AMA Clinical Examples in Radiology - 2013 Issue 3 (Summer)
Documentation Challenge
Documentation Challenge Reports that fail to adequately support the coding for the procedure performed not only have serious implications for fraud and abuse, but may also negatively impact how the physician can report the procedure. In each issue, you will be provided with a documentation challenge. This documentation challenge will serve as a learning tool for both coders and physicians. Brachial Plexus Magnetic Resonance Angiography (MRA) Clinical History Left arm pain after a fall. Procedure Left brachial plexus magnetic resonance angiography (MRA). Technique MRA scan of the left brachial plexus performed according to standard protocol. Comparison Cervical spine magnetic...
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Article Overview
This article presents a radiology documentation challenge focused on brachial plexus imaging and CPT code selection. It explains why clear reporting of the study type, anatomy, and contrast use matters, and it frames the discussion around comparing MRI and MRA documentation language. The piece is intended for coders and physicians who review musculoskeletal and upper-extremity imaging reports.
Why This Topic Matters
Incomplete or inconsistent imaging documentation can affect claim accuracy, reimbursement, and denial risk. This article helps readers understand the kinds of documentation gaps that make code assignment difficult and highlights why precise procedure language is important in radiology reporting.
Article Sections
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Brachial Plexus Magnetic Resonance Angiography (MRA)
Introduces the case study and presents the imaging report used for the documentation review.
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Discussion
Reviews the documentation issues raised by the report and discusses the broader CPT selection considerations for brachial plexus imaging.
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References
Lists supporting professional references and source materials.
What You Will Learn
- Why imaging documentation must clearly identify the exam performed
- What kinds of report elements affect CPT code selection for brachial plexus imaging
- How anatomy and clinical indication influence whether an upper-extremity MRI code is considered
- Why contrast documentation matters in radiology reporting
- How inconsistent procedure and impression language can complicate code assignment
Who Should Read This
- Medical coders
- Radiology coders
- Physicians
- Radiologists
- Coding auditors
Codes Discussed
Code Ranges Discussed
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