chembree
Guru
Does anyone have any opinions on how I should code this?
I am thinking about 75980, 47510?
CT-GUIDED CHOLECYSTOTOMY TUBE PLACEMENT:
CLINICAL HISTORY: Cholecystitis, abdominal pain.
TECHNIQUE: The risks, benefits and procedure itself were explained to
the patient, and informed written consent was obtained. The patient was
placed on table in the supine position. Drape was placed.
CT scan was performed to identify the safest place for entrance. This
area was marked, and this area cleaned and draped in sterile fashion. 1%
lidocaine was used to anesthetize the overlying soft tissues. Under CT
guidance, an 18-gauge Chiba needle was inserted through the liver into
the gallbladder. An Amplatz wire was then curled within the gallbladder,
tract serially dilated with 5- and 8-French dilators and an 8-French
pigtail drainage catheter placed in the gallbladder. A total of
approximately 60 mL malodorous bile was removed. Catheter secured to the
skin with 2-0 silk and catheter attached to suction bag. The patient
tolerated the procedure well without postprocedure complication. Sample
sent to laboratory for evaluation.
FINDINGS: Initial CT scan demonstrates thick-walled gallbladder with
some pericholecystic fluid as well as perihepatic free fluid. Subsequent
imaging demonstrates adequate positioning of the needle and wire within
the gallbladder. Pigtail catheter was placed, and final image
demonstrates decompression of the gallbladder.
IMPRESSION:
Successful CT-guided cholecystostomy tube placement as described above.
I am thinking about 75980, 47510?
CT-GUIDED CHOLECYSTOTOMY TUBE PLACEMENT:
CLINICAL HISTORY: Cholecystitis, abdominal pain.
TECHNIQUE: The risks, benefits and procedure itself were explained to
the patient, and informed written consent was obtained. The patient was
placed on table in the supine position. Drape was placed.
CT scan was performed to identify the safest place for entrance. This
area was marked, and this area cleaned and draped in sterile fashion. 1%
lidocaine was used to anesthetize the overlying soft tissues. Under CT
guidance, an 18-gauge Chiba needle was inserted through the liver into
the gallbladder. An Amplatz wire was then curled within the gallbladder,
tract serially dilated with 5- and 8-French dilators and an 8-French
pigtail drainage catheter placed in the gallbladder. A total of
approximately 60 mL malodorous bile was removed. Catheter secured to the
skin with 2-0 silk and catheter attached to suction bag. The patient
tolerated the procedure well without postprocedure complication. Sample
sent to laboratory for evaluation.
FINDINGS: Initial CT scan demonstrates thick-walled gallbladder with
some pericholecystic fluid as well as perihepatic free fluid. Subsequent
imaging demonstrates adequate positioning of the needle and wire within
the gallbladder. Pigtail catheter was placed, and final image
demonstrates decompression of the gallbladder.
IMPRESSION:
Successful CT-guided cholecystostomy tube placement as described above.
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