ACR White Paper: CCTA Structured Reporting

by Cheryl Proval on October 16, 2008

A group of luminary practitioners of coronary CT angiography (CCTA) penned a white paper1 to guide readers of CCTA in structured reporting for the modality. Citing referrer ease of use and the ability to improve quality through consistency, the authors discuss the primary elements of a structured report and provide templates for reporting CCTA with coronary-artery calcium score and CCTA with coronary-artery bypass grafts. The authors also cite the economic implications of structured reporting: Practices are assured that all of the elements necessary for proper coding are included.

The elements of a structured report are identical for all studies and modalities: a brief description of the exam; an indication, with pertinent clinical history, signs, and symptoms; a listing of the previous exams used for comparison, and their dates; relevant technical details of the exam necessary for CPT® coding, including all pharmaceuticals used; a statement of all finding in logical anatomical order, including quantitative measurements and links to representative images; and a succinct conclusion featuring important findings, impressions, and recommendations, preferably in a numbered list. For purposes of Medicare billing in academic institutions where residents or fellows report, it is essential that the attending physician attest that he or she was present for the entire procedure (if interventional) or that all images were personally reviewed.

The authors believe that CCTA particularly lends itself to structured reporting because there are a limited number of anatomic elements and variations in pathology. While many workstations provide structured report templates, in many cases, the RIS cannot currently accept these reports. The authors did add that the templates that they provide may require variations in reporting to describe findings outside the coronary arterial tree, particularly in reporting the results of coronary-artery bypass grafts, for which the type of artery, artery of distal anastomosis, and proximity of the graft to the sternum should be noted.

The Templates

For reporting of CCTA with coronary-artery calcium score, the template provides a highly formatted reporting formula with the ability to click on options under the following headings:

Indication: a [<>]–year-old [

] with [ < >] Comparison: [] [] Procedure: This section describes the study (CT of the heart obtained using prospective ECG triggering, with and without contrast), with brackets in which to insert dose measurements of contrast, beta blockers, and other pharmaceuticals. This section also includes clickable options to note no complications, the use of ECG tube modulation for reduced radiation exposure, and the CT dose index volume. Extracardiac findings: This section provides a place to note findings for the visualized lungs, mediastinum, and upper abdomen, as well as clickable options for the pulmonary arteries and the thoracic aorta [ ]. Agatston score: This section provides brackets in which to note the total coronary artery score, as well as brackets to note the distribution in the left main, left anterior descending, left circumflex, and right coronary arteries, and the percentage of similar patients who have less coronary-artery calcium. Cardiac morphology: Here, the interpreter has the option of clicking normal or dilated for the right and left atria; normal, dilated, or hypertrophied for the right and left ventricles; and five options for the pericardium. The template also provides a place to comment on the valves. Function: This section provides brackets in which to place the calculated left ventricular ejection fraction, the left ventricular end-diastolic volume, and the left ventricular end-systolic volume. Options are provided to select and edit with regard to wall motion. CCTA: This section is devoted to findings, beginning with the quality of the exam and extending through clickable options for all of the anatomic elements of the heart. Notably, this section requires no text entry, only point-and-click options. Impression: This is a free-text area of the report, meant for a concise summary of findings and recommendations. The authors recommend a numbered list in order of decreasing importance. The template for CCTA with coronary-artery bypass grafts provides an additional heading for bypass grafts: This area is formatted to present clickable options for all possible bypass vessel locations and conditions, aside from a set of brackets in which to insert the distance of the graft from the sternal notch. The authors note that this is a key landmark for surgeons.

Reference
1. Stillman AE, Rubin GD, Teague SD, White RD, Woodard PK, Larson PA. Structured reporting: coronary CT angiography: a white paper from the American College of Radiology and the North American Society for Cardiovascular Imaging. J Am Coll Radiol. 2008;7:796-800.