Radiology and the phrase “with contrast” will be the topic of discussion for this “Spotlight on CPT”.
When a radiology examination is ordered “with contrast” the purpose is to enhance the imaging so that the radiologist is better able to distinguish between normal and abnormal tissue under study. When contrast is administered it can be done intravascularly, intra-articularly, or intrathecally.
If we examine these individually, we see some distinctions that coding professionals must be aware of. First, when a CT scan, a computed tomographic angiography (CTA), a magnetic resonance imaging (MRI), or magnetic resonance angiography (MRA) are performed “with contrast”, the injection of the intravascular contrast is considered part of the procedure. No separate code should be assigned.
However, there is a difference to be noted when coding for spinal CTs, MRIs, or MRAs with contrast. Here both intrathecal and intravascular are included when “with contrast” is in the code description, but the intrathecal injection may be captured with code 61055 or 62284 as appropriate.
Joint injection codes should be used for intra-articular injections. Arthrography performed via CT or MRI and without radiographic arthrography will need three codes. The first code will be the joint injection code. The second will be the CT or MRI “with contrast”, and the third code will capture the needle placement for the contrast injection.
It is also worth pointing out the two other methods of administering contrast, namely oral and rectal, do not (alone) qualify the study as “with contrast”.
Now, light has been shed on coding “with contrast”.
About the Author
Dianna Foley, RHIA, CCS, CHPS, CDIP is
OHIMA's Education Coordinator. Dianna has been an HIM
professional for over 20 years. She progressed through the ranks of coder,
department supervisor, and department director, to her current role as a
coding consultant. She previously served as the program director for Medical Coding and HIT at Eastern Gateway Community College. Dianna earned her bachelor's degree from the University of Cincinnati and holds RHIA, CHPS, CDIP and CCS certifications. She is an AHIMA Approved ICD-10-CM/PCS Trainer and is a presenter on coding topics at the national, state, and regional levels. Dianna mentors new AHIMA members and also provides monthly educational lectures to coders and clinical documentation specialists.
