Computed tomographic angiography, head, with contrast material(s), CPT® 70496 - Targeted Probe and Educate Review Results - JF Part B

In order to fulfill its contractual obligation with CMS, Noridian Healthcare Solutions (Noridian), your Medicare Contractor, performs pre-payment reviews in accordance with CMS direction. CMS is required by the Social Security Act to ensure that payment is made only for those medical services that are reasonable and necessary. Medical review assesses submitted documentation to validate provider compliance with Medicare payment rules and regulations, including coverage, coding and billing guidelines.

This is to update providers of the claim review findings for 70496 Computed tomographic angiography (CTA), head, with contrast material(s), including noncontrast images, if performed, and image postprocessing. The results of this focused review are not a reflection on providers' competence as a health care professional or the quality of care provided to patients. Specifically, the results are based on the documentation requested by Medicare and/or your facility's compliance with the required documentation.

The Jurisdiction F, Part B Medical Review Department is conducting a Targeted Probe and Educate (TPE) review of CPT® 70496 – Computed tomographic angiography, head, with contrast material(s), including noncontrast images, if performed, and image postprocessing. The quarterly edit effectiveness results from October 1, 2023, through December 31, 2023, are as follows:

Top Denial Reasons

• Failure to return records.
• The documentation submitted was incomplete and/or insufficient.
• The documentation submitted does not support medical necessity.

Educational Resources

• How to respond to an ADR
• Documentation Guidelines for Medicare Services
• National Coverage Determination (NCD) 220.1

CTA of the head CPT® 70496

Computed tomographic angiography is a procedure used for the imaging of vessels to detect aneurysms, blood clots, and other vascular irregularities. Contrast medium is rapidly infused intravenously, at intervals, usually with an automatic injector, and the patient is scanned with thin section axial or spiral mode x-ray beams. The images obtained are acquired with narrower collimation and reconstructed at shorter intervals than standard CT images. Three-dimensional images are generated and postprocessing reconstruction is done at a workstation on the scanner. CTA also provides information unavailable with conventional angiography, such as vessel wall thickness (mural thrombus) and the venous anatomy of a target organ and/or associated organs within the scan range.

Sufficient information must be provided with claims to differentiate CT scans from other radiology services and to make coverage determinations. Carefully review claims to ensure that a scan is reasonable and necessary for the individual patient; i.e., the use must be found to be medically appropriate considering the patient's symptoms and preliminary diagnosis.

There is no general rule that requires other diagnostic tests to be tried before CT scanning is used. However, in an individual case the Medicare Administrative Contractor (MAC) medical staff may determine that use of a CT scan as the initial diagnostic test was not reasonable and necessary because it was not supported by the patient's symptoms or complaints stated on the claim form; e.g., "periodic headaches."

Claims for CT scans are reviewed for evidence of abuse, which might include the absence of reasonable indications for the scans, an excessive number of scans, or unnecessarily expensive types of scans considering the facts in the particular cases.