Proper Documentation for CTA Prior to TAVR

Documentation Requirements for Coding and Reimbursement of Computed Tomographic Angiography (CTA) Prior To Transcatheter Aortic Valve Repair (TAVR)

Prior to TAVR, a pre-procedural workup is essential to reduce procedural complications.  It is important for patients to be assessed not only for cardiovascular but also for noncardiovascular comorbidities.

Per the National Coverage Determination 20.32, TAVR is not covered for patients in whom existing co-morbidities would preclude the expected benefit from correction of the aortic stenosis. To make this determination, multiple diagnostic imaging studies may be needed.

When multiple procedures are performed, every study must have the required supporting documentation.  The purpose of this article is to point out documentation specifics required for code assignments.

 

DOCUMENTATION BASICS

  1. Every diagnostic study documented on a single report should be individually titled:
    • Per ACR Practice Parameter for Communication of Diagnostic Imaging Findings under Section II, A. Components of the Report, the name and type of exam should be documented.
    • Include the Title for each study to help designate true separation between studies rather than just within the field of view.
  2. Document the reason for each test performed:
    • Every test ordered and performed requires a reason for the test. It is therefore mandatory to provide relevant medical history that supports medical necessity for each study.
    • Examples:
      • Coronary CTA  – Non-rheumatic aortic valve stenosis
      • CTA abdominal aorta & bilateral iliofemoral lower extremity run-off – Claudication
      • CTA neck – Carotid stenosis
  3. Understand the requirements for every CPT code assigned:
    • Since the year 2000, the Department of Health and Human Services designated CPT codes as the national coding standard for physicians and other healthcare professional services and procedures under the Health Insurance Portability and Accountability Act (HIPAA).   In addition, CPT coding instructions clearly state, “Select the name of the procedure or service that accurately identifies the service performed.” Documentation of the study must match the code assigned. Review the following CPT code descriptions and pay attention to how they differ:
      • 75574   Computed tomographic angiography, heart, coronary arteries and bypass grafts (when present), with contrast material, including 3D image postprocessing (including evaluation of cardiac and morphology, assessment of cardiac function, and evaluation of venous structures, if performed)
        • Note:  If there was not an evaluation of the native coronary arteries and/or coronary artery bypass, then this code could not be assigned.
      • 75572   Computed tomography heart, with contrast material for evaluation of cardiac structures and morphology (including 3D image postprocessing, assessment of cardiac function and evaluation of venous structures, if performed)
        • Note:  This code is for the evaluation of the cardiac chambers and morphology but without an evaluation of the coronary arteries.
      • 71275   Computed tomographic angiography chest (noncoronary) with contrast material(s), including noncontrast images performed, and image postprocessing
        • Note:  This study would not be reported for an evaluation of the heart or coronary arteries.

 

OTHER CONSIDERATIONS

  • It is important to note that medical policies do vary by payor, including for Medicare Administrative Contractors (MACs)
  • There must be an order for every study performed and every order should include a relevant reason for the study to be performed

 

SUMMARY

  • Provide a title for every procedure performed
  • A relevant medical history must be documented for every procedure performed
  • Specify the area evaluated and document the findings
  • Become familiar with your payor-specific medical policies
  • There must be an order for every diagnostic study performed, and it should include a relevant reason for why the study was necessary

 

References:

  • CPT 2022 Professional Edition
  • CMS National Coverage Determination 20.32
  • American College of Radiology Practice Parameter for Communication of Diagnostic Imaging Findings

 

Wendy Block, CPC, RCC, CIRCC

Senior Coder, StreamlineMD

wblock@streamlinemd.com

StreamlineMD provides EHR & RCM Software & Service to Imaging & Image-Guided Procedure Specialists. Our Mission is to Improve Healthcare for All Americans.  Our Core Values that guide us on our mission are Service Quality, Teamwork, Accountability, Efficiency, Adaptability, Communication, and Integrity.