© Copyright 2025 American Medical Association. All rights reserved.
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.
© Copyright 2025 Coding Ahead. All rights reserved.
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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Date
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Action
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Notes
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|---|---|---|
| 2025-01-01 | Changed | Short Description changed. |
| Pre-1990 | Added | Code added. |
|
Code
|
Description
|
|---|---|
| A4641 | Radiopharmaceutical, diagnostic, not otherwise classified |
| A4642 | Indium in-111 satumomab pendetide, diagnostic, per study dose, up to 6 millicuries |
| A9500 | Technetium tc-99m sestamibi, diagnostic, per study dose |
| A9501 | Technetium tc-99m teboroxime, diagnostic, per study dose |
| A9502 | Technetium tc-99m tetrofosmin, diagnostic, per study dose |
| A9503 | Technetium tc-99m medronate, diagnostic, per study dose, up to 30 millicuries |
| A9504 | Technetium tc-99m apcitide, diagnostic, per study dose, up to 20 millicuries |
| A9505 | Thallium tl-201 thallous chloride, diagnostic, per millicurie |
| A9507 | Indium in-111 capromab pendetide, diagnostic, per study dose, up to 10 millicuries |
| A9508 | Iodine i-131 iobenguane sulfate, diagnostic, per 0.5 millicurie |
| A9509 | Iodine i-123 sodium iodide, diagnostic, per millicurie |
| A9510 | Technetium tc-99m disofenin, diagnostic, per study dose, up to 15 millicuries |
| A9512 | Technetium tc-99m pertechnetate, diagnostic, per millicurie |
| A9515 | Choline c-11, diagnostic, per study dose up to 20 millicuries |
| A9516 | Iodine i-123 sodium iodide, diagnostic, per 100 microcuries, up to 999 microcuries |
| A9517 | Iodine i-131 sodium iodide capsule(s), therapeutic, per millicurie |
| A9520 | Technetium tc-99m tilmanocept, diagnostic, up to 0.5 millicuries |
| A9521 | Technetium tc-99m exametazime, diagnostic, per study dose, up to 25 millicuries |
| A9524 | Iodine i-131 iodinated serum albumin, diagnostic, per 5 microcuries |
| A9526 | Nitrogen n-13 ammonia, diagnostic, per study dose, up to 40 millicuries |
| A9527 | Iodine i-125, sodium iodide solution, therapeutic, per millicurie |
| A9528 | Iodine i-131 sodium iodide capsule(s), diagnostic, per millicurie |
| A9529 | Iodine i-131 sodium iodide solution, diagnostic, per millicurie |
| A9530 | Iodine i-131 sodium iodide solution, therapeutic, per millicurie |
| A9531 | Iodine i-131 sodium iodide, diagnostic, per microcurie (up to 100 microcuries) |
| A9532 | Iodine i-125 serum albumin, diagnostic, per 5 microcuries |
| A9536 | Technetium tc-99m depreotide, diagnostic, per study dose, up to 35 millicuries |
| A9537 | Technetium tc-99m mebrofenin, diagnostic, per study dose, up to 15 millicuries |
| A9538 | Technetium tc-99m pyrophosphate, diagnostic, per study dose, up to 25 millicuries |
| A9539 | Technetium tc-99m pentetate, diagnostic, per study dose, up to 25 millicuries |
| A9540 | Technetium tc-99m macroaggregated albumin, diagnostic, per study dose, up to 10 millicuries |
| A9541 | Technetium tc-99m sulfur colloid, diagnostic, per study dose, up to 20 millicuries |
| A9542 | Indium in-111 ibritumomab tiuxetan, diagnostic, per study dose, up to 5 millicuries |
| A9543 | Yttrium y-90 ibritumomab tiuxetan, therapeutic, per treatment dose, up to 40 millicuries |
| A9544 | Iodine i-131 tositumomab, diagnostic, per study dose [deleted] |
| A9545 | Iodine i-131 tositumomab, therapeutic, per treatment dose [deleted] |
| A9546 | Cobalt co-57/58, cyanocobalamin, diagnostic, per study dose, up to 1 microcurie |
| A9547 | Indium in-111 oxyquinoline, diagnostic, per 0.5 millicurie |
| A9548 | Indium in-111 pentetate, diagnostic, per 0.5 millicurie |
| A9550 | Technetium tc-99m sodium gluceptate, diagnostic, per study dose, up to 25 millicurie |
| A9551 | Technetium tc-99m succimer, diagnostic, per study dose, up to 10 millicuries |
| A9552 | Fluorodeoxyglucose f-18 fdg, diagnostic, per study dose, up to 45 millicuries |
| A9553 | Chromium cr-51 sodium chromate, diagnostic, per study dose, up to 250 microcuries |
| A9554 | Iodine i-125 sodium iothalamate, diagnostic, per study dose, up to 10 microcuries |
| A9555 | Rubidium rb-82, diagnostic, per study dose, up to 60 millicuries |
| A9556 | Gallium ga-67 citrate, diagnostic, per millicurie |
| A9557 | Technetium tc-99m bicisate, diagnostic, per study dose, up to 25 millicuries |
| A9558 | Xenon xe-133 gas, diagnostic, per 10 millicuries |
| A9559 | Cobalt co-57 cyanocobalamin, oral, diagnostic, per study dose, up to 1 microcurie |
| A9560 | Technetium tc-99m labeled red blood cells, diagnostic, per study dose, up to 30 millicuries |
| A9561 | Technetium tc-99m oxidronate, diagnostic, per study dose, up to 30 millicuries |
| A9562 | Technetium tc-99m mertiatide, diagnostic, per study dose, up to 15 millicuries |
| A9563 | Sodium phosphate p-32, therapeutic, per millicurie |
| A9564 | Chromic phosphate p-32 suspension, therapeutic, per millicurie |
| A9566 | Technetium tc-99m fanolesomab, diagnostic, per study dose, up to 25 millicuries |
| A9567 | Technetium tc-99m pentetate, diagnostic, aerosol, per study dose, up to 75 millicuries |
| A9568 | Technetium tc-99m arcitumomab, diagnostic, per study dose, up to 45 millicuries |
| A9569 | Technetium tc-99m exametazime labeled autologous white blood cells, diagnostic, per study dose |
| A9570 | Indium in-111 labeled autologous white blood cells, diagnostic, per study dose |
| A9571 | Indium in-111 labeled autologous platelets, diagnostic, per study dose |
| A9572 | Indium in-111 pentetreotide, diagnostic, per study dose, up to 6 millicuries |
| A9580 | Sodium fluoride f-18, diagnostic, per study dose, up to 30 millicuries |
| A9582 | Iodine i-123 iobenguane, diagnostic, per study dose, up to 15 millicuries |
| A9584 | Iodine 1-123 ioflupane, diagnostic, per study dose, up to 5 millicuries |
| A9586 | Florbetapir f18, diagnostic, per study dose, up to 10 millicuries |
| A9587 | Gallium ga-68, dotatate, diagnostic, 0.1 millicurie |
| A9588 | Fluciclovine f-18, diagnostic, 1 millicurie |
| A9591 | Fluoroestradiol f 18, diagnostic, 1 millicurie |
| A9592 | Copper cu-64, dotatate, diagnostic, 1 millicurie |
| A9593 | Gallium ga-68 psma-11, diagnostic, (ucsf), 1 millicurie |
| A9594 | Gallium ga-68 psma-11, diagnostic, (ucla), 1 millicurie |
| A9595 | Piflufolastat f-18, diagnostic, 1 millicurie |
| A9596 | Gallium ga-68 gozetotide, diagnostic, (illuccix), 1 millicurie |
| A9597 | Positron emission tomography radiopharmaceutical, diagnostic, for tumor identification, not otherwise classified |
| A9598 | Positron emission tomography radiopharmaceutical, diagnostic, for non-tumor identification, not otherwise classified |
| A9599 | Radiopharmaceutical, diagnostic, for beta-amyloid positron emission tomography (pet) imaging, per study dose, not otherwise specified [deleted] |
| A9600 | Strontium sr-89 chloride, therapeutic, per millicurie |
| A9601 | Flortaucipir f 18 injection, diagnostic, 1 millicurie |
| A9604 | Samarium sm-153 lexidronam, therapeutic, per treatment dose, up to 150 millicuries |
| C9458 | Florbetaben f18, diagnostic, per study dose, up to 8.1 millicuries [deleted] |
| C9459 | Flutemetamol f18, diagnostic, per study dose, up to 5 millicuries [deleted] |
| C9898 | Radiolabeled product provided during a hospital inpatient stay |
| G0248 | Demonstration, prior to initiation of home inr monitoring, for patient with either mechanical heart valve(s), chronic atrial fibrillation, or venous thromboembolism who meets medicare coverage criteria, under the direction of a physician; includes: face-to-face demonstration of use and care of the inr monitor, obtaining at least one blood sample, provision of instructions for reporting home inr test results, and documentation of patient's ability to perform testing and report results |
| G0249 | Provision of test materials and equipment for home inr monitoring of patient with either mechanical heart valve(s), chronic atrial fibrillation, or venous thromboembolism who meets medicare coverage criteria; includes: provision of materials for use in the home and reporting of test results to physician; testing not occurring more frequently than once a week; testing materials, billing units of service include 4 tests |
| G0398 | Home sleep study test (hst) with type ii portable monitor, unattended; minimum of 7 channels: eeg, eog, emg, ecg/heart rate, airflow, respiratory effort and oxygen saturation |
| G0399 | Home sleep test (hst) with type iii portable monitor, unattended; minimum of 4 channels: 2 respiratory movement/airflow, 1 ecg/heart rate and 1 oxygen saturation |
| G0400 | Home sleep test (hst) with type iv portable monitor, unattended; minimum of 3 channels |
| G2066 | Interrogation device evaluation(s), (remote) up to 30 days; implantable cardiovascular physiologic monitor system, implantable loop recorder system, or subcutaneous cardiac rhythm monitor system, remote data acquisition(s), receipt of transmissions and technician review, technical support and distribution of results [deleted] |
| Q9982 | Flutemetamol f18, diagnostic, per study dose, up to 5 millicuries |
| Q9983 | Florbetaben f18, diagnostic, per study dose, up to 8.1 millicuries |
| No matching codes found | |
|
Code
|
Description
|
|---|---|
| 070.54 | Chronic hepatitis C without mention of hepatic coma |
| 150.0 | Malignant neoplasm of cervical esophagus |
| 150.1 | Malignant neoplasm of thoracic esophagus |
| 150.2 | Malignant neoplasm of abdominal esophagus |
| 156.0 | Malignant neoplasm of gallbladder |
| 156.2 | Malignant neoplasm of ampulla of vater |
| 156.8 | Malignant neoplasm of other specified sites of gallbladder and extrahepatic bile ducts |
| 156.9 | Malignant neoplasm of biliary tract, part unspecified site |
| 157.0 | Malignant neoplasm of head of pancreas |
| 157.1 | Malignant neoplasm of body of pancreas |
| 157.2 | Malignant neoplasm of tail of pancreas |
| 157.3 | Malignant neoplasm of pancreatic duct |
| 157.4 | Malignant neoplasm of islets of langerhans |
| 157.8 | Malignant neoplasm of other specified sites of pancreas |
| 157.9 | Malignant neoplasm of pancreas, part unspecified |
| 197.8 | Secondary malignant neoplasm of other digestive organs and spleen |
| 211.5 | Benign neoplasm of liver and biliary passages |
| 230.8 | Carcinoma in situ of liver and biliary system |
| 285.9 | Anemia, unspecified |
| 287.5 | Thrombocytopenia, unspecified |
| 288.8 | Other specified disease of white blood cells |
| 428.0 | Congestive heart failure, unspecified |
| 560.31 | Gallstone ileus |
| 570 | Acute and subacute necrosis of liver |
| 571.5 | Cirrhosis of liver without mention of alcohol |
| 571.6 | Biliary cirrhosis |
| 573.3 | Hepatitis, unspecified |
| 573.8 | Other specified disorders of liver |
| 573.9 | Unspecified disorder of liver |
| 574.00 | Calculus of gallbladder with acute cholecystitis, without mention of obstruction |
| 574.01 | Calculus of gallbladder with acute cholecystitis, with obstruction |
| 574.10 | Calculus of gallbladder with other cholecystitis, without mention of obstruction |
| 574.11 | Calculus of gallbladder with other cholecystitis, with obstruction |
| 574.20 | Calculus of gallbladder without mention of cholecystitis, without mention of obstruction |
| 574.21 | Calculus of gallbladder without mention of cholecystitis, with obstruction |
| 574.31 | Calculus of bile duct with acute cholecystitis, with obstruction |
| 574.40 | Calculus of bile duct with other cholecystitis, without mention of obstruction |
| 574.41 | Calculus of bile duct with other cholecystitis, with obstruction |
| 574.50 | Calculus of bile duct without mention of cholecystitis, without mention of obstruction |
| 574.51 | Calculus of bile duct without mention of cholecystitis, with obstruction |
| 575.0 | Acute cholecystitis |
| 575.11 | Chronic cholecystitis |
| 575.12 | Acute and chronic cholecystitis |
| 575.2 | Obstruction of gallbladder |
| 575.3 | Hydrops of gallbladder |
| 575.4 | Perforation of gallbladder |
| 575.5 | Fistula of gallbladder |
| 575.6 | Cholesterolosis of gallbladder |
| 575.8 | Other specified disorders of gallbladder |
| 576.0 | Postcholecystectomy syndrome |
| 576.1 | Cholangitis |
| 576.2 | Obstruction of bile duct |
| 576.3 | Perforation of bile duct |
| 576.4 | Fistula of bile duct |
| 576.5 | Spasm of sphincter of Oddi |
| 576.8 | Other specified disorders of biliary tract |
| 576.9 | Unspecified disorder of biliary tract |
| 577.0 | Acute pancreatitis |
| 577.1 | Chronic pancreatitis |
| 577.2 | Cyst and pseudocyst of pancreas |
| 577.8 | Other specified diseases of pancreas |
| 578.9 | Hemorrhage of gastrointestinal tract, unspecified |
| 751.69 | Other anomalies of gallbladder, bile ducts, and liver |
| 751.7 | Anomalies of pancreas |
| 789.00 | Abdominal pain, unspecified site |
| 789.07 | Abdominal pain, generalized |
| 789.1 | Hepatomegaly |
| 789.2 | Splenomegaly |
| 790.4 | Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [LDH] |
| 790.5 | Other nonspecific abnormal serum enzyme levels |
| 794.8 | Nonspecific abnormal results of function study of liver |
| No matching codes found | |