AMA Clinical Examples in Radiology - 2020 Issue 2 (Spring)
QUESTIONS AND ANSWERS
QUESTIONS AND ANSWERS Question Answer The technique portion of a carotid duplex Doppler report documents that a carotid duplex scan utilizing grayscale, color Doppler, and spectral Doppler was obtained. The findings describe: "There is antegrade flow in bilateral vertebral arteries. There is mild atherosclerotic disease involving the right and left carotid bulbs and the right and left internal carotid arteries." While the technique supports color and spectral analysis, are the findings sufficient to report a complete carotid Doppler evaluation? While the wording of the technique section of the report supports a Duplex Doppler evaluation, the findings described are...
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Article Overview
This article presents multiple radiology coding questions and answers focused on how common imaging studies are documented and reported. It is relevant to radiology coders, coding educators, and clinical documentation reviewers who work with ultrasound, CT colonography, CTA, and 3D postprocessing guidance. The discussion references CPT coding concepts and guidance from radiology coding resources, emphasizing documentation and report completeness at a general level.
Why This Topic Matters
The article helps readers understand whether documentation supports reporting specific imaging services and related add-on or postprocessing services. It is useful for recognizing when report content, study approach, and technical details affect radiology code selection and compliance.
Article Sections
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Carotid duplex Doppler reporting
Discusses documentation elements in carotid duplex studies and how report content relates to evaluation of extracranial arteries. References ultrasound imaging components and professional coding guidance.
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Virtual colonoscopy after incomplete optical colonoscopy
Covers computed tomographic colonography in the setting of an incomplete diagnostic colonoscopy and compares general diagnostic versus screening contexts. Focuses on colonography reporting considerations.
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Limited obstetric ultrasound with transvaginal ultrasound
Addresses obstetric ultrasound documentation when more than one ultrasound approach is used during the same encounter. Includes discussion of how separate study reporting is handled in a general sense.
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CTA and 3D postprocessing
Explains documentation issues surrounding computed tomographic angiography and related 3D rendering services. References contrast administration, postprocessing, and report language used for tomographic imaging.
What You Will Learn
- How radiology documentation affects reporting of vascular ultrasound studies
- How CT colonography is discussed in diagnostic and screening contexts
- How multiple obstetric ultrasound approaches are considered in reporting
- How CTA and 3D postprocessing documentation are addressed in radiology coding guidance
Who Should Read This
- Radiology coders
- Coding auditors
- Clinical documentation specialists
- Radiology billing staff
- Physician documentation reviewers
Codes Discussed
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