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.
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 [