The patient presents with sternoclavicular (SC) joint pain, and a CT of the chest with contrast is ordered. The radiology report describes the SC joint in its entirety, but no other surrounding structures. Should I code this to 71260 or 71260-52, as only the SC joint was studied?
CPT® does not define which specific structures must be studied to constitute a full and complete CT study. Rather, the patient’s needs/indication for the procedure defines whether a full and complete study is rendered. In this instance, 71260 is the correct code choice, as the patient presented with an indication-specific to the SC joint, and the SC joint was studied in its entirety.
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