Radiology Coding Alert

If your radiologist documents reconstruction during a computed tomography (CT) scan, you shouldn't automatically submit a CT angiography (CTA) code on your claim. Report CTA only if the radiologist performs reconstruction postprocessing of angiographic images and interpretation.

CTA allows radiologists to view a three-dimensional image of a patient's arterial and venous anatomy to diagnose potential problems. (See "Keep Sight of Anatomic Site to Select CTA Code" in article 2 for a list of the CTA codes.) Physicians who fail to document CTA appropriately, however, could be missing out on significant reimbursement.

Op Report Contains the Key to Code Selection

Consider the following scenario from Terri Benhardus, HIT, coding specialist at Regional Diagnostic Radiology in St. Cloud, Minn.

The radiologist performed a chest CT with contrast for a pulmonary embolism and dictated "reconstruction at 1.25-mm intervals." The dictation did not reference CTA, postprocessing or angiography.

"We sent the operative report to a coder who was handling our overflow, and she billed a CTA (71275)," Benhardus says. "I was not comfortable changing the code from CT (71250-71270) to CTA because our physicians usually clarify whether they performed a CTA, and they didn't do so in this situation."

Benhardus'instincts were correct. The July 2001 CPT Assistant states, "The key distinction between CTA and CT is that CTAincludes reconstruction postprocessing of angiographic images and interpretations." If your radiologist does not document this, you should not report a CTA code.

But what if the physician subsequently tells you that he meant to dictate "CTA" instead of simply dictating "reconstruction"? Can he change the documentation and initial it, or must he pay for his mistake by reporting only the CT code?

"The radiologist would need to dictate an amended report indicating the details of the exam to clarify that he imaged the vascular system and that the images were subsequently reconstructed," says Carrie Caldewey, RCC, CPC, coding specialist at Redwood Regional Medical Group in Santa Rosa, Calif. "Remember: If it isn't documented, it wasn't done."

Follow Doctor's Orders

Some carriers also believe in the other coding adage: If it wasn't ordered, it wasn't done. Coders should refer back to the physician's original order to determine whether he or she ordered a CT or CTA, says Lee Ahrens, RIS/PACS specialist at Thompson Health, a multispecialty healthcare provider in Canandaigua, N.Y.

"The procedure that the physician performs should be what was ordered,"Ahrens says, "so the chain of data from the physician's office to the operative report is consistent."

Some carriers echo this principle. Utah Medicare's policy states that CTA and CT scan "providers are expected to maintain a record of the attending physician's order for the scan performed."

Use Contingency Orders With Caution

There may be occasions when the ordering physician documents contingency orders in the record. For instance, your documentation might read, "Perform CT of abdomen, followed by abdominal CTA if clinically indicated." You cannot, however, include contingency orders in all patients'records "just in case." You should do this only if you strongly feel that the CTA might be warranted.

Many radiologists are not aware of the financial implications that can result from incomplete dictation or physician orders. If you perform a neck CTA (70498) but only document a neck CT with and without contrast (70492), you lose nearly $150 in reimbursement.