Please assist
Please find below 2 coding questions :
1. RE: Resection (open) of gallbladder
a. The ICD10 code is 0FT40ZZ
b. The question is should the cystic duct excision also be coded or is that an “assumed†part of the gallbladder resection? (0FB80ZZ)
2. RE: Intraoperative cholangiogram
a. ICD10 code BF031ZZ = PLAIN RADIOGRAPHY GALLBLADDER AND BILE DUCTS
i. OR ICD10 code BF131ZZ FLUOROSCOPY IMAGING OF GALLBLADDER AND BILE DUCTS
DOCTOR OP NOTES REGARDING GALLBLADDER REMOVAL
I placed a Balfour retractor and carefully dissected a fairly long gallbladder down in a retrograde fashion, identified the cystic artery and it was clipped with hemaclips. The cystic duct was identified and it was cannulated, held in place with a clip and an operative cholangiogram was performed with good flow into the duodenum, good filling of the intrahepatic radicals. No evidence of filling defects. The cholangiogram catheter was removed. Two clips were placed across the cystic duct. I cut the cystic duct just above the two clips, removed the cystic duct and sent it to the pathologist for evaluation. I did photograph it so I could have a picture for the patient. It had multiple small stones.
RADIOLOGY REPORT
EXAM: CHO - RAD CHOLANGIOGRAM, OPERATIVE
The cystic duct has been cannulated and contrast opacifies the intra- and extrahepatic biliary ductal system. Ducts are of normal diameter. There is spill of contrast into the duodenum. I see no filling defect to suggest a retained ductal calculus.
DOCTOR OP NOTES REGARDING CHOLANGIOGRAM
The cystic duct was identified and it was cannulated, held in place with a clip and an operative cholangiogram was performed with good flow into the duodenum, good filling of the intrahepatic radicals. No evidence of filling defects. The cholangiogram catheter was removed.
1. RE: Resection (open) of gallbladder
a. The ICD10 code is 0FT40ZZ
b. The question is should the cystic duct excision also be coded or is that an “assumed†part of the gallbladder resection? (0FB80ZZ)
2. RE: Intraoperative cholangiogram
a. ICD10 code BF031ZZ = PLAIN RADIOGRAPHY GALLBLADDER AND BILE DUCTS
i. OR ICD10 code BF131ZZ FLUOROSCOPY IMAGING OF GALLBLADDER AND BILE DUCTS
DOCTOR OP NOTES REGARDING GALLBLADDER REMOVAL
I placed a Balfour retractor and carefully dissected a fairly long gallbladder down in a retrograde fashion, identified the cystic artery and it was clipped with hemaclips. The cystic duct was identified and it was cannulated, held in place with a clip and an operative cholangiogram was performed with good flow into the duodenum, good filling of the intrahepatic radicals. No evidence of filling defects. The cholangiogram catheter was removed. Two clips were placed across the cystic duct. I cut the cystic duct just above the two clips, removed the cystic duct and sent it to the pathologist for evaluation. I did photograph it so I could have a picture for the patient. It had multiple small stones.
RADIOLOGY REPORT
EXAM: CHO - RAD CHOLANGIOGRAM, OPERATIVE
The cystic duct has been cannulated and contrast opacifies the intra- and extrahepatic biliary ductal system. Ducts are of normal diameter. There is spill of contrast into the duodenum. I see no filling defect to suggest a retained ductal calculus.
DOCTOR OP NOTES REGARDING CHOLANGIOGRAM
The cystic duct was identified and it was cannulated, held in place with a clip and an operative cholangiogram was performed with good flow into the duodenum, good filling of the intrahepatic radicals. No evidence of filling defects. The cholangiogram catheter was removed.
Comments
The cystic duct is always removed with the gallbladder as the appendix is always removed with the right hemicolectomy or cecectomy.
Robert S. Gold, MD
CEO, DCBA, Inc
4611 Brierwood Place
Atlanta, GA 30360
(770) 216-9691 (Office)
(404) 580-0204 (Cell)
Kim