Radiology billing is a tough niche to master. What makes it particularly confusing is the requirement of completely different billing codes for seemingly similar services, with minor differences. CPT code 72100 is one of these codes.
Although the procedure it represents is simple, its billing can be a bit confusing. That’s why we have created this detailed guide on 72100 billing. So, let’s start.
CPT Code 72100 – Description
CPT code 72100 is defined as:
“Radiologic examination, spine, lumbosacral; 2 or 3 views”
As defined, code 72100 is a diagnostic radiology code. It is used to bill a simple X-ray of the lumbar spinal region. Under this code, the technician can take images from two or three different angles, usually anteroposterior (AP) and lateral views.
An important thing to note here is that for 72100 to be valid for Medicare claims, the X-ray must be performed by a certified radiologic technologist (ARRT: R.T.-R). If a qualified radiologist does not perform the imaging, your claims will be denied.
Scenarios Where CPT Code 72100 is Applicable
Still not clear? Let’s make things simple with a couple of real-world scenarios in which CPT code 72100 can be used:
Pre-Surgery Evaluation
For our first scenario, let’s suppose that a 50-year-old patient is scheduled for lumbar fusion surgery. He has a severe degenerative disc disease that is impossible to manage with just medications. However, before proceeding with the operation, the surgeon needs baseline imaging to evaluate the exact vertebral levels. This can be done with a simple X-ray. So, the surgeon orders a 3-view X-ray of the lumbosacral spine.
Using the imaging results, the physician completes his surgical planning and performs the procedure successfully. In this case, the X-ray can be billed with CPT code 72100.
Trauma to Lower Back
Let’s consider another scenario.
Suppose a construction worker is brought to the ER by his coworkers. The worker had a hard fall from scaffolding, and he landed right on his lower back. He experiences severe pain, and even small movements are strenuous to make.
These symptoms suggest possible vertebral fractures or spinal injury. So, the attending physician orders an immediate X-ray of the lower spine. The results show a fracture in the lumbosacral region. Based on the results, the physician takes the necessary steps required for the treatment. In this case, CPT code 72100 can be used to bill the X-ray.
Applicable Modifiers for CPT Code 72100
You can use the following modifiers with CPT code 72100:
| Modifier | Description | Usage |
|---|---|---|
| 26 | Professional Component | When the physician only interprets the X-ray results and reports them. |
| TC | Technical Component | When the radiology facility performs the test. Used to bill for the technical part of the procedure. |
| 52 | Reduced Services | Used when the X-ray was partially reduced or eliminated. |
| 76 | Repeat Procedure by Same Physician | When the same physician repeats the lumbar X-ray on the same day. |
| 77 | Repeat Procedure by Another Physician | When another physician repeats the lumbosacral X-ray on the same day. |
Please note that if you have an imaging facility in your practice, and you perform both the technical and professional components of the service, modifier TC and 26 should not be appended.
CPT Code 72100 – Billing & Reimbursement Guidelines
Want to bill the CPT code 72100 properly? Here are some essential points to consider:
Provide Comprehensive Documentation
Like all CPT codes, documentation is vital for 72100 reimbursement. Your medical records must clearly demonstrate the clinical rationale for performing the X-ray study, including relevant patient history, physical examination findings, and prior treatment attempts, number of views, etc.
Verify the Medicare Reimbursement Rate
The national average reimbursement amount for 72100 is $38.49 in non-facility settings. For facility settings, exact price data is not available.
The following is a more detailed breakdown of the cost structure:
- Professional component:
- Facility price: $10.35
- Non-facility price: $10.35
- Technical component:
- Facility price: Not applicable
- Non-facility price: $28.14
You can check the exact reimbursement rate for your MAC locality via the PFS Lookup Tool.
Wrapping Up
By now, you must have a good idea of what CPT code 72100 is and how to bill it. However, we understand that it is a lot of information to retain. So, let’s do a quick recap of the essential points.
- Code 72100 is a radiology billing code used to bill a simple X-ray of the lumbar spine.
- The X-ray involves 2 or 3 views.
- Always remember to append relevant modifiers and provide comprehensive documentation.
If billing is not your strong suit and your practice is facing frequent denials, it is better to let a professional handle the billing. Our experts at MediBilMD offer specialized radiology billing services that are guaranteed to improve your revenue.
