Gastric emptying scintigraphy has quietly become a high impact study in neurology. Parkinson’s disease, diabetic autonomic neuropathy, multiple sclerosis, and other neurologic conditions often present with severe upper GI symptoms. Neurologists increasingly order gastric emptying studies to evaluate dysmotility and guide treatment.
The problem is that payers see CPT code 78264 and immediately think: high value nuclear medicine, technical plus professional components, and frequent documentation gaps. That combination attracts prepayment review and post payment audits. For many groups, a single coding or documentation pattern around 78264 can affect tens or hundreds of thousands of dollars a year in revenue exposure.
This article walks through how neurology practices, hospital based neurology service lines, and billing companies can handle CPT 78264 in a way that is clinically sound, billing compliant, and operationally scalable. You will see how to avoid common documentation traps, when to use related codes instead, and which workflow checkpoints protect both cash flow and audit risk.
1. What CPT 78264 Actually Covers, And Why Neurology Uses It So Often
CPT code 78264 describes a gastric emptying imaging study using a solid meal. The patient ingests a radiolabeled solid meal. Serial planar images are then obtained over a defined time period (commonly up to 4 hours) with calculation of gastric retention values and half time of emptying. The code typically includes the technical performance of the study and the professional interpretation when billed globally by a hospital or imaging provider.
Neurology service lines rely on CPT 78264 because disordered gastric motility is tightly linked with neurologic disease. Examples include:
- Parkinson’s disease, especially with significant autonomic dysfunction and early satiety or nausea
- Long standing diabetes with neuropathy where gastroparesis is suspected
- Multiple sclerosis or other demyelinating conditions with brainstem involvement
- Post stroke patients who have persistent upper GI symptoms without structural causes
From a revenue cycle perspective, CPT 78264 is attractive because it is a reimbursable, guideline supported test. The challenge is that the code is very specific. It applies to stomach only, solid meal studies, with specific imaging intervals. The more your documentation or protocol drifts from that definition, the more likely payers will downcode, deny, or flag you for audit.
RCM leaders should treat CPT 78264 as a monitored, high value code. It deserves the same internal attention you already give to high dollar EEG bundles, infusion regimens, or advanced neuroimaging.
2. Solid Study vs Expanded Transit: Selecting CPT 78264 Versus Related Codes
Many neurology driven gastric emptying referrals end up being broader than “stomach only”. Radiology or nuclear medicine may extend acquisition into the small bowel or colon, particularly if there is suspicion of generalized dysmotility. If billing teams do not align the final CPT selection with what was actually done, coding risk follows almost automatically.
At a high level:
- 78264 applies when the protocol is limited to gastric emptying of a solid meal, with imaging typically through 4 hours, and no formal small bowel or colonic transit interpretation.
- 78265 and related codes may be more appropriate if small bowel transit is also evaluated and interpreted.
- Other GI transit codes apply when the protocol includes extended multi day colonic transit.
Operationally, the risk arises from two failure points:
- The neurology order describes a generic “gastric emptying study” and does not specify scope.
- The nuclear medicine department uses different protocols by default, but the charge master or technologists still drop 78264 every time.
To keep your organization aligned, implement a simple decision framework between neurology, radiology, and billing:
- Standard protocol definition. Define which gastric emptying protocol qualifies for 78264. Include meal type, number and timing of acquisitions, and whether any small bowel or colonic evaluation is expected.
- Order templates. For neurology, build CPOE order options like “Gastric emptying, solid meal, stomach only” and “Gastric and small bowel transit evaluation” to nudge correct selection.
- Charge capture rules. Configure the RIS or EMR so that each protocol is mapped to the correct CPT, not left to manual selection by staff.
When you consistently match study scope to code selection, you simultaneously reduce denials, secondary coding edits, and audit evidence that you are misrepresenting services.
3. Documentation Standards That Protect CPT 78264 From Denials And Audits
For nuclear medicine driven codes like 78264, payers expect more than a one line impression. They look for a complete story that links neurologic symptoms, gastric dysmotility suspicion, protocol adherence, quantitative results, and clinical interpretation. When that story is missing pieces, two things happen. The claim may be denied outright for “insufficient documentation” or paid now and reopened later in an audit cycle.
A practical documentation checklist for 78264 in neurologic populations should include at least the following elements:
- Clear clinical indication. Link to a neurologic diagnosis, such as Parkinson’s disease with autonomic dysfunction, diabetic neuropathy, multiple sclerosis, or post stroke dysphagia with suspected delayed gastric emptying.
- Standardized patient preparation. Document key exclusion or prep items, such as NPO period, medication holds for prokinetics or opioids, and blood glucose level if diabetic. Payers sometimes use lack of prep documentation as an attack point on “test validity”.
- Meal description and radiotracer. Specify that a standardized solid meal was used, including composition when possible (for example, radiolabeled egg sandwich). This supports that the study meets gastric emptying guideline norms, not some non validated snack.
- Imaging intervals and duration. List acquisition times, such as images at 0, 1, 2, and 4 hours. For neurology patients, late delays are common, so payers want to see that the standard time points were captured.
- Quantitative results. Include percent gastric retention at each key time point and documented half time of emptying. Many MACs and commercial plans publish retention thresholds for abnormal gastric emptying; aligning your report with those norms makes medical necessity arguments much easier.
- Interpretation tied back to symptoms. Rather than “delayed gastric emptying present,” consider language like “Markedly delayed solid gastric emptying, consistent with suspected autonomic dysfunction in the setting of Parkinson’s disease,” then indicate if further neurologic or GI intervention is recommended.
Consider using a structured template within your nuclear medicine reporting system. When every required field is part of a standardized note, technologists and physicians are less likely to omit critical documentation. Compliance teams should periodically sample 78264 reports against this checklist and feed back omissions quickly.
4. Payer Behavior, Denial Patterns, And How To Respond When CPT 78264 Is Questioned
Understanding how payers view 78264 will help you design both front end workflows and back end appeal strategies. In practice, neurology gastric emptying claims attract several common denial categories.
4.1 Typical denial reasons related to CPT 78264
- Medical necessity not supported. The diagnosis on the claim does not clearly justify advanced GI motility testing. For example, unspecified nausea alone without any neurologic diagnosis or documented chronicity.
- Non covered indication per policy. Some payers restrict gastric emptying studies to defined conditions (for instance documented or strongly suspected gastroparesis) and deny studies ordered primarily to “reassure” or for poorly defined dyspepsia.
- Mismatched code vs report. The report explicitly analyzes small bowel transit or colonic progression, but 78264 was billed. During audit, this can be characterized as miscoding or misrepresentation of service scope.
- Technical and professional billing errors. In hospital based settings, confusion about when to append modifiers 26 and TC, or duplicate billing between the hospital and neurology group, can trigger denials or recoupments.
4.2 Practical response framework
When a 78264 claim is denied or questioned, create a standard internal process rather than ad hoc appeals.
- Verify code selection. Confirm that the protocol and dictation really align with a stomach only, solid meal study. If not, correct and resubmit with the appropriate CPT code and any necessary modifier.
- Cross check diagnosis mapping. Ensure that the ICD 10 codes on the claim include the relevant neurologic condition (for example G20 for Parkinson’s disease, E11.43 for diabetic autonomic neuropathy, or G35 for MS) and any GI symptom codes that support gastroparesis evaluation.
- Attach full report for appeals. Many payers auto deny based on claim level data only. When appealing, send the full nuclear medicine report that documents preparation, standardized protocol, and quantitative delay.
- Reference payer’s own policy language. Most MACs and national carriers have gastric emptying LCDs or medical policies that specify indications and required report elements. Appeal letters that quote those policies and connect documentation to them are much more successful than generic rebuttals.
Track denial rates for 78264 separately inside your denial management dashboards. If denial frequency for this code exceeds your global imaging denial rate by more than a few percentage points, that is a signal that upstream workflows or documentation templates need to be reviewed.
5. Workflow Design: Connecting Neurology, Nuclear Medicine, And Billing Around CPT 78264
Most 78264 related problems are really workflow problems. The neurologist or APP thinks in terms of symptoms and differential diagnosis. The nuclear medicine team focuses on image acquisition and quantitative analysis. The billing team focuses on codes, modifiers, and payer rules. If those three groups are not aligned, variation will creep in and payers will notice it first.
A practical way to align your teams is to map out the entire 78264 “journey” and build in three or four control points.
5.1 Suggested end to end workflow for neurology driven gastric emptying studies
- Order entry in neurology clinic. Use structured order sets that:
- Force selection of protocol type (stomach only vs extended transit).
- Require at least one qualifying neurologic or GI diagnosis.
- Embed basic instructions on medication holds and preparation so the patient arrives appropriately prepared.
- Scheduling and pre authorization.
- Patient access teams verify payer specific coverage rules and determine if a prior authorization is needed.
- For payers with strict gastric emptying policies, consider a pre visit template that captures symptoms, duration, and prior therapy to support authorization.
- Nuclear medicine protocol confirmation.
- On day of service, the technologist confirms the ordered protocol and verifies that it matches the department’s defined protocol mapped to 78264.
- Deviations, such as adding small bowel transit for clinical reasons, are flagged in real time so that coding can be adjusted later.
- Structured reporting.
- Physicians use a 78264 specific template with mandatory fields for preparation, meal, imaging intervals, quantitative results, and interpretation.
- Free text remains available for nuance, but key billing related elements are standardized.
- Charge capture and coding review.
- The RIS or EMR automatically assigns the CPT based on the selected protocol.
- A coding team member reviews any cases that deviate from standard protocol or have complex payer requirements (such as local LCDs).
Nailing these steps does more than protect a single CPT. It demonstrates to auditors that your organization has a system in place to control clinical variation, coding accuracy, and compliance for high value studies in general.
6. Metrics, Monitoring, And Periodic Internal Audits For CPT 78264
RCM leaders should not treat CPT 78264 as a “set it and forget it” code. Because payer policies, neurology practice patterns, and nuclear medicine technology all evolve, this code deserves explicit monitoring. A few simple metrics can make a big difference.
6.1 Suggested KPIs for neurology gastric emptying performance
- Volume by ordering provider and diagnosis. Track how many 78264 studies each neurologist or clinic orders per quarter and which neurologic diagnoses they attach. Sudden spikes may indicate outlier behavior that could invite payer questions.
- Initial denial rate. Monitor the percentage of initial 78264 claims denied for medical necessity, coding, or documentation. A target of less than 5 percent is reasonable in many markets. Higher than that suggests policy misalignment or weak documentation.
- Appeal success rate and time to resolution. Measure how often your appeals succeed and how long it takes to convert a denied 78264 claim to payment. Long cycles slow neurology service line cash flow, particularly in hospital settings where technical component amounts are significant.
- Audit requests by payer. If a payer consistently requests additional documentation or initiates post payment review focused on gastric emptying, that payer should be a priority for policy review and provider education.
On top of metrics, schedule internal coding and documentation audits at least annually focused on CPT 78264 and related nuclear medicine GI studies. Sampling even 25 to 50 cases can reveal consistent documentation omissions or incorrect use of 78264 where a broader transit code is warranted. Use findings to update templates, refresh provider education, and refine scheduling and prior authorization scripts.
7. When To Seek External Help With Neurology And Nuclear Medicine Billing
Smaller neurology groups or hospital systems with limited coding staff often struggle to keep GI nuclear medicine coding aligned with payer expectations, particularly when volumes are modest and policies are changing. In those settings, working with experienced RCM partners that handle multi specialty imaging and neurology can be more efficient than continuously retraining internal staff.
If your organization is looking to improve billing accuracy, reduce denials, and strengthen overall revenue cycle performance, working with experienced RCM professionals can make a measurable difference. One of our trusted partners, Quest National Services, specializes in full service medical billing and revenue cycle support for healthcare organizations that navigate complex payer environments and multi specialty workflows.
Regardless of whether you build capabilities internally or use outside support, the strategic objective is the same. Your neurology service line should be able to order clinically appropriate gastric emptying studies without worrying that payers will turn them into a recurring audit headache.
If you want to review your current neurology and nuclear medicine billing workflows, align protocols with payer policies, or reduce denial rates for codes like CPT 78264, you can contact us to discuss practical options tailored to your organization’s size and case mix.
References
Abell, T. L., Camilleri, M., Donohoe, K., Hasler, W. L., Lin, H. C., Maurer, A. H., … & Parkman, H. P. (2008). Consensus recommendations for gastric emptying scintigraphy: A joint report of the American Neurogastroenterology and Motility Society and the Society of Nuclear Medicine. American Journal of Gastroenterology, 103(3), 753–763. https://journals.lww.com/ajg/abstract/2008/03000/consensus_recommendations_for_gastric_emptying.38.aspx
Parkman, H. P., Hasler, W. L., & Fisher, R. S. (2004). American Gastroenterological Association technical review on the diagnosis and treatment of gastroparesis. Gastroenterology, 127(5), 1592–1622. https://www.gastrojournal.org/article/S0016-5085(04)01634-8/fulltext
Centers for Medicare & Medicaid Services. (n.d.). Local coverage determinations and articles for gastric emptying scintigraphy. Retrieved from https://www.cms.gov/medicare-coverage-database/search.aspx
