Hi. I'm not sure if I can code the 'unroofing' procedure with the cholecystectomy my physician performed since he did it after the gallbladder was removed. Is it included?
After the cholecystectomy was performed, -'the gallbladder was separated from the liver with electrocautery and placed in the endocath bag and removed from the epigastric port site. At the dome of the gallbladder junction with the liver there was a hepatic cyst which was seen on the preoperative ultrasound. The roof of the cyst was adjacent to the boarder of the gallbladder with the liver and was opened during removal of the gallbladder from the liver therefor the remaining cyst roof was sharply excised unroofing the cyst cavity which appeared to be about 3-4 cc. in volume with a smoothly lined cavity. Fluid contained in the cyst was clear in color without evidence of bile to suggest biliary ductal communication. The cyst wall was sent for path exam.
Any thoughts?
After the cholecystectomy was performed, -'the gallbladder was separated from the liver with electrocautery and placed in the endocath bag and removed from the epigastric port site. At the dome of the gallbladder junction with the liver there was a hepatic cyst which was seen on the preoperative ultrasound. The roof of the cyst was adjacent to the boarder of the gallbladder with the liver and was opened during removal of the gallbladder from the liver therefor the remaining cyst roof was sharply excised unroofing the cyst cavity which appeared to be about 3-4 cc. in volume with a smoothly lined cavity. Fluid contained in the cyst was clear in color without evidence of bile to suggest biliary ductal communication. The cyst wall was sent for path exam.
Any thoughts?