Correct coding and reimbursement for hepatobiliary scans

2015 12 09 10 04 29 272 Calculator Pen 200

In 2012, the American Medical Association (AMA) added the following current procedural terminology (CPT) codes for nuclear medicine hepatobiliary scans to better reflect current practice:

  • 78226: Hepatobiliary system imaging, including gallbladder when present
  • 78227: Hepatobiliary system imaging, including gallbladder when present; with pharmacologic intervention, including quantitative measurement(s) when performed

These code choices separate the differences in physician and technical work necessary to perform an imaging-alone study (78226) from imaging that includes pharmacological stimulation of gallbladder and contraction (78227).

For the exam, an intravenous injection of a radiopharmaceutical (such as Choletec from Bracco Imaging) is administered. Dynamic images of the liver, biliary tree, and intestines are obtained immediately following the injection and continue for approximately 60 minutes or until the gallbladder and upper small bowel are visualized. Additional views and delayed images up to 24 hours also may be obtained and should not be reported separately.

Kinevac (sincalide for injection) availability

Pharmacologic intervention during hepatobiliary imaging may be useful for providing additional information. Kinevac (Bracco) may be infused to stimulate the gallbladder to contract, enabling the calculation of a gallbladder ejection fraction, which helps identify appropriate surgical candidates. If the gallbladder is not visualized (despite radiotracer visualization in the intestinal tract within 30 to 60 minutes of imaging), morphine sulfate may be administered and additional images obtained. When pharmacologic intervention, such as with Kinevac and/or morphine sulfate, is performed, code 78227 is reported instead of 78226.

Unfortunately, shortly after the AMA introduced codes 78226 and 78227, Bracco Diagnostics announced a shortage of Kinevac -- the only drug approved by the U.S. Food and Drug Administration (FDA) and the most often used to stimulate the gallbladder. This shortage caused facilities to find other ways to stimulate the gallbladder to allow the quantitative measurements required for 78227. The shortage ended in late 2015, but confusion remains concerning the correct coding for hepatobiliary scans.

To report code 78227, there must be pharmacologic intervention during the scanning procedure. Pretreatment administration of a drug such as morphine cannot be used to justify 78227. In addition, because of the Kinevac shortage, many facilities turned to the use of nondrug products such as Ensure, half-and-half milk and cream, or fatty meals to stimulate the gallbladder. Kinevac is clinically preferred because it is more accurate and predictable than nondrug options. If a nondrug product is administered to stimulate the gallbladder to enable determination of the gallbladder ejection fraction, code 78226 must be reported instead of 78227.

Reporting and reimbursement

For hospital billing under the outpatient prospective payment system (OPPS), there is no reimbursement difference between codes 78226 and 78227. Both are assigned to ambulatory payment classification (APC) 5591 with a payment rate of $332.65.

It is imperative that the correct CPT code and all of the correct costs are reported because payment rates for a given year are based on claims from two years previously. All of the costs are used in payment decisions.

Hospitals should also report the appropriate healthcare common procedure coding system (HCPCS) codes for the radiopharmaceutical, such as for Choletec, which is A9537 -- technetium-99m (tc-99m) mebrofenin, diagnostic, per study dose, up to 15 mCi -- as well as codes for the drugs provided during the exam, including Kinevac and morphine sulfate:

  • For Kinevac, report J2805 -- injection, sincalide, 5 micrograms.
  • For morphine sulfate, report J2270 -- injection, morphine sulfate, up to 10 mg.

According to the 2014 claims data used for 2016 OPPS payment amounts, the cost variations ranged from less than $100 to more than $1,500 as shown below.

Cost variations for HCPCS codes
HCPCS Minimum cost Maximum cost Median cost Geometric mean cost
78226 $67.46 $1,598.56 $341.50 $330.36
78227 $88.26 $1,758.12 $402.49 $396.68

For no-hospital billing under the Medicare Physician Fee Schedule (MPFS), the correct code choice does affect reimbursement, as shown below.

Cost variations by code choice
HCPCS Modifier Cost
78226 26 $37.24
TC $308.99
78227 26 $45.47
TC $424.28

Nonhospital facilities billing the technical component or global billing should also report the appropriate HCPCS codes for the radiopharmaceutical and other drugs. Each Medicare administrative contractor (MAC) determines the payment rate for radiopharmaceuticals. Drugs are paid based on the average sales price (ASP). The current Medicare payment rate for Kinevac (J2805) is $91.82 per 5 micrograms, and for morphine sulfate (J2770), the rate is $1.01 per 10 mg.

Donna Richmond is a senior healthcare consultant, clinical consulting services, for Panacea Healthcare Solutions. In addition to her coding hotline responsibilities for Panacea, she performs a variety of radiology and cardiology audits and contributes to several webcasts and publications, including MedLearn Publishing's new Basics of Interventional Radiology Coding book.

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