Wiki ERCP Question

[tfrick2]

Here's my scenario:

A GI doctor does an ERCP on a patient. His dictated report only mentions the biliary tract and gallbladder being visualized. However, the radiologist's dictation mentions that the pancreatic duct is visualized as well.

Does the GI doctor needs to dictate an addendum to include the pancreatic duct, or is that considered to be incidental on the part of the radiologist?

I hope this makes sense! I will be posting this same scenario on the radiology forum as well, to get some opinions from that side.

Thank you for your help!

Tracy, CPC, CPC-H

 

[coachlang3]

Personally, I would think the reports would need to match.

According to my coding companion 2001 book by Ingenix the 43260 states the common bile duct and the whole biliary tract including the gallbladder are visualized. So if your doc didn't visualize the pancreatic duct I would say it was a reduced ERCP.

I have one doc that does a ton of ERCP's and after looking through some quickly, he always visualizes the PD.

So maybe your doc just forgot to state that this time?

 

[tfrick2]

Personally, I would think the reports would need to match.

According to my coding companion 2001 book by Ingenix the 43260 states the common bile duct and the whole biliary tract including the gallbladder are visualized. So if your doc didn't visualize the pancreatic duct I would say it was a reduced ERCP.

I have one doc that does a ton of ERCP's and after looking through some quickly, he always visualizes the PD.

So maybe your doc just forgot to state that this time?

That is a definite possibility. I think I will ask the GI doc to review his dictation. The whole thing just wasn't sitting well with me.

Thank you for your advice!
Tracy