jojogi
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Here is a copy of an actual note. I am thinking 43260, 997.4. Any help would be great.
PROCEDURE PERFORMED: Endoscopic retrograde cholangiopancreatography
)ERCP).
INDICATIONS: This is an ------- female who initially came in with
pancreatitis. Cholecystectomy and E.R.C.P. was done in October, 2010. The
E.R.C.P. did not show any stones in the colon bile duct. A pancreatic duct
stent was placed at that time prophylactically. After the cholecystectomy,
the patient was found to have a bile leak. Subsequent E.R.C.P. in
November, 2010 showed a bile leak. A bile duct stent was placed at that
time, and sphincterotomy was done. The E.R.C.P. is done to remove the bile
duct stents and to assess for presence of bile leak.
REFERRING PHYSICIAN:
INSTRUMENT:
MEDICATIONS:
Demerol 150 mg intravenously throughout the procedure.
Versed 5 mg intravenously throughout the procedure.
Phenergan 25 mg intravenously throughout the procedure.
COMPLICATIONS: None.
TECHNIQUE: The risks and benefits of the procedure were explained to the
patient with the help of a interpreter. The patient signed an
informed consent form. The patient was placed into the prone position.
The E.R.C.P. scope was introduced through the mouth and advanced to the
second portion of the duodenum. The bile duct previously placed CPD stent
was removed with the snare. The common bile duct was cannulated and a
cholangiogram was obtained. Standard monitoring was done throughout the
procedure.
FINDINGS:
1. Previous sphincterotomy and previously placed common bile duct stent
was visualized. The common bile duct stent was removed with the
snare.
2. The common bile duct was cannulated, and an cholangiogram was
obtained. There was no evidence of extravasation of contrast. There
were no strictures or filling defects in the common bile duct. The
common bile duct was 9 mm in size. The intrahepatic ducts look
normal.
IMPRESSION:
1. Previous sphincterotomy and previously placed common bile duct stent
visualized. Common bile duct stent removed with a snare.
2. No evidence of strictures filling the region of the common bile duct
. No evidence of extravasation of contrast. Common bile duct 9 mm in
size and intrahepatic duct is normal.
RECOMMENDATIONS:
1. Follow-up with primary care physician.
2. Follow-up in gastroenterology clinic as needed
PROCEDURE PERFORMED: Endoscopic retrograde cholangiopancreatography
)ERCP).
INDICATIONS: This is an ------- female who initially came in with
pancreatitis. Cholecystectomy and E.R.C.P. was done in October, 2010. The
E.R.C.P. did not show any stones in the colon bile duct. A pancreatic duct
stent was placed at that time prophylactically. After the cholecystectomy,
the patient was found to have a bile leak. Subsequent E.R.C.P. in
November, 2010 showed a bile leak. A bile duct stent was placed at that
time, and sphincterotomy was done. The E.R.C.P. is done to remove the bile
duct stents and to assess for presence of bile leak.
REFERRING PHYSICIAN:
INSTRUMENT:
MEDICATIONS:
Demerol 150 mg intravenously throughout the procedure.
Versed 5 mg intravenously throughout the procedure.
Phenergan 25 mg intravenously throughout the procedure.
COMPLICATIONS: None.
TECHNIQUE: The risks and benefits of the procedure were explained to the
patient with the help of a interpreter. The patient signed an
informed consent form. The patient was placed into the prone position.
The E.R.C.P. scope was introduced through the mouth and advanced to the
second portion of the duodenum. The bile duct previously placed CPD stent
was removed with the snare. The common bile duct was cannulated and a
cholangiogram was obtained. Standard monitoring was done throughout the
procedure.
FINDINGS:
1. Previous sphincterotomy and previously placed common bile duct stent
was visualized. The common bile duct stent was removed with the
snare.
2. The common bile duct was cannulated, and an cholangiogram was
obtained. There was no evidence of extravasation of contrast. There
were no strictures or filling defects in the common bile duct. The
common bile duct was 9 mm in size. The intrahepatic ducts look
normal.
IMPRESSION:
1. Previous sphincterotomy and previously placed common bile duct stent
visualized. Common bile duct stent removed with a snare.
2. No evidence of strictures filling the region of the common bile duct
. No evidence of extravasation of contrast. Common bile duct 9 mm in
size and intrahepatic duct is normal.
RECOMMENDATIONS:
1. Follow-up with primary care physician.
2. Follow-up in gastroenterology clinic as needed
Thanks for your responses, I appreciate your help.