Wiki ? correct CPT for c-spine x-ray

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Kimberley

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CERVICAL SPINE

INDICATION: Status post ACDF.

FINDINGS: AP, lateral, and oblique views of the cervical spine were obtained.

Comparison study of 09/25/08.

The patient is status post ACDF revision with fixation hardware traversing the C5, C6 and C7 vertebrae. The hardware components are intact and the alignment is normal. Inner body spacers from previous fusion also noted at C3-4 and C4-5. No listhesis. Endplate degenerative change noted at C2-3. There is no abnormal motion observed with flexion or extension.


IMPRESSION: Status post ACDF revision as described. The alignment is anatomic and there is no abnormal motion with flexion or extension.

72052???????
 
Originally I thought 72052 would be correct since flexion and extension were mentioned in the note. Although the description of 72052 seems to include more views than just three, and it really isn't stated that more than three views were taken. I think you would have to find out exactly what was done as the note isn't very clear. Here is what it says in the CDR:

The physician takes and examines two or three x-ray images of the spine in the neck. Code 72050 if four or more images are taken. Code 72052 if many images are taken to develop a complete overall examination cervical area of the spine. The patient may be asked to flex or extend the neck in this case, and images from different angles may be taken.

I think you really need to verify how many images were taken before you code 72052.
 
Views ?????

AP, lateral, and oblique views of the cervical spine were obtained.

Would this be considered 3 views or 4?
 
Hi Kimberly.

The report said that no abnormal motion with flexion or extension were seen, yet in FINDINGS it only mentions AP, lateral and oblique views and none of those views are able to tell whether extenxion and flexion of the cervical spine are normal, there are two more x-ray studies that do. In your case i would verify with the transcriber of the x-ray reports to look into that.

Now when coding the X-ray you are referring to use 72050 because there are 4 views in total, AP, lateral and right and left obliques.

Contact me if you have any questions
 
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