“If it isn’t written, it didn’t happen”
Those words have been repeated to medical billers and coders in training classes and seminars for over 20 years. Coding a CTA can be tricky even for the seasoned coder. Very precise information must be dictated to assist the coder in determining if the procedure was a CT or CTA. The Fall 2008 issue of “Clinical Examples in Radiology” clarified the coding and dictation issues surrounding CTA. In order to differentiate CT from CTA, dictated documentation must indicate that 3D images were acquired and interpretation for those images must be made in order to compliantly charge for a CTA. In order to report angiographic reconstructions 3D techniques must be used. Among the accepted techniques are MIP reconstructions and volume-rendered images. The coders will look for the accepted terminology (MIP reconstructions, etc.) in order to determine the correct CPT code to bill. For CTA, the use of a separate or integrated work station does not need to be indicated.
Clear and detailed documentation of any medical service is a necessary aspect of medical care. Medical records and reports are meant to accurately relay the services provided to the patient. In a way, the records are meant to tell a story, or put an “extra person” in the room with the physician and patient. In this case, the “extra person” is the coder reviewing your report. Without the correct information in the report, the procedure you actually performed may not be the procedure billed, resulting in missed revenue.