Ercp - major papilla

dovejsd

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I am new to GI coding, so I need some help. This is the dictation:
"The endoscope was introduced and advanced to the second portion of the duodeum. There was what appeared to be a small growth noted at the major papilla. Scout film was taken and showed unremarkable bowel gas pattern. The common bile duct was easily cannulated using sphincterotome. The initial cholangiogram showed severe dilatation of intra and extrahepatic biliary ducts. Sphincterotomy was performed. The sphincterotome was exchanged with extraction balloon catheter over guidewire. An occlusion cholangiogram confirmed the dilated common bile ducts to 18mm. There was evidence of a short severe stricture at the distal common bile duct for around 3 to 4 cm in length. Balloon sweep did not reveal any sludge, but there was a dark bile draining. A 10mm x 6cm fully covered metal stent was placed successfully across the biliary stricture with large amount of biliary drainage was noticed after the successful placement. Pacreatogram was not performed and the pancreatic duct was not accessed."

I have coded 43268 and 43262. Should I code the balloon sweep portion? If so, what is the code? Or is this just part of the procedure???

Thanks a million to anyone who can help!!!
 

coachlang3

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I'm not sure the reasoning anymore but I never code the extraction sweep if there is no sludge or stone findings.

To my eye you have the correct CPT's.

You would however code a balloon dilation if it had been done, just not the balloon or basket extraction.
 
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