Radiology Coding Alert

Question: Does the amount of contrast administered during a magnetic resonance imaging (MRI) scan need to be documented within the technique of the report?

Utah Subscriber

Answer: For information on exactly what needs to be included within a radiologist’s dictation report, you should refer to the American College of Radiology (ACR) Practice Parameter for Communication of Diagnostic Imaging Findings. Under part II.A.3.a (Procedures and materials), you’ll read the following:

“The report should include a description of the studies and/or procedures performed and any contrast media and/or radiopharmaceuticals (including specific administered activities, concentration, volume, and route of administration when applicable), medications, and catheters or devices used beyond those utilized for routine administration of contrast agents, if not recorded elsewhere.”

As you can see, there are no parameters that require the radiologist to document the amount of contrast used on a respective study. So long as the technique of the report states that contrast was or was not administered, you may report the appropriate MRI scan code.

However, keep in mind that some hospitals and independent diagnostic testing facilities (IDTFs) have policies in place that require the amount of contrast administered to be documented in the report. Make sure to check your facility or hospital system’s policy prior to adhering to the ACR practice parameters.