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Question:
If you are coding a computed tomography (CT) with contrast exam, and the contrast amount and type is given within the technique, but the words “with IV contrast” are not specifically used, does this suffice for the with contrast requirements?
Answer:
The route of administration must be in the medical record somewhere. It doesn’t necessarily have to be in the report itself, but if it’s not, then the coder has to run around to guarantee it was IV contrast (or intrathecal for spine exams or intra-articular for joint exams). In the report, it is best practice for the physician to dictate the type of contrast, the amount that is given, and the route of administration.
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