# Biliary Drainage Catheters



## BJTRAISTER (Aug 17, 2012)

I am looking for another opinion on this matter.  Documentation that I have seen indicates that code 47511 is generally only reported once per side per day (so 2 units per day) - my compliance department is trying to tell me that I should be coding more than that is the doctor places more cathers (say one right anterior, one right posterior, one left posterior).  Here is an example:

Indications: 61-year-old female with the history of cholangiocarcinoma. Patient has persistent hyperbilirubinemia despite biliary stent placement. The biliary stent was removed yesterday at an outside hospital. Interventional radiology consult for percutaneous PTC and biliary drainage catheter placement.

Procedure and Findings:
 The procedure was performed in the VIR suite following informed consent and a time out.  The patient received preprocedure IV antibiotics.  The patient was intubated and received general anesthesia under the care of an anesthesiologist.  With the patient
 in the supine position, the upper abdomen was prepped and draped in the usual sterile fashion.

 Left PTC:
 A subxiphoid percutaneous entry site was identified.  Using ultrasound guidance, a 15 cm, 21-G Echo Tip needle was inserted into a left bile duct. Using fluoroscopic guidance, contrast was gently injected through the needle which confirmed that a left bile duct was entered successfully. There were multiple dilated and tortuous biliary ducts within an atrophic left lobe. Given the angle of access and the limited wire purchase, cannulation of the left biliary system was difficult. Using fluoroscopic guidance, the echo tip needle was again placed in a slightly more central location with a better lateral medial angle. A 0.018 inch Nitrex guidewire was advanced through the needle into a left biliary duct. There was
 obstruction to the common bile duct. The needle was exchanged for a Greb set. The 0.018 inch guidewire was exchanged for a 0.035 inch guidewire. Using multiple wires and catheters, access to the common duct and subsequently small bowel was obtained. This was done without difficulty. A 5 French catheter was placed within the small bowel and secured.

 Right posterior PTC:
 Using fluoroscopic guidance, a percutaneous entry site was identified corresponding to the inferior liver along the posterior-axillary line at a lower intercostal space.  Using
 fluoroscopic guidance, a 15 cm, 21-G Echo Tip needle was inserted, aimed towards the cephalad liver. After several needle passes, a right posterior bile duct was successfully entered as confirmed by contrast injection. There was moderate dilatation of the posterior
 biliary system. A 0.018 inch Nitrex guidewire was advanced through the needle into a right posterior biliary duct.  The needle was exchanged for Greb and The 0.018 inch guidewire was exchanged for a 0.035 inch guidewire. Multiple unsuccessful attempts to gain access to the common bile duct past the obstruction were made. A catheter was left in place while attention was paid to the right anterior system.

 Right anterior PTC:
 Using fluoroscopic guidance, a percutaneous entry site was identified corresponding to the inferior liver along the anterior-axillary line at a lower intercostal space.  Using fluoroscopic guidance, a 15 cm, 21-G Echo Tip needle was inserted, aimed towards the cephalad liver.  After several needle passes, a right anterior bile duct was successfully entered as confirmed by contrast injection. There was also dilatation of the bile duct with
 complete occlusion. Accessed was achieved using a superior branch of the right anterior biliary system. A more inferior branch of the right anterior biliary system was chosen given the better trajectory for passing the obstruction. A 0.018 inch Nitrex guidewire was
 advanced through the needle into a right anterior biliary duct. The needle was exchanged for Greb set. Multiple attempts to gain access to the common bile duct were again made without success. Access to the left biliary system was then eventually achieve after multiple
 attempts. Cholangioplasty was then performed using a 8 mm balloon to facilitate reversal of the course of the catheter back into the common hepatic duct.. The catheter was exchanged for a 5 French TC catheter. Using fluoroscopic guidance, the catheter was reversed and a wire was placed within the common bile duct and subsequent in the small bowel. The 5 French catheter was then placed into the small bowel.

 Right posterior PTC:
 Simultaneous cholangioplasty through the right anterior and left biliary systems was performed. The balloons were deflated and immediately a 10 to gain access using the right posterior system into the common bile duct past the obstruction was made. This was
 unsuccessful. Over the wire, a Sos Omni catheter was placed and wire access across obstruction of the right posterior system into the left biliary system was made. Cholangioplasty was again performed using a 6 mm balloon. The TC catheter was again placed and and was reversed into the common bile duct. At this point, it was discovered
 that the right posterior biliary system drain directly into the left biliary system.

 Access to the right posterior, right anterior, and left biliary systems were obtained at this point. The clinical decision to place drainage catheters over this wire access was made.

 Biliary catheter placement:
 Biliary catheter placement was performed using fluoroscopic guidance at each PTC site in a similar fashion.  Dilation to 8-F was carried out over the guidewire.  Each internal / external biliary drainage catheter was placed into position over the guidewire.

 A fluoroscopic image demonstrated each biliary catheter was positioned with the upper side holes along the peripheral intrahepatic ducts and the distal catheter was in the small bowel.

 Each biliary catheter was secured with suture and dressed in the usual fashion.  Each catheter was placed to bag drainage.


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## MLS2 (Sep 6, 2012)

I would code for the three catheters, two on the right and one on the left.
looks like you have 47555/74363 as well of the right anterior and left biliary systems.


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