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The procedure described by CPT® Code 78216 involves imaging of the liver and spleen utilizing scintigraphy, a diagnostic technique that employs a radiolabeled isotope tracer, specifically 99mTC-sulfur colloid. This imaging is crucial for assessing the size and condition of these organs, as it aids in the identification of various abnormalities such as tumors, abscesses, hematomas, cysts, and hypersplenism. Additionally, it helps in detecting the radiocolloid shift that may occur due to hepatic dysfunction or portal hypertension. The process begins with the establishment of an intravenous line through which the radiolabeled isotope tracer is administered directly into the patient's circulatory system. 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, with a gamma camera placed over the upper abdomen to capture the images. The scanning process is conducted at specific intervals, during which the radioactive energy emitted from the liver and spleen is detected and converted into visual images. This procedure is particularly significant as both the liver and spleen are highly vascular organs, meaning that any compromise in the blood vessels of one organ can lead to alterations in blood flow in the surrounding organs. The physician is responsible for interpreting the scintigraphy results and providing a comprehensive written report detailing the findings.
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The imaging of the liver and spleen using CPT® Code 78216 is indicated for several clinical scenarios, particularly when there is a need to evaluate the vascular flow and overall health of these organs. The following conditions may warrant this procedure:
The procedure for CPT® Code 78216 involves several key steps that ensure accurate imaging of the liver and spleen. First, an intravenous line is established to facilitate the administration of the radiolabeled isotope tracer. This tracer, 99mTC-sulfur colloid, is crucial for the imaging process as it allows for the visualization of the vascular flow within the organs. The tracer can be injected directly into the circulatory system through the intravenous line. Alternatively, a blood sample may be drawn, and the tracer is then attached to heat-destroyed red blood cells (RBCs) before being reintroduced into the patient's body. After the tracer has been administered, a waiting period is observed to allow for adequate distribution and uptake by the liver and spleen. Following this period, 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 critical information regarding the vascular flow and overall condition of these organs. The physician will subsequently interpret the scintigraphy results and compile a written report detailing the findings.
After the completion of the imaging procedure using CPT® Code 78216, patients may be monitored briefly to ensure there are no immediate adverse reactions to the radiolabeled isotope 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 essential for the physician to provide any necessary follow-up instructions based on the individual patient's condition and the findings from the imaging study. The physician will also discuss the results with the patient, explaining any significant findings and potential next steps in management or treatment based on the interpretation of the scintigraphy.
| Short Descr | LVR&SPLEEN IMG W/VASC FLOW | Medium Descr | LIVER & SPLEEN IMAGING W/VASCULAR FLOW | Long Descr | Liver and spleen imaging; with vascular flow | 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 | 209 - Radioisotope scan and function studies |
| 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. | GC | This service has been performed in part by a resident under the direction of a teaching physician | 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 | 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 | 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 |
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| 2025-01-01 | Changed | Short Description changed. |
| Pre-1990 | Added | Code added. |
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