KODuncan
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Please help with code selection for an Excision Choledochal cyst with Hepaticojejunstomy??? The physician billed 47715 for the excision cyst. He feels this CPT covers both removal of the cyst and the Hepaticojejunstomy. He states "he only connected the intestines to the biliary system". I was looking at CPT 47760 for the Hepaticojejunstomy to bill along with the 47715...
Partial Op Note
During dissection around the choledochal cyst, near the liver, a small ductotomy was noted when bile was seen flowing from an area of dissection. This area was marked with a suture for later identification, and dissection was moved more distally to avoid any further injury. This plane was utilized to dissected distally on the choledochal cyst until it entered to the pancreatic head. Careful dissection into the pancreatic head freed the choledochal cyst to the level of the normal-appearing distal common bile duct. The distal common bile duct was suture ligated with Vicryl suture, and a surgical clip was placed for extra security. The distal portion of the choledochal cyst is amputated from the distal common bile duct. The choledochal cyst was dissected in a cephalad fashion taking care to dissected off of the portal vein without injury to the portal vein. Prior to division or dissection of the right and left hepatic ducts, preparation for the hepaticojejunostomy was made by laying out the Roux-en-Y for anastomosis. The ligament of Treitz was identified. An area of 15 cm distal to the ligament of Treitz was identified and the bowel divided with a GIA stapler. The mesentery was carefully mobilized taking care to maintain vessels with collateral flow for all segments of the jejunum. A biliary limb of jejunum was marked at 30 cm in length where an end-to-side jejunojejunostomy was performed. The biliary limb was passed in a retrocolic fashion one arcade to the right of the middle colic artery. The mesenteric hole for the biliary limb of jejunum was noted to be well-sized around the jejunum without need for alteration. Attention returned to the proximal dissection identifying and controlling a small branch artery to the choledochal cyst. The common hepatic duct connection to the choledochal cyst was identified and divided. Interestingly, after division, it was noted that there was no apparent way to pass a surgical instrument through the obvious lumen at the point of division of the common hepatic duct into the choledochal cyst. Injectable saline was placed through the distal opening into the choledochal cyst and was not noted to extravasate through any openings. The common hepatic duct was examined and noted not to have continuity at this point to the right or left hepatic ducts. At this point, the suture marking the area of duct anatomy earlier in the case was noted to be at the same area but more proximally. After careful dissection and probing as well as the use of a 3 French ureteral catheter, the right and left hepatic ducts were identified. The left hepatic duct allowed for passage of a 3 French ureteral catheter in good distance into the duct. However, the right hepatic duct while cannulated by the 3 French ureteral catheter, the catheter was not able to be advanced more than about a centimeter into the duct. Both of these orifice ease demonstrated clear extravasation of bile. A 3 French ureteral stent was placed into the left hepatic duct and utilized to place a 6-0 PDS suture into the duct for securing the duct to the hepaticojejunostomy. In a like fashion, a 6-0 PDS suture was placed into the right hepatic duct.
Partial Op Note
During dissection around the choledochal cyst, near the liver, a small ductotomy was noted when bile was seen flowing from an area of dissection. This area was marked with a suture for later identification, and dissection was moved more distally to avoid any further injury. This plane was utilized to dissected distally on the choledochal cyst until it entered to the pancreatic head. Careful dissection into the pancreatic head freed the choledochal cyst to the level of the normal-appearing distal common bile duct. The distal common bile duct was suture ligated with Vicryl suture, and a surgical clip was placed for extra security. The distal portion of the choledochal cyst is amputated from the distal common bile duct. The choledochal cyst was dissected in a cephalad fashion taking care to dissected off of the portal vein without injury to the portal vein. Prior to division or dissection of the right and left hepatic ducts, preparation for the hepaticojejunostomy was made by laying out the Roux-en-Y for anastomosis. The ligament of Treitz was identified. An area of 15 cm distal to the ligament of Treitz was identified and the bowel divided with a GIA stapler. The mesentery was carefully mobilized taking care to maintain vessels with collateral flow for all segments of the jejunum. A biliary limb of jejunum was marked at 30 cm in length where an end-to-side jejunojejunostomy was performed. The biliary limb was passed in a retrocolic fashion one arcade to the right of the middle colic artery. The mesenteric hole for the biliary limb of jejunum was noted to be well-sized around the jejunum without need for alteration. Attention returned to the proximal dissection identifying and controlling a small branch artery to the choledochal cyst. The common hepatic duct connection to the choledochal cyst was identified and divided. Interestingly, after division, it was noted that there was no apparent way to pass a surgical instrument through the obvious lumen at the point of division of the common hepatic duct into the choledochal cyst. Injectable saline was placed through the distal opening into the choledochal cyst and was not noted to extravasate through any openings. The common hepatic duct was examined and noted not to have continuity at this point to the right or left hepatic ducts. At this point, the suture marking the area of duct anatomy earlier in the case was noted to be at the same area but more proximally. After careful dissection and probing as well as the use of a 3 French ureteral catheter, the right and left hepatic ducts were identified. The left hepatic duct allowed for passage of a 3 French ureteral catheter in good distance into the duct. However, the right hepatic duct while cannulated by the 3 French ureteral catheter, the catheter was not able to be advanced more than about a centimeter into the duct. Both of these orifice ease demonstrated clear extravasation of bile. A 3 French ureteral stent was placed into the left hepatic duct and utilized to place a 6-0 PDS suture into the duct for securing the duct to the hepaticojejunostomy. In a like fashion, a 6-0 PDS suture was placed into the right hepatic duct.
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