Learn Why a Head CT Without Contrast Is Needed in Emergency Situations
Question: A 65-year-old patient arrived at the emergency department (ED) claiming a sudden onset of the worst headache of their life that peaked quickly when they were mowing the lawn. The headache was accompanied by neck stiffness and photophobia. They claimed they had no prior imaging or established diagnosis. A radiologist performed a CT of the head without contrast to rule out an acute bleed. The impression noted hyperdensity within the basal cisterns due to acute subarachnoid hemorrhage. Neurosurgery was notified immediately. What codes do I report? Oregon Subscriber Answer: Use 70450 (Computed tomography, head or brain; without contrast material) to report the CT of the head without contrast material. CT scans without contrast material are the fastest type of CT imaging, which is why providers use them in emergency situations, such as the one the patient presented with. Fresh blood is easy to spot on a noncontrast CT scan, so physicians order it when they suspect intracranial or subarachnoid hemorrhage. You’ll assign I60.9 (Nontraumatic subarachnoid hemorrhage, unspecified) to report the acute subarachnoid hemorrhage causing the hyperdensity within the basal cisterns. If the impression further specifies where the subarachnoid hemorrhage is occurring, you’ll assign the applicable code, such as one of the following: Of course, if the documentation doesn’t list a definitive diagnosis, then you’d assign a code that reflects the presenting symptom, which in this case would be R51.9 (Headache, unspecified). The documentation of sudden or thunderclap headache and neck stiffness will support the medical necessity of the head CT scan. Mike Shaughnessy, BA, CPC, Production Editor, AAPC
