Neurosurgery Coding Alert

Question: The neurosurgeon performed a lumbosacral X-ray for a patient who had lumbar spina bifida. How should I code this encounter?

South Carolina Subscriber

Answer: The X-ray code will depend on the type of lumbosacral X-ray the surgeon performed. Go back and check the notes for more clues; then, choose among the following X-ray codes:

• 72100 (Radiologic examination, spine, lumbosacral; 2 or 3 views)
• 72110 (… minimum of 4 views)
• 72114 (… complete, including bending views, minimum of 6 views)
• 72120 (… bending views only, 2 or 3 views)

As for the ICD-10-CM code, you’ll need to check for the presence of hydrocephalus. Then, you can choose from the following codes:

• Q05.2 (Lumbar spina bifida with hydrocephalus)
• Q05.7 (Lumbar spina bifida without hydrocephalus)

If you cannot confirm or deny the presence of hydrocephalus, report Q05.9 (Spina bifida, unspecified) instead. Defaulting to Q05.7 is not recommended, as the patient’s hydrocephalus status is unknown.

Modifier alert: Before submitting the claim, you need to check whether the surgeon used their own X-ray equipment or someone else’s. If they used someone else’s equipment, append modifier 26 (Professional component) to the X-ray code to show that you are only billing for your surgeon’s work, not the equipment used.

Chris Boucher, MS, CPC, Senior Development Editor, AAPC