Cholecystectomy
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Anatomy
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Diagnosis/ Condition
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Surgical treatment
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How to lead CPT code
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CPT code selection criteria
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Live chart sample
1.Anatomy
Gallbladder is reservoir which store bile juice that is produced by the Liver. Then it gets secreted into the 1st part of the duodenum. It is situated below the liver. It is green in Colour.
Bile juice from liver is transferred from right and left hepatic duct by joining together and forming common hepatic duct. Then through cystic duct it reaches gall bladder.
During digestion this collected bile juice go through common bile duct.
Next it combines to pancreatic duct and secreted the bile juice through opening in the duodenum called as Ampulla of Vater or Sphincter of Oddi.
2.Disease and Condition
1. The presence of gallstones in the bile duct is known as choledocholithiasis.
2. Cholelithiasis refers to gallstones in the gallbladder.
3. Gallbladder inflammation, called cholecystitis
4. Gallbladder Polyps
5. Biliary dyskinesia in condition when gall bladder does not work properly.
3.Surgical procedure (Cholecystectomy)
The Cholecystectomy is the surgical procedure for the removal of the gallbladder. There are two ways of removing gallbladder.
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Open approach
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Laparoscopic approach (Minimal invasive Procedure)
4.How to lead correct CPT Code
In CPT book ,go to cholecystecomy, you will get the code all code.
Cholecystecomy- Laparoscopic- 47562
Cholecystectomy- Laparoscopic- Cholangiography-47563
Cholecysteocmty- Laparoscopic- With exploration- 47564
Cholecystectomy- Open-47600
Cholecystectomy-Open- With Cholangiography- 47605
Cholecystectomy-Open- With Exploration- 47610,47612,47620
5.Code selection criteria for Cholecystectomy
The code selection criteria for Cholecystectomy is based on approach
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Approach : Open/Laparoscopy
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Application of cholangiogram
Tips 1 : If a provider begins a laparoscopic cholecystectomy and then converts to an open procedure, such as 47600, due to complications, report only the successful open procedure. Because open conversion cases often take much longer than a similar procedure that is open from the start, you might be able to use modifier 22, Increased procedural services. The provider must document the extra work and time for you to be able to use this modifier. Check with your payer for confirmation.
Tips 2 : Intraoperative Cholangiogram is the way of visualizing the common bile duct and flow of bile juice through special x ray machine during surgery. The contrast or radioactive dye is injected into the duct.
Live Sample Chart 1
PREOPERATIVE DIAGNOSIS: Acute acalculous cholecystitis.
POSTOPERATIVE DIAGNOSIS: Acute haemorrhagic cholecystitis.
PROCEDURE: After informed consent was obtained, the patient was brought to the operating room and placed supine on the operating room table. General endotracheal anesthesia was induced. The patient was then prepped and draped in the usual sterile fashion. An #11 blade scalpel was used to make a small infraumbilical skin incision in the midline. The fascia was elevated between two Ochsner clamps and then incised. A figure-of-eight stitch of 2-0 Vicryl was placed through the fascial edges.
The 11-mm port without the trocar engaged was then placed into the abdomen. A pneumoperitoneum was established. After an adequate pneumoperitoneum had been established, the laparoscope was inserted. Three additional ports were placed all under direct vision. An 11-mm port was placed in the epigastric area. Two 5-mm ports were placed in the right upper quadrant.
The patient was placed in reverse Trendelenburg position and slightly rotated to the left. The fundus of the gallbladder was retracted superiorly and laterally. The infundibulum was retracted inferiorly and laterally. Electrocautery was used to carefully begin dissection of the peritoneum down around the base of the gallbladder. The triangle of Calot was carefully opened up. The cystic duct was identified heading up into the base of the gallbladder. The cystic artery was also identified within the triangle of Calot. After the triangle of Calot had been carefully dissected, a clip was then placed high up on the cystic duct near its junction with the gallbladder. The cystic artery was clipped twice proximally and once distally. Scissors were then introduced and used to make a small ductotomy in the cystic duct, and the cystic artery was divided. An intraoperative cholangiogram was obtained. This revealed good flow through the cystic duct and into the common bile duct. There was good flow into the duodenum without any filling defects. The hepatic radicals were clearly visualized. The cholangiocatheter was removed, and two clips were then placed distal to the ductotomy on the cystic duct. The cystic duct was then divided using scissors. The gallbladder was then removed up away from the liver bed using electrocautery. The gallbladder was easily removed through the epigastric port site.
The liver bed was then irrigated and suctioned. All dissection areas were inspected. They were hemostatic. There was not any bile leakage. All clips were in place. The right gutter up over the edge of the liver was likewise irrigated and suctioned until dry. All ports were then removed under direct vision. The abdominal cavity was allowed to deflate. The fascia at the epigastric port site was closed with a stitch of 2-0 Vicryl. The fascia at the umbilical port was closed by tying the previously placed stitch. All skin incisions were then closed with subcuticular sutures of 4-0 Monocryl and 0.25% Marcaine with epinephrine was infiltrated into all port sites. The patient tolerated the procedure well. The patient is currently being aroused from general endotracheal anesthesia. I was present during the entire case.
Answer 47563: Laparoscopy, surgical; cholecystectomy with cholangiography. The provider removes the gallbladder through a laparoscope, a tubular instrument with a light source and camera inserted through the abdominal wall, to treat gallbladder disease. She injects dye and views the biliary ducts using X–ray images.
Live Sample Chart 2
PREOPERATIVE DIAGNOSIS: Acute acalculous cholecystitis.
POSTOPERATIVE DIAGNOSIS: Acute haemorrhagic cholecystitis.
PROCEDURE PERFORMED: Open cholecystectomy.
ANESTHESIA: Epidural with local.
COMPLICATIONS: None.
DISPOSITION: The patient tolerated the procedure well and was transferred to recovery in stable condition. SPECIMEN: Gallbladder.
INTRAOPERATIVE FINDINGS: The patient's gallbladder had some patchy and necrosis areas. There were particular changes on the serosal surface as well as on the mucosal surface with multiple clots within the gallbladder. The patient also had no plane between the gallbladder and the liver bed.
OPERATIVE PROCEDURE: After informed written consent, risks and benefits of the procedure were explained to the patient and discussed with the patient's family. The patient was brought to the operating room after an epidural was performed per anesthesia. Local anesthesia was given with 1% lidocaine. A paramedian incision was made approximately 5 cm in length with a #15 blade scalpel. Next, hemostasis was obtained using electro Bovie cautery.
Dissection was carried down transrectus in the midline to the posterior rectus fascia, which was grasped with hemostats and entered with a #10 blade scalpel. Next, Metzenbaum scissors were used to extend the incision and the abdomen was entered. The gallbladder was immediately visualized and brought up into view, grasped with two ring clamps elevating the biliary tree into view. Dissection was made to identify the cystic artery and cystic duct, which were both easily identified. The cystic artery was clipped, two distal and one proximal to the gallbladder cutting between with Metzenbaum scissors. The cystic duct was identified. A silk tie #3-0 silk was placed one distal and one proximal with #3-0 silk and then cutting in between with a Metzenbaum scissors. The gallbladder was then removed from the liver bed using electro Bovie cautery. A plane was created.
The hemostasis was obtained using the electro Bovie cautery as well as some Surgicel. The gallbladder was then removed as specimen, sent to pathology for frozen sections for diagnosis, of which the hemorrhagic cholecystitis was diagnosed on frozen sections. Permanent sections are still pending. The remainder of the fossa was hemostatic with the Surgicel and attention was next made to closing the abdomen. The peritoneum as well as posterior rectus fascia was approximated with a running #0 Vicryl suture and then the anterior rectus fascia was closed in interrupted figure-of-eight #0 Vicryl sutures. Skin staples were used on the skin and sterile dressings were applied and the patient was transferred to recovery in stable condition.