How To Use CPT Code 0215T

CPT 0215T describes the injection of a diagnostic or therapeutic agent into one or more additional cervical or thoracic paravertebral facet joints or the nerves that innervate those joints, under ultrasound guidance. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, and examples.

1. What is CPT Code 0215T?

CPT 0215T can be used to describe the injection of a diagnostic or therapeutic agent into one or more additional cervical or thoracic paravertebral facet joints or the nerves that innervate those joints, with the guidance of ultrasound. This code is used when the provider administers the injection to relieve pain or administer an anesthetic for a surgical procedure.

2. Official Description

The official description of CPT code 0215T is: ‘Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; third and any additional level(s) (List separately in addition to code for primary procedure).’ Notes: (Do not report 0215T more than once per day) (Use 0215T in conjunction with 0213T, 0214T) (For bilateral procedure, report 0215T twice. Do not report modifier 50 in conjunction with 0215T).

3. Procedure

1. After assessing the patient’s condition, the provider selects the appropriate levels for the injection.
2. Using ultrasound guidance, the provider inserts a needle into the additional cervical or thoracic paravertebral facet joint or the nerves that innervate the joint.
3. The provider administers the diagnostic or therapeutic agent into the joint or nerves to relieve pain or administer an anesthetic.
4. If necessary, the provider repeats the procedure for any additional levels.

4. Qualifying circumstances

Patients eligible to receive CPT 0215T services are those who require the injection of a diagnostic or therapeutic agent into additional cervical or thoracic paravertebral facet joints or the nerves that innervate those joints. The provider must use ultrasound guidance during the procedure. This code is typically used to relieve pain or administer an anesthetic for a surgical procedure.

5. When to use CPT code 0215T

CPT code 0215T should be used when the provider administers an injection into one or more additional cervical or thoracic paravertebral facet joints or the nerves that innervate those joints, with the guidance of ultrasound. This code should be used in conjunction with the primary procedure code. It should not be reported more than once per day, and if the procedure is performed bilaterally, the code should be reported twice without using modifier 50.

6. Documentation requirements

To support a claim for CPT 0215T, the provider must document the following information:

• The specific levels at which the injection was administered
• The use of ultrasound guidance during the procedure
• The type of diagnostic or therapeutic agent administered
• The purpose of the injection (relief of pain or administration of anesthetic)
• The date and time of the procedure
• Any additional relevant details or complications

7. Billing guidelines

When billing for CPT 0215T, ensure that the injection is performed at one or more additional cervical or thoracic paravertebral facet joints or the nerves that innervate those joints, with the guidance of ultrasound. Use the appropriate primary procedure code in conjunction with 0215T. If the procedure is performed bilaterally, report the code twice without using modifier 50. It is important to note that payers may not reimburse for this code if it is reported without an appropriate primary code.

8. Historical information

CPT 0215T was added to the Current Procedural Terminology system on January 1, 2011. There have been no updates to the code since its addition.

9. Examples

1. A provider administers an injection of a diagnostic agent into the additional cervical paravertebral facet joint under ultrasound guidance to determine the cause of a patient’s neck pain.
2. Using ultrasound guidance, a provider injects a therapeutic agent into the nerves that innervate the additional thoracic paravertebral facet joint to relieve a patient’s chronic back pain.
3. A provider administers an injection of an anesthetic agent into one more additional cervical paravertebral facet joints under ultrasound guidance to prepare a patient for a surgical procedure.
4. Using ultrasound guidance, a provider injects a diagnostic agent into the nerves that innervate the additional thoracic paravertebral facet joint to determine the cause of a patient’s chest pain.
5. A provider administers an injection of a therapeutic agent into the additional cervical paravertebral facet joint under ultrasound guidance to alleviate a patient’s chronic migraines.
6. Using ultrasound guidance, a provider injects a diagnostic agent into the nerves that innervate the additional thoracic paravertebral facet joint to diagnose the source of a patient’s radiating back pain.
7. A provider administers an injection of an anesthetic agent into one more additional cervical paravertebral facet joints under ultrasound guidance to relieve a patient’s acute neck pain.
8. Using ultrasound guidance, a provider injects a therapeutic agent into the nerves that innervate the additional thoracic paravertebral facet joint to manage a patient’s chronic spinal arthritis.
9. A provider administers an injection of a diagnostic agent into the additional cervical paravertebral facet joint under ultrasound guidance to investigate the cause of a patient’s limited neck mobility.
10. Using ultrasound guidance, a provider injects a therapeutic agent into the nerves that innervate the additional thoracic paravertebral facet joint to alleviate a patient’s chronic rib pain.