How To Use CPT Code 72110

CPT 72110 refers to a radiologic examination of the lumbosacral spine with a minimum of four views. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, similar codes, and examples of CPT 72110 procedures.

1. What is CPT 72110?

CPT 72110 is a diagnostic procedure code used to describe a radiologic examination of the lumbosacral spine, which involves taking a minimum of four X-ray views. This examination is performed to evaluate the patient’s spine for the presence of abnormal curves, fractures, or cancer.

2. 72110 CPT code description

The official description of CPT code 72110 is: “Radiologic examination, spine, lumbosacral; minimum of 4 views.”

3. Procedure

The 72110 procedure involves the following steps:

1. The patient is positioned on an X-ray table.
2. The provider carefully aligns the lumbar and sacral spine between the X-ray machine and a cassette containing the X-ray film or plate.
3. The X-ray beam is focused on the area to be photographed.
4. The patient remains still to prevent image blurring.
5. An X-ray machine sends a beam of radiation through the back, and the computer or a special film records the image.
6. Dense body parts, such as bones, appear white on the X-ray image, while softer body tissues appear darker.
7. A minimum of four views are taken during the examination.

4. Qualifying circumstances

Patients eligible to receive CPT code 72110 services are those who present with symptoms or conditions that warrant a radiologic examination of the lumbosacral spine. These may include, but are not limited to, the following:

• Back pain
• Sciatica
• Spinal deformities
• Spinal fractures
• Spinal infections
• Spinal tumors
• Disc herniation
• Spinal stenosis
• Spondylolisthesis
• Arthritis

5. When to use CPT code 72110

It is appropriate to bill the 72110 CPT code when a provider performs a radiologic examination of the lumbosacral spine with a minimum of four views to evaluate the patient’s spine for the presence of abnormal curves, fractures, or cancer. This code should be used when the examination is medically necessary and supported by the patient’s symptoms or conditions.

6. Documentation requirements

To support a claim for CPT 72110, the provider’s documentation should include the following information:

• Patient’s medical history and presenting symptoms or conditions
• Physical examination findings
• Indication for the radiologic examination
• Number of views taken during the examination
• Technical details of the procedure, such as patient positioning and X-ray projections
• Radiologic findings and interpretation
• Impression and recommendations for further evaluation or treatment, if applicable

7. Billing guidelines

When billing for CPT code 72110, keep in mind the following guidelines and tips:

• Use code 72100 for two or three views of the lumbosacral spine.
• Use code 72114 for a complete, or minimum of six views, of the lumbosacral spine.
• Use code 72120 for two or three views, bending views only, of the lumbosacral spine.
• Append professional component modifier 26 to the radiology code when reporting only the physician’s interpretation.
• Append modifier TC to the radiology code when reporting only the technical component. Note that payer policy may exempt hospitals from appending modifier TC.
• Do not append a professional or technical modifier when reporting a global service in which one provider renders both components.
• Ensure the provider’s documentation clearly describes each view taken and the patient’s body position and projection of the X-ray.

8. Historical information

CPT 72110 was added to the Current Procedural Terminology system on January 1, 1990. There have been updates to the code description, with the most recent change occurring on January 1, 2009.

9. Similar codes to CPT 72110

Five similar codes to CPT 72110 and how they differentiate are as follows:

• CPT 72100: Involves two or three views of the lumbosacral spine.
• CPT 72114: Involves a complete, or minimum of six views, of the lumbosacral spine.
• CPT 72120: Involves two or three views, bending views only, of the lumbosacral spine.
• CPT 72128: Involves a computed tomography (CT) scan of the lumbar spine.
• CPT 72132: Involves a CT scan of the lumbar spine with contrast material.

10. Examples

Here are 10 detailed examples of CPT code 72110 procedures:

1. A patient with chronic lower back pain and a history of spinal stenosis undergoes a radiologic examination of the lumbosacral spine with four views to assess the severity of the stenosis.
2. A patient with a suspected lumbar vertebral fracture after a fall undergoes a radiologic examination of the lumbosacral spine with four views to confirm the fracture and determine its extent.
3. A patient with a known spinal deformity, such as scoliosis, undergoes a radiologic examination of the lumbosacral spine with four views to monitor the progression of the deformity.
4. A patient with a history of spinal infections undergoes a radiologic examination of the lumbosacral spine with four views to evaluate for any new or recurrent infections.
5. A patient with persistent sciatica undergoes a radiologic examination of the lumbosacral spine with four views to identify any underlying disc herniation or other spinal abnormalities.
6. A patient with a suspected spinal tumor undergoes a radiologic examination of the lumbosacral spine with four views to assess the presence, location, and size of the tumor.
7. A patient with arthritis and worsening back pain undergoes a radiologic examination of the lumbosacral spine with four views to evaluate the extent of joint degeneration.
8. A patient with a history of spondylolisthesis undergoes a radiologic examination of the lumbosacral spine with four views to monitor the progression of vertebral slippage.
9. A patient with a suspected lumbar disc herniation undergoes a radiologic examination of the lumbosacral spine with four views to confirm the diagnosis and determine the severity of the herniation.
10. A patient with a history of spinal surgery undergoes a radiologic examination of the lumbosacral spine with four views to assess the postoperative alignment and stability of the spine.