margaret fahy
Guru
Hey Folks,
So...I do not see a code for a balloon angioplasty of a biliary anastomosis. There is an endocsopy code, and i saw an earlier post on here than one may use the endoscopy angioplasty code when applicable, but when is it applicable? What do you think about the one below?
I would code for the Cholangiogram and placement of the internal/external biliary cath...but i do not know what code to use for the Angioplasty.
CLINICAL HISTORY: History of hepatic mesenchymal hamartoma status
post resection and bile duct reconstruction to Roux-en-Y . Now
with abdominal pain and jaundice. MRCP demonstrated mild
dilatation of the PICC. Here for percutaneous transhepatic
cholangiogram and possible intervention.
PROCEDURE:
1. Ultrasound-guided access of the biliary system.
2. Cholangiogram.
3. Angioplasty of choledochojejunostomy anastomosis stricture
using 5 mm balloon catheter.
4. Placement of 10.2F internal/external biliary catheter.
PROCEDURE:
An US examination was performed of the liver demonstrating
dilated biliary ducts . The skin of the abdomen was prepped and
draped in sterile fashion and local anesthesia using ropivacaine
0.2% was infused at the RLQ insertion site. Using US guidance a
22G Chiba needle was advanced into a peripheral bile duct.
Initially mininally yellow bile was obtained denoting
long-standing obstruction. Then 0.018 Nitrex wire was advanced
and coiled into the biliary system. The needle was removed and 5F
micropuncture set was advanced over the wire into the biliary
system. Contrast was injected and cholangiogram was obtained.
Cholangiogram demonstrated diffuse moderate dilatation of the
biliary system. There is wall irregularity of some bile ducts
which could be related to obstruction and stasis. However, no
antegrade flow into the gut was seen. The main bile duct
appeared blind-ended at radiography in multiple projections.
An 8 French vascular sheath was placed over the wire into the
biliary system. A 0.018" diameter gold tip wire was used to probe
the end of the dilated duct. Multiple attempts were gently
performed until the wire was eventually atraumatically advanced
into the small bowel, followed by a 5F KMP catheter. The wire
was removed and contrast was injected which confirmed the
catheter tip in the bowel. The vascular sheath was injected and
multiple images were obtained in different positions. This
demonstrated short segment tight stenosis at the level of duct-
jejunostomy anastomosis.
Angioplasty of the anastomotic stricture was performed using 5
mm x 2 cm balloon catheter. Post angioplasty cholangiogram
demonstrated relief of stenosis, no extravasation, and prompt
contrast flow into the bowel.
The balloon was removed and 10.2 French internal/external biliary
catheter was advanced over the wire. The catheter was placed in a
such a fashion that some holes are in the biliary system and
distal holes are in the bowel. The distal loop of the catheter
was formed in the bowel. Contrast injection via the catheter
demonstrated satisfactory position of the catheter. The catheter
was secured to the skin with 3-0 prolene, a statlock, and gauze
with sterile dressing was applied.
FINDINGS:
1. Cholangiogram demonstrated moderate diffuse dilatation of the
biliary system with wall irregularity of some bile ducts. No
contrast flow into the bowel was noted. This is consistent with
obnstruction at the choledochojejunostomy anastomosis.
2. Angioplasty of choledochojejunostomy anastomosis using 5 mm
balloon catheter.
3. Placement of 10.2 French internal/external biliary catheter to
closed straight drainage.
Permanent ultrasound and fluoroscopic images were obtained and
stored in PACS system.
IMPRESSION
1. Biliary obstruction at the hepatoenterostomy.
3. Angioplasty of biliary anastomosis using 5 mm balloon
catheter.
4. Placement of 10.2 French internal/external biliary catheter.
Plan:
1. Biliary catheter should be left open to bag for 24 hours then
capped if patient is doing well.
2. Cholangiogram via the catheter should be scheduled in ~6-8
weeks for evaluation of the biliary system and planning for
eventual removal
So...I do not see a code for a balloon angioplasty of a biliary anastomosis. There is an endocsopy code, and i saw an earlier post on here than one may use the endoscopy angioplasty code when applicable, but when is it applicable? What do you think about the one below?
I would code for the Cholangiogram and placement of the internal/external biliary cath...but i do not know what code to use for the Angioplasty.
CLINICAL HISTORY: History of hepatic mesenchymal hamartoma status
post resection and bile duct reconstruction to Roux-en-Y . Now
with abdominal pain and jaundice. MRCP demonstrated mild
dilatation of the PICC. Here for percutaneous transhepatic
cholangiogram and possible intervention.
PROCEDURE:
1. Ultrasound-guided access of the biliary system.
2. Cholangiogram.
3. Angioplasty of choledochojejunostomy anastomosis stricture
using 5 mm balloon catheter.
4. Placement of 10.2F internal/external biliary catheter.
PROCEDURE:
An US examination was performed of the liver demonstrating
dilated biliary ducts . The skin of the abdomen was prepped and
draped in sterile fashion and local anesthesia using ropivacaine
0.2% was infused at the RLQ insertion site. Using US guidance a
22G Chiba needle was advanced into a peripheral bile duct.
Initially mininally yellow bile was obtained denoting
long-standing obstruction. Then 0.018 Nitrex wire was advanced
and coiled into the biliary system. The needle was removed and 5F
micropuncture set was advanced over the wire into the biliary
system. Contrast was injected and cholangiogram was obtained.
Cholangiogram demonstrated diffuse moderate dilatation of the
biliary system. There is wall irregularity of some bile ducts
which could be related to obstruction and stasis. However, no
antegrade flow into the gut was seen. The main bile duct
appeared blind-ended at radiography in multiple projections.
An 8 French vascular sheath was placed over the wire into the
biliary system. A 0.018" diameter gold tip wire was used to probe
the end of the dilated duct. Multiple attempts were gently
performed until the wire was eventually atraumatically advanced
into the small bowel, followed by a 5F KMP catheter. The wire
was removed and contrast was injected which confirmed the
catheter tip in the bowel. The vascular sheath was injected and
multiple images were obtained in different positions. This
demonstrated short segment tight stenosis at the level of duct-
jejunostomy anastomosis.
Angioplasty of the anastomotic stricture was performed using 5
mm x 2 cm balloon catheter. Post angioplasty cholangiogram
demonstrated relief of stenosis, no extravasation, and prompt
contrast flow into the bowel.
The balloon was removed and 10.2 French internal/external biliary
catheter was advanced over the wire. The catheter was placed in a
such a fashion that some holes are in the biliary system and
distal holes are in the bowel. The distal loop of the catheter
was formed in the bowel. Contrast injection via the catheter
demonstrated satisfactory position of the catheter. The catheter
was secured to the skin with 3-0 prolene, a statlock, and gauze
with sterile dressing was applied.
FINDINGS:
1. Cholangiogram demonstrated moderate diffuse dilatation of the
biliary system with wall irregularity of some bile ducts. No
contrast flow into the bowel was noted. This is consistent with
obnstruction at the choledochojejunostomy anastomosis.
2. Angioplasty of choledochojejunostomy anastomosis using 5 mm
balloon catheter.
3. Placement of 10.2 French internal/external biliary catheter to
closed straight drainage.
Permanent ultrasound and fluoroscopic images were obtained and
stored in PACS system.
IMPRESSION
1. Biliary obstruction at the hepatoenterostomy.
3. Angioplasty of biliary anastomosis using 5 mm balloon
catheter.
4. Placement of 10.2 French internal/external biliary catheter.
Plan:
1. Biliary catheter should be left open to bag for 24 hours then
capped if patient is doing well.
2. Cholangiogram via the catheter should be scheduled in ~6-8
weeks for evaluation of the biliary system and planning for
eventual removal
