Ask Dr. Z

Would you consider this documentation sufficient for billing a lumbar myelogram (72265-59) with LS spine CT (72132)? The physician orders a CT spine and lumbar myelogram. Documentation for the myelogram in the first example states: "Myelogram without significant compression on the thecal sac or exiting nerve roots, osseous structures are unremarkable." In a second example the documentation states: "Conus/Cauda: Tip of the conus is typical at L1. Individual nerves of the cauda equina are unremarkable. There is no evidence of arachnoiditis or other pathology." All elements of the LS CT are well documented in both instances. In either instance, can the lumbar myelogram be separately coded?