CPT code 78226 – Hepatobiliary system imaging (HIDA scan)

Key takeaways

CPT code 78226 reports a HIDA scan done without pharmacologic intervention. Sincalide/CCK or another pharmacologic agent, such as morphine, moves the study to 78227.

Patients without a gallbladder still qualify for 78226, as long as the report notes that the gallbladder is absent.

In 2026, the national Medicare non-facility rate for the global service is about $284.91, with a work RVU of 0.72.

Unsupported diagnosis codes and missing prior authorization cause most 78226 denials, so check both before the patient arrives.

Pabau, practice management software with built-in insurance billing, pre-fills the CMS-1500 from the patient record and checks required claim fields before sending.

CPT code 78226 covers a HIDA scan done without drugs

CPT code 78226 is defined by the American Medical Association as hepatobiliary system imaging, including gallbladder when present. It sits in the Nuclear Medicine section of the CPT code set, under Diagnostic, Gastrointestinal System. Clinicians call the study a HIDA scan or cholescintigraphy.

The tracer is a technetium-99m (Tc-99m) labeled iminodiacetic acid agent, usually mebrofenin or disofenin. After an IV injection, the liver takes it up and excretes it into bile. The camera then follows bile flow, gallbladder filling and drainage into the small bowel, usually over 60 minutes or longer.

No drug is given to make the gallbladder contract or to speed filling. That single condition is what keeps the study under 78226.

78226 or 78227? Any pharmacologic agent tips the code

CPT 78227 reads “with pharmacologic intervention, including quantitative measurement(s) when performed.” So the question is broader than whether an ejection fraction was calculated.

If sincalide/CCK or another pharmacologic agent, such as morphine, was given during the study, bill 78227. If no drug was given, bill 78226.

Here’s a quick example. A patient with suspected acute cholecystitis is scanned for 60 minutes. The gallbladder never fills, so the physician gives morphine and keeps imaging. That study now belongs under 78227, even though no ejection fraction was calculated.

Some coders assume 78226 needs a visible gallbladder. It doesn’t. “Including gallbladder when present” means post-cholecystectomy patients still qualify, as long as the report notes the absence and describes hepatobiliary function.

What the imaging report has to show before you bill

Auditors look at the report first. A study without a signed final interpretation is hard to defend, however well it was performed. Build your clean claim requirements for 78226 around these elements.

• Physician order: a signed order for hepatobiliary scintigraphy, or HIDA scan, with the clinical indication
• Radiopharmaceutical: the agent name, dose in mCi, route, and injection date and time
• Acquisition: the imaging timeframe, typically 60 minutes, plus any delayed images taken
• Findings: liver uptake, bile duct visualization, bowel transit, and gallbladder filling or its absence
• No pharmacologic agent: a clear statement that no sincalide, CCK, morphine or other drug was given
• Signed interpretation: by the interpreting physician, not only a technologist note

Keep the order and the signed report together, ready to attach if a payer asks. Your superbill documentation should list the tracer’s HCPCS code next to 78226 at charge entry.

Diagnoses that support medical necessity for a HIDA scan

Medical necessity for 78226 rests on a diagnosis that justifies imaging the liver and biliary tree. Payers compare the ICD-10-CM code on the claim with their coverage policies. If the code isn’t on the list, expect a denial.

When the order describes an acute episode on top of chronic disease, K81.2 usually fits better than K81.0 alone. Check your MAC’s coverage articles and LCDs, if any, for hepatobiliary imaging before submitting. A code Medicare accepts may still fail under a specific Medicare Advantage plan.

Modifiers 26 and TC split the claim by who did the work

The modifier depends on who owns the camera and who reads the study. Four situations cover almost every 78226 claim.

The classic error looks like this. A radiologist reads a hospital outpatient HIDA scan and bills 78226 with no modifier. The hospital has already billed the technical side on its own claim. The payer sees two claims for one study and denies or cuts the physician’s line. Confirm the billing arrangement before charge entry, every time.

2026 Medicare rates: About $285 for the global service

The Medicare Physician Fee Schedule (MPFS) sets national rates for 78226 each year. The figures below come from the CMS Physician Fee Schedule lookup. Your allowed amount will differ by locality, because each one carries its own GPCI adjustments.

Use the FastRVU 2026 RVU lookup to pull work, practice expense and malpractice RVUs with your locality applied. The tracer is not part of these rates. It goes on its own HCPCS line, covered in the NCCI section below.

Prior authorization: Medicare skips it, many other plans don’t

Original Medicare Part B doesn’t require prior authorization for 78226. Other payers set their own rules, so confirm before scheduling. Here’s how the main payer types usually line up.

• Original Medicare Part B: no prior authorization for 78226 under current guidance. Confirm with your MAC.
• Medicare Advantage: many plans require it for nuclear medicine imaging. Check each plan’s policy.
• Medicaid: rules vary by state and by managed care plan.
• Commercial payers (BCBS, Aetna, Cigna, UHC): many require it for nuclear imaging. Check the payer portal.
• Missed authorization: expect a denial. Many payers won’t grant authorization after the service.

Put the check at scheduling, not at billing. When a HIDA scan is ordered, the front desk confirms whether the plan needs authorization before the patient arrives. Our guide to the prior authorization process walks through that intake step.

How a 78226 claim moves from order to payment

A HIDA scan claim passes five checkpoints. The code is decided at the scanner, but most denials start at scheduling, charge entry and follow-up.

In practice, the handoffs trip claims up. The technologist knows whether morphine was given, but the coder only sees the report. If the report is silent, the coder guesses, and a wrong guess is either upcoding or lost revenue.

Why 78226 claims get denied, and how to stop it

Nuclear medicine denials follow a predictable pattern. Tracking 78226 denials by reason, as part of your denial management workflow, shows you which process to fix.

Payers attach claim adjustment reason codes (CARCs) to each rejection. On HIDA scans, three come up most. CARC 50 means not medically necessary, and CARC 197 means precertification or authorization was absent. CARC 4 flags a procedure code inconsistent with the modifier. Look up any others in our guide to reading denial codes quickly.

NCCI edits and the tracer line

NCCI edits treat 78227 as the fuller version of the same study. Reporting both for one patient on one date triggers a column 1/column 2 edit, with 78226 as the bundled code. Modifier 59 only applies to two separate, fully documented sessions on the same day, which is rare.

The tracer is reported on its own HCPCS Level II line. For Tc-99m hepatobiliary agents, the codes are:

• A9537: Technetium Tc-99m mebrofenin, diagnostic, per study dose, up to 15 millicuries
• A9510: Technetium Tc-99m disofenin, diagnostic, per study dose, up to 15 millicuries

Whether the tracer pays separately depends on setting. Hospital outpatient departments usually have it packaged into the facility payment. Imaging centers billing in a non-facility setting are more likely to report it separately. The AAPC Codify CPT lookup shows bundling context alongside each descriptor.

Before you submit: A 78226 claim checklist

Run through this list before the claim leaves your practice. It takes a minute and catches the errors covered above.

• The report states that no sincalide, CCK, morphine or other drug was given.
• The interpreting physician has signed the final report.
• The diagnosis code matches payer policy and is linked to the 78226 line.
• The modifier matches who billed what: 26, TC or none.
• The authorization number is on the claim for plans that require one.
• The tracer sits on its own line as A9537 or A9510, where the payer pays it separately.
• There’s no 78227 line for the same date of service.

How Pabau keeps HIDA scan claims complete before they go out

Most 78226 errors start at charge entry. Someone retypes the order, diagnosis and authorization number into a claim form, and one wrong digit sends it back.

Pabau removes most of that retyping. Its faster claims management pre-fills the CMS-1500 from the patient record. ICD-10 and CPT lookup libraries sit in the same screen. Before the claim can be sent, Pabau checks that required fields, such as the authorization number, are complete.

In the US, claims go out through Claim.MD, a clearinghouse that supports CMS-1500 and 837P submission. Your team can run eligibility checks, post ERAs and track claim status there, without logging into each payer portal.

Send complete nuclear medicine claims first time

Pabau pre-fills the CMS-1500 from the patient record and checks required fields, like authorization numbers, before a 78226 claim goes out. US claims then route through Claim.MD with eligibility checks and ERA posting.

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Conclusion

Settle the drug question before you pick a code. Ask the technologist, read the report, and make sure the report says what was given. Once that’s clear, a covered diagnosis, the right component modifier and an auth number on file remove most of the remaining risk.

The trade-off is a few extra minutes at scheduling and charge entry. That costs far less than reworking a denied nuclear medicine claim weeks later.

Book a demo to see how Pabau pre-fills and checks HIDA scan claims before they reach the clearinghouse.

Continue your research

Need a structured approach to claim denials? Denial management in healthcare covers the end-to-end denial workflow from CARC identification through appeals.

Want to understand what goes on a clean claim? Clean claim requirements explains every field payers check before adjudicating a nuclear medicine or radiology claim.

Looking for how clearinghouses fit into billing? Medical claims clearinghouses explains how 837P files, ERAs, and eligibility checks connect your practice to payers.

Checking coverage before the scan? Insurance eligibility verification shows what to confirm at intake so the claim doesn’t bounce.

Billing the drug-assisted version? CPT code 78227 covers HIDA scans with sincalide, morphine or another pharmacologic agent.

Frequently asked questions