Question:

What keywords need to be in the radiology report to assign a CTA code?

Answer:

Clinical Examples in Radiology, Volume 13, Issue 2, Spring provides that the key elements to look for in a dictation to support the assignment of a CTA code include “dynamic contrast imaging of vessels and 3-dimensional (3D) angiographic post-processing”. This means that they “ must include 3D evaluation of the vessels, with 3D defined as MIP [maximum intensity projection], surface-shaded rendering, or volume rendering. Furthermore, it relates that “if the 3D post-processed imaging (eg, volume rendering) is of structures other than vessels” then CPT 76376 or 76377 “may be reported in addition to the CT code for the anatomic region evaluated, assuming medical necessity and an appropriate order(s)” is provided. The article further reinforces the importance of the coder to remember that CPT codes are assigned on the basis of the actual service provided and documented in the medical report”, and therefore when it is not clear whether the report details a CT or CTA study, that “the coder should work closely with the interpreting radiologist to clarify and obtain the appropriate information. This will help ensure that all pertinent information has been captured, allowing for the submission of the correct code”.

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