Order is for 72010......before the addendum would the appropriate CPT be 72080? After addendum 72010? Does rad documenting FULL SPINE in addendum suffice for cervical, thoracic and lumbar even though there is no discussion of the cervical spine???


TWO VIEWS OF THE SPINE - 07/28/10 AT 09:29 AM

CLINICAL INDICATION: Scoliosis.

COMPARISON: 03/10/10 at 09:18 AM.

DISCUSSION: Frontal and lateral views of the thoracolumbar spine are submitted and
compared to the previous study. Again noted is the S-shaped curvature of the
thoracolumbar spine. There is 24 degrees of levoscoliosis from the superior endplate of
T1 to inferior endplate of T4. There is 80 degrees of dextroscoliosis from the superior
endplate of T5 to the inferior endplate of T11. On the prior study this measured 74
degrees. There is 58 degrees of levoscoliosis of the thoracolumbar spine from the
superior endplate of T12 to the inferior endplate of L3; on the prior study it measured 63
degrees. There is a large amount of stool within the colon and into the rectosigmoid
region. The lateral image is somewhat limited due to the arms superimposed over the
spine. The dysraphic changes of the spine are again noted.

IMPRESSION: 1. 24 degrees of levoscoliosis from the superior endplate of T1 to the inferior endplate of T4.2. Slight increase in the dextroscoliosis of T5 to T11 now measuring 80 degrees.3. 58 degrees of levoscoliosis from T12 to L3. 4. Large amount of stool within the colon and into the rectosigmoid region.

ADDENDUM: Frontal and lateral views of the full spine are submitted for evaluation of scoliosis.