Radiology Coding Alert

Write up this ‘rule out appendicitis’ scenario to treat yourself to CEUs If you get spooked by having to choose CT codes based on contrast use or deciding which diagnosis codes to claim, follow our experts step-by-step through this real report for tips on how to choose the proper code every time. Header: Abdominal and pelvic CT with enhance, CT reformation body

Dictated report: CT of abdomen and pelvis

Indication: 26-year-old female with abdominal pain, rule out acute appendicitis

Technique: Contiguous axial images were obtained from the lung bases through the pubic symphysis following the uneventful administration of oral and intravenous contrast, 150 cc Isovue-300 at 3 cc/sec. FOV=32 cm.

Findings: Lung windows demonstrate subpleural opacity in the right lower lobe, likely representing atelectasis. No parenchymal nodule or mass within the visualized lung bases. No pleural or pericardial effusion.

The liver, gallbladder, adrenal glands, spleen, pancreas, and kidneys are normal. The bladder is adequately distended without evidence for bladder wall thickening. Both ovaries are visualized, contain normal-appearing follicles. There is also a 2.1- x 1.4-cm physiologic cyst within the right ovary.

The appendix is distended, contains a few 3- to 4-mm appendicoliths, demonstrates abnormal bowel wall enhancement, and is associated with moderate adjacent periappendiceal fat stranding. The remaining bowel is normal. No periappendiceal fluid collection or abscess.

Impression: Acute appendicitis. Verify Contrast to Choose CPT Smart start: If you quickly skim the report, you’ll see that you’re coding two complete examinations--a CT of the abdomen and a CT of the pelvis.

Your radiologist’s documentation must include discussion of the anatomical structures of both the abdomen and pelvis for you to code CT studies of both sites, says Sheldrian Leflore, CPC, an independent California coding consultant whose specialties include radiology. You also need to have orders for CT studies of both the abdomen and pelvis and documentation of medical necessity before you code.

In our sample report, the radiologist notes the state of the abdominal structures (liver, gallbladder, pancreas, intestines) and the pelvic structures (bladder, ovaries). As a result, you can narrow your CPT Codes choices to 74150-74170 (Computed tomography, abdomen ...) and 72192-72194 (Computed tomography, pelvis ...).

Next: To select the proper code from each range, determine if the provider performed the studies with contrast, without contrast, or with a complete examination prior to and after the administration of contrast.

“Oral and rectal contrast studies are not considered ‘with contrast’ studies,” says Carrie Caldewey, CPC, an experienced radiology coder and coding supervisor for Northern [...]