Neurology & Pain Management Coding Alert

Question: Encounter notes indicate that the provider performed ‘CT, max. facial area. w/3D rendering.’ What are the correct code(s) for this service?

Ohio Subscriber

Answer: This encounter note translates to a computed tomography (CT) scan of the maxillofacial area with three-dimensional rendering. We can help you narrow down your code choices, but you’re going to need to do some digging in the encounter form in order to arrive at the correct codes.

Do this: Go back and check the notes for evidence of contrast material, as well as whether the 3D rendering involved image postprocessing on an independent workstation.

Then, choose from the following codes for your claim:

For the CT scan, choose among:

• 70486 (Computed tomography, maxillofacial area; without contrast material)
• 70487 (… with contrast material(s))
• 70488 (… without contrast material, followed by contrast material(s) and further sections)

For the 3D rendering, choose between:

• 76376 (3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image postprocessing under concurrent supervision; not requiring image postprocessing on an independent workstation)
• 76377 (… requiring image postprocessing on an independent workstation).