General Surgery Coding Alert

Answer: The standard radical pancreaticoduodenectomy, or Whipple procedure (48150, pancreatectomy, proximal subtotal with total duodenectomy, partial gastrectomy, choledochoenterostomy and gastrojejunostomy [Whipple-type procedure]; with pancreatojejunostomy), usually includes removal of the gallbladder and ligature of the cystic duct as described in most standard surgical texts, says M. Trayser Dunaway, MD, a general surgeon in Camden, S.C. Some references do state, however, a concomitant cholecystectomy is not always necessary, but it is usually performed.

Sludge is not typically a top priority when a patient requires a Whipple, Dunaway says, so it is unlikely the gallbladder is being removed for that reason. Rather, the gallbladder most likely is removed to avoid subsequent problems, sludge or not.

Open cholecystectomy (47600) is bundled with the Whipple in the national Correct Coding Initiative, although the CCI edit of 48150 with 47600 has a 1 indicator, which means that attaching modifier -59 (distinct procedural service) to the 47600 overrides the edit under certain conditions. If documentation shows that the patient had chronic or acute cholecystitis and was symptomatic when the decision to perform the Whipple was made conceivably 48150 could be separately billed, but such a scenario occurs infrequently. Furthermore, if the pathology report shows chronic inflammation but this is not mentioned in the documentation, then 47600 could not be billed separately, says Kathleen Mueller, RN, CPC, CCS-P, an independent general surgery coding and reimbursement specialist in Lenzburg, Ill.