A physician that I code for ordered CTA per stroke protocol. Is this enough to support a CTA charge?


No, an order for computed tomography angiography (CTA) per-protocol is not enough to support the CTA charge. Any exam ordered “per protocol” or “per routine” must still be supported with the documentation required to charge for the exam–payers and auditors will not recognize your protocol and charging based on “protocol” orders can often result in down-coding due to a lack of supporting documentation. CTA documentation specifically must include and show two key requirements. First, imaging of the vessels must be demonstrated. Second, 3D post-processing should be detailed. To report angiographic reconstructions, the physician must demonstrate the use of different techniques which are classified as 3D techniques. The imaging of the vessels alone is not necessarily considered a CTA for coding purposes. If a 3D reconstruction of images is not appropriately documented, a CTA study should not be reported. Codes should be reported based on both the technique and the body of the report and not the title or header.

Stroke is a leading cause of death. Readers should note that the month of May is National Stroke Awareness Month, which is intended to promote public awareness while lowering stroke rates within the United States.


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