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Radiology Coding Alert

Biliary Coding Flows From Operative Report

Published on Sat Dec 01, 2001

Attention to detail in the operative report is vital to correctly reporting interventional procedures involving cholangiography and the biliary system. Coders must not only pair the appropriate procedure codes with radiological supervision and interpretation services (RS&I) but also pay close attention to global surgical periods and appropriate modifiers.
 
Interventional radiologists often diagnose and treat patients with conditions that interfere with the flow of bile through the biliary system. Obstructing lesions, including intraductal and extraductal tumors, inflammatory strictures and stones, can restrict flow between the liver, gallbladder, pancreas and the gastrointestinal tract, leading to dilatation of the ducts, infection and blood chemistry imbalances (e.g., 576.2, obstruction of bile duct). Radiologists employ a variety of therapeutic techniques to relieve pressure and correct the underlying condition, according to Gary Dorfman, MD, FACR, FSCVIR, past president of the Society for Cardiovascular and Interventional Radiology (SCVIR) and president of Health Care Value Systems in North Kingstown, R.I.
 
When diagnosing a suspected biliary condition after noninvasive imaging, radiologists will perform cholangiography, imaging studies to identify what is blocking or interfering with the normal flow of bile. Lisa Grimes, RT [R], radiology special procedures technologist and reimbursement specialist for the University of Texas/Houston Health Science Center, says one of two surgical codes and an RS&I code would be assigned for the study.

How To Report Imaging Studies

In one instance, the radiologist will insert a needle (with or without an intracatheter or sheath) directly into the biliary system, and bile will be aspirated and subsequently tested for infection, Grimes says. Then, contrast will be injected into the bile ducts and liver, and images obtained. This procedure would be reported with surgical CPT 47500 (injection procedure for percutaneous transhepatic cholangiography) and RS&I CPT 74320 (cholangiography, percutaneous, transhepatic, radiological supervision and interpretation).
 
At other times, this diagnostic procedure will be performed through an existing T-tube, which may have been inserted in the patient during an earlier surgical procedure, or through a previously placed percutaneous transhepatic drainage catheter. Dorfman notes that a T-tube is a device often implanted in the common bile duct intraoperatively to provide external drainage when the flow of bile is restricted. When imaging is performed through the T-tube, 47505 (injection procedure for cholangiography through an existing catheter [e.g., percutaneous transhepatic or T-tube]) is reported instead of 47500. RS&I code 74320 would again be assigned. Code 47500 has been assigned 1.96 work relative value units (RVUs), compared with 0.76 for 47505. This is understandable because 47505 is performed through an existing opening into the biliary system and requires less physician work "" he says.
 
While 47500 and 47505 are classified as diagnostic codes Dorfman says they are most frequently used prior to therapy. ""Often interventional radiologists perform cholangiography to obtain images and information allowing them to proceed with the medical decision-making to select and perform other therapies in the most effective manner "" he says. ""In these cases the injection and RS&I codes would be reported in addition to the subsequent procedure codes.""

Identifying Therapeutic Procedures

Once the condition has been diagnosed the radiologist will often proceed with immediate therapeutic interven-tion which might involve catheterization to allow bile drainage or stent placement to open a stricture. According to Dorfman percutaneous transhepatic catheterization (PTC) is often used as a temporary solution when the patient has an infection. In this case a pigtail catheter is introduced over a guidewire into an obstructed bile duct. ""The physician then dilates a tract through the liver to allow external drainage "" he says. This would be reported with 47510 (introduction of percutaneous transhepatic catheter for biliary drainage) and 75980 (percutaneous transhepatic biliary drainage with contrast monitoring radiological supervision and interpretation).
 
Once the infection is under control and the bile ducts have decompressed the radiologist may return to the interventional suite and place a stent which is described in 47511 (introduction of percutaneous transhepatic stent for internal and external biliary drainage). ""In cases where there is a significant infection and radiologists are encountering a great deal of resistance negotiating the bile duct they won't want to risk introducing bacteria into the bloodstream which could result in a serious case of biliary sepsis "" Dorfman says. ""Therefore they will postpone placing the stent at that time and instead catheterize the patient to allow drainage."" Like 47510 47511 is accompanied by an RS&I code in this case 75982 (percutaneous placement of drainage catheter for combined internal and external biliary drainage or of a drainage stent for internal biliary drainage in patients with an inoperable mechanical biliary obstruction radiological supervision and interpretation).
 
If cholangiography was performed before either therapeutic procedure Dorfman notes it would be reported in addition to the catheterization or stent placement. For instance the physician may have conducted an imaging study to localize a stricture and immediately placed the percutaneous transhepatic catheter.  

Either 47500 or 47505 would be reported with 74320 as well as 47510 and 75980. ""However if the radiologist repeats the cholangiography after PTC it would not be separately reportable "" he says. ""The description for RS&I code 75980 clearly states that contrast monitoring to ensure the correction position of the catheter is included.""

Global Periods and Modifiers

Although it is common for a stent to be placed a day or two after PTC Grimes cautions coders to be aware of the global periods that affect the service. ""Code 47510 has a 90-day global period which means that routine pre- and postoperative services are included in the surgical service "" she says. Typically 47511 may not be reported within that global period. However when radiologists plan a two-part procedure (e.g. performing PTC and placing a stent a day or two later when an infection has been treated) both procedures may be billed. ""Coders would append modifier -58 (staged or related procedure or service by the same physician during the postoperative period) to indicate the medical necessity of both services "" she says.
 
If complications arise and an unplanned although related procedure must be performed modifier -78 (return to the operating room for a related procedure during the postoperative period) would be appended to the subsequent service Grimes notes. ""Also the patient may need another procedure for a totally unrelated condition like filter placement for deep vein thrombosis "" she says. ""If a situation like this arises the second procedure would be modified with modifier -79 (unrelated procedure or service by the same physician during the postoperative period).""

Subsequent Procedures

Follow-up procedures may also be performed after the catheter has been placed Dorfman says. ""For instance biliary crystals may form and create an obstruction in the catheter and the radiologist will need to replace the blocked device "" he says. ""This is reported with 47525 (change of percutaneous biliary drainage catheter) and 75984 (change of percutaneous tube or drainage catheter with contrast monitoring [e.g. gastrointestinal system genitourinary system abscess] radiological supervision and interpretation)."" He adds that if cholangiography is performed before the catheter exchange 47505 and 74320 may also be reported.
 
At other times a T-tube must be repositioned or exchanged. ""It may become dislodged from the liver or perhaps even fractured "" Dorfman says. In this case 47530 (revision and/or reinsertion of transhepatic tube) is used along with 75984.
 
Besides re-establishing proper bile flow interventional radiologists provide other services related to the biliary system. These are described in 47552-47556. Two of these codes are assigned when the radiologist takes biopsy samples Dorfman explains: 47552 (biliary endoscopy percutaneous via T-tube or other tract; diagnostic with or without collection of specimen[s] by brushing and/or washing [separate procedure]) and 47553 ( with biopsy single or multiple). ""These codes typically come into play with patients who have not been previously diagnosed with cancer. However during cholangiography the radiologist identifies a mass and performs the biopsy."" Code 47552 describes a brush biopsy he notes and 47553 a needle biopsy.
 
Codes 47555 ( with dilation of biliary duct stricture[s] without stent) and 47556 ( with dilation of biliary duct stricture[s] with stent) are used when the radiologist opens a narrowing of a bile duct with balloon dilation Grimes says. Code 47555 is used when a temporary stent or no stent is positioned while 47556 is assigned when a permanent plastic or metal device is placed. ""This might be a bit confusing "" Dorfman says ""because 47555 reads 'without stent.' However that language refers to a permanent stent that has no external access not a temporary one with retained external access.""
 
Imaging guidance codes 74363 (percutaneous trans-hepatic dilation of biliary duct stricture with or without placement of stent radiological supervision and interpretation) and 75982 are also reported with 47552-47556.
 
Some confusion arises when considering 47554 (biliary endoscopy percutaneous via T-tube or other tract; with removal of stone[s]) Dorfman adds. CPT contains a second virtually identical code to describe removal of bile duct stones: 47630 (biliary duct stone extraction percutaneous via T-tube tract basket or snare [e.g. Burhenne technique]). He recommends using 47630: ""I have always used this code without problem and it is also recommended by SCVIR."" Code 47554 carries a work RVU of 9.06 while 47630 is valued at 9.11 work RVUs.
 
Note: Codes 47552-47556 are endoscopy codes and many coding experts maintain they cannot be used for percutaneous procedures that do not involve endoscopy. While professional organizations like SCVIR continue to recommend them they may not withstand an audit. Although the endoscopy codes describe procedures similar to what is being performed CPT 2002 states it is not correct to select a code that's ""close"" to the procedure. If there is no exact description CPT requires an unlisted-procedure code be used instead. Radiology coders should  ask individual payers for the most appropriate manner to code these services.
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