How To Use CPT Code 72131

CPT 72131 is a diagnostic procedure involving computed tomography (CT) of the lumbar spine without contrast material. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, similar codes, and examples of CPT 72131 procedures.

1. What is CPT 72131?

CPT 72131 is a diagnostic procedure that involves the use of computed tomography (CT) to examine the lumbar spine without the use of contrast material. This code is used by medical professionals to diagnose, manage, and treat diseases related to the lumbar spine.

2. 72131 CPT code description

The official description of CPT code 72131 is: “Computed tomography, lumbar spine; without contrast material.”

3. Procedure

1. The patient is positioned and sedated as necessary.
2. The patient lies on the scanner bed, which moves slowly into the scanner.
3. The provider takes cross-sectional images of the lumbar spine without injecting contrast material.
4. The provider examines the images on a computer monitor.
5. The provider interprets the diagnostic results from the lumbar images obtained.
6. The computer stores, reconstructs, and reproduces the images as prints for further evaluation as necessary.

4. Qualifying circumstances

Patients who are eligible to receive CPT 72131 services are those who require a diagnostic examination of their lumbar spine without the use of contrast material. This may include patients with suspected spinal disorders, injuries, or diseases that can be diagnosed and managed through CT imaging. The provider must determine the necessity of the procedure based on the patient’s medical history, symptoms, and physical examination findings.

5. When to use CPT code 72131

It is appropriate to bill the 72131 CPT code when a provider performs a computed tomography (CT) examination of the lumbar spine without using contrast material. This code should be used when the provider determines that a CT scan without contrast is the most appropriate diagnostic tool for the patient’s condition.

6. Documentation requirements

To support a claim for CPT 72131, the following information should be documented:

• Patient’s medical history and symptoms
• Physical examination findings
• Reason for the CT scan without contrast
• Details of the procedure, including patient positioning and sedation
• Interpretation of the diagnostic results
• Any follow-up recommendations or treatment plans

7. Billing guidelines

When billing for CPT 72131, keep in mind the following guidelines and tips:

• Use code 72132 for a CT of the lumbar spine with contrast material.
• Use code 72133 for a CT of the lumbar spine without contrast material, followed by contrast material and further sections.
• Code the service as without contrast if oral or rectal contrast is administered.
• Contrast must be intravascular, intraarticular, or intrathecal to assign a code with contrast.
• Check payer policies for contrast coverage and reportable supply codes.
• Append modifier 26 for the physician’s interpretation of the radiology service.
• Append modifier TC for the technical component of the radiology service.
• Do not append a professional or technical modifier when reporting a global service.

8. Historical information

CPT 72131 was added to the Current Procedural Terminology system on January 1, 1990. The code was changed on January 1, 2003, from “Computerized axial tomography, lumbar spine; without contrast material” to its current description.

9. Similar codes to CPT 72131

Five similar codes to CPT 72131 and how they differentiate are:

• CPT 72132: Involves a CT of the lumbar spine with contrast material.
• CPT 72133: Involves a CT of the lumbar spine without contrast material, followed by contrast material and further sections.
• CPT 72141: Involves a CT of the cervical spine without contrast material.
• CPT 72146: Involves a CT of the thoracic spine without contrast material.
• CPT 72148: Involves a CT of the lumbosacral spine without contrast material.

10. Examples

Here are 10 detailed examples of CPT code 72131 procedures:

1. A patient with a history of chronic lower back pain undergoes a CT scan of the lumbar spine without contrast to evaluate for degenerative disc disease.
2. A patient with a suspected lumbar spine fracture after a fall undergoes a CT scan without contrast to confirm the diagnosis and assess the extent of the injury.
3. A patient with a known spinal tumor undergoes a CT scan of the lumbar spine without contrast to monitor tumor growth and response to treatment.
4. A patient with a history of spinal surgery undergoes a CT scan of the lumbar spine without contrast to evaluate for postoperative complications or hardware failure.
5. A patient with suspected spinal stenosis undergoes a CT scan of the lumbar spine without contrast to assess the severity of the condition and plan for potential surgical intervention.
6. A patient with a history of chronic back pain and recent onset of radiculopathy undergoes a CT scan of the lumbar spine without contrast to evaluate for nerve root compression.
7. A patient with a suspected lumbar spine infection undergoes a CT scan without contrast to assess the extent of the infection and guide treatment planning.
8. A patient with a history of scoliosis undergoes a CT scan of the lumbar spine without contrast to evaluate the progression of the spinal curvature and plan for potential surgical intervention.
9. A patient with a suspected lumbar spine herniated disc undergoes a CT scan without contrast to confirm the diagnosis and assess the severity of the condition.
10. A patient with a history of spinal fusion surgery undergoes a CT scan of the lumbar spine without contrast to evaluate for potential pseudarthrosis or hardware failure.