If I have a report that has the indication as "diagnostic angiogram with embolization" and the report states there are no other studies for comparison. The body of the report goes on to describe the exact location of a bleed as found on the diagnostic angiogram that was ordered. Does the report have to state explicitly that "the decision to intervene (or perform the embolization) was based on this diagnostic angiogram"? Or, does the fact that the order was for a diagnostic angiogram and there were no other comparison studies sufficient to code for the diagnostic studies prior to the embolization? Thank you
Is this all done in one procedure? Proper documentation should show the findings.
In addition, the AMA Guidelines state:
"With regard to CPT descriptors for imaging services, “images” must contain anatomic information unique to the patient for which the imaging service is provided. “Images” refer to those acquired in either an analog (ie, film) or digital (ie, electronic) manner."
Does this clarify and answer your question? If not feel free to submit more information.