M65.9

Other synovitis and tenosynovitis

M65.841 – M65.849

Other synovitis and tenosynovitis, hand

M65.871 – M65.879

Other synovitis and tenosynovitis, ankle and foot

M65.88

Other synovitis and tenosynovitis, other site

M65.89

Other synovitis and tenosynovitis, multiple sites

M65.9

Synovitis and tenosynovitis, unspecified

M67.30 – M67.39

Transient synovitis

M70.20 – M70.22

Olecranon bursitis, elbow

M70.30 – M70.32

Other bursitis of elbow

M70.60 – M70.62

Trochanteric bursitis, hip

M70.70 – M70.72

Other bursitis of hip

M71.30

Other bursal cyst, unspecified site

M71.38

Other bursal cyst, other site

M71.39

Other bursal cyst, multiple sites

M72.1

Knuckle pads

M72.2

Plantar fascial fibromatosis

M72.4

Pseudosarcomatous fibromatosis

M72.8 – M72.9

Fibroblastic disorders

M75.80 – M75.92

Other shoulder lesions and shoulder lesion, unspecified

M76.10 – M76.12

Psoas tendinitis, side

M76.20 – M76.22

Iliac crest spur, hip

M76.30 – M76.32

Iliotibial band syndrome

M76.60 – M76.62

Achilles tendinitis

M76.70 – M76.72

Peroneal tendinitis

M76.811 – M76.899

Other specified enthesopathies of lower limb, except foot

M76.861 – M76.869

Other enthesopathies, lower leg

M77.00 – M77.02

Medial epicondylitis, elbow

M77.10 – M77.12

Lateral epicondylitis, elbow

M77.30 – M77.32

Calcaneal spur

M77.40 – M77.42

Metatarsalgia,foot

M77.50 – M77.52

Other enthesopathy, foot

M77.9

Enthesopathy, unspecified

M79.1

Myalgia

M79.3

Panniculitis, unspecified

M79.601 – M79.676

Pain in limb

M79.7

Fibromyalgia

REIMBURSEMENT INFORMATION:

The total number of procedures (20550, 20551, 20552, and 20553), in any combination, is limited to four (4) in a 30-day period and (6) in six months.

The tendon injection codes 20550 and 20551 are to be reported for multiple injections per single tendon or ligament. Multiple injections to the same tendon sheath or ligament would be reported only once per session, while injections to multiple tendon sheaths, tendon origins, tendon insertions, ligaments or aponeuroses would be reported for each injection.

The trigger point injection codes 20552 and 20553 are to be reported once per day, regardless of the number of trigger points or muscles injected. A set of trigger point injections means injections in several trigger points in one sitting.

Imaging guidance should not be reported with trigger point injections (20552 or 20553).

NOTE: Services in excess of the limitations shown above are subject to medical review of documentation for determination of medical necessity. The following information may be required documentation to support medical necessity: physician history and physical, physician progress notes, treatment plan, current medications and/or history of medication use, physical therapy assessment and/or progress notes.

LOINC Codes:

Documentation Table

LOINC Codes

LOINC Time Frame Modifier Code

LOINC Time Frame Modifier Codes Narrative

Physician history and physical

28626-0

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Attending physician visit note

18733-6

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Treatment plan

18776-5

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Current, discharge, or administered medications

34483-8

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Physical therapy initial assessment

18735-1

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Physical therapy progress note

11508-9

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage: The following Local Coverage Determination (LCD) was reviewed on the last guideline reviewed date: Injection of Trigger Points (L33912) located at fcso.com.

DEFINITIONS:

Anesthetic agent: a drug that causes loss of feeling in a part of the body (local, topical anesthesia), or loss of feeling in the entire body and loss of consciousness (general anesthesia).

Aponeurosis: a sheet-like tendinous expansion, mainly serving to connect a muscle with the parts it moves.

Dry needling: the insertion of a needle into a trigger point without injecting any medication, to try to deactivate the trigger point; the needle is removed and the procedure is often followed by stretching exercises.

Ligament: a fibrous connective tissue which attaches bone to bone, serving to hold structures together and keep them stable.

Steroid agent: a substance also referred to as corticosteroid, similar to hormones produced by the adrenal gland that fight stress associated with illness and injury; they reduce inflammation and affect the immune system.

Tendon: a fibrous connective tissue that attaches muscle to bone or to a structure.

Tendon sheath: the white, fibrous covering surrounding a tendon.

Trigger point: areas of taut muscle bands or palpable knots of the muscle, that are painful on compression and can produce referred pain, referred tenderness, and/or motor dysfunction.

RELATED GUIDELINES:

Prolotherapy, 02-20000-08
Temporomandibular Joint (TMJ) Dysfunction; Diagnosis and Treatment, 02-20000-12

OTHER:

None applicable.

REFERENCES:

  1. Alvarez DJ. Trigger points: diagnosis and management. Am Fam Physician. 15 Feb 2002; 65(4): 653 – 60.
  2. American Academy of Orthopedic Surgeons. Trigger Finger. June 2010. Accessed 07/12/11.
  3. American Institute of Ultrasound in Medicine Practice Guideline: Musculoskeletal Ultrasound Examination (April 2012). Accessed at http://www.aium.org/ on 05/31/13.
  4. American Medical Association, CPT 2004 Changes: An Insider’s View.
  5. Botwin KP, Sharma K, Saliba R, Patel BC. Ultrasound-Guided Trigger Point Injections in the Cervicothoracic Musculature: A New and Unreported Technique. Pain Physician 2008; 11:885-889.
  6. Campagna R, Guerini H. The tendons: Interventional sonography. Journal of Ultrasound (2012) 15, 56e60.
  7. Dıra├žoğlu D, Vural M, Karan A, Aksoy C. Effectiveness of dry needling for the treatment of temporomandibular myofascial pain: a double-blind, randomized, placebo controlled study. J Back Musculoskelet Rehabil. 2012 Jan 1;25(4):285-90.
  8. ECRI Health Technology Assessment Information Services. Custom Hotline Response. Trigger Point Injection Therapies for Chronic, Nonmalignant Back Pain. Updated 02/12/07.
  9. Epis O, et. al. Ultrasound imaging for the rheumatologist (XVI): Ultrasound-guided procedures. Clin Exp Rheumatol 2008; 26; 515-518.
  10. Ferrante FM, Bearn L, Rothrock R, King L. Evidence against Trigger Point Injection Technique for the Treatment of Cervicothoracic Myofascial Pain with Botulinum Toxin Type A. Anesthesiology. Aug 2005; 103(2): 377-383.
  11. Filner B. Trigger Point Injections: Techniques, Pitfalls and Alternatives. Tips on practicing good technique for inactivating trigger points while avoiding pitfalls and minimizing complications. Presentation at the American Academy of Pain Management annual meeting. September 2008.
  12. Florida Medicare Part B Local Coverage Determination L29199, Injection of Trigger Points, 03/17/09. Accessed 05/31/13.
  13. Freeman MD, Centeno CJ, Nystrom NA. Central sensitization is a reversible response to focal soft-tissue neck pain in chronic whiplash. American Academy of Orthopedic Surgeons. 2010 Annual Meeting Poster Presentation P276.
  14. Geso L, Filippucci E, Meenagh G, Gutierrez M, Ciapetti A, Salaffi F, Grassi W. CS injection of tenosynovitis in patients with chronic inflammatory arthritis: the role of US. D Rheumatology (Oxford). 2012 Jul;51(7):1299-303.
  15. Harmon D, Alexiev V. Sonoanatomy and Injection Technique of the Iliolumbar Ligament. Pain Physician 2011; 14:469-474.
  16. Hashiuchi T, Sakurai G, Morimoto M, Komei T, Takakura Y, Tanaka Y. Accuracy of the biceps tendon sheath injection: ultrasound-guided or unguided injection? A randomized controlled trial. J Shoulder Elbow Surg. 2011 Oct;20(7):1069-73.
  17. Hayes, Inc. Hayes Search & Summary: Trigger Point Injection for Treatment of Pain, Lansdale, PA: Hayes, Inc.; April 2007.
  18. Institute for Clinical Systems Improvement (ICSI). Assessment and management of chronic pain. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI). 2007 Mar. 87 p.
  19. Jose J, Schallert E, Lesniak B. Sonographically guided therapeutic injection for primary medial (tibial) collateral bursitis. J Ultrasound Med. 2011 Feb;30(2):257-61.
  20. Kalichman L, Vulfsons S. Dry needling in the management of musculoskeletal pain. J Am Board Fam Med. 2010 Sep-Oct;23(5):640-6.
  21. Lee DH, Han SB, Park JW, Lee SH, Kim KW, Jeong WK. Sonographically guided tendon sheath injections are more accurate than blind injections: implications for trigger finger treatment. J Ultrasound Med. 2011 Feb;30(2):197-203.
  22. Manchikanti, L., Singh, V., Kloth, D. Interventional Pain Management Practice Policies; Trigger Point Injections. American Society of Interventional Pain Physicians. Accessed 04/08/09.
  23. Mayoral O, et. al. Efficacy of Myofascial Trigger Point Dry Needling in the Prevention of Pain after Total Knee Arthroplasty: A Randomized, Double-Blinded, Placebo-Controlled Trial. Evidence-Based Complementary and Alternative Medicine Volume 2013, Article ID 694941.
  24. McAlindon T, et. al. American College of Rheumatology Report on Reasonable Use of Musculoskeletal Ultrasonography in Rheumatology Clinical Practice. Arthritis Care & Research Vol. 64, No. 11, November 2012, pp 1625–1640.
  25. McDermott JD, Ilyas AM, Nazarian LN, Leinberry CF. Ultrasound-guided injections for de Quervain's tenosynovitis. Clin Orthop Relat Res. 2012 Jul;470(7):1925-31.
  26. Merriam Webster Medical Dictionary, web edition.
  27. Muir JJ, et. al. The accuracy of ultrasound-guided and palpation-guided peroneal tendon sheath injections. Am J Phys Med Rehabil. 2011 Jul;90(7):564-71.
  28. Myburgh C, Hartvigsen J, Aagaard P, Holsgaard-Larsen A. Skeletal muscle contractility, self-reported pain and tissue sensitivity in females with neck/ shoulder pain and upper Trapezius myofascial trigger points– a randomized intervention study. Chiropractic & Manual Therapies 2012, 20:36.
  29. Peloso P, Gross A, Haines T, Trinh K, Goldsmith CH, Burnie S, Cervical Overview Group. Medicinal and injection therapies for mechanical neck disorders. Cochrane Database of Systematic Reviews 2007, Issue 3. Art. No.: CD000319. DOI: 10.1002/14651858.CD000319.pub4.
  30. Practice guidelines for chronic pain management. An updated report by the American Society of Anesthesiologists. Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine. Anesthesiology 2010 Apr;112(4):810-33.
  31. Reach JS, Easley ME, Chuckpaiwong B, Nunley JA. Accuracy of ultrasound guided injections in the foot and ankle. Foot Ankle Int. 2009 Mar;30(3):239-42.
  32. Resnick DK, Choudhri TF, Dailey AT, Groff MW, Khoo L, Matz PG, Mummaneni P, Watters WC 3rd, Wang J, Walters BC, Hadley MN, American Association of Neurological Surgeons/Congress of Neurological Surgeons. Guidelines for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 13: injection therapies, low-back pain, and lumbar fusion. J Neurosurg Spine 2005 Jun; 2(6):707-15.
  33. Scott A, Guo B. Trigger point injections for chronic non-malignant musculoskeletal pain. Health Technology Assessment 35. Edmonton, AB: Alberta Heritage Foundation for Medical Research; January 2005.
  34. Smith J, Wisniewski SJ, Wempe MK, Landry BW, Sellon JL. Sonographically guided obturator internus injections: techniques and validation. J Ultrasound Med. 2012 Oct;31(10):1597-608.
  35. Uemoto L, et. al. Laser therapy and needling in myofascial trigger point deactivation. Journal of Oral Science, Vol. 55, No. 2, 175-181, 2013.
  36. VernonH, Schnieder M. Chiropractic management of myofascial trigger points and myofascial pain syndrome: Summary of Clinical Practice Recommendations from the Commission of the Council on Chiropractic Guidelines and Practice Parameters. COUNCIL ON CHIROPRACTIC GUIDELINES AND PRACTICE PARAMETERS. June 2008.
  37. Wong CSM, Wong SHS. A New Look at Trigger Point Injections. Anesthesiol Res Pract. 2012; 2012: 492452.
  38. Yablon CM. Ultrasound-guided intervention of the foot and ankle. Semin Musculoskelet Radiol. 2013 Feb;17(1):60-8.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 07/25/13.

GUIDELINE UPDATE INFORMATION:

09/15/03

Developed separate MCG created for Tendon Sheath, Ligament and Trigger Point Injections from Outpatient Pain Management 02-61000-01.

01/01/04

Annual HCPCS coding update.

09/15/05

Review and revision of guideline consisting of updated references.

07/15/07

Review, current coverage maintained, guideline reformatted, references updated.

11/15/07

Review and revision of guideline consisting of updated references and addition of diagnosis codes.

01/01/09

Annual HCPCS coding update: revised descriptor for 20552 and 20553.

05/15/09

Scheduled review: update of position statement to include coverage criteria, update of description section to include medical necessity management statement, update reimbursement statement, and references.

09/15/09

Unscheduled review. Update position statement for trigger point injections.

10/15/10

Revision; related ICD-10 codes added.

07/01/11

Revision; formatting changes.

08/15/11

Scheduled review, revise description and ICD9 coding sections; update references, formatting changes.

04/01/12

Revision; updated ICD10 coding with new and revised codes.

09/15/13

Unscheduled review. Revised description, position statement, reimbursement section, program exceptions section and definitions. Updated references. Reformatted guideline.

10/01/15

Revision; updated ICD9 and ICD10 coding sections.

11/01/15

Revision: ICD-9 Codes deleted.

01/01/16

Annual CPT/HCPCS coding update. Revised code 20553 descriptor. Revised Program Exceptions section.

DECISION TREE

Date Printed: December 17, 2017: 10:18 PM