ERCP w/ spinct, balloon dil, stone rem. and stent

jojogi

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Here are my thoughts, please let me know if anyone else would do it differently and why. I would code 43268, 43264-52,59, 43262-59, 43271-59. (I am a little confused about the stone extraction. Since no stones were found, I appended the mod 52 but I'm not to sure)

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TECHNIQUE: The risks and benefits of the procedure were explained to the
patient. The patient signed an informed consent form. The patient was
placed into the prone position. The endoscope was introduced through the
mouth and advanced to the second portion of the duodenum. The ampulla was
identified. The ampulla had cannulated. A sphincterotomy was performed.
Multiple attempts were done to remove the bile duct stones with the
balloon. Common bile duct dilation was performed with Hurricaine biliary
balloon dilation. A plastic stent was placed into the common bile duct.
The patient tolerated the procedure well. Standard monitoring was done for
the procedure.

FINDINGS: The common bile duct was dilated to 67 mm in diameter. There
were 3 filling defects seen in the common bile duct. A sphincterotomy was
performed. Multiple attempts were made at common bile duct stone
extraction with the balloon, however every time the balloon ruptured.
Hence, common bile duct dilation was done with a Hurricaine biliary balloon
dilator. A 6 mm x 4 cm Hurricaine biliary dilator was used. Another
attempt at stone extraction with balloon sweep was made after the dilation;
however this was resolve in stone extraction from the common bile duct.
Hence, a 7 French x 10 cm plastic stent was placed in the common bile
duct.
 
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