CPT 78262Radiology

Gastroesophageal reflux std

CPT code 78262 covers a nuclear medicine test that uses a small amount of radioactive material to detect and measure acid reflux from the stomach into the esophagus. This imaging study helps diagnose gastroesophageal reflux disease (GERD) by tracking stomach contents over time.

Showing rates for

National Average

Base Medicare rate

$216.07

This calculator gives a typical-case estimate using standard Medicare modifier rules. Actual payment depends on payer policies, documentation, code-specific CMS status indicators, and locality. Verify before billing.

RVU breakdown

Work RVU

0.68

PE RVU (NF)

5.93

MP RVU

0.07

Total RVU

6.68

Conversion factor: 32.3465 · Source: CMS MPFS RVU25A · Confidence: High

NCCI bundling edits

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Billing tips

Always verify whether facility is billing globally or splitting technical and professional components with modifier 26/TC, as incorrect component billing is the leading cause of payment delays
Impact: Prevents 100% claim rejection and 30-60 day payment delays from incorrect component billing
Document the exact imaging protocol duration and number of images acquired, as CPT 78262 is specifically for standard protocol; extended studies may require different coding
Impact: Ensures correct code selection and prevents downcoding or recoupment averaging $50-75 per study
Include ICD-10 codes that support medical necessity such as K21.9 (GERD), R12 (heartburn), or R63.3 (feeding difficulties) with clear symptom documentation in the order
Impact: Reduces medical necessity denials by approximately 40% and prevents the $216.07 write-off
Bill on the date of service when imaging is performed, not when the final report is dictated, to avoid timely filing issues
Impact: Prevents timely filing denials which result in 100% loss of the $216.07 reimbursement
For pediatric patients under age 1, ensure documentation includes developmental concerns or aspiration risk to strengthen medical necessity
Impact: Decreases pre-authorization denials by 30% and expedites approval process by 5-7 days
Verify that radiopharmaceutical administration (CPT 78262 includes this) is not separately billed, as it is bundled into the procedure code
Impact: Prevents unbundling denials and refund demands averaging $25-40 for separately billed radiopharmaceutical codes

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Frequently asked questions

What is the Medicare reimbursement rate for CPT 78262 in 2025?

The 2025 Medicare national average reimbursement rate for CPT 78262 is $216.07 for both facility and non-facility settings. This is based on a total RVU of 6.68 and the 2025 conversion factor of 32.3465.

How many RVUs is CPT code 78262 worth?

CPT 78262 has a total RVU value of 6.68, consisting of 0.68 work RVUs, 5.93 practice expense RVUs, and 0.07 malpractice RVUs based on the 2025 Medicare Physician Fee Schedule.

Can CPT 78262 be billed with modifier 26 for professional component only?

Yes, CPT 78262 can be split into professional and technical components. Use modifier 26 when billing only the physician interpretation and report, or modifier TC when billing only the technical component (equipment, supplies, technologist). Most hospital-based radiologists bill with modifier 26 while the facility bills TC.

What diagnosis codes support medical necessity for CPT 78262?

Common supporting diagnosis codes include K21.9 (gastro-esophageal reflux disease without esophagitis), K21.0 (GERD with esophagitis), R12 (heartburn), R63.3 (feeding difficulties), and J69.0 (aspiration pneumonitis). Pediatric indications may include P92.1 (regurgitation and rumination of newborn) or R06.83 (snoring) when aspiration is suspected.

How does CPT 78262 differ from gastric emptying study 78264?

CPT 78262 specifically evaluates gastroesophageal reflux by tracking retrograde movement of stomach contents into the esophagus, while CPT 78264 measures the rate of gastric emptying to diagnose gastroparesis or dumping syndrome. They assess different gastrointestinal functions and should not be confused, though both may be indicated in the same patient for comprehensive evaluation.

Is prior authorization required for CPT 78262 gastroesophageal reflux studies?

Prior authorization requirements vary by payer. Many commercial insurance plans require pre-certification for nuclear medicine procedures including CPT 78262, while Medicare typically does not require prior authorization but may conduct post-payment reviews for medical necessity. Always verify with the specific payer before scheduling.

What is the typical patient preparation for a procedure coded as 78262?

Patients typically fast for 4-6 hours before the study (pediatric fasting times are age-adjusted). Documentation should include that the patient ingested the radiotracer mixed with age-appropriate food or formula, and any medications affecting gastric motility were discontinued per protocol. Proper patient preparation documentation supports medical necessity and code assignment.