Medicare payment for Payment for 20550/20551

Issue: Payment for 20550/20551

I have received several inquires regarding Medicare (FCSO) policies (LCD) on injection codes
20550, 20551.

History: Recently, I argued a case with an ALJ (Administrative Law Judge) regarding apparent
confusion with the LCD that was referenced for injections. To avoid belaboring the issue, I
indicated that the policy under certain circumstances was inappropriately applied to adjudicate
claims for 20550 and 20551 resulting in denials to providers. After lengthy discussion and
substantiation of the argument, the judge agreed. I then took the argument to Medicare (FCSO)
and they agreed to honor my request and make appropriate changes.
My argument was that criteria for trigger point injections were erroneously being applied to
20550/51.

Resolution: Rather than writing a new policy on these codes, they were to modify the existing
LCD to avoid the confusion of applying trigger point injection criteria to these non-trigger point
CPT codes.

Conclusion: This change is the result of my request to remove the restrictions from these codes.
This modified LCD should result in reimbursement of 20550/51 under appropriate
circumstances, eliminating denials that in the past resulted in non-payment for these services. By
removing these codes from the LCD, it eliminates the issues encountered (denials as stated). The
exclusion of these codes from the LCD is extremely favorable and in no way implies that these
codes are not billable. (An LCD is written when there are issues with provider utilization, i.e.,
abuse, over utilization etc. Therefore, one will note that many codes do not have an LCD. This
is a good thing. It is a bad thing when an LCD is written for a CPT code. That implies a
problem has been encountered and the payer is applying strict guidelines/parameters for
payment.)