What are the CPT and ICD-10 codes Exam: CT scan of lumbar spine w/o contrast Clinical History: Chronic LBP with recent worsening. No known injury. Comparison Study(s): Radiographic examination of the lumber spine 2 years ago. Technique: Thin collimation helical CT examination of the spine is performed in the axial plane without intravenous contrast with images obtained from the mid T10 vertebral body level through the S2 segment. Coronal and sagittal reformatted images are generated and reviewed. Findings: (H2) Five non-rib bearing lumbar type vertebra are redemonstrated. Diffuse osteopenia mildly limits evaluation. There is again noted mild levoconvex scoliosis centered at the L2-L3 level. There is redemonstration of anterolisthesis of L4 and L5 measuring approximately 6 mm while on the prior radiographic examination it measured 10 mm. Grade I/II anterolisthesis of L5-S1 redemonstrated measuring approximately 0.6 mm, not significantly changed. The vertebral bodies are otherwise normal in alignment and height. No acute fracture nor destructive bone lesion is seen. There is likely fusion of the L4-L5 facet joints. T10-T11: Minimal posterior disc bulging endplate spurring is likely present without central canal stenosis. The neural foramina are patent. Mild facet arthropathy is present. T11-T12: Posterior disc bulging and endplate spurring causes ventral sac flattening slightly eccentric to the right but without central canal stenosis. Mild facet arthropathy is present. Mild bilateral neural foraminal narrowing due to endplate spurring and facet arthropathy. T12-L1: No gross disc abnormalities seen nor is there central canal stenosis. The neural foramina are patent and the facet joints are maintained. L1-L2: There is minor posterior disc bulging and endplate spurring causing ventral sac flattening and in association with prominent post epidural fat causing mild central canal stenosis. Mild bilateral neural foraminal narrowing is present due to lateral disc bulging, endplate spurring and mild facet arthropathy. L2-L3: Posterior disc bulging is present as well us posterior plate spurring causing ventral sac flattening and in association with congenital canal narrowing appears to cause mild to moderate central canal stenosis. Moderate bilateral neural foraminal narrowing is present, right greater than left due to endplate and facet joint spurring. L3-L4: Posterior disc bulging and endplate spurring in association with ligament flavum buckling and hypertrophic facet degenerative changes causing moderate central canal stenosis. Moderate left and moderate to severe right neural foraminal narrowing are due to lateral disc bulging and endplate spurring and facet arthropathy. L4-L5: There is unroofing of the posterior aspect of the intervertebral disc, well as mild disc bulging causing ventral sac flattening but without gross, central canal stenosis. Moderate right and moderate to severe left neural foraminal narrowing are present due to spondylolisthes.

1. What are the CPT and ICD-10 codes
Exam:
CT scan of lumbar spine w/o contrast
Clinical History:
Chronic LBP with recent worsening. No known injury.
Comparison Study(s):
Radiographic examination of the lumber spine 2 years ago.
Technique:
Thin collimation helical CT examination of the spine is performed in the axial plane without
intravenous contrast with images obtained from the mid T10 vertebral body level through the S2
segment. Coronal and sagittal reformatted images are generated and reviewed.
Findings: (H2)
Five non-rib bearing lumbar type vertebra are redemonstrated. Diffuse osteopenia mildly limits
evaluation. There is again noted mild levoconvex scoliosis centered at the L2-L3 level. There is
redemonstration of anterolisthesis of L4 and L5 measuring approximately 6 mm while on the prior
radiographic examination it measured 10 mm. Grade I/II anterolisthesis of L5-S1 redemonstrated
measuring approximately 0.6 mm, not significantly changed.
The vertebral bodies are otherwise normal in alignment and height. No acute fracture nor
destructive bone lesion is seen. There is likely fusion of the L4-L5 facet joints.
T10-T11:
Minimal posterior disc bulging endplate spurring is likely present without central canal stenosis.
The neural foramina are patent. Mild facet arthropathy is present.
T11-T12:
Posterior disc bulging and endplate spurring causes ventral sac flattening slightly eccentric to the
right but without central canal stenosis. Mild facet arthropathy is present. Mild bilateral neural
foraminal narrowing due to endplate spurring and facet arthropathy.
T12-L1:
No gross disc abnormalities seen nor is there central canal stenosis. The neural foramina are
patent and the facet joints are maintained.
L1-L2:
There is minor posterior disc bulging and endplate spurring causing ventral sac flattening and in
association with prominent post epidural fat causing mild central canal stenosis. Mild bilateral
neural foraminal narrowing is present due to lateral disc bulging, endplate spurring and mild facet
arthropathy.
L2-L3:
Posterior disc bulging is present as well us posterior plate spurring causing ventral sac flattening
and in association with congenital canal narrowing appears to cause mild to moderate central
canal stenosis. Moderate bilateral neural foraminal narrowing is present, right greater than left due
to endplate and facet joint spurring.
L3-L4:
Posterior disc bulging and endplate spurring in association with ligament flavum buckling and
hypertrophic facet degenerative changes causing moderate central canal stenosis. Moderate left

2. and moderate to severe right neural foraminal narrowing are due to lateral disc bulging and
endplate spurring and facet arthropathy.
L4-L5:
There is unroofing of the posterior aspect of the intervertebral disc, well as mild disc bulging
causing ventral sac flattening but without gross, central canal stenosis. Moderate right and
moderate to severe left neural foraminal narrowing are present due to spondylolisthesis, lateral
disc bulging, endplate spurring and facet arthropathy.
L5-S1:
There is unroofing of the posterior aspect of the intervertebral disc. No gross central canal
stenosis is seen. Moderate to severe bilateral neural foraminal narrowing is present secondary to
spondylolisthesis, endplate spurring and facet arthropathy.
There is diffuse atherosclerosis of the abdominal aorta. There is mild aneurysmal dilatation of the
infrarenal abdominal aorta approximately 4 cm proximal to the bifurcation. This fusiform dilatation
measures approximately 5 cm in length and measures 3.3 cm in maximum AP diameter and 3.2
cm in maximal transverse diameter.
Impression:
No acute osseous or ligamentous abnormality of the lumbar spine and there is no obstructive bone
lesion.
Spondylolisthesis of L4 and L5 as well as L5 and S1. No significant change since previous study
of spine two years ago.
Multilevel degenerative disc and facet arthropathy causing central canal stenosis at the L1-L2, L2-
L3 and L3-L4 levels detailed above. Multilevel bilateral neural foraminal narrowing also detailed
above.
Mild aneurysmal dilatation of the infrarenal abdominal aorta measuring 3.3 cm in maximum AP
diameter and 3.2 cm in maximum transverse diameter.
Electronically Signed By: Sarah Neeson, MD