# BILIARY- Help



## chembree (May 11, 2009)

Can someone help me code this. 
I may be way off but this is what I have...
47505
74305
74363
47525
75984

I have not checked medlearn yet so i do not have my modifiers, yet. 

Thanks for the help!

 EXAM:

   1. Biliary check and change.
   2. Biliary dilatation.

   TECHNIQUE: The risk, benefits and the procedure itself were explained to
   the patient and informed written consent was obtained. The patient was
   placed on the table in the supine position. 4.5 grams Zosyn IV was
   administered for prophylaxis prior to starting the procedure. The right
   flank was cleaned and draped in a sterile fashion including the existing
   biliary catheter. A small amount of contrast was injected, which
   demonstrated frank extravasation into the peroneal cavity. A stiff
   angled glidewire was then used to negotiate through the existing
   catheter into small bowel loops. The catheter was removed. A 7-French
   long vascular sheath was then inserted through which a Kumpe catheter
   was placed into the small bowel. The wire was exchanged for an ultra
   stiff Amplatz wire. A pullback cholangiogram was then performed. A 5 mm
   x 2 cm balloon was then inserted and used to dilate from the common bile
   duct into the small bowel. Subsequently, under ultrasound guidance 1%
   lidocaine used to anesthetize the soft tissues adjacent to the access
   site. A 4-French catheter preloaded over a needle was then inserted
   under ultrasound guidance into the perihepatic space. Approximately 10
   mL of bloody bilious fluid was removed. Further fluid cannot be removed.
   At this time, a 10 French biliary drain was then advanced over the
   existing wire into the small bowel. Advancement was markedly limited and
   the pigtail could not be formed. The catheter was secured in place using
   2-0 silk and a sterile dressing was applied. Catheter attached to the
   gravity bag.

   FINDINGS:

   1. Initial contrast injection demonstrates extravasation of contrast in
   the perihepatic space secondary.
   2. Pullback cholangiogram continues to demonstrate complete occlusion of
   the mid to proximal common bile duct without contrast extending into
   small bowel.  There is continued moderate left and right biliary ductal
   dilatation however, it is markedly improved from previous examination
   and the previous filling defects have resolved. Note is made that prior
   to placement of the Amplatz wire, confirmation of location  in small
   bowel was confirmed with contrast administration.

   3. Successful placement of 10 French biliary drain internal/external
   however distal pigtail could not be performed. Further advancement
   cannot be performed.

   IMPRESSION:

   1.. Interval pulling back of the 8 French biliary drainage catheter into
   the perihepatic space. This likely caused mild amount of biliary leak
   which elevated patient's total bilirubin. There was still a moderate
   amount of bile extending from the original 8 French drainage catheter
   into drainage bag prior to procedure.

   2. Interval improvement in the intra and extrahepatic ductal dilatation
   with resolution of previous common bile duct clots/debris.

   3. Continued complete obstruction of the mid common bile duct without
   contrast extending into the small bowel even after dilatation.

   4. Successful placement of 10 French internal external biliary drain.
   Note is made again that distal pigtail cannot be well formed therefore
   it is potential that this catheter will migrate out as well.  Therefore,
   serial KUBs to be performed to document adequate positioning. After
   patient's bilirubin begins to decrease and the patient improves, attempt
   at advancing catheter deeper into the small bowel with formation of the
   pigtail to secure in place or down sizing to an 8 French catheter in
   order form the pigtail in small bowel may be performed. Possibility of
   stent placement exists however there is potential kinking of the stent
   do to tortuosity of the distal duct to anastomosis of the small bowel.

   5. Perihepatic free fluid, some of which is bilious. Patient will be
   admitted overnight for 23 hour observation.  Repeat CT scan to evaluate
   perihepatic fluid is recommended with possible CT-guided aspiration.

   6. Recommend catheter remain to gravity bag. The above findings were
   discussed with Perrino, as well as IMS and the patient will be admitted
   overnight.


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## MLS2 (May 11, 2009)

let's see...I see the 74305/47505-51 and the exchange of the biliary cath: 75984/47525

They did dilate the common bile duct so i'm thinking 74363/47555

Almost sounds like a 76942/49080 was also done (fluid removed under US from perihepatic space)



any other thoughts on this one?


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