Summary & Overview
CPT 0201T: Sacral Augmentation with Cement Injection
CPT code 0201T denotes a sacral augmentation procedure in which cement material is injected through bilateral sacral needles to stabilize a fractured sacrum. The technique may include cavity creation with a balloon or mechanical device, use of imaging guidance, and optional bone biopsy. This procedure is relevant nationally as an option for management of sacral insufficiency fractures and other sacral structural failures, particularly in older adults and patients with compromised bone integrity.
Key payers addressed include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. The publication provides a concise reference for clinicians, coders, and policy analysts on clinical context, expected sites of service, and common billing modifiers associated with the procedure. Readers will learn how the code is defined, typical clinical indications and settings, and what to expect in payer coverage discussions. The document also summarizes commonly reported modifiers and notes where input data is not available, enabling stakeholders to align coding, documentation, and prior authorization practices with national expectations.
Data not available in the input: Associated taxonomies, specific ICD-10 diagnosis mappings, related codes, and payer-specific coverage policies.
Billing Code Overview
CPT code 0201T describes a sacral augmentation procedure in which the provider injects cement material through needles on both sides of a fractured sacrum. The procedure may include creation of a cavity using a balloon or mechanical device and can be performed with imaging guidance. Bone biopsy may be performed during the same procedure.
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Service type: Minimally invasive sacral augmentation / vertebral augmentation procedure
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Typical site of service: Hospital outpatient department or ambulatory surgical center; procedure may also occur in specialized interventional radiology or spine procedure suites
Clinical & Coding Specifications
Clinical Context
A 78-year-old female with osteoporosis presents with acute sacral pain after a ground-level fall. Imaging (CT and MRI) demonstrates a non-displaced compression fracture of the sacrum with persistent, severe focal pain refractory to conservative care (analgesics, bracing, and physical therapy) for six weeks. The interventional spine team evaluates the patient and determines sacroplasty is indicated to stabilize the fracture and provide pain relief.
The clinical workflow: pre-procedure evaluation includes informed consent, review of imaging to localize fracture lines, coagulation assessment, and optimization of comorbidities. In the interventional suite under fluoroscopic or CT guidance, the provider administers local anesthesia and/or conscious sedation or monitored anesthesia care as appropriate. Using bilateral trans-sacral or transiliac needle approaches, the provider advances needles into the fractured sacral ala(s), may create a cavity using a balloon or mechanical device, and injects polymethylmethacrylate (PMMA) cement through needles on both sides of the fractured sacrum. Image guidance is used throughout to confirm needle and cement position and to monitor for extravasation. If clinically indicated, a bone biopsy may be obtained during the same session. Post-procedure monitoring includes neurovascular checks, pain assessment, and a post-procedure imaging check. Discharge instructions cover activity restrictions, wound care, and signs of complications that require urgent evaluation.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
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