Code This Cerebral CT Scan Case
Question: A 65-year-old patient presented with memory loss and confusion. The patient’s primary care physician (PCP) ordered a brain CT scan with contrast. The radiologist performed the scan and interpreted the results. The report listed the findings as “atrophy of the cerebral cortex, suggestive of Alzheimer’s disease.” How do I report this visit? New Mexico Subscriber Answer: Use 70460 (Computed tomography, head or brain; with contrast material(s)) to report the brain CT imaging scan with contrast. Double-check the radiology report to ensure the provider administered the contrast intravascularly, intra-articularly, or intrathecally. If the contrast material is administered orally, then you cannot report a “with contrast” CPT® code. Next, turn to the ICD-10-CM code book for the atrophy of the cerebral cortex finding. Assign G31.9 (Degenerative disease of nervous system, unspecified) to report the diagnosis. The physician mentioned the findings were “suggestive of Alzheimer’s disease,” but this does not mean you can report an Alzheimer’s disease diagnosis code. The patient’s condition could be indicative of Alzheimer’s disease, but further testing is required to confirm. Mike Shaughnessy, BA, CPC, Development Editor, AAPC
