Question cholecystostomy

salindarose

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How do I bill this? There is no imaging guidance, it technically is not done "percutaneously" although a "new incision" was created but I don't think that counts. If I am stuck with an unlisted code, would it be best to simply code for the diagnostic laparoscopy and call the drain placement inclusive?


Pre-op diagnosis: Acute cholecystitis

Post-op diagnosis: Acute cholecystitis

Procedure: Diagnostic laparoscopy, cholecystostomy tube placement (14Fr mic feeding tube)

Anesthesia: General Surgery

EBL: 10 cc

Specimen: gallbladder fluid sent for culture

Indications for procedure: Patient is a 77 year old male who presented to the ED with abdominal pain. Work up was suspicious for acute cholecystitis. It was recommended he get a laparoscopic cholecystectomy.


Description of procedure: The patient was brought to the operating room and placed in supine position. Time out was performed. Anesthesia was administered. The patient's abdomen was prepped and draped in standard sterile fashion. Pneumoperitoneum was achieved via supraumbilical veress needle. A 5mm trocar was placed supraumbilically. An 11mm epigastric port and two 5 mm right subcostal ports were placed under direct vision. The patient was put into reverse trendelenburg position and rotated to the left. There were dense omental inflammatory adhesions involved with the gallbladder. These were taken down bluntly. The gallbladder appeared extremely inflamed and tense. A laparoscopic needle was used to aspirate it. The fluid that was drained from the gallbladder appeared somewhat purulent and turbid. It was sent for culture. Due to the inflammation of the gallbladder it was extremely difficult to safely access the hepaticocystic triangle. Therefore it was decided to drain the gallbladder instead. A 14 Fr mic feeding tube was introduced into the abdomen via a new incision in the abdominal wall made directly over the gallbladder. A cholecystostomy was made in the fundus of the gallbladder and the feeding tube was inserted into this hole. The bulb of the feeding tube was inflated with 5cc of sterile water. A 19Fr JP drain was placed in the area of the gallbladder and brought out through the superior right subcostal 5mm port site.. The pneumoperitoneum was slowly deflated while the cholecystostomy tube was retracted until the gallbladder was flush with the anterior abdominal wall. The JP drain was secured with 3-0 nylon. Ports were removed. The 11mm fascial defect was closed with 0 vicryl. Remaining wound were closed with 3-0 vicryl and reinforced with skin glue. Counts were correct x2 at the end of the case. The patient was awoken and sent to recovery in good condition.
 

jnorman82

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I do believe you'll need an unlisted code, but perhaps it'd be more comparable to 47490? I think the new incision does count, and the code includes the imaging but I don't think the imaging needs to happen per se. They were seeing things through the lap. You certainly do not want to code diagnostic laparoscopy and call the drain placement inclusive because you'll short change the doctor.
 

thomas7331

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What is documented here is not a percutaneous procedure. 47490 is an interventional radiology procedure that is less invasive than a laparoscopic procedure - the catheter in the percutaneous procedure would be threaded over a guidewire that was placed with imaging guidance and there would be no incision. I would agree with using 47579 here.

I agree with the post above that coding as a diagnostic laparoscopy would greatly undervalue the amount of work here (diagnostic lap has only 5.14 RVUs, less than half of lap chole which is 10.47). I'd agree with asking the physician for a comparable code, but if you can't do that or if the physician can't suggest one, I'd go with the 47562 as that is closer to what was done here.
 
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