How To Use CPT Code 72081

CPT 72081 describes the radiologic examination of the entire thoracic and lumbar spine, including the skull, cervical spine, and sacral spine if performed. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, similar codes and billing examples.

1. What is CPT Code 72081?

CPT 72081 is used to capture a radiologic examination of the entire thoracic and lumbar spine, including the skull, cervical spine, and sacral spine if performed. This diagnostic procedure is performed to evaluate the patient for spine abnormalities, such as scoliosis or other spinal deformities. The provider takes a single X-ray image from a specific angle or direction to obtain a comprehensive view of the spine.

2. Official Description

The official description of CPT code 72081 is: ‘Radiologic examination, spine, entire thoracic and lumbar, including skull, cervical and sacral spine if performed (eg, scoliosis evaluation); one view.’

3. Procedure

1. In this diagnostic procedure, the patient is positioned on an X-ray table.
2. The provider captures a single X-ray image of the entire thoracic and lumbar spine from a specific angle or direction.
3. The X-ray image may include the skull, cervical spine, and sacral spine if necessary.
4. The purpose of the procedure is to evaluate the patient for spine abnormalities, such as scoliosis or other deformities.
5. The provider may take additional views if necessary, such as two or three views for the entire back (use CPT code 72082) or four or five views (use CPT code 72083).
6. If the provider takes at least six views of the entire back, use CPT code 72084.

4. Qualifying circumstances

CPT 72081 is performed when there is a need to evaluate the entire thoracic and lumbar spine, including the skull, cervical spine, and sacral spine if necessary. The procedure is typically done to assess the patient for spine abnormalities, such as scoliosis or other deformities. The provider must capture a single X-ray image from a specific angle or direction to obtain a comprehensive view of the spine.

5. When to use CPT code 72081

CPT code 72081 should be used when the provider performs a radiologic examination of the entire thoracic and lumbar spine, including the skull, cervical spine, and sacral spine if necessary. This code is appropriate when a single X-ray image is taken from a specific angle or direction to evaluate the patient for spine abnormalities. It should not be used when multiple views are taken, as there are separate codes for those scenarios.

6. Documentation requirements

To support a claim for CPT code 72081, the provider must document the following information:

• Reason for the radiologic examination of the entire thoracic and lumbar spine
• Specific angle or direction from which the X-ray image was taken
• Inclusion of the skull, cervical spine, and sacral spine if performed
• Number of views taken, if applicable
• Any additional findings or observations
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT code 72081, ensure that the provider captures a single X-ray image of the entire thoracic and lumbar spine, including the skull, cervical spine, and sacral spine if necessary. If the provider takes additional views, use the appropriate codes (72082, 72083, or 72084) based on the number of views. Modifier 26 should be appended to the radiology code if reporting only the physician’s interpretation, and modifier TC should be appended if reporting only the technical component. However, payer policies may exempt hospitals from appending modifier TC. If the provider renders both the professional and technical components, do not append any modifiers.

8. Historical information

CPT code 72081 was added to the Current Procedural Terminology system on January 1, 2016. There have been no updates or changes to the code since its addition.

9. Examples

1. A patient undergoes a radiologic examination of the entire thoracic and lumbar spine, including the skull and cervical spine, to evaluate for scoliosis.
2. A provider captures a single X-ray image of the entire thoracic and lumbar spine, including the skull, cervical spine, and sacral spine, to assess for spinal deformities.
3. A patient receives a radiologic examination of the entire thoracic and lumbar spine, including the skull and cervical spine, to investigate potential spine abnormalities.
4. A provider performs a radiologic examination of the entire thoracic and lumbar spine, including the skull, cervical spine, and sacral spine, to evaluate the patient’s spine health.
5. A patient undergoes a radiologic examination of the entire thoracic and lumbar spine, including the skull and cervical spine, to screen for scoliosis or other spine abnormalities.
6. A provider captures a single X-ray image of the entire thoracic and lumbar spine, including the skull, cervical spine, and sacral spine, to assess the patient’s spine alignment.
7. A patient receives a radiologic examination of the entire thoracic and lumbar spine, including the skull and cervical spine, to diagnose potential spine conditions.
8. A provider performs a radiologic examination of the entire thoracic and lumbar spine, including the skull, cervical spine, and sacral spine, to evaluate the patient’s spine curvature.