Mar 24, 2008 · Best answers. 0. Mar 25, 2008. #2. If the release was done through an incision try 26055; "The physician makes an incision in a tendon sheath to release tension in the tendon. (For example, this procedure would be performed to relieve trigger finger .) The physician incises the skin overlying the tendon and dissects to the tendon sheath The ... CPT Coding: 20552 Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s) ... 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 siteArticle Guidance. This Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L33912, Injection of Trigger Points. Please refer to the LCD for reasonable and necessary requirements. Coding Guidelines. No more than 3 Trigger point injection sessions in a rolling 12 months will be considered reasonable and necessary, regardless of the code billed. CPT 20552 limits to 1 or 2 muscles and 20553 is 3 or more muscles. The number of injections into the muscle group are not billed separately. 20553 Injection(s); single or multiple trigger point(s), 3 or more muscles; Many are still so confused on how to bill for Trigger Points. Here are my Coding and Billing Tips: 1. There is NO anatomical modifier; these 2 codes are not unilateral - so modifier 50, LT or RT is not applicable; 2. Code and bill based on the number of muscles (not ...The HCPCS drug code and dose is not required when CPT 20612 is reported for aspiration and not for injection or when the ICD-10-CM codes reported are M77.11 or M77.12 and there is no injection. The medication being injected, designated by an appropriate HCPCS drug code must be submitted on the same claim, same day of service as the claim for ...This Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L35010, Trigger Point Injections. Please refer to the LCD for reasonable and necessary requirements. Coding Guidance. Notice: It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if ...20553 Injection(s); single or multiple trigger point(s), 3 or more muscles 20560 Needle insertion(s) without injection(s); 1 or 2 muscle(s) (investigational) 20561 Needle insertion(s) without injection(s); 3 or more muscles (investigational) ICD-10 Diagnosis Codes That Support Medical Necessity for 20552 – 20553:A discussion thread on how to code bilateral trigger finger injections with 20550 modifier. See different suggestions and opinions from AAPC members and experts.The CPT® codes for reporting arthrocentesis are 20600–20615. The descriptors start by stating that the codes represent arthrocentesis — aspiration from or injection into a joint, or both aspiration and injection of the same joint. Proper code selection is based on two factors: Whether ultrasound guidance is used.When the current procedural terminology (CPT) codes are run through the VistA integrated billing system, based on the VHA Chief Business Office Reasonable Charges, a complication can more than double the charges associated with A1 pulley surgery. ... The effect of corticosteroid injection for trigger finger on blood glucose level in diabetic ...November 18, 2021: Revised to include HCPCS codes L3806 and L3807 under the Wrist-Hand-Finger Orthoses section: October 28, 2021: Originally PublishedNo more than 3 Trigger point injection sessions in a rolling 12 months will be considered reasonable and necessary, regardless of the code billed. CPT 20552 limits to 1 or 2 muscles and 20553 is 3 or more muscles. The number of injections into the muscle group are not billed separately. The code includes all injections made into the muscle.In the world of medical billing and coding, accurate CPT code descriptions are essential for ensuring proper reimbursement and maintaining compliance. CPT codes, or Current Procedu...You'll need to use the correct modifier for each finger. 20551-F7 (right hand, middle finger) 20551-F3 (left hand, ring finger)Using a 16- or 18-gauge needle attached to the 3-mL syringe, draw up a combination of 0.5 mL of lidocaine and 0.25 mL of corticosteroid (either triamcinolone or betamethasone). Next, change to a 25-gauge needle. Place the needle in the midline of the finger, through the finger flexion crease at the base of the finger, and angle it approximately ...When the current procedural terminology (CPT) codes are run through the VistA integrated billing system, based on the VHA Chief Business Office Reasonable Charges, a complication can more than double the charges associated with A1 pulley surgery. ... The effect of corticosteroid injection for trigger finger on blood glucose level in diabetic ...Injection, tendon sheath, ligament, trigger points or ganglion cyst (20550) Injection, therapeutic; single tendon origin or insertion (20551) Arthrocentesis, aspiration and/or injection; small joint, bursa or ganglion cyst eg, fingers, toes) (20600)CPT Coding: Technique: Indications: Complications: Contraindications: Follow-up Care / Rehab Protocol: Alternatives: Outcomes: ... Trigger Finger Release CPT. CPT: 26055 Trigger Finger Release ... Trigger finger injection; Trigger Finger Release ...Just to make sure I am understanding correctly, based on the the 2010 response "Injection of painful scar tissue is reported using CPT code 64999, Unlisted procedure, nervous system" the correct code choice used to be 64999. However, the 2013 article directs us to use the appropriate injection code instead of 64999 "A "neuroma" is …The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Trigger Point Injections L37635. More than four (4) trigger point injections in a year's time will not be covered. If a patient requires more than four (4) procedures of either CPT codes 20552 or 20553 during ... You'll need to use the correct modifier for each finger. 20551-F7 (right hand, middle finger) 20551-F3 (left hand, ring finger) For those times when your fingers are deep in your gloves to protect them from the cold—or they're just otherwise occupied—there is NoseDial. It's a simple iPhone dialer that's opt...Code trigger-point injections 20550 (injection tendon sheath ligament trigger points or ganglion cyst) says Kathleen Mueller RN CPC CCS-P an independent general surgery coding and reimbursement specialist in Lenzburg Ill.She notes that because 20550's descriptor includes the word ""points "" carriers -- commercial and …CPT Description. 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 muscle(s). Trigger Point Injections are used to treat painful areas of muscle that contain trigger points, or knots of muscle that form when muscles do not relax.The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Trigger Point Injections L37635. More than four (4) trigger point injections in a year's time will not be covered. If a patient requires more than four (4) procedures of either CPT codes 20552 or 20553 during ...Revision History Information. Posted 02/15/2024 This article is being retired effective 03/31/2024 and is being replaced with A59553 Billing and Coding: Trigger Point Injections. Posted 08/31/2023 Review completed 07/20/2023 with no change in coverage. 09/30/2021 Review completed 08/26/2021 with no change in coverage.In the world of medical billing and coding, accuracy is crucial. One small error in assigning a Current Procedural Terminology (CPT) code can lead to significant consequences, incl...CPT codes: 99213-25, 20553, 73120/LT Diagnosis: ICD-9 7291 ICD-10 M79.7 Coding for trigger-point injections continues to create a lot of confusion on proper coding guidelines. Keep in mind, two CPT4 codes can be used for trigger-point procedures: 20552—Injection(s); single or multiple trigger point(s), one or two muscle(s); and 20553—Single ...20550-50 51. I would not use bilateral modifier for fingers as fingers are not bilateral , you have 10. Bilateral is for paired organs or body parts. I would recommend to use either the finger modifiers or the XS modifier and list on separate lines. 20550 F2.5. When to use CPT code 20553. It is appropriate to bill the 20553 CPT code when the provider performs trigger point injections in three or more muscles to treat a patient’s musculoskeletal condition. The provider must have determined that the patient’s condition warrants the use of trigger point injections and that the patient has not ...CPT Code 26440, Surgical Procedures on the Hand and Fingers, Repair, Revision, and/or Reconstruction Procedures on the Hand and Fingers - Codify by AA ... the provider performs tenolysis, which releases the flexor tendon of the palm or finger from adhesions. This surgical procedure is limited to either the palm or finger. ... Trigger and ...Injection, tendon sheath, ligament, trigger points or ganglion cyst (20550) Injection, therapeutic; single tendon origin or insertion (20551) Arthrocentesis, aspiration and/or injection; small joint, bursa or ganglion cyst eg, fingers, toes) (20600)I am getting conflicting information on billing for trigger point injections. Does anyone know if we should be billing an established patient office visit any time a patient gets a trigger point injection? I have been told just to bill the injection and I have read that I should be adding an office code with a modifier 25.Sep 14, 2013. #2. 20551 is for trigger points into various muscles, just one or 2. More than 2 muscles injected is 20552. Both of these codes can be billed only a single time per encounter. If your physician is injecting tendons, the code would be 20550 Injection (s); single tendon sheath, or ligament, aponeurosis (eg, plantar "fascia")Jul 10, 2010 · How to code multiple injections. So my hand surgeon is doing injections of the tendon sheath for tigger finger of the Middle finger and ring finger CPT 20550 x 1, than he does injections on the same fingers but in the PIP joint of each finger CPT 20600 x2. Per CCI the 20550 is bundled into 20600 yet a modifer is allowed. The official description of CPT code 20552 is: “Injection (s); single or multiple trigger point (s), 1 or 2 muscle (s)”. 3. Procedure. The 20552 procedure involves the following steps: The patient is appropriately prepped and the area to be treated is anesthetized. The provider palpates the muscle to determine the location of the trigger point.The 2024 edition of ICD-10-CM M65.30 became effective on October 1, 2023. This is the American ICD-10-CM version of M65.30 - other international versions of ICD-10 M65.30 may differ. Convert M65.30 to ICD-9-CM. Reimbursement claims with a date of service on or after October 1, 2015 require the use of ICD-10-CM codes.Tendon sheath or Ligament (e.g., iliolumbar Ligament, trigger finger):CPT 20550; Tendon origin/insertion: CPT 20551; Trigger point injection (1 or 2 muscles):CPT 20552; Trigger point injection (3 or more muscles):CPT 20553; ... This might include an E/M code for an evaluation or an injection code if a therapeutic injection is performed.CPT Coding: Technique: Indications: Complications: Contraindications: Follow-up Care / Rehab Protocol: Alternatives: Outcomes: ... Trigger Finger Release CPT. CPT: 26055 Trigger Finger Release ... Trigger finger injection; Trigger Finger Release ...No more than 3 Trigger point injection sessions in a rolling 12 months will be considered reasonable and necessary, regardless of the code billed. CPT 20552 limits to 1 or 2 muscles and 20553 is 3 or more muscles. The number of injections into the muscle group are not billed separately. The code includes all injections made into the muscle.Do not code the injections or how may injections are done on a single muscle, code the muscle (s). 20552 and 20553 are used to report single or multiple injections on 1-3 or more muscles. 20552 - 1 or 2 muscle (s) 20553 - 3 or more muscles. Modifier 50 - Bilateral. Bilateral surgical indicator 50 may apply as well, so be sure to …Question: Can you please confirm the accurate CPT code for injection at the A1 pulley for trigger finger? This is an example of the documentation, "bilateral trigger finger injections provided for both long fingers at A1 pulley." Would 20550 or 20551 be accurate? Sign up for a membership to view the answer to this question.A discussion thread on how to code bilateral trigger finger injections with 20550 modifier. See different suggestions and opinions from AAPC members and experts.Thirty nine percent of second and third corticosteroid injections for trigger finger yield long-term relief. While most patients ultimately require surgical release, 50% of patients receiving repeat trigger injections realize one year or more of symptomatic relief. ... (CPT) codes 20550 (injection; tendon sheath, ligament), 20551 (injection ...Oct 12, 2012. #2. the difference between 20550 and 20552/20553 is 20550 is an injection into a single tendon sheath or origin. If the Dr. is injecting trigger points, 2 or fewer muscle groups is 20552 and 3 or more muscle groups is 20553. Here is a break down of the muscle groups to help you decide how many different muscle groups were injected: 1. The HCPCS drug code and dose is not required when CPT 20612 is reported for aspiration and not for injection or when the ICD-10-CM codes reported are M77.11 or M77.12 and there is no injection. The medication being injected, designated by an appropriate HCPCS drug code must be submitted on the same claim, same day of service as the claim for ... The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Trigger Point Injections L37635. More than four (4) trigger point injections in a year's time will not be covered. If a patient requires more than four (4) procedures of either CPT codes 20552 or 20553 during ...Answer: Yes, you can report codes such as 26055 ( Tendon sheath incision [e.g., for trigger finger]) multiple times during the same procedure when appropriate. List each finger on separate lines on your claim and include the "F" modifier (such as F1, Left hand, second digit) to indicate the finger treated. Note: If the surgeon made two separate ...CPT Description. 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 muscle(s). Trigger Point Injections are used to treat painful areas of muscle that contain trigger points, or knots of muscle that form when muscles do not relax.CPT codes: 99213-25, 20553, 73120/LT Diagnosis: ICD-9 7291 ICD-10 M79.7 Coding for trigger-point injections continues to create a lot of confusion on proper coding guidelines. Keep in mind, two CPT4 codes can be used for trigger-point procedures: 20552—Injection(s); single or multiple trigger point(s), one or two muscle(s); and …No more than 3 Trigger point injection sessions in a rolling 12 months will be considered reasonable and necessary, regardless of the code billed. CPT 20552 limits to 1 or 2 muscles and 20553 is 3 or more muscles. The number of injections into the muscle group are not billed separately.Oct 1, 2015 · The HCPCS drug code and dose is not required when CPT 20612 is reported for aspiration and not for injection or when the ICD-10-CM codes reported are M77.11 or M77.12 and there is no injection. The medication being injected, designated by an appropriate HCPCS drug code must be submitted on the same claim, same day of service as the claim for ... Trigger Finger Release 26055. Prep and drape in standard sterile fashion. Local anesthetic injected into skin and flexor sheath. Longitudinal incision over A1 pully between the distal transverse palmar crease and the base of the finger flexion crease. Blunt dissection under loop magnification down to A1 pulley.Basics the trigger finger/point injection cpt code 20550-20551. The physician injects a therapeutic agent toward a single tendon sheath, or ligament, aponeurosis like as this plantar fillet are 20550 real into …May 27, 2010 · Answer: Yes, you can report codes such as 26055 ( Tendon sheath incision [e.g., for trigger finger]) multiple times during the same procedure when appropriate. List each finger on separate lines on your claim and include the "F" modifier (such as F1, Left hand, second digit) to indicate the finger treated. Note: If the surgeon made two separate ... CPT Codes. Surgery. Surgical Procedures on the Musculoskeletal System. Surgical Procedures on the Hand and Fingers. Incision Procedures on the Hand and Fingers. 26055. 26045. 26055. 26060.CPT Codes. Surgery. Surgical Procedures on the Musculoskeletal System. Surgical Procedures on the Hand and Fingers. Incision Procedures on the Hand and Fingers. 26055. 26045. 26055. 26060.A bilateral pudendal block was given under finger guidance into the Alcock’s canal. ... ileococcygeus, coccygeus and puborectalis muscles bilaterally. The provider has documented the injections as trigger point injections. However, when injecting a toxin such as botulinum, is it more appropriate to assign a code for chemodenervation from …Florida Subscriber. Answer: The diagnoses you offered indicate that the orthopedist is probably injecting the tendon sheath or ligament, which would point to 20550* ( Injection; tendon sheath, ligament, ganglion cyst ). To show Medicare that the physician injected multiple digits, append the finger modifiers (-FA through -F9) to 20550 on ...No more than 3 Trigger point injection sessions in a rolling 12 months will be considered reasonable and necessary, regardless of the code billed. CPT 20552 limits to 1 or 2 muscles and 20553 is 3 or more muscles. The number of injections into the muscle group are not billed separately.CPT 20552 limits to 1 or 2 muscles and 20553 is 3 or more muscles. The number of injections into the muscle group are not billed separately. The code includes all injections made into the muscle. Medication. The drug used for the injection must be on the same claim as the trigger point administration.20553 Injection(s); single or multiple trigger point(s), 3 or more muscles; Many are still so confused on how to bill for Trigger Points. Here are my Coding and Billing Tips: 1. There is NO anatomical modifier; these 2 codes are not unilateral - so modifier 50, LT or RT is not applicable; 2. Code and bill based on the number of muscles (not ...Jan 22, 2016. #6. You can bill for the drugs used for the trigger point injections. However, it varies by carrier if they will pay them. It doesn't hurt to bill it and receive your denials so you can substantiate who pays and who doesn't. You may need to create a "zero charge" bill for these drugs if you match your inventory.Dec 8, 2021 · Trigger Finger (trigger thumb when involving the thumb) is the inhibition of smooth tendon gliding due to mechanical impingement at the level of the A1 pulley that causes progressive pain, clicking, catching, and locking of the digit. Diagnosis is made by physical examination with presence of active triggering and tenderness at the A1 pulley. Trigger point injection- an invasive procedure where medication is injected directly into a trigger point. 5 . Background. ... Enter the CPT/HCPCS code in the MCD Search and select your state from the drop down. (You may have to accept the AMA License Agreement.) Look for a Billing and Coding Article in the results and open it.The Current Procedural Terminology (CPT ®) code 26055 as maintained by American Medical Association, is a medical procedural code under the range - Incision Procedures …Trigger point injection, or TPI, is a medical procedure that involves injecting an anesthetic or corticosteroid substance to relieve a trigger point, which is a painful area or knot in a muscle. For clinical responsibility, terminology, tips and additional info start codify free trial.Feb 15, 2003 · Am Fam Physician. 2003;67 (4):745-750. Joint injection of the wrist and hand region is a useful diagnostic and therapeutic tool for the family physician. In this article, the injection procedures ... The Current Procedural Terminology (CPT ®) code 26055 as maintained by American Medical Association, is a medical procedural code under the range - Incision Procedures …The codes for reporting TPs include: Injection (s); single or multiple trigger point (s); 20552 1 or 2 muscle (s) 20553 3 or more muscles. Modifiers and Units. Modifiers: Although it may seem logical to report modifiers RT, LT, or 59, the code descriptions clearly identify the codes for 1-2 muscles injected or 3 or more muscles injected, making ...Article Guidance. This Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L33912, Injection of Trigger Points. Please refer to the LCD for reasonable and necessary requirements. Coding Guidelines.Aspiration and Injection CPT Codes. Puncture aspiration of abscess, hematoma, bulla, or cyst (10160) Injection, therapeutic; carpal tunnel (20526) Injection, therapeutic; single tendon origin or insertion (20551) Arthrocentesis, aspiration and/or injection; small joint, bursa or ganglion cyst eg, fingers, toes) (20600) Arthrocentesis ...Trigger Finger (trigger thumb when involving the thumb) is the inhibition of smooth tendon gliding due to mechanical impingement at the level of the A1 pulley that causes progressive pain, clicking, …6. Best answers. 0. Feb 8, 2011. #4. 20550 says "injection (s) of a single tendon sheath...) the coding tips in the coding companion state that if more than one tendon is injected in the same incounter, each injection should be reported separately. You can bill 20550 more than once during the same encounter.Apr 2, 2006 · But when the patient's symptoms don't improve, surgeons may choose to perform a trigger finger release. The problem: Some coders review trigger finger release documentation and overlook the appropriate code, 26055 ( Tendon sheath incision [e.g., for trigger finger]). Trigger point injection CPT codes include: 20552 CPT code: This code is used when one or two muscle groups are injected. 20553 CPT code: This code is used when three or more muscle groups are injected.Combat the #1 denial reason - mismatched CPT-ICD-9 codes - with top Medicare carrier and private payer accepted diagnoses for the chosen CPT® code. View the CPT® code's corresponding procedural code and DRG.What is the trigger finger ICD-10 code? M65, unspecified trigger finger 30 is an ICD-10-CM code that can be used for reimbursement purposes to indicate a diagnosis. ICD-10-CM M65, 2020 edition. On October 1, 2019, 30 became effective. When trigger point injection codes 20552 and 20553 are used, how do these codes work?A capital injection is an inflow of cash, stock or even debt into a company. A capital injection is an inflow of cash, stock or even debt into a company. Let&aposs say Company XYZ ...In cases of trigger finger, liquid corticosteroids are injected into the base of the affected finger or thumb. Corticosteroids are thought to work by reducing swelling, allowing the tendon to move freely again. This can sometimes happen within a few days of having the injection, but it usually takes a few weeks.© 1995-2024 by the American Academy of Orthopaedic Surgeons. "All Rights Reserved." This website and its contents may not be reproduced in whole or in part without ...Injection, tendon sheath, ligament, trigger points or ganglion cyst (20550) Injection, therapeutic; single tendon origin or insertion (20551) Arthrocentesis, aspiration and/or injection; small joint, bursa or ganglion cyst eg, fingers, toes) (20600)No more than 3 Trigger point injection sessions in a rolling 12 months will be considered reasonable and necessary, regardless of the code billed. CPT 20552 limits to 1 or 2 muscles and 20553 is 3 or more muscles. The number of injections into the muscle group are not billed separately.Trigger point injection, or TPI, is a medical procedure that involves injecting an anesthetic or corticosteroid substance to relieve a trigger point, which is a painful area or knot in a muscle. For clinical responsibility, terminology, tips and additional info start codify free trial.
No more than 3 Trigger point injection sessions in a rolling 12 months will be considered reasonable and necessary, regardless of the code billed. CPT 20552 limits to 1 or 2 muscles and 20553 is 3 or more muscles. The number of injections into the muscle group are not billed separately.. Yerberia san judas
Nubain (Injectable) received an overall rating of 8 out of 10 stars from 25 reviews. See what others have said about Nubain (Injectable), including the effectiveness, ease of use a...Learn how to bill and code trigger point injections for myofascial pain relief by physical therapists and pain management professionals. Find out the CPT codes, modifiers, units, and ICD-10-CM codes for this procedure.In the world of medical billing and coding, accurate CPT code descriptions are essential for ensuring proper reimbursement and maintaining compliance. CPT codes, or Current Procedu...This was achieved by querying our medical database each week using Current Procedural Terminology (CPT) code 20550, “injection(s) single tendon sheath, … Trigger Finger Release 26055. Prep and drape in standard sterile fashion. Local anesthetic injected into skin and flexor sheath. Longitudinal incision over A1 pully between the distal transverse palmar crease and the base of the finger flexion crease. Blunt dissection under loop magnification down to A1 pulley. To date, my two hand surgeons have never required ultrasound for a trigger injection. It sounds like your physician is using ultrasound routinely. The codes may not hit an edit, but before I would bill it out I would want the physician to document the medical necessity for the ultrasound to guide the needle for the patient.Use this page to view details for the Local Coverage Article for Billing and Coding: Trigger Point Injections. The page could not be loaded. The CMS.gov Web site currently does not fully support browsers with "JavaScript" disabled.The HCPCS drug code and dose is not required when CPT 20612 is reported for aspiration and not for injection or when the ICD-10-CM codes reported are M77.11 or M77.12 and there is no injection. The medication being injected, designated by an appropriate HCPCS drug code must be submitted on the same claim, same day of service as the claim for ...To date, my two hand surgeons have never required ultrasound for a trigger injection. It sounds like your physician is using ultrasound routinely. The codes may not hit an edit, but before I would bill it out I would want the physician to document the medical necessity for the ultrasound to guide the needle for the patient. Trigger finger is a condition affecting tendons that flex the fingers and thumb, typically resulting in a sensation of locking or catching when you bend and straighten your digits. Other symptoms may include pain and stiffness in the fingers and thumb. The condition is also known as stenosing tenosynovitis. The ring finger and thumb are most ... The medication used with the injection is reported with a HCPCS Drug code “J-code” or a revenue code. Unclassified drugs billed with J3490, J3590, J9999 or …Article Text. The following billing and coding guidance is to be used with its associated Local Coverage Determination. Injection therapies for Morton's neuroma do not involve the structures described by CPT code 20550 and 20551 or direct injection into other peripheral nerves but rather the focal injection of tissue surrounding a specific …Therefore when the internist injects three different muscles you can only report one code 20553. Before CPT introduced 20552-20553 in 2002 internal medicine coders could use modifier -59 to report 20550 (Injection; tendon sheath ligament or ganglion cyst) multiple times for trigger point injections in different sites. Created Date.No more than 3 Trigger point injection sessions in a rolling 12 months will be considered reasonable and necessary, regardless of the code billed. CPT 20552 limits to 1 or 2 muscles and 20553 is 3 or more muscles. The number of injections into the muscle group are not billed separately.The trigger point injection CPT codes are 20552 and 20553, also called a dry beedling procedure. CPT 20552 narrates injection (s) administration in a single or multiple trigger ….
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