CPT® Code 0216T

Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral; single level

Paravertebral facet joints, also known as zygapophyseal joints, are critical structures located on the posterior aspect of the spine, situated on either side of the vertebrae where one vertebra overlaps another. These joints play a significant role in spinal movement and stability. Pain originating from these joints can be attributed to various conditions, including post-laminectomy syndrome, which may occur after spinal surgery that destabilizes the joints, leading to scar tissue formation or recurrent disc herniation. Other potential causes of facet joint pain include degenerative conditions such as spondylosis, spondylolisthesis, and arthritis. The procedure described by CPT® Code 0216T involves the injection of a diagnostic or therapeutic agent into the paravertebral facet joint or the nerves that innervate that joint, utilizing ultrasound guidance for precision. This technique begins with the preparation of the skin over the facet joint, followed by the administration of a local anesthetic to minimize discomfort. A spinal needle is then carefully directed into the facet joint space until it encounters bone or cartilage, ensuring accurate placement. To confirm the correct positioning of the needle, a small amount of contrast material is injected. Subsequently, a local anesthetic and/or steroid is administered to provide pain relief. The initial injection serves a diagnostic purpose, helping to identify the specific source of pain. If the patient experiences significant pain relief following this diagnostic injection, a therapeutic injection may be performed on a subsequent date, utilizing a long-acting local anesthetic combined with a steroid for prolonged relief. For billing purposes, CPT® Code 0216T is designated for a single lumbar or sacral facet joint injection, while additional levels can be billed using CPT® Codes 0217T and 0218T for subsequent injections at the second and third levels, respectively.