Outpatient Facility Coding Alert

Question: If the title of the report states “complete scoliosis series including supine and erect,” would you send the report back to the provider for an addendum to include the number of views?

Florida Subscriber

Answer: In this example, the number of views does not need to be included in the exam title. However, if “Complete scoliosis series including supine and erect” is what’s included in the technique — without a reference to number of views — then you should send the report back to the provider for an addendum.

When coding complete scoliosis series examinations, the first factor you want to consider is the terminology of code set 72081-72084. Typically, when the term “complete” is used within the radiology specialty, most coders automatically assume that they should report the code with the highest level of views.

Assuming the views are documented in the technique, this assumption is correct — unless you are coding a “complete” thoracic and lumbar spine series. This spinal series, also known as a “complete scoliosis series,” is not considered “complete” based on the number of views. Rather, the “complete” phrasing pertains to the anatomic sites imaged. For example, code 72081 (Radiologic examination, spine, entire thoracic and lumbar, including skull, cervical and sacral spine if performed (eg, scoliosis evaluation); one view) involves a single view of the entire lumbar and thoracic spine, including the cervical spine, sacral spine, and skull, when performed. As you can see, you can code a “complete” spinal series with just one view imaged.

Using this information, you can conclude that the phrasing “Complete scoliosis series including supine and erect” in the technique does not warrant any code greater than 72082 (… 2 or 3 views). Therefore, you should send the report back to the provider to include the number of views. This is for both compliance purposes and to avoid billing for fewer views than the provider performed. 

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