Neurosurgery Coding Alert

Question: The surgeon performed a computed tomography (CT) scan of a patient’s spine. There’s nothing else in the notes. Can I choose the correct code with this information?

Ohio Subscriber

Answer: No. You need more information to code this encounter correctly. Re-read the notes for more details, but if there is nothing else there, go ask the surgeon the following questions:

• What portion of the spine did you scan?  You need to know, specifically, whether the surgeon scanned the thoracic or lumbar portion of the spine.
• Did you use contrast material? There are separate codes for spinal CT to indicate the use of contrast material.
• When did you use contrast material? The contrast material codes also contain two coding subgroups: surgeries where the physician uses contrast materials throughout the procedure, and surgeries where the physician performs the CT scan without contrast materials, and then with contrast materials.

Then, once you have answers to the above questions, you can look to the following CPT^® codes to report a spinal CT scan.

• 72128 (Computed tomography, thoracic spine; without contrast material)
• 72129 (… with contrast material)
• 72130 (… without contrast material, followed by contrast material(s) and further sections)
• 72131 (Computed tomography, lumbar spine; without contrast material)
• 72132 (… with contrast material)
• 72133 (… without contrast material, followed by contrast material(s) and further sections).