lfoot56@yahoo.com
Guest
I have this note coded 43274, 43274,59, & 43264,59. Both pancreatic duct and common bile duct stents were placed along with removal of sludge, however; the pancreatic duct stent fell out during the sweeping of the common bile duct. Can I still charge for both stent placements even it one fell out? See op note below. Thank you for you help.
ERCP scope was inserted into the oropharynx. Scope was advanced partial
visualization to the second part of duodenum. Scope was reduced and
ampulla was very prominent and was looking downwards. It was very hard to
engage the sphincterotome into the papilla. I was able to engage the
sphincterotome into the papilla. Guidewire was advanced. It was going
towards common bile duct; however, _____ turned to the left into the PD.
Small injection was given to confirm the placement. Pancreatogram looked
unremarkable. I decided to put a stent inside the pancreatic duct.
Five-centimeter 3-French stent was placed over the guidewire into the
pancreatic duct. Good pancreatic duct drainage was noticed. No contrast
was seen hanging inside the pancreatic duct. After multiple suctioning,
all the contrast came out of the pancreatic duct. Pancreatic duct was left
in place and sphincterotome was once again passed through the scope and
bile duct cannulation was done by changing the angle. Guidewire was
advanced into the common bile duct. This was followed by sphincterotome
advancement. Cholangiogram was obtained, which revealed very dilated
common bile duct. Distal common bile duct was not filling that well.
Sphincterotomy was performed. Then, sphincterotome was withdrawn and
biliary balloon was passed over the guidewire into the common bile duct.
Balloon was inflated to 15 millimeters and contrast was injected. Once
again, dilated common bile duct was noticed along with non-filling of the
distal common bile duct due to a sludge ball. Duct was swept multiple
times. I was not able to pull 15-millimeter balloon from the ampullary
orifice, but I was able to pull 12-millimeter balloon. Very thick bile
along with sludge was seen coming out of the ampullary orifice. Multiple
sweeps were made. While I was making the sweep, pancreatic duct fell out.
By this time, the pancreatic duct had emptied itself out. I decided to put
a biliary stent as I was not convinced that the bile duct is free of all
the sludge. A 10-French 7-centimeter stent was placed over the guidewire
into the common bile duct. Good bile flow was noticed. Very thick sludgy
bile was noticed. Scope was withdrawn. The patient tolerated the
procedure well.
ERCP scope was inserted into the oropharynx. Scope was advanced partial
visualization to the second part of duodenum. Scope was reduced and
ampulla was very prominent and was looking downwards. It was very hard to
engage the sphincterotome into the papilla. I was able to engage the
sphincterotome into the papilla. Guidewire was advanced. It was going
towards common bile duct; however, _____ turned to the left into the PD.
Small injection was given to confirm the placement. Pancreatogram looked
unremarkable. I decided to put a stent inside the pancreatic duct.
Five-centimeter 3-French stent was placed over the guidewire into the
pancreatic duct. Good pancreatic duct drainage was noticed. No contrast
was seen hanging inside the pancreatic duct. After multiple suctioning,
all the contrast came out of the pancreatic duct. Pancreatic duct was left
in place and sphincterotome was once again passed through the scope and
bile duct cannulation was done by changing the angle. Guidewire was
advanced into the common bile duct. This was followed by sphincterotome
advancement. Cholangiogram was obtained, which revealed very dilated
common bile duct. Distal common bile duct was not filling that well.
Sphincterotomy was performed. Then, sphincterotome was withdrawn and
biliary balloon was passed over the guidewire into the common bile duct.
Balloon was inflated to 15 millimeters and contrast was injected. Once
again, dilated common bile duct was noticed along with non-filling of the
distal common bile duct due to a sludge ball. Duct was swept multiple
times. I was not able to pull 15-millimeter balloon from the ampullary
orifice, but I was able to pull 12-millimeter balloon. Very thick bile
along with sludge was seen coming out of the ampullary orifice. Multiple
sweeps were made. While I was making the sweep, pancreatic duct fell out.
By this time, the pancreatic duct had emptied itself out. I decided to put
a biliary stent as I was not convinced that the bile duct is free of all
the sludge. A 10-French 7-centimeter stent was placed over the guidewire
into the common bile duct. Good bile flow was noticed. Very thick sludgy
bile was noticed. Scope was withdrawn. The patient tolerated the
procedure well.