General Surgery Coding Alert

Question: The surgeon treated a patient with a large choledochal cyst. The procedure involved an open cholecystectomy with en bloc excision of extrahepatic bile ducts (roux-en-Y reconstruction) with hepaticojejunostomy. What are the correct CPT and ICD-9 codes? Texas Subscriber Answer: The correct ICD-9 code will depend on whether the patient has an acquired or congenital choledochal cyst. You would expect to see the congenital cyst more commonly in pediatric patients. Assuming that the patient has an acquired cyst, the correct diagnosis code is 576.8 (Other specified disorders of the biliary tract). On the other hand, if your surgeon is treating a patient with a congenital choledochal cyst, you should report the diagnosis as 751.69 (Other anomalies of gallbladder, bile ducts, and liver). CPT does not provide a specific code to describe excision of extrahepatic bile ducts, but you will find some codes that describe the subsequent reconstruction. For the cholecystectomy, [...]