How To Use CPT Code 72265

CPT 72265 describes the radiological supervision and interpretation for a myelogram of the lumbar and sacral spine. 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 72265?

CPT 72265 can be used to represent the radiological supervision and interpretation for a myelogram of the lumbar and sacral spine. This code is used when a provider performs imaging supervision and interpretation for this procedure, which involves injecting contrast material and taking X-ray images to detect any injury or abnormal growth in the spinal canal and its contents.

2. Official Description

The official description of CPT code 72265 is: ‘Myelography, lumbosacral, radiological supervision and interpretation.’

3. Procedure

1. The provider inserts a needle under fluoroscopic guidance to inject contrast material into the subarachnoid space, allowing visualization of the lumbosacral spinal canal and associated structures.
2. The provider changes the position of the patient by tilting the X-ray table, enabling the contrast material to reach different levels in the spinal canal.
3. The provider observes the flow under fluoroscopy and takes a series of X-rays with the table tilted at various angles.

4. Qualifying circumstances

CPT 72265 is used when a provider performs imaging supervision and interpretation for a myelogram of the lumbar and sacral spine. It should not be reported in conjunction with codes 62284, 62302, 62303, 62304, or 62305. If both 62284 and 72265 are performed by the same provider for lumbosacral myelography, use code 62304. For complete lumbosacral myelography via injection procedure at C1-C2, see codes 61055 and 72265.

5. When to use CPT code 72265

CPT code 72265 should be used when a provider performs the radiological supervision and interpretation for a myelogram of the lumbar and sacral spine. It should not be used for other procedures or imaging studies.

6. Documentation requirements

To support a claim for CPT 72265, the provider must document the following information:

• Details of the myelogram procedure performed
• Specific findings observed during the procedure
• Interpretation of the images obtained
• Signature of the provider performing the radiological supervision and interpretation

7. Billing guidelines

When billing for CPT 72265, ensure that the provider performing the service is reporting the radiological supervision and interpretation for a myelogram of the lumbar and sacral spine. It should not be reported with other specific codes mentioned in the qualifying circumstances. If multiple providers are involved in the service, appropriate modifiers should be appended to indicate reduced service and professional component.

8. Historical information

CPT 72265 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates to the code since its addition.

9. Examples

1. A radiologist performing the radiological supervision and interpretation for a myelogram of the lumbar and sacral spine to evaluate a patient with suspected spinal stenosis.
2. An interventional radiologist overseeing the myelogram procedure and interpreting the images for a patient with a history of spinal cord injury.
3. A neurosurgeon supervising the myelogram and providing the interpretation for a patient with suspected spinal tumor.
4. An orthopedic surgeon performing the radiological supervision and interpretation for a myelogram of the lumbar and sacral spine to assess a patient with chronic back pain.
5. A neuroradiologist overseeing the myelogram procedure and interpreting the images for a patient with suspected herniated disc in the lumbar and sacral spine.
6. A pain management specialist performing the radiological supervision and interpretation for a myelogram of the lumbar and sacral spine to guide the placement of a spinal cord stimulator.
7. A spine surgeon supervising the myelogram and providing the interpretation for a patient with suspected spinal infection.
8. An oncologist overseeing the myelogram procedure and interpreting the images for a patient with metastatic cancer to the lumbar and sacral spine.
9. A neurologist performing the radiological supervision and interpretation for a myelogram of the lumbar and sacral spine to evaluate a patient with unexplained leg weakness.
10. An anesthesiologist supervising the myelogram procedure and interpreting the images for a patient with suspected spinal cord compression.