Ask Dr. Z

Can I use regular CPT codes (CT without contrast) 72125, 72128, and 72131 to report intraoperative CT guidance with spinal procedure? Or would you recommend use of an unlisted code?

"68-year-old woman undergoing L2-S1 revision of posterior spinal fusion. Non-contrast axial images of the lumbar spine were obtained intraoperatively for surgical guidance. Coronal and sagittal reformatted images were reviewed. There has been interval placement of a clamp on the T12 spinous process. Post-surgical changes are again demonstrated with posterior fusion hardware in the lower lumbar spine, extending from the L4 level to at least the L5 level. Note that the inferior extent of the hardware is incompletely included in the field-of-view on this exam. A soft tissue defect in the posterior midline soft tissues is compatible with the intraoperative state. Curvilinear, metallic structures within the posterior soft tissue defect may represent packing material/gauze. Multi-level degenerative changes are again identified with anterior and posterior osteophyte formation, disc space narrowing, and vacuum disc phenomenon at multiple levels. Additionally, there are facet joint degenerative changes in the lower lumbar spine."