The Operative Report-really need assistance
I have attached the portion of the operative report that has me confused and guessing if additional procedure beyond the Open Chole. can be billed.
Gallbladder removed sent to path, attempts were made for cholangiogram, but unsuccessful......RUQ qas irrigated throughly, tract of cholecysytostomy tube identified , this went through simply omentum and was wrapped in omentum. Because of pts chronic RUQ pain, this was opened to rul out abscess or abnormality. No abscess noted, scar and tract were resected along with Bovie electocautery and discarded. Would irrigated, a drain wa placed in gallbladde bed, taked to skin...Would was then closed in layers......
Is this "extra" work inclusive to the gallbladder removal or is there an additional CPT for the cholecystostomy tube and tract removal