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No stones delivered

  1. #1
    Pensacola, Florida
    Default No stones delivered
    Medical Coding Books
    I need opinions on this op note. 43262 is not in question. Would you also code the stone removal (balloon sweep) since no stones were removed? (43264-52 vs 43264)
    The indication was CBD stone, and I don't feel balloon sweeps are a routine part of an ERCP. Our physician's only do it when they are attempting to remove stones/sludge.

    PREOPERATIVE DIAGNOSIS: Common bile duct stone in a patient with
    biliary tract disease / cholecystitis and/or cholelithiasis.

    1. When the standard wire guided access to the biliary tree was
    unsuccessful, the patient underwent a pre-cut / needle knife
    fistulotomy to access the biliary tree.
    2. The fistulotomy was extended with a standard wire guided
    3. Depth was approximately 8 mm in diameter.
    4. No filling defects were found of the extrahepatic biliary tree.
    5. There was no filling of the gallbladder.
    6. The sphincterotomy accommodated both a 9 and 12 mm inflation of an
    extraction balloon when the extrahepatic biliary tree was patrolled
    for possible debris, sludge, and /or stones (none was delivered).

    Bridgette Martin LPN, CPC, CEMC, CGIC

  2. #2
    Charlotte, NC
    43262 only

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