How To Use CPT Code 0200T

CPT 0200T describes a percutaneous sacral augmentation procedure, specifically the unilateral injection(s) using a balloon or mechanical device, when necessary. This article will provide an overview of the code, including the official description, procedure details, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, and examples.

1. What is CPT Code 0200T?

CPT 0200T is a code used to describe a percutaneous sacral augmentation procedure. This procedure involves the injection of cement material through a needle into one side of a fractured sacrum. The provider may also use a balloon or mechanical device to create a cavity in the vertebral body before injecting the cement. Imaging guidance and bone biopsy may be performed during this procedure as well.

2. Official Description

The official description of CPT code 0200T is: ‘Percutaneous sacral augmentation (sacroplasty), unilateral injection(s), including the use of a balloon or mechanical device, when used, 1 or more needles, includes imaging guidance and bone biopsy, when performed.’

3. Procedure

1. The provider begins by prepping and anesthetizing the patient, typically using local anesthesia.
2. Using a balloon or mechanical device, the provider creates a cavity in the sacral region of the vertebra.
3. A specialized bone tamp is then used to expand the collapsed vertebra, allowing for the injection of cement material.
4. The provider injects polymethylmethacrylate or other bone cement into the cavity of the fractured zone of the sacrum using a needle.
5. Imaging guidance, such as computed tomography or fluoroscopy, may be used to ensure accurate placement of the injection.
6. This procedure helps alleviate pain and provides mechanical support for patients with compression fractures or metastatic malignancies of the spine.

4. Qualifying circumstances

This procedure is typically performed on patients with compression fractures of the sacrum or metastatic malignancies affecting the sacral region. The provider must use a balloon or mechanical device to create a cavity in the vertebral body and inject cement material into the fractured zone. While imaging guidance and bone biopsy are not essential for this procedure, they are included in the code if performed by the provider.

5. When to use CPT code 0200T

CPT code 0200T should be used when a provider performs a percutaneous sacral augmentation procedure, including the unilateral injection(s) using a balloon or mechanical device. This code is appropriate when one or more needles are used and when imaging guidance and bone biopsy are performed. It is important to note that for bilateral sacral augmentation, a different code (0201T) should be used.

6. Documentation requirements

When reporting CPT code 0200T, the provider must document the following:

• The patient’s diagnosis, indicating the need for sacral augmentation
• The use of a balloon or mechanical device to create a cavity in the vertebral body
• The date and details of the procedure, including the start and end times
• Any imaging guidance or bone biopsy performed
• The injection of cement material into the fractured zone of the sacrum
• Any complications or additional procedures performed
• The provider’s signature and credentials

7. Billing guidelines

When billing for CPT code 0200T, ensure that the procedure meets the specific criteria outlined in the code description. It is important to note that this code should not be reported if other related codes (CPT 98966-98968) have already been performed within the previous seven days. Additionally, for bilateral sacral augmentation, use the appropriate code (0201T). It is also important to consider the location of the testing when coding for pulmonary function tests, as they have both a professional and technical component.

8. Historical information

CPT code 0200T was added to the Current Procedural Terminology system on January 1, 2010. Since its addition, there have been no updates or changes to the code.

9. Examples

1. A provider performs a percutaneous sacral augmentation procedure, injecting cement material into a fractured sacrum using a balloon and imaging guidance.
2. Using a mechanical device, a provider creates a cavity in the vertebral body and injects bone cement into the fractured zone of the sacrum during a sacral augmentation procedure.
3. During a percutaneous sacral augmentation procedure, a provider uses a needle to inject cement material into the sacrum, without the use of a balloon or mechanical device.
4. Imaging guidance and bone biopsy are performed during a sacral augmentation procedure, where the provider injects cement material into the fractured zone of the sacrum using a balloon.
5. A provider performs a percutaneous sacral augmentation procedure, injecting bone cement into the sacrum using a mechanical device and without the need for imaging guidance.
6. Using a balloon and imaging guidance, a provider creates a cavity in the vertebral body and injects cement material into the fractured zone of the sacrum during a sacral augmentation procedure.
7. During a percutaneous sacral augmentation procedure, a provider uses multiple needles to inject cement material into the sacrum, without the use of a balloon or mechanical device.
8. Imaging guidance and bone biopsy are performed during a sacral augmentation procedure, where the provider injects bone cement into the fractured zone of the sacrum using a mechanical device.
9. A provider performs a percutaneous sacral augmentation procedure, injecting cement material into the sacrum using a balloon and imaging guidance.
10. Using a mechanical device, a provider creates a cavity in the vertebral body and injects bone cement into the fractured zone of the sacrum during a sacral augmentation procedure, without the need for imaging guidance.