How To Use CPT Code 78630

CPT 78630 describes the diagnostic procedure of cerebrospinal fluid flow imaging, specifically cisternography. 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 78630?

CPT 78630 is used to describe a diagnostic procedure that checks the flow pattern of cerebrospinal fluid (CSF) in the head. This procedure, known as cisternography, is commonly performed to rule out CSF leaks and diagnose hydrocephalus, a condition characterized by abnormal accumulation of CSF in the brain.

2. Official Description

The official description of CPT code 78630 is: ‘Cerebrospinal fluid flow, imaging (not including introduction of material); cisternography.’

3. Procedure

1. During cisternography, the healthcare provider administers a radioactive substance or tracer into the cerebrospinal fluid around the spinal cord through a lumbar puncture.
2. A special device called a scintillation or gamma camera is then used to detect the gamma rays emitted by the radioactive substance.
3. Images are taken at specific time intervals, such as 24, 48, and 72 hours post-injection.
4. The computer processes the emission data to produce multi-dimensional images of the distribution of the radioactive substance in the CSF, particularly in the cisterns of the brain.

4. Qualifying circumstances

CPT 78630 is performed when there is a need to assess the flow of cerebrospinal fluid in the head. It is commonly used to rule out CSF leaks and diagnose hydrocephalus. The procedure is typically performed by a healthcare provider who specializes in nuclear diagnostic imaging.

5. When to use CPT code 78630

CPT code 78630 should be used when a healthcare provider performs cisternography to evaluate the flow of cerebrospinal fluid in the head. It is important to note that this code does not include the introduction of any material.

6. Documentation requirements

To support a claim for CPT 78630, the healthcare provider must document the following information:

• Reason for performing cisternography
• Details of the radioactive substance or tracer used
• Date and time of the procedure
• Images taken at specific time intervals
• Interpretation of the images
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT 78630, ensure that the procedure is performed by a healthcare provider specializing in nuclear diagnostic imaging. It is important to follow the specific guidelines provided by the payer regarding the use of modifiers and reporting of radiopharmaceutical substances.

8. Historical information

CPT 78630 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 undergoes cisternography to evaluate the flow of cerebrospinal fluid and rule out CSF leaks.
2. Cisternography is performed on a patient with suspected hydrocephalus to diagnose and assess the abnormal accumulation of cerebrospinal fluid in the brain.
3. A healthcare provider uses cisternography to evaluate the flow pattern of cerebrospinal fluid in a patient with unexplained symptoms.
4. Cisternography is performed on a patient post-surgery to monitor the flow of cerebrospinal fluid and ensure proper healing.
5. A healthcare provider utilizes cisternography to assess the effectiveness of a treatment for a cerebrospinal fluid-related condition.
6. A patient undergoes cisternography as part of a research study on cerebrospinal fluid flow patterns in specific populations.
7. Cisternography is performed on a patient with a history of recurrent CSF leaks to identify the source and plan appropriate treatment.
8. A healthcare provider uses cisternography to evaluate the flow of cerebrospinal fluid in a patient with suspected intracranial hypertension.
9. Cisternography is performed on a patient with unexplained neurological symptoms to assess the flow of cerebrospinal fluid and identify any abnormalities.
10. A healthcare provider utilizes cisternography to evaluate the effectiveness of a surgical intervention on cerebrospinal fluid flow in a patient.