How To Use CPT Code 78216

CPT 78216 describes the imaging procedure used to examine the liver and spleen and assess their function. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, similar codes and billing examples.

1. What is CPT Code 78216?

CPT 78216 is a code used to describe a specialized radiologic procedure that examines the liver and spleen. This procedure is performed to identify certain conditions or assess the function of these organs. It involves the use of imaging techniques to capture images of the liver and spleen and detect any abnormalities or issues.

2. Official Description

The official description of CPT code 78216 is: ‘Liver and spleen imaging; with vascular flow.’

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.
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 images of the liver and spleen, allowing the healthcare professional to assess their structure and function.
5. The images may include information about the vascular flow in these organs, providing additional insights into their health.
6. The procedure is typically painless and non-invasive, with minimal risks or side effects.

4. Qualifying circumstances

CPT 78216 is used when there is a need to examine the liver and spleen using imaging techniques. This may be necessary to identify certain conditions or assess the function of these organs. The procedure is typically performed by a radiologist or other qualified healthcare professional who specializes in diagnostic imaging. It is important to note that specific clinical indications and medical necessity may determine the need for this procedure.

5. When to use CPT code 78216

CPT code 78216 should be used when there is a need to perform liver and spleen imaging with vascular flow. This code is appropriate when the healthcare professional uses imaging techniques to capture images of the liver and spleen and assess their function. It is important to ensure that the procedure meets the specific criteria outlined in the code description.

6. Documentation requirements

To support a claim for CPT code 78216, the healthcare professional must document the following information:

• Reason for performing the liver and spleen imaging
• Details of the imaging procedure, including the use of vascular flow imaging
• Date and time of the procedure
• Findings and observations from the imaging
• Any additional relevant information or clinical indications
• Signature of the healthcare professional performing or supervising the procedure

7. Billing guidelines

When billing for CPT code 78216, it is important to ensure that the procedure meets the specific criteria outlined in the code description. The healthcare professional performing or supervising the procedure should be appropriately qualified and trained in diagnostic imaging. It is also important to follow any additional guidelines or requirements set forth by the payer or insurance company. It is recommended to review the specific billing guidelines and requirements for CPT code 78216 to ensure accurate and appropriate billing.

8. Historical information

CPT code 78216 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 liver and spleen imaging with vascular flow to assess the function of these organs and identify any abnormalities.
2. A radiologist performs liver and spleen imaging with vascular flow to evaluate the effectiveness of a treatment for a liver condition.
3. A healthcare professional uses liver and spleen imaging with vascular flow to monitor the progression of a known liver disease in a patient.
4. A patient with suspected spleen dysfunction undergoes liver and spleen imaging with vascular flow to aid in diagnosis and treatment planning.
5. A physician orders liver and spleen imaging with vascular flow to investigate the cause of unexplained abdominal pain in a patient.
6. A radiology technologist performs liver and spleen imaging with vascular flow as part of a routine screening for a high-risk population.
7. A patient with a history of liver disease undergoes liver and spleen imaging with vascular flow to assess the response to a new medication.
8. A healthcare professional uses liver and spleen imaging with vascular flow to evaluate the extent of liver damage in a patient with a known liver condition.
9. A radiologist performs liver and spleen imaging with vascular flow to guide a biopsy procedure in a patient with suspected liver or spleen abnormalities.
10. A patient with a family history of liver disease undergoes liver and spleen imaging with vascular flow as a preventive measure.