How To Use CPT Code 0054T

CPT 0054T describes a computer-assisted musculoskeletal surgical navigational orthopedic procedure that utilizes image-guidance based on fluoroscopic images. This article will cover the official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, and examples of CPT code 0054T.

1. What is CPT Code 0054T?

CPT 0054T can be used to describe a computer-assisted musculoskeletal surgical navigational orthopedic procedure that incorporates image-guidance based on fluoroscopic images. This code is used as an add-on procedure to the primary orthopedic procedure code, and it involves the use of surgical navigation technology to guide and validate the placement and positioning of orthopedic implants.

2. Official Description

The official description of CPT code 0054T is: ‘Computer-assisted musculoskeletal surgical navigational orthopedic procedure, with image-guidance based on fluoroscopic images (List separately in addition to code for primary procedure).’ This code is used to indicate the utilization of computer-assisted navigation technology during an orthopedic procedure, specifically with the aid of fluoroscopic images.

3. Procedure

1. The provider begins by acquiring preoperative data using fluoroscopy to obtain measurements and plan the surgery.
2. During the procedure, the provider updates the fluoroscopic images and data in real-time or as it occurs.
3. Using surgical navigation technology, the provider displays the position of the surgical implants on a computer screen in relation to the patient’s anatomy.
4. The provider uses markers placed on instruments, bone structures, and implants, along with a tracking sensor, to track the relative position of these elements during the surgery.
5. By superimposing real-time tool movements over preoperative images, the provider can precisely guide the instrumentation and ensure accurate placement and positioning of the orthopedic implants.

4. Qualifying circumstances

CPT 0054T is used when a provider utilizes computer-assisted surgical navigation technology with image-guidance based on fluoroscopic images during an orthopedic procedure. This procedure is most commonly used for the accurate placement and positioning of orthopedic implants in knee or hip reconstruction or replacement surgeries. The use of surgical navigation technology can be with either open systems or closed systems, depending on the specific instruments and implants used.

5. When to use CPT code 0054T

CPT code 0054T should be used as an add-on code in conjunction with a primary orthopedic procedure code to indicate the utilization of computer-assisted surgical navigation technology with image-guidance based on fluoroscopic images. It is important to note that this code should only be reported when the procedure meets the specific criteria outlined in the official description.

6. Documentation requirements

To support a claim for CPT 0054T, the provider must document the following information:

• Documentation of the primary orthopedic procedure performed
• Description of the computer-assisted surgical navigation technology used
• Details of the fluoroscopic images utilized for image-guidance
• Explanation of the markers and tracking sensor used for tracking the relative position of instruments, bone structures, and implants
• Documentation of the real-time updates and display of the implant position in relation to the patient’s anatomy
• Record of any preoperative data acquisition and measurements obtained using fluoroscopy
• Explanation of how the surgical navigation technology was used to guide the instrumentation and ensure accurate implant placement and positioning

7. Billing guidelines

When billing for CPT 0054T, it is important to ensure that the procedure meets the specific criteria outlined in the official description. This code should only be reported as an add-on code in conjunction with a primary orthopedic procedure code. Additionally, it is recommended to check with the payer regarding coverage and reimbursement policies for this specific procedure. It is also important to note that CPT code 0054T should not be reported with CT or MRI image guidance procedures, as there are separate codes available for those scenarios.

8. Historical information

CPT code 0054T was added to the Current Procedural Terminology system on January 1, 2004. There have been historical changes to the code, including a code change in 2005 and reactivation in 2009. However, no updates have been made to the code since its reactivation.

9. Examples

1. A provider utilizing computer-assisted surgical navigation technology with image-guidance based on fluoroscopic images during a knee replacement surgery.
2. A surgeon using surgical navigation technology to guide the placement of orthopedic implants during a hip reconstruction procedure.
3. An orthopedic specialist utilizing computer-assisted navigation to ensure accurate positioning of implants in a knee revision surgery.
4. A provider incorporating image-guided surgical navigation technology during a hip replacement procedure to enhance precision and accuracy.
5. A surgeon utilizing computer-assisted navigation with fluoroscopic images to guide the placement of orthopedic implants in a complex joint reconstruction surgery.
6. An orthopedic specialist using surgical navigation technology to assist with the accurate placement of orthopedic implants in a knee arthroscopy procedure.
7. A provider utilizing computer-assisted surgical navigation technology with image-guidance based on fluoroscopic images during a hip resurfacing surgery.
8. A surgeon incorporating image-guided navigation to ensure precise positioning of orthopedic implants in a revision hip replacement procedure.
9. An orthopedic specialist using surgical navigation technology to guide the placement of orthopedic implants in a knee osteotomy procedure.
10. A provider utilizing computer-assisted navigation with fluoroscopic images to enhance accuracy in the placement of orthopedic implants during a hip arthroscopy procedure.