Proper Dictation for CTA Exams

May 19, 2021

APS performs regular audits of client report documentation, CPT®/ICD-10 code assignment and their possible relation to carrier edits. One area that APS auditors see as problematic, is proper dictation for CTA exams. Following is a breakdown of this area. 

CTA studies require 3D postprocessing to be done. The 3D imaging is included with the CTA CPT codes. Coders cannot assign a CTA code unless the 3D imaging is documented in the report. If the study does not include 3D imaging, or only includes 2D, that study should be coded as a CT scan instead of a CTA. 

Coders look for any of the following terms to be documented when coding CTA studies:

  • 3D postprocessing
  • MIP – maximum intensity projection
  • Shaded surface rendering
  • Volume rendering 

If a CTA only has multiplanar reconstruction (MPR) documented, this is considered to be a 2D study and would be coded as a CT scan, not a CTA.  

Correct Documentation Example:
Order: CTA Chest Abdomen and Pelvis
Technique: Helical acquisition of the chest, abdomen and pelvis were obtained from the apex of the lungs through the symphysis pubis, before and after the administration of IV contrast.  Multiplanar and 3D reconstruction were created, including maximum intensity projections (MIP).

The correct CPT codes for this report would be 71275, CTA chest (noncoronary) with contrast material(s), including noncontrast images, if performed, and image postprocessing and 74174, CTA abdomen and pelvis with contrast material(s), including noncontrast images, if performed, and image postprocessing.

Incorrect Documentation Example:
Order: CT Angio Neck W WO Contrast
Technique: Volume data was acquired through the neck with IV contrast administration.

The correct CPT code for this report would be 70491, CT soft tissue neck with contrast.  The technique does not state that the exam was performed without and with contrast and it does not give the 3D postprocessing documentation to code it for a CTA, 70498.


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