Summary & Overview

CPT 72158: MRI Lumbar Spine, Without and With Contrast

CPT code 72158 represents MRI of the lumbar spinal canal and contents performed both without and with intravenous contrast. This combined MRI study enhances detection of epidural disease, nerve-root compression, neoplasm, infection, and postoperative scar versus recurrent disc or tumor by comparing non-contrast and contrast-enhanced sequences.

The analysis covers major national payers including Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find concise clinical context, typical sites of service, common billing modifiers, and guidance on how this service is described in claims. The report summarizes reimbursement and utilization benchmarks where available and highlights recent policy updates or national payer coverage trends relevant to contrast-enhanced lumbar spine MRI.

Intended for coding professionals, radiology departments, and revenue cycle staff, the publication explains billing considerations for a combined non-contrast and contrast MRI of the lumbar spine, clarifies typical clinical indications, and outlines areas where payer policies commonly differ. Data not available in the input is noted explicitly in relevant sections.

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Billing Code Overview

CPT code 72158 describes a diagnostic magnetic resonance imaging (MRI) of the lumbar spinal canal and contents performed both without and with contrast material. This is a combined study in which images are acquired first without intravenous contrast and then repeated after contrast administration to improve visualization of soft tissues, nerve roots, and potential enhancing lesions.

Service type: Diagnostic imaging (MRI lumbar spine, without and with contrast)
Typical site of service: Outpatient imaging centers or hospital outpatient departments; may also be performed in inpatient settings when clinically indicated.

Clinical & Coding Specifications

Clinical Context

A 52-year-old patient presents to the outpatient radiology department with progressive low back pain, unilateral lower-extremity radicular symptoms and intermittent neurogenic claudication. Conservative care (physical therapy, NSAIDs, activity modification) has been insufficient and the referring spine specialist requests advanced imaging to evaluate for herniated nucleus pulposus, spinal stenosis, epidural fibrosis or neoplasm.

The clinical workflow: the referring provider orders a lumbar spine MRI with and without contrast (CPT 72158). The patient arrives at an imaging center or hospital outpatient radiology suite (typical site of service). Screening for MRI safety (implants, pregnancy, allergies to gadolinium) and renal function assessment (eGFR review) are completed. The MRI technologist obtains non-contrast sequences of the lumbar spinal canal and neural elements first, then a gadolinium-based contrast agent is administered intravenously and post-contrast sequences are obtained. The interpreting radiologist documents findings, compares prior imaging if available, and issues a final report. Results guide treatment decisions such as epidural steroid injection, surgical consultation, or oncologic workup.

Coding Specifications

Modifier	Description	When to Use
`26`	Professional component	Use when billing only the radiologist interpretation separate from technical component.
`TC`	Technical component	Use when billing only equipment, technologist, and supplies for the study.
`52`	Reduced services	Use when the study is partially completed or limited relative to full protocol.
`53`	Discontinued procedure	Use when the exam is started but terminated for patient safety or intolerance.
`59`	Distinct procedural service	Use to indicate a separately identifiable service when performed same day as another procedure.
`76`	Repeat procedure by same physician	Use when the same provider repeats the MRI on the same day.
`77`	Repeat procedure by another physician	Use when a different provider repeats the MRI on the same day.
`91`	Repeat clinical diagnostic laboratory test	Rare for imaging; used if repeat lab testing influences contrast administration decision (e.g., repeat eGFR) but generally uncommon.
`22`	Increased procedural services	Use when documentation justifies substantially greater technical effort or time (rare for standard MRI protocols).
`50`	Bilateral procedure	Not typically applicable to lumbar MRI but included when laterality coding is required for related procedures.
`62`	Two surgeons	Not applicable to radiology interpretation; used in operative settings when two surgeons operate.
`73`	Discontinued outpatient hospital/ambulatory surgery before anesthesia	Rarely applicable; included for completeness when scheduling/checkout differs.
`76`	Repeat procedure by same physician	(Duplicated intentionally in CMS lists; use as above.)

Taxonomy Code	Specialty	Notes
`2085R0202X`	Diagnostic Radiology	Most common interpreting specialty for lumbar spine MRI.
`2084P0800X`	Neuroradiology	Subspecialty interpretation for complex spinal cord, nerve root or neoplastic disease.
`208600000X`	Physical Medicine & Rehabilitation	Frequent ordering specialty for radicular pain and functional assessment.
`207R00000X`	Orthopaedic Surgery	Common ordering specialty for degenerative spine disease and surgical planning.
`208800000X`	Neurology	Orders imaging for radiculopathy, myelopathy, or inflammatory conditions.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`M51.16`	Intervertebral disc disorders with radiculopathy, lumbar region	Common indication for lumbar MRI to identify herniation compressing nerve roots.
`M48.06`	Spinal stenosis, lumbar region	MRI evaluates degree of central and foraminal canal narrowing and neural element compression.
`M54.16`	Radiculopathy, lumbar region	Imaging is used to localize and characterize nerve root impingement causing radicular pain.
`G55.1`	Compression of nerve roots, lumbar region	MRI assists in identifying the anatomic source of nerve root compression.
`C79.51`	Secondary malignant neoplasm of bone, vertebrae	With suspected metastatic disease or primary tumor, contrast-enhanced MRI assesses marrow replacement and epidural involvement.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`72148`	Magnetic resonance (e.g., proton) imaging, spinal canal and contents, lumbar; without contrast material	Often performed when contrast is contraindicated or as the initial non-contrast exam before deciding on contrast administration; `72158` includes both without and with contrast.
`72157`	Magnetic resonance (e.g., proton) imaging, spinal canal and contents, lumbar; with contrast material(s)	Single-phase contrast study; `72158` differs by explicitly coding both non-contrast and post-contrast sequences together.
`72141`	Magnetic resonance imaging, spinal canal and contents; cervical without contrast	Related anatomic study when multi-region spine assessment is needed.
`72146`	Magnetic resonance imaging, spinal canal and contents; thoracic without contrast	Performed when thoracolumbar symptoms suggest more extensive evaluation.
`73721`	Magnetic resonance (e.g., proton) imaging, any joint of lower extremity; without contrast	May be ordered in parallel when radicular symptoms suggest hip or sacroiliac pathology contributing to symptoms.