General Surgery Coding Alert

Question: Which code(s) should I use to report cholecystectomy with cholangiogram and exploration of common bile duct?

Texas Subscriber

Answer: For an open procedure, you should report 47610 (Cholecystectomy with exploration of common duct). If the surgeon performed the cholecystectomy and exploration endoscopically, you should instead report 47564 (Laparoscopy, surgical; cholecystectomy with exploration of common duct).
 
You should report a single code for this procedure, even if the surgeon began the procedure endoscopically and had to convert to an open procedure. CPT rules dictate that you should report the open procedure only.
 
If the surgeon converts a laparoscopic cholecystectomy to an open chole-cystectomy, be sure to include V64.41 (Laparoscopic surgical procedure converted to open procedure) as a secondary diagnosis. Using V64.41 does not affect the primary diagnosis (for instance, 575.0, Acute cholecystitis), which should remain the same, regardless of the surgeon's surgical approach.
 
You should also add additional diagnosis codes to describe the conditions that lead to the decision to change from laparoscopic to open approach. These conditions could include adhesions, abscess or others.

 - Technical and coding advice for You Be the Coder and Reader Questions provided by Marcella Bucknam, CPC, CCS, CPC-H, CCS-P, HIM program coordinator at Clarkson College in Omaha, Neb.