How to Report a Cardiac CTA

Physicians use cardiac computed tomographic angiography as a medical procedure for evaluating blood vessels of the heart. Cardiac CTA involves the use of an X-ray machine moving in different angles around the body to produce detailed 3D images. The procedure sometimes involving the injection of contrast iodine-based dye intravenously administered. By using cardiac CTA, physicians can study for coronary artery disease and anomalies.

Things You'll Need

• Current Procedural Terminology (CPT) coding books

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Instructions

• 1

  Explain the procedure's need, nature and extent. Verify any indications, symptoms or clinical history of coronary heart disease with the patient and family. Record the date, time, and equipment that will be used.

• 2

  Log the diagnostic procedure using X-rays based on whether contrast dye is used, creating 3-D images using 64 multi-slice computed tomography. Examine findings within coronary arteries and bypass grafts for calcified plaques as an indication of coronary artery disease. Write the exact procedure performed with the current procedural terminology (CPT) codes, a short code used in place of long medical information.

• 3

  Explain the final diagnosis from all findings during the procedure. State professional medical impressions concerning the patient's status, including diagnostic and therapeutic procedures along with concurrent problems. Write down any prescribed follow-up care.