Radiology Coding Alert

Question: A patient had a CT of the abdomen and pelvis without contrast by one radiologist, and then later the same day had the same study with contrast by a different radiologist in the same group, under the same tax ID. The second radiologist referenced the first CT in her report. How should I report this?


New York Subscriber
Answer: Don't be tempted to report two separate CTs for this patient. Instead, report one unit of 74170 (Computed tomography, abdomen; without contrast material, followed by contrast material[s] and further sections) and one unit of 72194 (Computed tomography, pelvis; without contrast material, followed by contrast material[s] and further sections).

Why? Most payers allow you to code only one CT per anatomic area per day.

Report the CT under the second radiologist's identification number. She read both the with and without contrast CTs.

Remember to verify that you have documentation to support reporting both the abdominal and pelvic CTs.

Exception: You may be able to show medical necessity for different and non-concurrent exams.

For example, one physician performed the first set of non-contrast studies in an acute setting and for signs or symptoms most appropriately diagnosed by a non-contrast study. Later on the same day (perhaps after some therapeutic intervention) the patient has a new set of circumstances that need evaluation with a contrast study. Though this scenario is rare, you technically should be able to code the exams as separate procedures. Just be ready for a denial that will require you to resubmit with appropriate documentation.