AMA Clinical Examples in Radiology - 2015 Issue 3 (Summer)
Questions and Answers
QUESTIONS AND ANSWERS Question Answer We are starting to perform cerebrospinal fluid (CSF) flow with magnetic resonance imaging (MRI). The study is typically done after performing an MRI of the brain without contrast followed by MRI with contrast. Please provide the proper Current Procedural Terminology (CPT®) code to use when reporting the study. To code for CSF flow studies using MRI, it would be appropriate to report the MRI code for the body part imaged (either brain or spine) using the appropriate without, with, or without and with contrast material code. MRI procedures are tailored to help answer...
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Article Overview
This Q&A article addresses several radiology coding and documentation topics for imaging and procedure reporting. It is relevant to coders, radiology staff, compliance teams, and anyone working with CPT-based reporting who needs to understand how general guidance applies to MRI, ultrasound, breast imaging documentation, and vertebroplasty. The article also references ACR practice parameters and CPT professional guidance as part of the discussion.
Why This Topic Matters
Radiology coding often depends on the study performed, the anatomic area imaged, and whether documentation supports what was done. This article helps readers recognize the kinds of reporting and documentation issues that can affect accurate CPT-based billing and record integrity.
Article Sections
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MRI CSF flow study reporting
Discusses reporting considerations for an MRI-based cerebrospinal fluid flow study and references guidance tied to brain imaging and contrast-related exam structure.
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Ultrasound for inguinal hernia or groin lymph nodes
Covers ultrasound reporting questions related to groin-area findings and compares several ultrasound exam categories tied to different anatomic sites.
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Bilateral chest ultrasound and documentation
Addresses documentation and reporting concerns for chest ultrasound exams, including discussion of bilateral examinations and radiology report completeness.
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Bilateral breast ultrasound documentation
Reviews whether breast ultrasound documentation is complete when both sides are not clearly described in the report and cites practice-parameter-based documentation expectations.
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Vertebroplasty at multiple spinal levels
Explains reporting considerations for vertebroplasty when more than one spinal level is involved and notes the relevance of 2015 CPT guidance.
What You Will Learn
- How the article frames imaging-reporting questions across multiple radiology scenarios.
- What types of documentation are emphasized for ultrasound and other imaging studies.
- How the article situates vertebroplasty reporting within CPT guidance changes.
- Which professional sources are cited in support of the discussion.
Who Should Read This
- Medical coders
- Radiology billing staff
- Compliance professionals
- Radiologists
- Imaging documentation specialists
Codes Discussed
Modifiers Discussed
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