When reporting CPT® codes 76376 and 76377 for 3-D analysis, what key documentation requirements must be included in the radiology report to ensure accurate coding and avoid ambiguity?
In order to report the correct CPT code for the 3-D analysis (76376 or 76377), it should be documented within the radiology report as to whether the 3-D was performed on an independent workstation or on the acquisition scanner. Making an explicit statement within the radiology report will avoid ambiguity and aid the coder in accurately coding for the 3-D reconstruction. Some practices may separately document this in the patient’s electronic medical record, but not actually in the report. (Clinical Examples in Radiology, volume 5, issue 4, Fall 2009).
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