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Abdominal Fistulogram with Catheter

  1. #1
    Question Abdominal Fistulogram with Catheter
    Medical Coding Books
    Can someone please help a fellow coder and I understand the following report? We know what a fistula study is but it confused us when a catheter was left in.

    Reason For Study: abdominal fistula

    History: 75-year-old male with persistent fistulous tract at the site of prior gastrostomy. The patient the patient has another gastrostomy of the past year which has been functioning.

    The skin fistulous tract was cleanse the Chloraprep solution. A 10 French Foley catheter with balloon inflated 3 cc was gently advanced into the cutaneous piece fistula tract. With balloon occluding the orifice, contrast injection into the Foley catheter during fluoroscopic visualization demonstrates immediate filling of the tract entering into the stomach. The catheter was secured to the skin within the fistula and the patient was transferred for CT scan of the abdomen.

    1. Cutaneous fistula at the prior gastrostomy site appears to drain from the gastric lumen. A CT scan will be performed to determine any additional intervening structures.

  2. #2
    Alexandria, LA
    probably 49021 and 75989.

  3. #3
    Default Abdominal fistulogram with catheter
    Reading the report it looks like the catheter was left in for the Injection of contrast material for the CT scan. It does not appear that they were leaving it in for drainage. Hope that makes sense.

  4. #4
    Salt Lake City
    When a fistulogram is performed through a tube or catheter it is 49424 and 76080 if it the dye is put right into the fistula tract it is 20501 and 76080.
    Jenifer McPolin CPC, CPMA, RCC

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