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In a particular scenario, the radiologist refers to a triplecontrast CT; what does he mean here? Normally, a triple-contrast CT refers to the scans of the abdomen and/or pelvis involving intravenous (IV), oral, and rectal contrast. You may particularly see these when a physician wants to see internal damage from a penetrating wound. Watch the order of administration and scanning as this affects your coding. As per CPT's radiology guidelines, ‘oral and/or rectal contrast administration alone doesn't qualify as a study with contrast." On the other hand, “Intravascularly administered contrast does qualify for a “with contrast" code. As a consequence, if the patient gets IV contrast before the scanning starts, then the IV contrast will still be present in the later scans with the added oral and rectal contrast. This means you shouldn't report ‘without contrast' scans. All of the scans are ‘with contrast'. Here is an instance: The radiologist may scan the abdomen and pelvis with intravenous contrast, and then scan them again after administration of oral and rectal barium contrast. In this situation, you should report new code 74177 (Computed tomography, abdomen and pelvis; with contrast material[s]). Remember: Documentation shouldn't refer only to a triple-contrast. The exact types of contrast and methods of administration should be documented. That'll allow you to select the appropriate code(s) and help you support your coding choices to payers and auditors. For more on this and other specialty-specific articles to assist your radiology coding, sign up for a good medical coding resource like Coding Institute.
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