"We sent the operative report to a coder who was handling our overflow, and she billed a CTA (71275)," Benhardus says. "I was not comfortable changing the code from CT (71250-71270) to CTA because our physicians usually clarify whether they performed a CTA, and they didn't do so in this situation."
Benhardus'instincts were correct. The July 2001 CPT Assistant states, "The key distinction between CTA and CT is that CTAincludes reconstruction postprocessing of angiographic images and interpretations." If your radiologist does not document this, you should not report a CTA code. But what if the physician subsequently tells you that he meant to dictate "CTA" instead of simply dictating "reconstruction"? Can he change the documentation and initial it, or must he pay for his mistake by reporting only the CT code?
"The radiologist would need to dictate an amended report indicating the details of the exam to clarify that he imaged the vascular system and that the images were subsequently reconstructed," says Carrie Caldewey, RCC, CPC, coding specialist at Redwood Regional Medical Group in Santa Rosa, Calif. "Remember: If it isn't documented, it wasn't done." Follow Doctor's Orders Some carriers also believe in the other coding adage: If it wasn't ordered, it wasn't done. Coders should refer back to the physician's original order to determine whether he or she ordered a CT or CTA, says Lee Ahrens, RIS/PACS specialist at Thompson Health, a multispecialty healthcare provider in Canandaigua, N.Y.
"The procedure that the physician performs should be what was ordered,"Ahrens says, "so the chain of data from the physician's office to the operative report is consistent."
Some carriers echo this principle. Utah Medicare's policy states that CTA and CT scan "providers are expected to maintain a record of [...]