How To Use CPT Code 72128

CPT 72128 describes the diagnostic procedure of computed tomography (CT) of the thoracic spine without the use of contrast material. 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 72128?

CPT 72128 is used to describe a diagnostic procedure called computed tomography (CT) of the thoracic spine. This procedure involves the use of X-ray technology to create cross-sectional images of the upper and middle back, specifically the vertebrae T1 through T12. Unlike other CT scans, CPT 72128 does not require the administration of contrast material.

2. Official Description

The official description of CPT code 72128 is: ‘Computed tomography, thoracic spine; without contrast material.’

3. Procedure

1. During the procedure, the patient is positioned appropriately and may be sedated if necessary.
2. The patient lies on the scanner bed, which slowly moves into the CT scanner.
3. The provider takes multiple cross-sectional images of the thoracic spine using the rotating X-ray tube and detectors.
4. No contrast material is injected into the patient during this procedure.
5. The provider examines the cross-sectional images on a computer monitor to interpret the diagnostic results.
6. The images may be stored, reconstructed, and reproduced for further evaluation if needed.

4. Qualifying circumstances

CPT 72128 is typically performed on patients who require diagnostic imaging of their thoracic spine. This procedure may be necessary to diagnose, manage, or treat various diseases or conditions affecting the upper and middle back. It is important to note that CPT 72128 specifically refers to CT scans without the use of contrast material.

5. When to use CPT code 72128

CPT code 72128 should be used when a provider performs a CT scan of the thoracic spine without the administration of contrast material. It is important to ensure that the procedure is accurately documented and meets the specific criteria outlined in the code description.

6. Documentation requirements

To support a claim for CPT 72128, the provider must document the following information:

• Reason for performing the CT scan of the thoracic spine
• Confirmation that no contrast material was used during the procedure
• Date and time of the procedure
• Specific findings or observations from the diagnostic images
• Interpretation of the results by the provider

7. Billing guidelines

When billing for CPT 72128, it is important to ensure that the procedure meets the specific criteria outlined in the code description. Providers should also be aware of any additional guidelines or requirements set by individual payers. It is important to accurately report the service and any associated modifiers, such as professional component modifier 26 or technical component modifier TC, if applicable.

8. Historical information

CPT 72128 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates or changes to the code since its addition.

9. Examples

1. A patient undergoes a CT scan of the thoracic spine without contrast material to evaluate a suspected spinal injury.
2. A provider performs a CT scan of the thoracic spine without contrast material to assess the progression of a degenerative disc disease.
3. A patient with persistent back pain undergoes a CT scan of the thoracic spine without contrast material to identify any potential abnormalities.
4. A provider orders a CT scan of the thoracic spine without contrast material to investigate the cause of a patient’s unexplained neurological symptoms.
5. A CT scan of the thoracic spine without contrast material is performed on a patient with a history of spinal tumors to monitor for any signs of recurrence.
6. A provider utilizes a CT scan of the thoracic spine without contrast material to guide a surgical intervention for a patient with a spinal deformity.
7. A patient with suspected spinal infections undergoes a CT scan of the thoracic spine without contrast material to aid in diagnosis and treatment planning.
8. A provider orders a CT scan of the thoracic spine without contrast material to evaluate the effectiveness of a previous spinal surgery.
9. A CT scan of the thoracic spine without contrast material is performed on a patient with suspected spinal fractures following a traumatic injury.
10. A provider utilizes a CT scan of the thoracic spine without contrast material to assess the progression of a patient’s spinal stenosis.