How To Use CPT Code 78215

CPT 78215 describes a specialized radiologic procedure used to examine the liver and spleen for certain conditions or to assess their function. This article will cover the official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, similar codes and billing examples.

1. What is CPT Code 78215?

CPT 78215 is a code used to describe a liver and spleen scan, which is a specialized radiologic procedure. This procedure is performed to examine the liver and spleen for specific conditions or to assess their function. It involves the use of a special camera that detects gamma radiation emitted by a radioisotope injected into a peripheral vein and extracted by the liver. The procedure provides planar images of the liver and spleen to aid in diagnosis and treatment planning.

2. Official Description

The official description of CPT code 78215 is: ‘Liver and spleen imaging; static only.’

3. Procedure

1. The patient is positioned on the examination table in a supine position.
2. The arm is cleaned with an antiseptic solution, and a small amount of radioactive tracer is injected into a peripheral vein.
3. After approximately 30 minutes, a scanner is placed over the right upper quadrant of the abdomen to detect the gamma rays emitted by the radionuclide in the liver and spleen tissue.
4. The scanner captures planar images of the liver and spleen, providing static views of these organs.
5. The images are then interpreted by a radiologist or other qualified healthcare professional to make a diagnosis or assess the function of the liver and spleen.

4. Qualifying circumstances

CPT 78215 is typically performed when there is a clinical need to evaluate the liver and spleen for specific conditions or to assess their function. It may be ordered by a physician or other qualified healthcare professional based on the patient’s symptoms, medical history, or the results of other diagnostic tests. The procedure is generally performed on patients who are able to cooperate and lie still during the imaging process.

5. When to use CPT code 78215

CPT code 78215 should be used when a liver and spleen scan is performed to obtain static images of these organs. It is important to note that this code specifically refers to static imaging only and does not include imaging of vascular flow. If the procedure involves imaging of blood flow by labeling red blood cells, CPT code 78202 should be used instead.

6. Documentation requirements

To support a claim for CPT code 78215, the healthcare professional must document the following information:

• Indication for the liver and spleen scan
• Date and time of the procedure
• Details of the procedure, including the use of a radioactive tracer and the positioning of the scanner
• Interpretation of the images by a radiologist or other qualified healthcare professional

7. Billing guidelines

When billing for CPT code 78215, it is important to ensure that the procedure performed aligns with the description of the code. This code should be used for static imaging of the liver and spleen only. If the procedure involves imaging of vascular flow, CPT code 78202 should be used instead. It is also important to follow any specific billing guidelines provided by the payer or applicable coding guidelines.

8. Historical information

CPT code 78215 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates or changes to the code since its addition.

9. Examples

1. A patient undergoes a liver and spleen scan to evaluate the function of these organs after experiencing unexplained abdominal pain.
2. A liver and spleen scan is performed on a patient with a history of liver disease to assess the progression of the condition.
3. A physician orders a liver and spleen scan for a patient with suspected splenomegaly to confirm the diagnosis.
4. A liver and spleen scan is performed on a patient with a known liver tumor to assess its size and location.
5. A patient undergoes a liver and spleen scan as part of a preoperative evaluation for a planned liver surgery.
6. A liver and spleen scan is performed on a patient with suspected liver metastases to determine the extent of the disease.
7. A physician orders a liver and spleen scan for a patient with suspected liver cirrhosis to assess the severity of the condition.
8. A liver and spleen scan is performed on a patient with a history of autoimmune hepatitis to monitor the response to treatment.
9. A patient undergoes a liver and spleen scan to evaluate the function of these organs after a recent liver transplant.
10. A liver and spleen scan is performed on a patient with suspected portal hypertension to assess blood flow in these organs.