How To Use CPT Code 0221T

CPT 0221T describes the placement of a posterior intrafacet implant(s) in the lumbar region, including imaging and the placement of bone graft(s) or synthetic device(s) at a single level. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, and examples.

1. What is CPT Code 0221T?

CPT 0221T can be used to describe the placement of a posterior intrafacet implant(s) in the lumbar region. This procedure involves the use of imaging and the placement of bone graft(s) or synthetic device(s) to expand and stabilize the facet joint space. It is typically performed to alleviate pain caused by degenerative changes or trauma in the lumbar vertebral region.

2. Official Description

The official description of CPT code 0221T is: ‘Placement of a posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic device(s), single level; lumbar.’

3. Procedure

1. The provider begins by making an incision in the lumbar region of the vertebral column.
2. They then extend the incision down to the fascia and muscle, exposing the bone.
3. A synthetic spacer or an allograft, typically made from the bone of the femur or tibia, is placed into the facet joint at a single level of the lumbar vertebra.
4. The procedure is performed under fluoroscopic guidance or other imaging technique to ensure accurate placement.
5. Any bleeding is controlled, and the wound is closed in layers.

4. Qualifying circumstances

CPT 0221T is performed on patients who have degenerative changes or trauma in the lumbar vertebral region that cause pain and require the expansion and stabilization of the facet joint space. The procedure involves the placement of a posterior intrafacet implant(s) using imaging and may include the placement of bone graft(s) or synthetic device(s) at a single level in the lumbar region.

5. When to use CPT code 0221T

CPT code 0221T should be used when a provider performs the placement of a posterior intrafacet implant(s) in the lumbar region, including imaging and the placement of bone graft(s) or synthetic device(s) at a single level. This code is specific to the lumbar region and should not be used for other levels of the spine.

6. Documentation requirements

To support a claim for CPT 0221T, the provider must document the following information:

• Patient’s diagnosis and the need for the placement of a posterior intrafacet implant(s)
• Details of the procedure, including the use of imaging and the placement of bone graft(s) or synthetic device(s)
• Date of the procedure
• Any complications or additional procedures performed
• Signature of the provider

7. Billing guidelines

When billing for CPT 0221T, ensure that the procedure involves the placement of a posterior intrafacet implant(s) in the lumbar region, including imaging and the placement of bone graft(s) or synthetic device(s) at a single level. It is important to follow the guidelines and not report this code in conjunction with any radiological service or specific codes related to the lumbar region. Additional tips and considerations for reporting CPT 0221T may be provided by the payer or coding guidelines.

8. Historical information

CPT 0221T 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 patient with degenerative changes in the lumbar region undergoes the placement of a posterior intrafacet implant(s) using imaging and the placement of bone graft(s) at a single level to alleviate pain.
2. Following a traumatic injury to the lumbar region, a patient requires the placement of a synthetic device(s) in the facet joint, including imaging and the use of bone graft(s) at a single level.
3. A provider performs the placement of a posterior intrafacet implant(s) using fluoroscopic guidance and the placement of bone graft(s) in the lumbar region for a patient with chronic pain.
4. Due to degenerative changes in the lumbar vertebrae, a patient undergoes the placement of a posterior intrafacet implant(s) with the use of imaging and synthetic device(s) at a single level.
5. A patient with trauma in the lumbar region requires the placement of a posterior intrafacet implant(s) using imaging and the placement of bone graft(s) to stabilize the facet joint at a single level.
6. Following a diagnosis of degenerative changes in the lumbar region, a patient undergoes the placement of a synthetic spacer in the facet joint, including imaging and the use of bone graft(s) at a single level.
7. A provider performs the placement of a posterior intrafacet implant(s) using fluoroscopic guidance and the placement of synthetic device(s) in the lumbar region for a patient with chronic back pain.
8. Due to trauma in the lumbar vertebrae, a patient requires the placement of a posterior intrafacet implant(s) with the use of imaging and bone graft(s) at a single level.
9. A patient with degenerative changes in the lumbar region undergoes the placement of a posterior intrafacet implant(s) using imaging and the placement of synthetic device(s) at a single level to alleviate pain.
10. Following a traumatic injury to the lumbar region, a patient requires the placement of a synthetic spacer in the facet joint, including imaging and the use of bone graft(s) at a single level.