How To Use CPT Code 0202T

CPT 0202T describes a surgical procedure known as posterior vertebral joint(s) arthroplasty. This article will cover the official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, and examples.

1. What is CPT Code 0202T?

CPT 0202T is a code used to describe a surgical procedure called posterior vertebral joint(s) arthroplasty. This procedure involves the replacement of one or more joints in the lumbar spine with a prosthetic device. It may also include facetectomy, laminectomy, foraminotomy, and the injection of bone cement. The procedure is performed under fluoroscopic guidance and aims to stabilize the spine while maintaining its normal motion.

2. Official Description

The official description of CPT code 0202T is: ‘Posterior vertebral joint(s) arthroplasty (eg, facet joint[s] replacement), including facetectomy, laminectomy, foraminotomy, and vertebral column fixation, injection of bone cement, when performed, including fluoroscopy, single level, lumbar spine.’

3. Procedure

1. The surgeon begins by making an incision over the affected lumbar vertebrae and retracting the paravertebral muscles to access the spine.
2. Partial resection is performed to remove the posterior lumbar component and insert the facet prosthesis.
3. Facetectomy, laminectomy, foraminotomy, and the injection of bone cement may be performed as necessary.
4. The procedure is guided by fluoroscopy, which allows the surgeon to visualize the spine during the surgery.
5. Hemostasis is ensured, and the excised area is closed in layers to complete the procedure.

4. Qualifying circumstances

CPT 0202T is typically performed on patients who require the replacement of one or more facet joints in the lumbar spine. It may be necessary for conditions such as degenerative disc disease, spinal stenosis, or facet joint arthritis. The procedure is performed by a qualified surgeon and may involve additional surgical techniques such as facetectomy, laminectomy, foraminotomy, and the injection of bone cement.

5. When to use CPT code 0202T

CPT code 0202T should be used when a surgeon performs posterior vertebral joint(s) arthroplasty on a single level of the lumbar spine. It is important to note that this code should not be reported in conjunction with other specific codes related to spinal procedures, as indicated in the notes provided.

6. Documentation requirements

To support a claim for CPT code 0202T, the surgeon must document the following information:

• Patient’s diagnosis and the need for posterior vertebral joint(s) arthroplasty
• Details of the surgical procedure performed, including facetectomy, laminectomy, foraminotomy, and the injection of bone cement
• Use of fluoroscopy during the procedure
• Date and duration of the surgery
• Any additional procedures performed during the same surgical session
• Signature of the performing surgeon

7. Billing guidelines

When billing for CPT code 0202T, ensure that the procedure meets the criteria outlined in the official description. It is important to note that this code should not be reported with certain other specific codes related to spinal procedures, as indicated in the notes provided. Familiarize yourself with the specific billing guidelines and requirements of the payer to ensure accurate and appropriate reimbursement.

8. Historical information

CPT code 0202T was added to the Current Procedural Terminology system on January 1, 2010. It has undergone changes in its designation as an inpatient-only (IPO) procedure, with removal and subsequent re-addition to the IPO list in later years.

9. Examples

1. A surgeon performs posterior vertebral joint(s) arthroplasty on a single level of the lumbar spine for a patient with degenerative disc disease.
2. Facet joint replacement, facetectomy, and laminectomy are performed during a posterior vertebral joint(s) arthroplasty procedure on a patient with spinal stenosis.
3. A surgeon performs posterior vertebral joint(s) arthroplasty with the injection of bone cement for a patient with facet joint arthritis in the lumbar spine.
4. Posterior vertebral joint(s) arthroplasty is performed on a single level of the lumbar spine using fluoroscopic guidance for a patient with a herniated disc.
5. A surgeon performs posterior vertebral joint(s) arthroplasty on a single level of the lumbar spine for a patient with spondylolisthesis.
6. Facetectomy, laminectomy, and foraminotomy are performed during a posterior vertebral joint(s) arthroplasty procedure on a patient with spinal instability.
7. A surgeon performs posterior vertebral joint(s) arthroplasty on a single level of the lumbar spine for a patient with facet joint degeneration.
8. Posterior vertebral joint(s) arthroplasty is performed on a single level of the lumbar spine for a patient with a vertebral fracture.
9. A surgeon performs posterior vertebral joint(s) arthroplasty on a single level of the lumbar spine for a patient with failed previous spinal fusion.
10. Facetectomy, laminectomy, and the injection of bone cement are performed during a posterior vertebral joint(s) arthroplasty procedure on a patient with spinal deformity.