# Biliary Exchange question



## Liza559 (Sep 14, 2010)

Hello all,
I am verifying what code would be used along with, when pt. has 47505/74305. Guidewire inserted through existing biliary cath and advaced to sm.bowel. Catheter removed, over wire a sheath is inserted & advanced as distally as possible. A 5 fr diagnostic cath is insered to gastroenteric anastomosis. At completion of procedure guidewire was left in place through diagnostic cath along with 8 fr sheath. Pt then was transferred to the GI dept for their procedure.
Pt. returns to IR and asked to reinsert external biliary catheter.
What would you code this as? The 1st part is what I am really questioning. Should an exchange 47525/75984 be billed for part 1 and if so, if there is no biliary catheter left in place only a diagnostic catheter, then we are getting hit with a device code edit? 
Thoughts?
Thanks, Liza


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## dpeoples (Sep 14, 2010)

Liza559 said:


> Hello all,
> I am verifying what code would be used along with, when pt. has 47505/74305. Guidewire inserted through existing biliary cath and advaced to sm.bowel. Catheter removed, over wire a sheath is inserted & advanced as distally as possible. A 5 fr diagnostic cath is insered to gastroenteric anastomosis. At completion of procedure guidewire was left in place through diagnostic cath along with 8 fr sheath. Pt then was transferred to the GI dept for their procedure.
> Pt. returns to IR and asked to reinsert external biliary catheter.
> What would you code this as? The 1st part is what I am really questioning. Should an exchange 47525/75984 be billed for part 1 and if so, if there is no biliary catheter left in place only a diagnostic catheter, then we are getting hit with a device code edit?
> ...



This is difficult to answer without more detail, however, I would be inclined to use 
47525 or 47530 (depending on more detail)and of course 75984.
I do not see 47505/74305 documented above but that would make sense.

What procedure did the GI department perform?

HTH


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## Liza559 (Sep 15, 2010)

I did not include the complete dictation that is why you do not see 47505/74305 stated but the procedure the GI dept. performed was a stent placement via endoscopy but used the wire as a guidance that was placed from our section. Then the patient was returned to IR and asked to place a external biliary cath.


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## msncoder (Sep 15, 2010)

This is a complete shot in the dark here...but to me it sounds like the external biliary cath was removed and a guidewire placed just to keep the site opened and to keep the cath from being in the way before the patient went to the OR for their GI stent procedure and then returned to the IR department to "replace" the external cath. Did the report give you any indication why the biliary cath needed to be removed? If it was due to obstruction/malfunction then I would say that the guidewire & diagnostic cath mentioned in the first part would be inherent to the return IR visit where the biliary cath was replaced and you would charge 47525/75984 (C1729 for the cath but in most cases it's not payable separately and considered a packaged service/item). If it was removed only as prevention/precaution for the GI stent procedure then I do not think it should be charged as a replacement.....could be wrong on that one so I'm emailing an expert from Medlearn to clarify......maybe an E/M but just from the info you provided it does not sound like this was a diagnostic procedure that can be billed. 

Danny, what do you think because I know you're about to disagree with me!!!!


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## Liza559 (Sep 15, 2010)

Thank you for getting back to me, would this be helpful to you if a included the complete dictation on this procedure?


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## msncoder (Sep 15, 2010)

Definitely! Maybe there's something somewhere on the report that may indicate the intent of the exam/procedure and clear up several questions....I hope!


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## dpeoples (Sep 15, 2010)

msncoder said:


> This is a complete shot in the dark here...but to me it sounds like the external biliary cath was removed and a guidewire placed just to keep the site opened and to keep the cath from being in the way before the patient went to the OR for their GI stent procedure and then returned to the IR department to "replace" the external cath. Did the report give you any indication why the biliary cath needed to be removed? If it was due to obstruction/malfunction then I would say that the guidewire & diagnostic cath mentioned in the first part would be inherent to the return IR visit where the biliary cath was replaced and you would charge 47525/75984 (C1729 for the cath but in most cases it's not payable separately and considered a packaged service/item). If it was removed only as prevention/precaution for the GI stent procedure then I do not think it should be charged as a replacement.....could be wrong on that one so I'm emailing an expert from Medlearn to clarify......maybe an E/M but just from the info you provided it does not sound like this was a diagnostic procedure that can be billed.
> 
> Danny, what do you think because I know you're about to disagree with me!!!!



hmmm...actually I agree with everything you said except the last part about maybe using a E/M code, but I like your reasoning

Our IR docs often do the stent placement (47556/74363) that I think the GI people did in this case, and they usually replace the drainage catheter at the same time (47525/75984) and I do indeed code both procedures when performed.

The note would definately clarify the intent.

HTH


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## Liza559 (Sep 15, 2010)

I was incorrect on my original scenrio. I was reviewing charges as well for this procedure and located only an external catheter charge that is why the original ? was to place the external. I did not see the 2nd dictation. We are correcting this from our end but I can see now from the 2nd dictation it was for a int/ext placement. 

Here is the complete dictations for both visits.
1st encounter:
Clinic. HX: Choledocholithiasis
Comparison: Transhepatic Cholangiogram-5/17/2010
Technique: Patient's indwelling percutaneous transhepatic biliary drainage catheter injected with contrast material, opacifying a nondilated biliary tree. Large intraluminal stone redemonstrated, as previously noted.
Guidewire inserted through existing biliary catheter and advanced into small bowel. Catheter removed. Over this guidewire an 8 French vascular sheath was inserted and advanced as distally as possible. Next, a 5 French diagnostic catheter was inserted through this sheath and advanced in retrograde fashion as much as possible. Catheter advanced to level of gastroenteric anastomosis. Multiple attempts were then made to pass a guidewire through this anastomosis into lumen of the stomach, but were unsuccessful.
At completion of procedure guidewire was left in place through 5 French diagnostic catheter, with both of these located at level of gastroenteric anastomosis. 8 French vascular sheath left in place, as well.
Impression: Successful retrograde placement of sheath, catheter and guidewire to level of gastroenteric anastomosis.

Encounter 2:
Clinical HX: Same as above
Comparison: Same day, earlier exam
Technique:
Patient returns to interventional radiology suite folllowing interval endoscopic removal of previously described moderate to large sized stone within common bile duct. Asked to reinsert percutaneous transhepatic biliary drainage catheter as a temporary precautionary measure.
Guidewire inserted through existing 5 French diagnostic catheter, which was subsesquently removed, as was an indwelling 8 French vascular sheath. Over this guidewire a new 10 French multiside hole biliary drainage catheter was inserted and side holes placed such that biliary tree was adequately drained. Limited cholangiography perfomred, which did not redemonstrate previously noted stone. Smaller apparent filling defects within biliary tree likely represent areas of thrombus and or debris.
Catheter left in place, draining well internally.
Impression: Successful percutaneous biliary drainage catheter replacement.


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## dpeoples (Sep 16, 2010)

Liza559 said:


> I was incorrect on my original scenrio. I was reviewing charges as well for this procedure and located only an external catheter charge that is why the original ? was to place the external. I did not see the 2nd dictation. We are correcting this from our end but I can see now from the 2nd dictation it was for a int/ext placement.
> 
> Here is the complete dictations for both visits.
> 1st encounter:
> ...



Encounter 1
47505/74305
I would not code an exchange (at this po0int) because the new cath was placed to facilitate the stone extraction.

Encounter 2
47525/75894
or 
47530/75894 if new catheter is larger and has more holes ( I consider that a revision) than the one removed prior to the stone extraction.

HTH


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## Liza559 (Sep 16, 2010)

Thank you fvery much with your help with this one.


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