How To Use CPT Code 0216T

CPT 0216T describes the injection of a diagnostic or therapeutic agent into a single lumbar or sacral paravertebral facet joint or the nerves innervating that joint, with the guidance of ultrasound. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, and examples.

1. What is CPT Code 0216T?

CPT 0216T can be used to describe the injection of a diagnostic or therapeutic agent into a single lumbar or sacral paravertebral facet joint or the nerves innervating that joint. This code is used when the provider uses ultrasound guidance to administer the injection for the purpose of pain relief or as an anesthetic for a surgical procedure.

2. Official Description

The official description of CPT code 0216T is: ‘Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral; single level.’ This code can be reported with modifier 50 to indicate a bilateral procedure.

3. Procedure

1. The provider uses ultrasound guidance to identify the specific lumbar or sacral paravertebral facet joint or the nerves innervating that joint.
2. A needle is inserted at a single level of the lumbar or sacral vertebrae under ultrasound guidance.
3. The provider administers a diagnostic or therapeutic agent into the paravertebral facet joint or the nerves and branches that supply the joint.
4. The agent administered may include pain relievers or anesthetic agents.
5. The procedure is performed to relieve pain or to administer an anesthetic for a surgical procedure.

4. Qualifying circumstances

Patients eligible to receive CPT 0216T services are those who require the injection of a diagnostic or therapeutic agent into a single lumbar or sacral paravertebral facet joint or the nerves innervating that joint. This procedure is typically performed for the purpose of pain relief or as an anesthetic for a surgical procedure. The provider must use ultrasound guidance to ensure accurate placement of the needle.

5. When to use CPT code 0216T

CPT code 0216T should be used when the provider administers an injection into a single lumbar or sacral paravertebral facet joint or the nerves innervating that joint, using ultrasound guidance. This code should be reported for each level injected. If the procedure is performed bilaterally, modifier 50 should be appended to indicate a bilateral procedure.

6. Documentation requirements

To support a claim for CPT 0216T, the provider must document the following information:

• The specific lumbar or sacral paravertebral facet joint or nerves innervating that joint injected
• The use of ultrasound guidance for accurate needle placement
• The type of diagnostic or therapeutic agent administered
• The purpose of the injection (e.g., pain relief or anesthetic for a surgical procedure)
• Date and time of the procedure
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 0216T, ensure that the provider uses ultrasound guidance for accurate needle placement. Modifier 50 should be appended if the procedure is performed bilaterally. It is important to note that CPT 0216T should not be reported if CPT codes 0217T or 0218T have already been performed in the previous seven days. Additionally, consider the location of the testing and the professional and technical components of the procedure when coding.

8. Historical information

CPT 0216T 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 a diagnostic agent into a single lumbar paravertebral facet joint under ultrasound guidance for the purpose of determining the cause of a patient’s back pain.
2. A provider injects a therapeutic agent into a single sacral paravertebral facet joint to relieve a patient’s chronic pain, using ultrasound guidance.
3. Using ultrasound guidance, a provider administers an anesthetic agent into the nerves innervating a single lumbar paravertebral facet joint to provide pain relief during a surgical procedure.
4. A provider performs a diagnostic injection into a single sacral paravertebral facet joint under ultrasound guidance to determine the source of a patient’s leg pain.
5. Using ultrasound guidance, a provider injects a therapeutic agent into the nerves supplying a single lumbar paravertebral facet joint to alleviate a patient’s sciatica symptoms.
6. A provider administers an anesthetic agent into a single sacral paravertebral facet joint under ultrasound guidance to provide pain relief during a surgical procedure.
7. Using ultrasound guidance, a provider injects a diagnostic agent into a single lumbar paravertebral facet joint to determine the cause of a patient’s hip pain.
8. A provider performs a therapeutic injection into the nerves innervating a single sacral paravertebral facet joint under ultrasound guidance to alleviate a patient’s chronic pelvic pain.
9. Using ultrasound guidance, a provider administers a diagnostic agent into a single lumbar paravertebral facet joint to identify the source of a patient’s radiating leg pain.
10. A provider injects a therapeutic agent into the nerves supplying a single sacral paravertebral facet joint under ultrasound guidance to provide pain relief for a patient with chronic lower back pain.