Radiology Coding Alert

Question: Does the provider need to document the contrast amount administered during a computed tomography (CT) procedure within the technique of the radiology report?

Texas Subscriber

Answer: Yes, the radiologist should document the amount of contrast administered during a CT scan within the radiology report’s technique section.

According to the American College of Radiology (ACR) Practice Parameter for Communication of Diagnostic Imaging Findings, section II.B.3.a, “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.”

While the radiologist should document the amount of contrast amount within the radiology report, it is not necessary for billing the procedure. “The amount of contrast is only necessary for billing the contrast medium. As long as the documentation includes what type of contrast was administered, you can assign a code for the scan,” says Kristen R. Taylor, CPC, CHC, CHIAP, associate partner of Pinnacle Enterprise Risk Consulting Services.

Some hospitals and independent diagnostic testing facilities (IDTFs) have established policies that require the provider to document the amount of contrast administered in the report, so it’s important to review your facility or hospital system’s rules before following the ACR’s practice parameters.