CT and CTA on the Same Day – OK to Code? The Answer is More Complex Than You May Think.

“ Can we code and bill for both a CT and CTA on the lapp sidereal day ? ”
This is one of the most frequently asked questions when we talk about diagnostic image. The answer ? technically, yes, and so far the answer is not that aboveboard. With many situations there ’ s by and large a ‘ but ’ with these types of answers and here the software documentation needs to be quartz glass clear in order to submit codes for both exams .
Before we get to those documentation requirements, a promptly review .

CT and CTA – What’s the Difference?

Computed imaging ( CT ) scans take cross-sectional images of easy tissues or skeletal anatomy. Computed imaging angiography ( CTA ) takes the CT scan a step far by creating cross-sectional images of soft tissues, skeletal anatomy, and vascular structures. After the read is complete, calculator post-processing is used to create 3D images .
This 3D post-processing is the key differentiation between a criterion CT and a CTA .
The imagination of the vessels alone is not necessarily considered a CTA for coding purposes. To report a CTA code, 3D post-processing must
be done
to evaluate the vessels – if there is no three-d reformatting performed to evaluate the vessels, then the examination should be coded as a CT and not a CTA. If the details in the documentation are unclear as to whether the examination should be coded as a CTA vs. a CT, it ’ s constantly best to request clearing. even though a doctor may identify a procedure as a CTA, that ’ s not always the case from a coding perspective .
Code selections should be made based on the services provided and detailed in the software documentation .

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CT and CTA Performed on the Same Day

For situations where a CT and a CTA are performed on the same day, the NCCI Policy Manual for Medicare Services says the following in Chapter IX, Section D :
“ Computed imaging ( CT ) and computed tomographic angiography ( CTA ) procedures for the like anatomic placement may be reported together in limited circumstances. If a unmarried technical report is performed which is used to generate images for disjoined CT and CTA reports, only one routine, either the CT or CTA, for the anatomic region may be reported. Both a CT and CTA may be reported for the same anatomic region if they are performed at disjoined affected role encounters or if two distinguish and distinct technical studies, one for the CT and one for the CTA, are performed at the same patient find. The medical necessity for the latter position is rare. ”

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But there are some authoritative things to consider before coding a CT and CTA together .
first, if the purpose was to perform a CTA, then only the
CTA should be coded
. Any non-contrast CT images taken during a CTA ( i.e., for localization of function purposes ) are considered a part of the CTA and should not be coded individually .
second, CT and CTA can both be coded and billed only if separate
full and complete
studies are done .

  • What constitutes a distinct, separate
    technical study?

A branch set-up and distinguish acquisition would be one in which the affected role position in the scanner is different from the first study and different acquisition parameters are used .
documentation should clearly indicate and account for the divide technical studies performed and there should be checkup necessity for each before coding for both a CT and a CTA .
A scenario where it would be appropriate to report both a CT and a CTA on the lapp day are for patients where a stroke is suspected, and a full and complete CT is done of the head along with CTA of the brain and/or the neck.

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clinical Examples in Radiology ( volume 4, Issue 3, Summer 2008 ) besides offers an exercise where a CT reveals a tumor on the head of the pancreas and a CTA is recommended and performed on the lapp day for far evaluation. Of course, software documentation must intelligibly support that the studies were full, separate and complete. And remember, good because we are able to code for it doesn ’ t inevitably mean everything will be paid, that is going to be based on payer policies .
then, can we code and bill for a CT and a CTA on the lapp day ? Yes, but be sure the software documentation intelligibly indicates full, disjoined studies were performed and modify as necessity .

Guidance with a full range of CT/MR services

It ’ second all in the CT/MR Coder, your one-stop solution. Designed to specifically respond to real-world gull, software documentation and charge issues for a full moon crop of CT/MR services with feasible solutions, translated into clear-cut education, actionable tips and casing examples – an invaluable resource for radiology providers .

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