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Thread: BILIARY- Help

  1. #1
    Join Date
    Apr 2007
    Dallas, GA

    Default BILIARY- Help

    AAPC: Back to School
    Can someone help me code this.
    I may be way off but this is what I have...

    I have not checked medlearn yet so i do not have my modifiers, yet.

    Thanks for the help!


    1. Biliary check and change.
    2. Biliary dilatation.

    TECHNIQUE: The risk, benefits and the procedure itself were explained to
    the patient and informed written consent was obtained. The patient was
    placed on the table in the supine position. 4.5 grams Zosyn IV was
    administered for prophylaxis prior to starting the procedure. The right
    flank was cleaned and draped in a sterile fashion including the existing
    biliary catheter. A small amount of contrast was injected, which
    demonstrated frank extravasation into the peroneal cavity. A stiff
    angled glidewire was then used to negotiate through the existing
    catheter into small bowel loops. The catheter was removed. A 7-French
    long vascular sheath was then inserted through which a Kumpe catheter
    was placed into the small bowel. The wire was exchanged for an ultra
    stiff Amplatz wire. A pullback cholangiogram was then performed. A 5 mm
    x 2 cm balloon was then inserted and used to dilate from the common bile
    duct into the small bowel. Subsequently, under ultrasound guidance 1%
    lidocaine used to anesthetize the soft tissues adjacent to the access
    site. A 4-French catheter preloaded over a needle was then inserted
    under ultrasound guidance into the perihepatic space. Approximately 10
    mL of bloody bilious fluid was removed. Further fluid cannot be removed.
    At this time, a 10 French biliary drain was then advanced over the
    existing wire into the small bowel. Advancement was markedly limited and
    the pigtail could not be formed. The catheter was secured in place using
    2-0 silk and a sterile dressing was applied. Catheter attached to the
    gravity bag.


    1. Initial contrast injection demonstrates extravasation of contrast in
    the perihepatic space secondary.
    2. Pullback cholangiogram continues to demonstrate complete occlusion of
    the mid to proximal common bile duct without contrast extending into
    small bowel. There is continued moderate left and right biliary ductal
    dilatation however, it is markedly improved from previous examination
    and the previous filling defects have resolved. Note is made that prior
    to placement of the Amplatz wire, confirmation of location in small
    bowel was confirmed with contrast administration.

    3. Successful placement of 10 French biliary drain internal/external
    however distal pigtail could not be performed. Further advancement
    cannot be performed.


    1.. Interval pulling back of the 8 French biliary drainage catheter into
    the perihepatic space. This likely caused mild amount of biliary leak
    which elevated patient's total bilirubin. There was still a moderate
    amount of bile extending from the original 8 French drainage catheter
    into drainage bag prior to procedure.

    2. Interval improvement in the intra and extrahepatic ductal dilatation
    with resolution of previous common bile duct clots/debris.

    3. Continued complete obstruction of the mid common bile duct without
    contrast extending into the small bowel even after dilatation.

    4. Successful placement of 10 French internal external biliary drain.
    Note is made again that distal pigtail cannot be well formed therefore
    it is potential that this catheter will migrate out as well. Therefore,
    serial KUBs to be performed to document adequate positioning. After
    patient's bilirubin begins to decrease and the patient improves, attempt
    at advancing catheter deeper into the small bowel with formation of the
    pigtail to secure in place or down sizing to an 8 French catheter in
    order form the pigtail in small bowel may be performed. Possibility of
    stent placement exists however there is potential kinking of the stent
    do to tortuosity of the distal duct to anastomosis of the small bowel.

    5. Perihepatic free fluid, some of which is bilious. Patient will be
    admitted overnight for 23 hour observation. Repeat CT scan to evaluate
    perihepatic fluid is recommended with possible CT-guided aspiration.

    6. Recommend catheter remain to gravity bag. The above findings were
    discussed with Perrino, as well as IMS and the patient will be admitted

  2. #2


    let's see...I see the 74305/47505-51 and the exchange of the biliary cath: 75984/47525

    They did dilate the common bile duct so i'm thinking 74363/47555

    Almost sounds like a 76942/49080 was also done (fluid removed under US from perihepatic space)

    any other thoughts on this one?
    Last edited by MLS2; 05-14-2009 at 07:00 AM.

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