© Copyright 2025 American Medical Association. All rights reserved.
The procedure described by CPT® Code 78215 involves the imaging of the liver and spleen using a technique known as scintigraphy. This imaging method utilizes a radiolabeled isotope tracer, specifically 99mTC-sulfur colloid, which is introduced into the patient's circulatory system. The primary purpose of this procedure is to assess the size and condition of the liver and spleen, allowing for the identification of various abnormalities such as tumors, abscesses, hematomas, cysts, and hypersplenism. Additionally, it can reveal changes in the radiocolloid distribution that may occur due to hepatic dysfunction or portal hypertension. The process begins with the establishment of an intravenous line through which the radiolabeled tracer is administered. Alternatively, a blood sample may be taken, and the tracer is attached to heat-destroyed red blood cells (RBCs) before being reintroduced into the body. Following a designated waiting period, the patient is positioned on an imaging table, and a gamma camera is placed over the upper abdomen to capture images. The scanning is conducted at specific intervals, during which the radioactive energy emitted from the liver and spleen is detected and converted into visual images. It is important to note that if vascular flow imaging is required, a different code, CPT® Code 78216, should be utilized. The liver and spleen are highly vascular organs, and any compromise in the blood vessels of one organ can affect the blood flow in the surrounding organs. After the imaging is completed, the physician interprets the scintigraphy results and generates a written report detailing the findings.
© Copyright 2025 Coding Ahead. All rights reserved.
The imaging of the liver and spleen using scintigraphy, as described by CPT® Code 78215, is indicated for several clinical scenarios. The following conditions may warrant this procedure:
The procedure for CPT® Code 78215 involves several key steps that ensure accurate imaging of the liver and spleen. The first step is the establishment of an intravenous line, which allows for the direct administration of the radiolabeled isotope tracer, 99mTC-sulfur colloid, into the patient's circulatory system. Alternatively, a blood sample may be drawn, and the tracer is then attached to heat-destroyed red blood cells (RBCs) before being injected back into the patient. This method ensures that the tracer is effectively delivered to the organs of interest. After the tracer has been administered, a prescribed waiting period is observed to allow for adequate distribution of the tracer within the liver and spleen. Following this interval, the patient is positioned on an imaging table, and a gamma camera is placed over the upper abdomen. The scanning process is then initiated, during which the gamma camera captures images at specific intervals. The radioactive energy emitted from the liver and spleen is detected and converted into visual images, providing a detailed representation of the organs' condition. It is important to note that if vascular flow imaging is required, CPT® Code 78216 should be utilized instead. The physician will subsequently interpret the scintigraphy results and compile a written report detailing the findings, which is essential for further clinical decision-making.
After the completion of the scintigraphy procedure for CPT® Code 78215, patients may be monitored briefly to ensure there are no immediate adverse reactions to the radiolabeled tracer. Generally, there are no specific post-procedure care requirements, and patients can typically resume their normal activities shortly after the imaging is completed. However, it is advisable for patients to follow any specific instructions provided by their healthcare provider regarding hydration or any other considerations. The physician will review the images obtained during the procedure and provide a comprehensive report of the findings, which will be used to guide further diagnostic or therapeutic actions as necessary.
| Short Descr | LVR&SPLEEN IMG STATIC ONLY | Medium Descr | LIVER & SPLEEN IMAGING STATIC ONLY | Long Descr | Liver and spleen imaging; static only | Status Code | Active Code | Global Days | XXX - Global Concept Does Not Apply | PC/TC Indicator (26, TC) | 1 - Diagnostic Tests for Radiology Services | Multiple Procedures (51) | 0 - No payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 0 - 150% payment adjustment for bilateral procedures does NOT apply. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 0 - Payment restriction for assistants at surgery applies to this procedure... | Co-Surgeons (62) | 0 - Co-surgeons not permitted for this procedure. | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Procedure or Service, Not Discounted when Multiple | ASC Payment Indicator | Radiology service paid separately when provided integral to a surgical procedure on ASC list; payment based on OPPS relative payment weight. | Type of Service (TOS) | 4 - Diagnostic Radiology | Berenson-Eggers TOS (BETOS) | I1E - Standard imaging - nuclear medicine | MUE | 1 | CCS Clinical Classification | 210 - Other radioisotope scan |
| 26 | Professional component: certain procedures are a combination of a physician or other qualified health care professional component and a technical component. when the physician or other qualified health care professional component is reported separately, the service may be identified by adding modifier 26 to the usual procedure number. | X5 | Diagnostic services requested by another clinician: for reporting services by a clinician who furnishes care to the patient only as requested by another clinician or subsequent and related services requested by another clinician; this modifier is reported for patient relationships that may not be adequately captured by the above alternative categories; reporting clinician service examples include but are not limited to, the radiologist's interpretation of an imaging study requested by another clinician | 52 | Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use). | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | AQ | Physician providing a service in an unlisted health professional shortage area (hpsa) | GC | This service has been performed in part by a resident under the direction of a teaching physician | MC | Ordering professional is not required to consult a clinical decision support mechanism due to the significant hardship exception of electronic health record or clinical decision support mechanism vendor issues | MG | The order for this service does not have applicable appropriate use criteria in the qualified clinical decision support mechanism consulted by the ordering professional | MH | Unknown if ordering professional consulted a clinical decision support mechanism for this service, related information was not provided to the furnishing professional or provider | Q6 | Service furnished under a fee-for-time compensation arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area | TC | Technical component; under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier 'tc' to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier tc; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles | X4 | Episodic/focused services: for reporting services by clinicians who provide focused care on particular types of treatment limited to a defined period and circumstance; the patient has a problem, acute or chronic, that will be treated with surgery, radiation, or some other type of generally time-limited intervention; reporting clinician service examples include but are not limited to, the orthopedic surgeon performing a knee replacement and seeing the patient through the postoperative period | XE | Separate encounter, a service that is distinct because it occurred during a separate encounter | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service |
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| 2025-01-01 | Changed | Short Description changed. |
| Pre-1990 | Added | Code added. |