BILIARY- Help

chembree

Guru
Messages
243
Location
Dallas, GA
Best answers
0
Can someone help me code this.
I may be way off but this is what I have...
47505
74305
74363
47525
75984

I have not checked medlearn yet so i do not have my modifiers, yet.

Thanks for the help!:D

EXAM:

1. Biliary check and change.
2. Biliary dilatation.

TECHNIQUE: The risk, benefits and the procedure itself were explained to
the patient and informed written consent was obtained. The patient was
placed on the table in the supine position. 4.5 grams Zosyn IV was
administered for prophylaxis prior to starting the procedure. The right
flank was cleaned and draped in a sterile fashion including the existing
biliary catheter. A small amount of contrast was injected, which
demonstrated frank extravasation into the peroneal cavity. A stiff
angled glidewire was then used to negotiate through the existing
catheter into small bowel loops. The catheter was removed. A 7-French
long vascular sheath was then inserted through which a Kumpe catheter
was placed into the small bowel. The wire was exchanged for an ultra
stiff Amplatz wire. A pullback cholangiogram was then performed. A 5 mm
x 2 cm balloon was then inserted and used to dilate from the common bile
duct into the small bowel. Subsequently, under ultrasound guidance 1%
lidocaine used to anesthetize the soft tissues adjacent to the access
site. A 4-French catheter preloaded over a needle was then inserted
under ultrasound guidance into the perihepatic space. Approximately 10
mL of bloody bilious fluid was removed. Further fluid cannot be removed.
At this time, a 10 French biliary drain was then advanced over the
existing wire into the small bowel. Advancement was markedly limited and
the pigtail could not be formed. The catheter was secured in place using
2-0 silk and a sterile dressing was applied. Catheter attached to the
gravity bag.

FINDINGS:

1. Initial contrast injection demonstrates extravasation of contrast in
the perihepatic space secondary.
2. Pullback cholangiogram continues to demonstrate complete occlusion of
the mid to proximal common bile duct without contrast extending into
small bowel. There is continued moderate left and right biliary ductal
dilatation however, it is markedly improved from previous examination
and the previous filling defects have resolved. Note is made that prior
to placement of the Amplatz wire, confirmation of location in small
bowel was confirmed with contrast administration.

3. Successful placement of 10 French biliary drain internal/external
however distal pigtail could not be performed. Further advancement
cannot be performed.

IMPRESSION:

1.. Interval pulling back of the 8 French biliary drainage catheter into
the perihepatic space. This likely caused mild amount of biliary leak
which elevated patient's total bilirubin. There was still a moderate
amount of bile extending from the original 8 French drainage catheter
into drainage bag prior to procedure.

2. Interval improvement in the intra and extrahepatic ductal dilatation
with resolution of previous common bile duct clots/debris.

3. Continued complete obstruction of the mid common bile duct without
contrast extending into the small bowel even after dilatation.

4. Successful placement of 10 French internal external biliary drain.
Note is made again that distal pigtail cannot be well formed therefore
it is potential that this catheter will migrate out as well. Therefore,
serial KUBs to be performed to document adequate positioning. After
patient's bilirubin begins to decrease and the patient improves, attempt
at advancing catheter deeper into the small bowel with formation of the
pigtail to secure in place or down sizing to an 8 French catheter in
order form the pigtail in small bowel may be performed. Possibility of
stent placement exists however there is potential kinking of the stent
do to tortuosity of the distal duct to anastomosis of the small bowel.

5. Perihepatic free fluid, some of which is bilious. Patient will be
admitted overnight for 23 hour observation. Repeat CT scan to evaluate
perihepatic fluid is recommended with possible CT-guided aspiration.

6. Recommend catheter remain to gravity bag. The above findings were
discussed with Perrino, as well as IMS and the patient will be admitted
overnight.
 

MLS2

Guest
Messages
276
Best answers
0
let's see...I see the 74305/47505-51 and the exchange of the biliary cath: 75984/47525

They did dilate the common bile duct so i'm thinking 74363/47555

Almost sounds like a 76942/49080 was also done (fluid removed under US from perihepatic space)



any other thoughts on this one?
 
Last edited:
Top