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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

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Category 1 substances may receive limited enforcement discretion if compounders meet the policy's conditions