Gallbladder Disease: Remove the Uncertainty Surrounding Treatment
Key terms in the report will help you code.
by Jeanne L.L. Plouffe, AS, CPC, CGSC
The gallbladder is a glandular sac located under the liver. It’s primary function is to store and concentrate bile produced by the liver. Before a meal, the gallbladder is filled with bile, enlarging to the size of a small pear. During a meal, the gallbladder squeezes bile into the small intestine through ducts. The bile (an acid) is essential to proper digestion and absorption of essential fats and nutrients. After a meal, the gallbladder is empty and becomes flat.
When a gallbladder is not functioning properly, the patient may experience many signs and symptoms:
- Pain, primarily on the upper right side of the abdomen, but can radiate to the back
- Pain waking you up at night
- Pain following meals; intolerance of fatty foods
- Burning sensation in the stomach
- Nausea, vomiting
- Loss of appetite
Abdominal ultrasound is a common test to confirm a diagnosis of gallbladder disease. A patient also may undergo a hepatobiliary iminodiacetic acid (HIDA) scan with cholecystokinin (CCK)—a medication given to determine the gallbladder’s ejection fraction (a measure of how much bile leaves the gallbladder when it contracts). An ejection fraction less than 35 percent indicates a nonfunctioning gallbladder.
Code Common Diagnoses
Common examples of gallbladder disease diagnoses (with a crosswalk to ICD-10-CM) are shown in Table A.
CPT® Coding for Treatment
There are several treatment options for gallbladder disease, which may be surgical, endoscopic, or nonsurgical. Nonsurgical treatment includes oral medication to dissolve gallstones and, for asymptomatic gallstones, diet and exercise.
Endoscopic treatment includes endoscopic retrograde cholangiopancreatography (ERCP), in which an endoscope passes through the patient’s oropharynx, esophagus, and stomach into the small intestine. The ampulla of Vater is cannulated; contrast fills this area, allowing visualization of the common bile duct and the whole biliary tract, including the gallbladder.
Codes describing ERCP include:
43264 Endoscopic retrograde cholangiopancreatography (ERCP); with endoscopic retrograde removal of calculus/calculi from biliary and/or pancreatic ducts; and
43265 Endoscopic retrograde cholangiopancreatography (ERCP); with endoscopic retrograde destruction, lithotripsy of calculus/calculi, any method.
Per CPT® instructions, you may separately report radiological supervision and interpretation using:
74328 Endoscopic catheterization of the biliary ductal system, radiological supervision and interpretation;
74329 Endoscopic catheterization of the pancreatic ductal system, radiological supervision and interpretation; or
74330 Combined endoscopic catheterization of the biliary and pancreatic ductal systems, radiological supervision and interpretation, as appropriate.
For example, a patient is admitted to the hospital with epigastric pain with nausea, vomiting, and jaundice. Lab results show the patient has elevated bilirubin (a brownish-yellow substance found in bile) and high levels of amylase and lipase (enzymes produced by the pancreas). Ultrasonography shows gallstones with dilated bile duct. A gastroenterologist performs an ERCP with removal of stones from biliary and pancreatic ducts.
CPT® coding is 43264 and 74330-26. Modifier 26 Professional component is added to 74330 to alert the payer that the physician is billing only his or her portion of the service (the facility providing the radiology equipment and staff will report the technical component of the service).
Surgical treatment of gallbladder disease may include either laparoscopic or open cholecystectomy (note that when a laparoscopic procedure is converted to an open procedure, you should report only the definitive, open procedure).
During laparoscopic cholecystectomy, four small incisions are made in the abdomen and laparoscopic instruments are used to remove the gallbladder.
CPT® codes include:
47562 Laparoscopy, surgical; cholecystectomy
47563 cholecystectomy with cholangiography
47564 cholecystectomy with exploration of common duct
Note: Diagnostic laparoscopy (47560 Laparoscopy, surgical; with guided transhepatic cholangiography, without biopsy) is included in surgical laparoscopy.
For example, a primary care physician refers a patient to a general surgeon for possible gallbladder surgery. The patient presents with results from abdominal ultrasound, which shows cholelithiasis (ICD-9-CM 574.20). Surgery is recommended. The resulting operative report documents:
After induction of anesthesia, an incision was made. Subumbilical Veress needle inserted and insufflation of abdomen performed. After adequate insufflation, trocars were inserted. Gallbladder was grasped and withdrawn over liver. Cystic duct delineated, clipped on the gallbladder side and incised. Digital fluoroscopic cholangiography revealed no intraluminal defects or obstruction. Cystic duct triply clipped and transected. Gallbladder resected from liver bed and removed through xiphoid port.
In this case, the correct CPT® codes are 47563 and 74300-26. The postoperative diagnosis is cholelithiasis with acute cholecystitis (ICD-9-CM 574.00). Because the pre- and postoperative diagnoses are different, you should wait for the pathology report before assigning a final diagnosis code.
“Open” cholecystectomy involves making an incision on the right side of the abdomen, under the rib cage, through which the gallbladder is removed.
CPT® codes include:
47605 with cholangiography
47610 Cholecystectomy with exploration of common duct;
47612 with choledochoenterostomy
47620 with transduodenal sphincterotomy or sphincterplasty, with or without cholangiography
There are over 40 possible code selections available in the biliary tract portion of the CPT® codebook; and yet, there may be an occasion when none of the codes accurately describe the surgery performed. When this occurs, turn to 47999 Unlisted procedure, biliary tract for open procedures and 47579 Unlisted laparoscopy procedure, biliary tract for laparoscopic procedures.
For example, a general surgeon provides a consult for a patient in the hospital with acute upper right quadrant abdominal pain radiating to the back. The patient undergoes a HIDA scan with CCK, which shows an ejection fraction of 18 percent. The preoperative diagnosis is acute cholecystitis (ICD-9-CM 575.0). Due to the patient’s previous abdominal surgical history, an open procedure is recommended. The resulting operative report states:
After induction of anesthesia a subcostal incision was made on the right side. Skin and subcutaneous tissue were incised, rectus fascia incised, rectus muscle transected, and peritoneum entered. The gallbladder was grasped and withdrawn over the liver. The dissection was carried down retrograde in the gallbladder bed using electrocoagulation. The cystic duct identified, clamped transected and tied with 2-0 silk. The gallbladder was removed, subcostal incision closed and sutured.
In this case, you would report CPT® 47600. The pathology report diagnosis is acute and chronic cholecystitis (ICD-9-CM 575.12). Again: Because pre- and postoperative diagnoses are different, you should wait for pathology before assigning a diagnosis code.
Remember: The op report is a road map that will guide you to the appropriate procedure code(s). Educating your physicians and yourself on the key elements needed in an op report is essential in selecting the most appropriate CPT® codes (regardless of specialty).
Jeanne L.L. Plouffe, AS, CPC, CGSC, has over 30 years of experience in specialty coding and reimbursement. She has dedicated more than 20 years of her career to general and vascular surgery coding challenges. Plouffe is coding and compliance manager, PCMG division at Phoenix Children’s Hospital. She and her staff are responsible for coding and education for more than 230 providers in more than 15 different specialties. Plouffe is a frequent speaker for local chapters in Arizona, has presented at AAPC national conferences, and is a member of the Phoenix, Ariz., local chapter.