2025 CPT code 0200T
Percutaneous sacral augmentation (sacroplasty) with unilateral injection(s), including use of a balloon or mechanical device (when used), one or more needles, imaging guidance, and bone biopsy (when performed).
Modifiers may be applicable to this code. For example, modifier 50 would be used for a bilateral procedure, though another code exists already for this.
Medical necessity must be clearly documented. This typically includes severe pain due to a sacral fracture that has not responded to conservative treatment, or pain from an osteolytic lesion or metastatic disease. Supporting documentation, such as imaging studies and previous treatment records, should be included.
The physician prepares the patient, administers anesthesia (usually local), creates a cavity in the sacrum (if necessary) using a balloon or mechanical device, injects bone cement, and monitors the procedure using imaging guidance.
In simple words: The doctor injects a special cement into your sacrum (tailbone) to help fix a fracture. They might use a balloon or tool to create a small space before injecting the cement. X-ray or other imaging is used to guide the procedure, and a small bone sample may be taken during the procedure.
This code describes a minimally invasive procedure where bone cement is injected into the sacrum to stabilize a fracture. A cavity may be created in the sacrum using a balloon or mechanical device before cement injection. The procedure includes imaging guidance and bone biopsy, if performed. It is typically performed unilaterally.
Example 1: A 70-year-old female with a painful sacral fracture due to osteoporosis undergoes percutaneous sacral augmentation with a unilateral injection of bone cement., A patient with multiple myeloma and a painful osteolytic lesion in the sacrum undergoes sacroplasty with bone biopsy to confirm the diagnosis and inject cement for pain relief. , A patient with metastatic cancer to the sacrum causing instability and pain undergoes percutaneous sacral augmentation with cavity creation using a balloon device and unilateral cement injection for pain relief and stabilization.
Documentation should include the medical necessity for the procedure, details of the fracture, type of cement used, use of a balloon or mechanical device, imaging guidance reports, bone biopsy results (if performed), and any complications.
** This code includes imaging guidance and bone biopsy, when performed. It is important to differentiate between unilateral and bilateral procedures, and to ensure proper documentation supports medical necessity.
- Specialties:Pain Management, Radiology, Orthopedic Surgery
- Place of Service:Ambulatory Surgical Center, Hospital Outpatient, Inpatient Hospital (under specific circumstances)