AMA Clinical Examples in Radiology - 2020 Issue 3 (Summer)
Non-Contrast CT Followed by Contrast CT of Abdomen and Pelvis
DOCUMENTATION CHALLENGE Non-Contrast CT Followed by Contrast CT of Abdomen and Pelvis Reports that fail to adequately support the coding for the procedure performed not only have serious implications for fraud and abuse but also may negatively affect how the physician can report the procedure. In each issue of Clinical Examples in Radiology, you will be provided with a documentation challenge. This documentation challenge will serve as a learning tool for both coders and physicians. CLINICAL HISTORY A 37-year-old male patient presents with painless gross hematuria. COMPARISON Magnetic resonance imaging of the pelvis on 12/6/2018 and computed tomography (CT)...
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Article Overview
This article reviews a radiology coding documentation challenge involving abdominal and pelvic CT services, with attention to how the report supports code selection and related billing/reporting elements. It is aimed at coders, physicians, and other clinicians who work with radiology documentation, CPT, ICD-10-CM, HCPCS supply reporting, modifier usage, and MIPS measure awareness.
Why This Topic Matters
Accurate radiology coding depends on documentation that clearly supports the service performed and any associated reporting requirements. This article helps readers understand the broad documentation and reporting issues that can affect CPT selection, diagnosis reporting, contrast-related supply reporting, and quality measure awareness.
Article Sections
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Documentation Challenge
Introduces the coding documentation issue and frames the article as a learning example for radiology reporting.
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Clinical History / Comparison / Technique / Findings / Impression
Summarizes the patient context and the imaging report elements provided for review, including the study context and reported findings.
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Discussion
Addresses the broader coding and reporting considerations raised by the example, including documentation completeness, contrast-related reporting, diagnosis sequencing, and quality measure references.
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Sources
Lists the referenced professional and regulatory source materials used in the article.
What You Will Learn
- How this radiology documentation challenge is structured
- What kinds of report elements are relevant to abdominal and pelvic CT coding
- How contrast documentation and related supply reporting are discussed at a high level
- How diagnosis reporting and incidental findings are addressed in the example
- Which radiology quality measure topics are mentioned in connection with the case
Who Should Read This
- Medical coders
- Radiologists
- Physicians
- Radiology billing staff
- Compliance professionals
- Clinical documentation improvement staff
Codes Discussed
Code Ranges Discussed
Modifiers Discussed
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