When charging for computed tomography (CT) with contrast, contrast amount, type and route should be included

Q.

If you are performing and charging for a computed tomography (CT) with contrast exam, and the contrast amount and type are given within the technique, but the words “with IV contrast” are not specifically used, does this suffice for the “with contrast” requirements?

A.

The route of administration must be in the medical record somewhere. It doesn’t necessarily have to be in the report itself but, if it’s not, the coder has to search to guarantee it was, in fact IV contrast (or intrathecal for spine exams or intra-articular for joint exams). As such, in the report, it is best practice for the physician to dictate the type of contrast, the amount that is given, and the route of administration.