allowry5
Contributor
Can someone please guide me to the correct code for the below op note. I am looking for the correct CPT code for the cyst that could not be biopsied or aspirated but was punctured. Thanks
Procedure performed:
Pancreas:
The PD measures 2.8 mm in the head, 3 mm in the genu, 2.4 mm in the body and 1 mm in the tail of the pancreas.
The parenchyma in the pancreas is normal in appearance on EUS imaging.
There is an anechoic thin wall 16.3 mm cyst seen in the head of the pancreas.
There is 1 internal septation seen within the cyst.
There are no mural nodules or solid components seen within the cyst.
The cyst connects to the main PD by a thin filamentous side branch.
This represents a Side Branch IPMN.
Cellvizio (CLE) findings:
Reticular pattern with finger like projections, this is consistent with IPMN.
The CBD measures 5.6 mm in the extrahepatic segment.
There is no wall thickening, sludge or stones seen in the gallbladder.
No significant left or right lobe liver lesions seen on visualized survey views of the liver.
A small amount of bleeding was seen after the cyst was punctured, in the duodenal bulb this stopped spontaneously.
A resolution clip was placed prophylactically.
No bleeding seen at the end of the procedure.
Procedure performed:
1.Linear Endoscopic ultrasound with Cellvizio of the pancreatic cyst
2.Linear Endoscopic ultrasound to the pancreatic/biliary system with biopsy of Pancreas
3.EGD2.Linear Endoscopic ultrasound to the pancreatic/biliary system with biopsy of Pancreas
Preoperative diagnosis:
1. Hx of Side Branch IPMN - Enlarging Pancreatic Cyst
Postoperative diagnosis:
Postoperative diagnosis:
1. Side Branch IPMN
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Impression:
EGD:
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Impression:
EGD:
Small amount solid food was seen in the body of the stomach.
EUS:
The ampulla is normal in appearance on EUS imaging.
EUS:
The ampulla is normal in appearance on EUS imaging.
Pancreas:
The PD measures 2.8 mm in the head, 3 mm in the genu, 2.4 mm in the body and 1 mm in the tail of the pancreas.
The parenchyma in the pancreas is normal in appearance on EUS imaging.
There is an anechoic thin wall 16.3 mm cyst seen in the head of the pancreas.
There is 1 internal septation seen within the cyst.
There are no mural nodules or solid components seen within the cyst.
The cyst connects to the main PD by a thin filamentous side branch.
This represents a Side Branch IPMN.
-s/p 22 g Sharkcore needle was used to puncture cyst, and then the moray forceps was advanced thru the channel and used for biopsy of the wall of the head/uncinate of pancreas - due to malfunction of the equipment we were unable to aspirate the cyst.
Cellvizio (CLE) findings:
Reticular pattern with finger like projections, this is consistent with IPMN.
The CBD measures 5.6 mm in the extrahepatic segment.
There is no wall thickening, sludge or stones seen in the gallbladder.
No significant left or right lobe liver lesions seen on visualized survey views of the liver.
A small amount of bleeding was seen after the cyst was punctured, in the duodenal bulb this stopped spontaneously.
A resolution clip was placed prophylactically.
No bleeding seen at the end of the procedure.