Radiology Coding Alert

Find out how your interpretation of this report matches with our experts'

Test your coding savvy and see how well you mastered the techniques you learned in "Bone Up on How to Code From Bona Fide Reports" by trying your hand at coding this clinical example.

Dictated Report: The patient had extensive bowel resection and has a cholecystotomy tube and a jejunostomy tube.

Isovue 300 was injected through the cholecystotomy tube. Upon injection of the tube, there is immediate opacification of what appears to be a loop of jejunum that is draining into the bag via a jejunal drain. There is no opacification of the biliary system. It is possible that the gallbladder is contracted around the tube although tube position outside the gallbladder is not excluded but felt to be less likely.

The course of the tube appears to be appropriate.

Conclusion: There appears to be a fistula between the gallbladder and the jejunum.


 
Answer: This report appears to be for "a contrast exam via an existing biliary system catheter in a patient with a biliary fistula. What makes it so unique is the presence of both a cholecystotomy tube and a jejunostomy tube with an abnormal communication between the two," says Jackie Miller, RHIA, CPC, senior consultant for Coding Strategies Inc. in Powder Springs, Ga.

Experts warn: Pay close attention to the reports you get - don't just assume they fall into the categories you see most often. For example, a procedure very similar to the one in the sample report could be performed to create a connection between the biliary system and the jejunum, but this would not qualify as a fistula. Another possibility is that the wrong tube was injected and that the jejunostomy tube was visualized rather than the biliary tube. A fistula diagnosis wouldn't work here either. Check the report for discussions of anatomy by the radiologist and surgeon that indicate your report may be different from the average procedure.

What to do: Once you confirm that the report you have is for a true fistula, Marvel J. Hammer, RN, CPC, CHCO, owner of MJH Consulting in Denver, suggests looking for specifics when you've determined the general procedures involved:

What medication/contrast was injected?

Via what route - intravenous, intra-arterial, intra-articular, physician-placed tube, intrathecal?

What form of Radiology visualization was used?

What were the findings?

Diagnosis designation: The report's conclusion indicates a fistula - an abnormal duct or passage. Your ICD-9 index directs you to use 575.5 for a fistula of the gallbladder, Miller says. If you look up fistula of jejunum, the index points you to 569.81 (Fistula of  intestine, excluding rectum and anus). But note the other important exclusion under the descriptor: "excludes: fistula of intestine to internal organs." So, you know 575.5 is the correct choice for this particular fistula.

CPT concerns: You need to code for the injection procedure and the radiologic supervision and interpretation with this report, Hammer says.

For the injection, you know that the patient had a cholecystotomy tube prior to this procedure and this was where the physician injected the Isovue 300. If you keep this in mind when looking for your procedure code, you'll easily choose 47505 (Injection procedure for cholangiography through an existing catheter [e.g., percutaneous transhepatic or T-tube]).

This code conveniently directs you to use 74305 (Cholangiography and/or pancreatography; through existing catheter, radiological supervision and interpretation) for radiological supervision and interpretation.

Self-defense: If your physician wants tips on how to create a more complete report, recommend that he include the solution quantity of any injections performed and specify the type of radiology visualization used, Hammer says. If he's not convinced, let him know that this information is good to have for liability purposes. If a patient has a reaction to contrast, the record will prove that the right amount was correctly administered.