2025 CPT code 21116
(Active) Effective Date: N/A Revision Date: N/A Injection Procedures - Arthrography Musculoskeletal System Feed
Injection procedure for temporomandibular joint arthrography.
Modifiers may be applicable depending on the circumstances of service.Consult the CPT codebook and payer guidelines for appropriate modifier use.Examples may include 50 (bilateral procedure), 76 (repeat procedure by the same physician), or 77 (repeat procedure by another physician).
Medical necessity for a TMJ arthrogram is typically established when other less invasive diagnostic methods have failed to provide a definitive diagnosis, or when there is a strong clinical suspicion of a specific TMJ pathology (e.g., internal derangement, inflammation) that requires visualization of the joint structures for proper management.Payers will assess medical necessity based on the specific clinical scenario and documentation.
The physician or qualified healthcare professional is responsible for prepping the patient, administering local anesthesia (if necessary), inserting the needle into the TMJ under fluoroscopic guidance, injecting the contrast material, aspirating joint fluid (if indicated), removing the needle, and ensuring proper imaging is obtained.Interpretation of the images is typically billed separately.
In simple words: The doctor injects a special dye into the jaw joint to take X-rays. This helps them see the joint better to diagnose problems.
This CPT code describes the injection of contrast material into the temporomandibular joint (TMJ) for arthrography.The procedure involves inserting a needle into the TMJ cavity under fluoroscopic guidance, injecting contrast medium (and possibly air for double contrast), aspirating some joint fluid for analysis (if indicated), and removing the needle.Imaging is performed following the injection.
Example 1: A patient presents with TMJ pain and clicking.The physician orders a TMJ arthrogram to visualize the joint structures and diagnose the cause of the symptoms. Code 21116 is used to report the injection procedure., A patient has undergone previous TMJ surgery, and the physician needs to assess the joint for potential complications.A TMJ arthrogram with code 21116 is used to evaluate the joint's post-surgical status., A patient experiences persistent jaw pain and limited range of motion. The physician performs a TMJ arthrogram using code 21116 to identify any structural abnormalities or inflammatory processes within the joint.
The medical record should clearly document the indication for the TMJ arthrogram, including the patient's symptoms, clinical findings, and the reason for the arthrogram.The procedure report should detail the type of contrast material used, the technique of injection (including fluoroscopic guidance), aspiration of joint fluid (if done), and the amount of contrast material injected.Radiology reports should also be included.
** Accurate coding requires thorough documentation of the procedure, including the type and amount of contrast used, the technique of injection, and the results of any joint fluid aspiration.Always consult the most current CPT coding guidelines and payer-specific rules for proper billing practices.
- Revenue Code: I1F (STANDARD IMAGING - OTHER)
- RVU: This information is not available in the provided text. RVUs vary based on geographic location, payer, and other factors. Consult the specific payer's fee schedule or a reliable RVU database for current values.
- Payment Status: Active
- Modifier TC rule: No information on TC modifier applicability for this code is available in the provided text.Consult payer guidelines and relevant coding resources.
- Fee Schedule : Historical fee schedule data is not available in the provided text. Consult historical fee schedules from specific payers for this information.
- Specialties:Oral and Maxillofacial Surgery, Radiology, Dentistry
- Place of Service:Office, Outpatient Hospital, Ambulatory Surgical Center