Orthopedic Coding Alert

Question: Encounter notes indicate that the provider 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?

Pennsylvania Subscriber

Answer: The notes narrow down your code choices to a six-pack, but that’s as far as they will take you. Go back to the notes and double-check for more detail, because you’ll need it to code this correctly.

If you still come up short upon reread of encounter notes, go ask the surgeon these questions:

1. What portion of the spine did you scan? You’ll need to know, specifically, whether the surgeon scanned the thoracic or lumbar portion of the spine.

2. Did you use contrast material? There are separate codes for spinal CT to indicate the use of contrast material.

3. 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.

Once you’ve answers to the above questions, choose from one of the following codes for the 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.