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Sphincteroplasty help!!

  1. #1
    Default Sphincteroplasty help!!
    Medical Coding Books
    INDICATION: Choledocholithiasis, 15 mm common bile duct stone, poor surgical candidate with high-risk for general anesthesia.

    TECHNIQUE: The risks, benefits and potential complications, procedural details and alternatives were discussed with the patient prior to proceeding. The patient brought into the interventional suite. Conversation was made prior to the procedure also with patient's son.

    MAC anesthesia was provided by anesthesia department under the supervision of Dr. XXXX.

    The existing internal/external biliary drain was gently injected with nonionic contrast in the performance of cholangiogram again showing filling defect of the common bile duct with the filling defect more proximal near the confluence of the left and right hepatic ducts. Guidewire was inserted. After dilatation up to 12 French a 12 French sheath was then placed and brought to the level of the stone. A safety wire additional was then placed through the ampulla as well to have two wires in position. A basket was used to reposition the stone from the proximal location to the distal common bile duct. Next, over one of the guidewires KMP catheter was placed and exchanged for an 018 guidewire to allow placement of a 6 mm x 4 cm angioplasty balloon brought to the sphincter for sphincterplasty. Next, an 8mm x 4 cm cutting balloon was then used for sphincter plasty. This was followed by a 10 mm balloon and then a 12 mm balloon for sphincter plasty bringing the balloon to 12 atmospheres with each dilatation and angioplasty duration for each balloon was 60 seconds. Next, following sphincteroplasty a Cook occlusion balloon was utilized making several passes from the common hepatic duct/common bile duct into the duodenum. Balloon bursting occurred on three occasions. A Fogarty balloon was then utilized. This allowed removal of the stone from the common bile duct through the sphincter/ampulla on into the duodenum. Fluoroscopic image captures the stone filling defect within the duodenum. The safety wire was removed. Over the existing wire after removal of 12 French sheath a new 12 French internal biliary stent was then placed with its coiled portion into the duodenum. Both the internal biliary drain and the cholecystostomy tube were then clamped. The patient tolerated the procedure well and recovered in PACU following the procedure.

    IMPRESSION: Sphincteroplasty up to 12 mm allowed passage of common bile duct stone into the duodenum through the sphincter using occlusion balloon. Repeat cholangiography this upcoming Monday will be planned.

    Can anyone offer any guidance for this chart? This is what I have came up with....

  2. #2
    This is not an incisional procedure; it was done by a percutaneous sphincteroplasty by balloon dilation technique. I would use these codes: 47999, 74363, 47505, 74305, 47525, and 75984

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