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Find out if you know what 鈥榮tatic only鈥� means.

Patients who present with upper-right abdominal pain, yellowing skin and eyes, or loss of appetite might have issues going on with their livers. An imaging scan with a radioactive tracer helps radiologists visualize the organ to evaluate the patient for several possible conditions.

Keep reading to learn how to accurately report liver imaging scans.

Locate Liver Scan Procedure Codes

The largest organ in the human body, the liver, performs several key functions including making bile, converting food into energy, and producing blood plasma proteins. The two main lobes of the liver feature numerous small and larger ducts that form the hepatic duct, which transports bile to the gallbladder and duodenum.

Near the liver is the spleen. This smaller organ filters and stores blood, breaks down red blood cells, and helps make lymphocytes.

A radiologist will perform imaging scans of these organs for several reasons. 鈥淭hese reasons include looking for diseases such as cirrhosis, hepatitis, or cancer, or to determine if the organ is larger than it should be or contains masses,鈥� says Kristen R. Taylor, CPC, CHC, CHIAP, CRCR, associate partner of Pinnacle Enterprise Risk Consulting Services.

A liver scan or liver and spleen imaging scan is a procedure that falls under nuclear medicine since the radiologist uses a radioactive tracer during the scan. Healthy tissue absorbs the tracer, which forces the tissue to appear bright on the images. Dimmer areas on the scan are tissue where the tracer wasn鈥檛 absorbed well, and this can be an indicator of an issue with the organs.

You鈥檒l assign one of the following codes when the provider scans only the liver:

• 78201 (Liver imaging; static only)
• 78202 (鈥� with vascular flow)

However, if the provider images the liver and the spleen then you鈥檒l assign one of the codes below:

• 78215 (Liver and spleen imaging; static only)
• 78216 (鈥� with vascular flow)

Upon review of each code鈥檚 descriptor, you鈥檒l surmise that the codes differ by which organs the physician imaged and the type of scan performed.

Know How Static and Vascular Flow Scans Differ

The liver imaging scan CPT^庐 codes include 鈥渟tatic only鈥� and 鈥渨ith vascular flow鈥� wording in the descriptors.

鈥淎 static liver scan is the standard exam where images are captured to provide function and abnormality information,鈥� Taylor explains.

During a static liver or liver/spleen scan, the radiologist injects the radioisotope into the patient鈥檚 peripheral vein and waits about 30 minutes. The provider then places the scanner over the abdomen鈥檚 right upper quadrant (RUQ) to capture planar images to look for the nuclear tracer in the body structures.

If the provider injects radioactive tracer into the patient and captures images of just the liver, you鈥檒l assign 78201 to report the procedure. You鈥檒l assign 78215 if the provider scans the liver and spleen.

On the other hand, 鈥渢he vascular flow scan uses ultrasound to view the vessels and blood flow within the liver,鈥� Taylor adds.

This means that if the provider images the liver and then uses ultrasound to visualize the blood flow and blood vessels, you鈥檒l assign 78202. Assign 78216 when the radiologist visualizes the liver, spleen, and blood vessels and flow of both organs.

Scan the Documentation

Before you can assign the correct liver imaging procedure code, you鈥檒l need to review the medical documentation to find the pertinent information that you鈥檒l use to report the procedure. Taylor explains that the documentation should include the following information:

• Indication for the scan
• Technique used
• Findings related to the size
• Abnormalities found, if any
• Measurements of relevant body structures
• Doppler evaluation, if used
• Final diagnosis

If the provider documents a definitive diagnosis, you鈥檒l assign an appropriate ICD-10-CM code to reflect the diagnosis. Below are examples of common diagnoses with applicable diagnosis codes determined by liver imaging scans:

• Cirrhosis: K74.3 (Primary biliary cirrhosis)
• Hepatitis: B17.11 (Acute hepatitis C with hepatic coma)
• Cancer: C22.8 (Malignant neoplasm of liver, primary, unspecified as to type)

Of course, if the physician鈥檚 documentation doesn鈥檛 include a final diagnosis, you鈥檒l assign codes that reflect the reason for the patient鈥檚 visit on the date of service.

Mike Shaughnessy, BA, CPC, Development Editor, AAPC