Documentation best practices for CT exams using iodinated contrast

Q.

For CT exams, do you know if we have to specify the type and volume of contrast for billing, or is just the statement that iodinated contrast was administered acceptable? I am unable to find a specific reference source demonstrating how this should be documented. Could you direct me to a written reference that I am able to share with my providers?

A.

The information must be in the medical record. While it is best practice to document that in the dictated report, it doesn’t have to be there as long as it can be found in the patient’s medical record.

Consider this:

If a doctor orders a pain medicine, she/he must be specific about what pain medicine, how much, whether IV, oral, IM, etc. Then the nurse who gives the pain medicine must document that information as well. There is no difference with contrast material. It is a drug. It must be documented just like any other drug.

For billing purposes, hospitals should report the contrast material even if it is not paid separately. Imaging centers and doctor’s offices that perform contrast-enhanced exams are paid separately, but all must document it appropriately.

The ACR Practice Parameter for Documentation can be found on the ACR website 

https://www.acr.org/-/media/ACR/Files/Practice-Parameters/CommunicationDiag.pdf