No stones delivered
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