Jenannurb
Contributor
MD did an ERCP w/ stent (43274) and also attempted to place duodenal stent w/o success.
dye was injected, pt re positioned but to no avail.
Can we code (as he wants to) for the unsuccessful stent placement? What CPT would be appropriate?
See op note below.
""Procedure: ERCP with sphincterotomy, biliary stent placement, attempted duodenal stent placement (EGD with fluoro)
Date of Procedure: 5/10/2017
Pre-operative Diagnosis: pancreas cancer, duodenal obstruction
Sedation: GETA
ASA Class: 3
Mallampati Class:III (soft and hard palate and base of uvula visible)
Procedure Details
Informed consent was obtained for the procedure, including conscious sedation. Risks including infection, perforation, hemorrhage, adverse drug reaction and aspiration and pancreatitis were discussed. The patient was placed in the left lateral simiprone position.* Based on the pre-procedure assessment, including review of the patient's medical history, medications, allergies, and review of systems, he had been deemed to be an appropriate candidate for GETA sedation.* He was monitored continuously with ECG tracing, pulse oximetry, blood pressure monitoring, and direct observation.
* *
The duodenoscope was inserted into the mouth and advanced under direct vision to the second portion of the duodenum.
Findings:
Survey of the esophagus, stomach and duodenum revealed retained fluid/food in stomach. Over 2 liters suctioned out.
The major papilla was identified in the second portion of the duodenum.* A Microvasive Hydrotome catheter was positioned just inside the major papilla.
A guidewire was advanced into the common bile duct under fluoroscopic guidance without the need for contrast injection.* The catheter was then advanced over the wire into the region of the common bile duct.* Next a cholangiogram was obtained
.
This demonstrated distal cbd stricture.
A sphincterotomy was performed.* Next 10 x 60 uncovered biliary stent placed to level of cystic duct takeoff and extended four interstices into duodenum.
There was no narrowing in first/second/third portions of duodenum. Dye was injected into duodenum and there was narrowing at ligament of treitz. Pt's head was put in trendelenburg position and dye failed to go through into jejunum nor did it when head was elevated.
It was determined stricture was too far down to stent. F/u imaging showed no extraluminal air/contrast. The patient tolerated the procedure well.
Impression:* *
Distal biliary stricture s/p ercp/sphincterotomy/stent placement
Small bowel stricture near ligament of treitz not amenable to standard duodenal stenting
Recommendations:
Will discuss results with pt, consider surgical gastrojejunostomy vs surgical jejunostomy. Favor the former given pt's aspiration risk. Another alternative would be palliative care. In some cases we perform EUS Guided Gastrojejunostomy with Axios stent, but pt's anatomy is not favorable for this.""
dye was injected, pt re positioned but to no avail.
Can we code (as he wants to) for the unsuccessful stent placement? What CPT would be appropriate?
See op note below.
""Procedure: ERCP with sphincterotomy, biliary stent placement, attempted duodenal stent placement (EGD with fluoro)
Date of Procedure: 5/10/2017
Pre-operative Diagnosis: pancreas cancer, duodenal obstruction
Sedation: GETA
ASA Class: 3
Mallampati Class:III (soft and hard palate and base of uvula visible)
Procedure Details
Informed consent was obtained for the procedure, including conscious sedation. Risks including infection, perforation, hemorrhage, adverse drug reaction and aspiration and pancreatitis were discussed. The patient was placed in the left lateral simiprone position.* Based on the pre-procedure assessment, including review of the patient's medical history, medications, allergies, and review of systems, he had been deemed to be an appropriate candidate for GETA sedation.* He was monitored continuously with ECG tracing, pulse oximetry, blood pressure monitoring, and direct observation.
* *
The duodenoscope was inserted into the mouth and advanced under direct vision to the second portion of the duodenum.
Findings:
Survey of the esophagus, stomach and duodenum revealed retained fluid/food in stomach. Over 2 liters suctioned out.
The major papilla was identified in the second portion of the duodenum.* A Microvasive Hydrotome catheter was positioned just inside the major papilla.
A guidewire was advanced into the common bile duct under fluoroscopic guidance without the need for contrast injection.* The catheter was then advanced over the wire into the region of the common bile duct.* Next a cholangiogram was obtained
.
This demonstrated distal cbd stricture.
A sphincterotomy was performed.* Next 10 x 60 uncovered biliary stent placed to level of cystic duct takeoff and extended four interstices into duodenum.
There was no narrowing in first/second/third portions of duodenum. Dye was injected into duodenum and there was narrowing at ligament of treitz. Pt's head was put in trendelenburg position and dye failed to go through into jejunum nor did it when head was elevated.
It was determined stricture was too far down to stent. F/u imaging showed no extraluminal air/contrast. The patient tolerated the procedure well.
Impression:* *
Distal biliary stricture s/p ercp/sphincterotomy/stent placement
Small bowel stricture near ligament of treitz not amenable to standard duodenal stenting
Recommendations:
Will discuss results with pt, consider surgical gastrojejunostomy vs surgical jejunostomy. Favor the former given pt's aspiration risk. Another alternative would be palliative care. In some cases we perform EUS Guided Gastrojejunostomy with Axios stent, but pt's anatomy is not favorable for this.""