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The procedure described by CPT® Code 0202T involves arthroplasty of the posterior vertebral joint(s), specifically targeting the facet joints located in the lumbar spine. The facet joints, which are paired posterior joints situated between the vertebrae, play a crucial role in providing stability and facilitating movement in the spine. These joints have flat articular surfaces that allow for smooth articulation between adjacent vertebrae. When the intervertebral disc sustains damage, the facet joints can become compromised, leading to conditions such as nerve compression and significant back pain. The surgical intervention aims to repair or replace the damaged facet joints to alleviate pain and restore function. During the procedure, the surgeon makes an incision over the affected lumbar segment to access the facet joints. Fluoroscopy, a real-time imaging technique, is utilized to enhance visualization of the surgical site, ensuring precision in the execution of the procedure. The intervertebral ligament is carefully divided to expose the lamina, which may be partially or fully excised to reveal the involved nerve root. The surgeon then explores the facet joints, excising the damaged joint, typically focusing on the lower facet, although the upper facet may also be removed if necessary. To relieve nerve compression, the vertebral foramen is enlarged using specialized instruments. Stabilization of the spine is achieved through the placement of a facet joint prosthesis or a vertebral column fixator device, and bone cement may be injected to enhance stability. The procedure concludes with meticulous control of bleeding, irrigation of the wound, and closure of the incisions. This code specifically reports surgical intervention at a single level of the lumbar spine, addressing the complexities associated with facet joint repair and stabilization.
© Copyright 2025 Coding Ahead. All rights reserved.
The procedure described by CPT® Code 0202T is indicated for patients experiencing significant pain and dysfunction due to damage to the posterior vertebral joints, specifically the facet joints. The following conditions may warrant this surgical intervention:
The surgical procedure for CPT® Code 0202T involves several critical steps to ensure effective treatment of the facet joints. Each step is detailed as follows:
After the completion of the procedure, patients typically require monitoring for any immediate complications. Post-operative care may include pain management, physical therapy, and follow-up appointments to assess recovery. Patients are advised to follow specific instructions regarding activity restrictions and rehabilitation exercises to ensure optimal healing and recovery. The expected recovery period may vary based on individual patient factors and the extent of the surgery performed.
| Short Descr | POST VERT ARTHRPLST 1 LUMBAR | Medium Descr | POST VERT ARTHRPLSTY W/WO BONE CEMENT 1 LUMB LVL | Long Descr | 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 | Status Code | Carriers Price the Code | Global Days | XXX - Global Concept Does Not Apply | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 0 - No payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 0 - 150% payment adjustment for bilateral procedures does NOT apply. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 0 - Payment restriction for assistants at surgery applies to this procedure... | Co-Surgeons (62) | 0 - Co-surgeons not permitted for this procedure. | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Inpatient Procedures, not paid under OPPS | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P1F - Major procedure - explor/decompr/excis disc | MUE | 1 | CCS Clinical Classification | 3 - Laminectomy, excision intervertebral disc |
| 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | 22 | Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service. | 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 80 | Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s). | 82 | Assistant surgeon (when qualified resident surgeon not available): the unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code number(s). | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | GC | This service has been performed in part by a resident under the direction of a teaching physician | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service |
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| 2017-01-01 | Changed | Guideline changed. |
| 2010-01-01 | Added | First appearance in code book in 2010. |
| 2009-07-01 | Added | - |
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