Radiology Coding Alert

Question: Our radiologist performed computed tomography (CT) studies with and without contrast followed by a CT reconstruction on a patient with suspected pulmonary embolism. Our radiologist wants to report 71270, 71275 and 76375 for this procedure. Is this correct?

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Answer: No. Your code choice will depend on whether the radiologist performed CT studies with and without contrast followed by reconstruction, as he documented, or whether he performed a CT angiography (CTA) study. Because he recommended that you report the CTA code (71275, Computed tomographic angiography, chest, without contrast material[s], followed by contrast material[s] and further sections, including image postprocessing), he may have actually performed a CTA.

As reported in the April 2003 Radiology Coding Alert, CT with reconstruction does not always signal CTA, and you should never automatically report a CTA code if you see the word "reconstruction" on the chart. Diagnoses involving the blood vessels, however, such as pulmonary embolism or abdominal aortic aneurysm (blood vessel-related diagnoses often include the keywords "embolism," "thrombosis," "aneurysm" or "AV fistula"), often require CTA studies. Non-blood vessel-related diagnoses, such as those performed to typify lung masses, require CTAstudies much less frequently.

Ask the radiologist whether he performed a CTA or a CT. If he says he performed a CT study with and without contrast followed by reconstructions, you should report 71270 (Computed tomography, thorax; without contrast material, followed by contrast material[s] and further sections) and +76375 (Coronal, sagittal, multiplanar, oblique, 3-dimensional and/or holographic reconstruction of computerized axial tomography, magnetic resonance imaging, or other tomographic modality), not 71275.

If he says he performed a CTA, you should report 71275 only, and the radiologist should dictate an addendum to his operative note stating that he performed a CT angiogram of the thorax.