Radiology CPT Coding

kmac23

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When it comes to radiology coding, where do you get the CPT from, the order or the report?

Example: Ordering Physician states to do a Pelvic Ultrasound (76856/76830) but in addition to this the Radiologist also does a complete Doppler (93975).

Would you code directly from the order (which is what the hospital did!) or would you code from the radiology report?

Just need clarification. TIA
 

ducharme

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order and report. The technologist assigns the CPT and the physician must state what he is doing in report. You code from the physician's finding/report .
e.g. CT of the chest, abdomen and pelvis with intravenous contrast. This is physicians statement which must match the code being billed, which is 71260 chest with contrast, 74177 abd and pelvis with contrast, pt has endometrial cancer with findings of pulmonary and soft tissue metastases. Hepatic metastases, all of which is coded. When physician description does not match what is billed, you will need to query the physician to find out what is going to arrive at the correct CPT, maybe need to use an unlisted code.
 
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