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

  1. #1
    Default ERCP w/ spinct, balloon dil, stone rem. and stent
    Medical Coding Books
    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)


    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

  2. #2
    Springfield, Missouri
    Hmm...I see the confusion. I would query the physician about the stone extraction. I am not sure I would bill if no stones were found. Hope this helps.

  3. #3
    Thanks, I will.

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