How To Use CPT Code 78458

CPT 78458 describes the diagnostic nuclear medicine procedure used to image venous thrombosis, specifically through a venogram. 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 78458?

CPT 78458 is a code used to describe a diagnostic nuclear medicine procedure that involves imaging the vascular system to identify the presence and location of any thrombi, or clots, in the vein. This procedure is performed by injecting a radiopharmaceutical agent and taking X-ray or nuclear images of the blood vessels. CPT 78458 specifically refers to a bilateral study, meaning it is performed on both sides of the body.

2. Official Description

The official description of CPT code 78458 is: ‘Venous thrombosis imaging, venogram; bilateral.’

3. Procedure

1. The provider prepares the patient for the procedure.
2. A radioactive substance is injected into the blood vessels of the arms or legs, either through injection or a small catheter.
3. The radioactive substance travels through the blood circulation.
4. The provider takes X-ray or nuclear images of the blood vessels to identify any blockage or narrowing caused by a clot.
5. The procedure is performed bilaterally, meaning both sides of the body are imaged.

4. Qualifying circumstances

CPT 78458 is used when the provider performs a bilateral venogram to diagnose deep vein thrombosis. It is important to note that this code specifically refers to a bilateral study, so if the procedure is performed unilaterally (on one side), a different code should be used.

5. When to use CPT code 78458

CPT code 78458 should be used when the provider performs a bilateral venogram to diagnose deep vein thrombosis. It is important to ensure that the procedure is performed on both sides of the body to accurately report this code. If the procedure is performed unilaterally, a different code should be used.

6. Documentation requirements

To support a claim for CPT 78458, the provider must document the following information:

• Indication for the procedure, such as suspected deep vein thrombosis
• Details of the procedure, including the use of a radiopharmaceutical agent and the bilateral nature of the study
• Date and time of the procedure
• Findings from the imaging, including the presence and location of any thrombi
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 78458, ensure that the procedure is performed bilaterally, as indicated by the code description. If the procedure is performed unilaterally, a different code should be used. It is also important to follow any specific billing guidelines provided by payers or coding guidelines. Modifier 26 should be appended to the radiology code if reporting only the physician’s interpretation, and modifier TC should be appended if reporting only the technical component. However, payer policies may exempt hospitals from appending modifier TC. If the radiopharmaceutical substance is billed separately, the appropriate code should be used.

8. Historical information

CPT 78458 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates to the code since its addition.

9. Examples

1. A patient presents with symptoms of deep vein thrombosis, and the provider performs a bilateral venogram to diagnose the condition.
2. A patient with a history of clotting disorders undergoes a bilateral venogram to monitor the presence and location of any thrombi.
3. A patient who recently had surgery develops swelling in their legs, and a bilateral venogram is performed to rule out deep vein thrombosis.
4. A patient with a suspected pulmonary embolism undergoes a bilateral venogram to identify any clots in the veins leading to the lungs.
5. A patient with chronic venous insufficiency undergoes a bilateral venogram to assess the extent of the condition and identify any underlying thrombi.
6. A patient with a history of deep vein thrombosis in one leg undergoes a bilateral venogram to compare the condition of both legs and monitor for any new clots.
7. A patient with a family history of clotting disorders undergoes a bilateral venogram as a preventive measure to identify any early signs of deep vein thrombosis.
8. A patient with persistent leg pain and swelling undergoes a bilateral venogram to determine if a clot is causing the symptoms.
9. A patient with a suspected blood clot in the arm undergoes a bilateral venogram to confirm the diagnosis and determine the location of the clot.
10. A patient with a history of deep vein thrombosis in one leg undergoes a bilateral venogram to assess the condition of both legs and monitor for any recurrence of clots.