How To Use CPT Code 72158

CPT 72158 is a diagnostic procedure involving magnetic resonance imaging (MRI) of the lumbar spinal canal and contents, performed without and with 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 code 72158 procedures.

1. What is CPT 72158?

CPT 72158 is a diagnostic procedure that involves the use of magnetic resonance imaging (MRI) to visualize the lumbar spinal canal and its contents. The procedure is performed first without the use of contrast material, and then again with contrast material to enhance the image quality. This code is used by medical coders and billers to report the service provided by healthcare professionals when performing this specific diagnostic procedure.

2. 72158 CPT code description

The official description of CPT code 72158 is: “Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; lumbar.”

3. Procedure

1. The patient is positioned on the MRI scanning table, and the lumbar region is aligned with the scanner’s magnetic field.
2. The patient is instructed to hold their breath and remain still while the initial images are taken without contrast material.
3. Contrast material is then injected into the patient’s bloodstream to enhance the image quality of the lumbar spinal canal and its contents.
4. Additional images are taken with the contrast material in place, capturing various sequences and angles of the lumbar spine.
5. The healthcare provider reviews the images, analyzes the results, and interprets the findings.
6. A written report of the findings is prepared by the provider.

4. Qualifying circumstances

Patients who are eligible to receive CPT code 72158 services are those experiencing symptoms or conditions that require a detailed examination of the lumbar spinal canal and its contents. This may include patients with back pain, sciatica, spinal stenosis, herniated discs, or other spinal abnormalities. The healthcare provider must determine that an MRI with and without contrast material is medically necessary for the accurate diagnosis and treatment of the patient’s condition.

5. When to use CPT code 72158

It is appropriate to bill the 72158 CPT code when a healthcare provider performs an MRI of the lumbar spinal canal and its contents, both without and with contrast material, for the purpose of diagnosing, managing, or treating a patient’s condition. The use of contrast material must be deemed medically necessary by the provider to enhance the image quality and provide a more accurate diagnosis.

6. Documentation requirements

To support a claim for CPT 72158, the following information should be documented:

• Patient’s medical history and presenting symptoms or conditions
• Physical examination findings related to the lumbar spine
• Reason for performing the MRI with and without contrast material
• Details of the contrast material used, including type, dosage, and route of administration
• Findings and interpretation of the MRI images
• Diagnosis and treatment plan based on the MRI results
• Written report of the findings, signed by the healthcare provider

7. Billing guidelines

When billing for CPT code 72158, keep in mind the following guidelines:

• Append modifier 26 to the radiology code when reporting only the physician’s interpretation of the radiology service.
• Append modifier TC to the radiology code when reporting only the technical component of the radiology service. Note that some payers may exempt hospitals from appending modifier TC, as their portion is inherently technical.
• Do not append a professional or technical modifier when reporting a global service in which one provider renders both the professional and technical components.
• Code the service as without contrast when the provider administers oral or rectal contrast, as the radiology service includes these types of contrast.
• Check individual payer policies for contrast coverage and reportable supply codes when providers supply contrast material.

8. Historical information

CPT 72158 was added to the Current Procedural Terminology system on January 1, 1992. There have been no updates to the code since its addition.

9. Similar codes to CPT 72158

Five similar codes to CPT 72158 and how they differ are:

• CPT 72156: This code is for an MRI of the entire spinal canal and its contents, without and with contrast material, covering the cervical, thoracic, and lumbar regions.
• CPT 72157: This code is for an MRI of the thoracic spinal canal and its contents, without and with contrast material.
• CPT 72148: This code is for an MRI of the lumbar spine, without contrast material.
• CPT 72149: This code is for an MRI of the lumbar spine, with contrast material.
• CPT 72146: This code is for an MRI of the thoracic spine, without contrast material.

10. Examples

Here are 10 detailed examples of CPT code 72158 procedures:

1. A patient with chronic lower back pain and sciatica undergoes an MRI of the lumbar spinal canal and its contents, without and with contrast material, to evaluate for disc herniation or spinal stenosis.
2. A patient with a history of spinal surgery presents with new-onset back pain and numbness in the legs. An MRI of the lumbar spinal canal and its contents, without and with contrast material, is performed to assess for post-surgical complications or recurrent spinal abnormalities.
3. A patient with suspected lumbar spinal infection undergoes an MRI of the lumbar spinal canal and its contents, without and with contrast material, to visualize the extent of the infection and guide treatment planning.
4. An MRI of the lumbar spinal canal and its contents, without and with contrast material, is performed on a patient with a known spinal tumor to assess the tumor’s size, location, and potential impact on surrounding structures.
5. A patient with a history of spinal trauma undergoes an MRI of the lumbar spinal canal and its contents, without and with contrast material, to evaluate for any residual damage or complications.
6. An MRI of the lumbar spinal canal and its contents, without and with contrast material, is performed on a patient with progressive neurological symptoms to assess for spinal cord compression or other spinal abnormalities.
7. A patient with a suspected lumbar spinal vascular malformation undergoes an MRI of the lumbar spinal canal and its contents, without and with contrast material, to visualize the abnormal blood vessels and guide treatment planning.
8. An MRI of the lumbar spinal canal and its contents, without and with contrast material, is performed on a patient with a history of spinal inflammation to assess for any ongoing inflammatory processes or complications.
9. A patient with a known spinal deformity undergoes an MRI of the lumbar spinal canal and its contents, without and with contrast material, to evaluate the impact of the deformity on surrounding structures and guide treatment planning.
10. An MRI of the lumbar spinal canal and its contents, without and with contrast material, is performed on a patient with unexplained lower extremity weakness to assess for any spinal abnormalities that may be causing the symptoms.