How To Use CPT Code 0441T

CPT 0441T describes the percutaneous cryoablation procedure, which involves the destruction of a distal/peripheral nerve in the lower extremity using freezing temperatures. This article will cover the official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, and examples of CPT code 0441T.

1. What is CPT Code 0441T?

CPT 0441T is a code that represents the percutaneous cryoablation procedure. This procedure involves the use of freezing temperatures to destroy a distal/peripheral nerve in the lower extremity. It is typically performed to treat complex regional pain syndrome or other neuropathy conditions. The provider uses imaging guidance during the procedure to ensure accurate placement of the cryoablation needle and to monitor the destruction of the nerve.

2. Official Description

The official description of CPT code 0441T is: ‘Ablation, percutaneous, cryoablation, includes imaging guidance; lower extremity distal/peripheral nerve.’

3. Procedure

1. The patient is appropriately prepped and anesthetized, usually with moderate sedation.
2. The provider locates the area to be treated and injects lidocaine to provide local anesthesia.
3. A small skin incision is made over the area to be treated.
4. Using imaging guidance, the provider inserts a cryoablation needle down to the distal/peripheral nerve in the lower extremity.
5. An “ice ball” is delivered through the needle to destroy (ablate) the nerve.
6. The provider may follow a freeze-thaw, freeze-thaw protocol to ensure complete destruction of the nerve.
7. Once satisfied with the destruction of the nerve, the provider removes the needle and closes the small incision.

4. Qualifying circumstances

CPT 0441T is typically performed on patients with complex regional pain syndrome or other neuropathy conditions that require the destruction of a distal/peripheral nerve in the lower extremity. The procedure is performed by a provider who is experienced in percutaneous cryoablation and uses imaging guidance to ensure accurate placement of the cryoablation needle. The patient must be appropriately prepped and anesthetized, usually with moderate sedation, and the provider must document the specific nerve being treated.

5. When to use CPT code 0441T

CPT code 0441T should be used when a provider performs percutaneous cryoablation to destroy a distal/peripheral nerve in the lower extremity. This code is appropriate for cases involving complex regional pain syndrome or other neuropathy conditions that require nerve destruction. It is important to note that CPT code 0441T includes imaging guidance, so this service should not be reported separately.

6. Documentation requirements

To support a claim for CPT code 0441T, the provider must document the following information:

• Specific diagnosis or condition requiring the percutaneous cryoablation procedure
• Details of the procedure, including the specific nerve being treated and the use of imaging guidance
• Date of the procedure
• Start and end times of the procedure
• Any complications or additional procedures performed
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT code 0441T, ensure that the procedure meets the criteria outlined in the official description. The provider should use imaging guidance during the procedure, and this should not be reported separately. It is important to review any specific payer guidelines or policies regarding the use of CPT code 0441T to ensure accurate billing.

8. Historical information

CPT code 0441T was added to the Current Procedural Terminology system on July 1, 2016. There have been no updates or changes to the code since its addition.

9. Examples

1. A provider performs percutaneous cryoablation to destroy a distal/peripheral nerve in the lower extremity of a patient with complex regional pain syndrome.
2. Using imaging guidance, a provider performs cryoablation to ablate a specific distal/peripheral nerve in the lower extremity of a patient with neuropathy.
3. A patient with chronic pain undergoes percutaneous cryoablation of a distal/peripheral nerve in the lower extremity to alleviate their symptoms.
4. A provider uses cryoablation to destroy a specific distal/peripheral nerve in the lower extremity of a patient with nerve damage resulting in numbness and weakness.
5. Using imaging guidance, a provider performs percutaneous cryoablation to treat a distal/peripheral nerve in the lower extremity of a patient with neuropathy-related pain.
6. A patient with complex regional pain syndrome undergoes cryoablation of a specific distal/peripheral nerve in the lower extremity to relieve their symptoms.
7. A provider performs percutaneous cryoablation to ablate a distal/peripheral nerve in the lower extremity of a patient with chronic neuropathic pain.
8. Using imaging guidance, a provider destroys a specific distal/peripheral nerve in the lower extremity of a patient with nerve damage using cryoablation.
9. A patient with complex regional pain syndrome undergoes cryoablation of a distal/peripheral nerve in the lower extremity to improve their quality of life.
10. A provider performs percutaneous cryoablation to treat a specific distal/peripheral nerve in the lower extremity of a patient with neuropathy-related symptoms.