THE CODING EDGE® ARCHIVES

Table of Contents

Coding Recommendations - Feature Article 07/15/98
   

Procedure Practice
    

Using ICD-9-CM and CPT-4, assign codes for the procedure(s) described in this "real-life" operative report.

Hint: The following text is, as you would expect, very technical and "dense;" we suggest you print this page for easier use. Your Browser's "File, Print" command should achieve this with no problem. Should you have difficulties printing this -or any other- page, please let us know.
   

PP logo 

Procedure: ERCP with sphincterotomy and removal of common duct stone

Indications for Procedure: The patient is a 62-year-old woman with documented obstructing common duct stone. She is status post T-tube insertion for creation of a biliary drainage tract. She now presents for sphincterotomy and stone removal.

Description of Procedure: The patient was brought to the endoscopy suite and sedated with IV Versed and Fentanyl. After the pharynx was anesthetized with Xylocaine spray, a guidewire and snare were advanced through the external biliary drain site into the duodenum.

Next the side-viewing duodenoscope was inserted per os and advanced into the esophagus, stomach, and duodenum. Esophageal, gastric, and duodenal mucosa were all noted to be unremarkable. The scope was positioned in place and a guidewire was grasped by the external snare and pulled up into the bile duct and out through the skin.

The sphincterotome was then advanced over the guidewire up into the bile duct and positioned across the papilla of Vater. The papilla was noted to be lying in the base of a large duodenal diverticulum. The sphincterotomy was then performed to a total of 1.0 cm. There was a moderate amount of bleeding that resolved spontaneously. Estimated blood loss was less than 25 cc. Next a 1.1 mm. balloon was advanced over a guidewire up into the bile duct and pulled out clearing the duct of all gravel and small stone material.

Before concluding the procedure, a follow-up cholangiogram was performed and revealed no further evidence of stones within the duct. There was free flow of contrast out to the T-tube site, revealing a well-established drainage tract. A mild stricture of the right hepatic duct was observed, but no residual stones were seen. During the procedure the pancreatic duct was also visualized and appeared to be patent and of normal caliber. It is anticipated that excellent drainage has been established. The procedure was thus terminated and all instruments were withdrawn. The patient tolerated the procedure well. She will be discharged after recovery from sedation.

   

     

Using the above samples, do your own coding and then compare it with our recommendations.

Notice: This part of our web site was prepared to assist in understanding and maintaining good coding skills. For proper use of this feature, reference must be made to official coding guidelines when necessary. The information here presented is only to be used as a supplement to those guidelines. Laguna Medical Systems, Inc., makes no representations or guarantees as to amounts that will be paid by Medicare or other third party payers.
 

 

Please be aware that the Coding Edge® Archive pages are NOT retroactively updated
to reflect possible coding rules and regulation changes made after the publishing date.