Jenannurb
Contributor
I would love some input as to how to code this procedure.
Op report as below:
Procedure: ERCP with* Sphincterotomy, stone extraction
Date of Procedure: 3/29/2017
Pre-operative Diagnosis: cbd stones, failure of biliary drainage on intraoperative cholangiogram
Sedation: GETA, gentamycin, indomethacin
ASA Class: 3
Mallampati Class:III (soft and hard palate and base of uvula visible)
Procedure Details
Informed consent was obtained for the procedure, including conscious sedation. Risks including infection, perforation, hemorrhage, adverse drug reaction and aspiration and pancreatitis were discussed. The patient was placed in the left lateral simiprone position.* Based on the pre-procedure assessment, including review of the patient's medical history, medications, allergies, and review of systems, she had been deemed to be an appropriate candidate for mac sedation.* She was monitored continuously with ECG tracing, pulse oximetry, blood pressure monitoring, and direct observation.
* *
The duodenoscope was inserted into the mouth and advanced under direct vision to the second portion of the duodenum.
Findings:
Survey of the esophagus, stomach and duodenum was normal.*
The major papilla was identified in the second portion of the duodenum.* A Microvasive Hydrotome catheter was positioned just inside the major papilla.
A guidewire was advanced into the common bile duct under fluoroscopic guidance without the need for contrast injection.* The catheter was then advanced over the wire into the region of the common bile duct.* Next a cholangiogram was obtained
.
This demonstrated distal filling defects.
A sphincterotomy was performed.* Next balloon used to extract 3 cholesterol stones. F/u imaging showed no extraluminal air/contrast, good drainage. The patient tolerated the procedure well.
Impression:* *
Choledocholithiasis s/p ercp/sphincterotomy/stone extraction
**I am thinking that it gets a 43264 and a 43277
any help would be great!
Jennifer
Op report as below:
Procedure: ERCP with* Sphincterotomy, stone extraction
Date of Procedure: 3/29/2017
Pre-operative Diagnosis: cbd stones, failure of biliary drainage on intraoperative cholangiogram
Sedation: GETA, gentamycin, indomethacin
ASA Class: 3
Mallampati Class:III (soft and hard palate and base of uvula visible)
Procedure Details
Informed consent was obtained for the procedure, including conscious sedation. Risks including infection, perforation, hemorrhage, adverse drug reaction and aspiration and pancreatitis were discussed. The patient was placed in the left lateral simiprone position.* Based on the pre-procedure assessment, including review of the patient's medical history, medications, allergies, and review of systems, she had been deemed to be an appropriate candidate for mac sedation.* She was monitored continuously with ECG tracing, pulse oximetry, blood pressure monitoring, and direct observation.
* *
The duodenoscope was inserted into the mouth and advanced under direct vision to the second portion of the duodenum.
Findings:
Survey of the esophagus, stomach and duodenum was normal.*
The major papilla was identified in the second portion of the duodenum.* A Microvasive Hydrotome catheter was positioned just inside the major papilla.
A guidewire was advanced into the common bile duct under fluoroscopic guidance without the need for contrast injection.* The catheter was then advanced over the wire into the region of the common bile duct.* Next a cholangiogram was obtained
.
This demonstrated distal filling defects.
A sphincterotomy was performed.* Next balloon used to extract 3 cholesterol stones. F/u imaging showed no extraluminal air/contrast, good drainage. The patient tolerated the procedure well.
Impression:* *
Choledocholithiasis s/p ercp/sphincterotomy/stone extraction
**I am thinking that it gets a 43264 and a 43277
any help would be great!
Jennifer
