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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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If applicable, document that you have tried and failed other treatments, including lifestyle modifications, other medications, and behavioral programs

Get your patients to focus on the metabolic gains, appetite suppression, and functional benefits observed in trials