AMA Clinical Examples in Radiology - 2013 Issue 4 (Fall)
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 affect 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. Clinical History Right side abdominal and chest pain. Rule out pulmonary embolism. Procedure Computed tomography angiography (CTA) of the chest. Technique CTA examination performed with multiplanar reconstruction (MPR) imaging demonstrates no intraluminal filling defects to suggest pulmonary embolism. The...
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Article Overview
This article presents a radiology documentation challenge focused on chest imaging documentation, coding support, and the distinction between routine CT and CT angiography reporting. It is intended for coders, radiologists, and other revenue cycle professionals who need to evaluate whether the medical record supports the reported service. The discussion centers on documentation elements, imaging terminology, ordering considerations, and general guidance from professional and Medicare sources.
Why This Topic Matters
Accurate procedure documentation affects compliant code assignment, audit risk, and whether a study can be reported as a standard CT or a CT angiography service. The article helps readers understand what kinds of report details are relevant to selecting the correct chest imaging code set.
Article Sections
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Documentation Challenge
Introduces the coding education scenario and explains that the report is being reviewed as a documentation support exercise for a radiology service.
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Clinical History
Summarizes the patient’s presenting context and the general reason the imaging study was performed.
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Procedure
Identifies the imaging service performed at a broad level.
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Technique
Describes the technical imaging report content, including reported findings and terminology used in the exam narrative.
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Impression
Presents the report’s concluding diagnostic summary.
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Discussion
Explains the documentation issues raised by the case and discusses the general distinctions among the relevant chest CT code choices.
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References
Lists external professional and Medicare sources cited by the article.
What You Will Learn
- How documentation completeness affects radiology code selection
- What kinds of report elements are relevant to chest CT and CT angiography review
- How professional and Medicare guidance can influence documentation expectations
- Why ordering language and imaging terminology matter in radiology coding workflows
Who Should Read This
- Medical coders
- Radiology coders
- Radiologists
- Revenue cycle staff
- Compliance professionals
Codes Discussed
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