previous list should provide the basis for
discussion with the radiologists to ensure
that the report is appropriately documented for CTA when that is the performed service.
there is not a standard template for the
documentation of these studies. As long
as the key elements are documented
somewhere in the report it will support
the billing of a CTA study.
There are a couple of key issues to
point out in the dictation. First, for a CTA
it is not required that the radiologist indicate a separate workstation was utilized
for the 3D component of the study. This
information is required for a non-angio-graphic 3D study to ensure that the correct code is selected and supported, but
for CTAs it does not impact the coding
assignment. The second key issue is that
the creation and interpretation of 3D
images is important. There must be documentation of 3D in a CTA report. Usually, this occurs with the documentation
CTA. For example, Highmark Medical
Services, Inc. (MAC J12) and First Coast
Service Options, Inc. (MAC J9) have the
following criteria for CTAs of the thorax:
The MDCT angiography of the chest
for non-cardiac assessment (CPT code
71275) is indicated for the following signs
or symptoms of disease:
1. Assessment of a symptomatic patient
when presentation is suspicious for
2. Abnormalities of extra-cardiac vascu-lature such as aortic dissection, aortic
aneurysm, pulmonary AVM and
other abnormalities of the systemic
3. Assessment of suspected congenital
anomalies of the great vessels; or
Insurance coverage requirements for CTA
studies vary by payor. Some payors (eg,
Trailblazer) have the same requirements
for CT and CTA of the thorax, while
others have more stringent guidelines for
4. Assessment of mediastinal or lung
parenchymal lesions, the vascularity of
which is unknown or ill defined, but is
critical to the diagnosis.
Box 1 is a sample report of a CTA of the
chest. It is important to remember that
BOX 1. Sample Report of a CTA of the Chest
Indications: Chest pain and shortness of breath, rule out pulmonary
Technique: CTA of the chest was performed on a 64-slice multiple-detector
row CT system. A total of 100 cc of Optiray 350 was infused. Multiple sets
of 2- and 3-dimensional MIP reformatted images of the aorta, pulmonary
arteries, and mediastinum were generated and reviewed independently
on a 3D workstation.
It is important that you ensure you are
billing correctly for CT/CTA studies
based on what is documented. From a
facility perspective, you may know that a
CTA study is being performed, but if it is
not adequately documented you may
have a refund obligation in the event of
a payor audit. This is a key issue that I
recommend all organizations, regardless
of which side you are billing, review to
Findings: The lungs are clear. No infiltrates are seen. There are no pleural
effusions. There is no lymphadenopathy. The mediastinum shows a small
hiatal hernia. Evaluation of the main and segmental pulmonary artery
branches reveals no evidence for pulmonary emboli. The aorta is normal
in caliber with no evidence for aneurysm or dissection. The heart is normal
in size with a small pericardial effusion.
1American College of Radiology. ACR Radiology
Coding Source. May-June 2009.
2American Medical Association. CPT® Assistant.
3American Medical Association. CPT® Assistant.
Impression: No evidence for pulmonary embolus. Small pericardial
effusion. Small hiatal hernia.
Melody W. Mulaik is president and co-founder of
Coding Strategies, Inc. She is a nationally recognized
speaker and has delivered numerous presentations at
AHRA annual meetings and conferences. Melody is a
member of AHRA, has published extensively, and may
be contacted at firstname.lastname@example.org.