Physician Documented Retained Bile Duct Stones? Use 574.50

By Author: erinarticle
Total Articles: 105
Comment this article

How would you report a T-tube cholangiogram through the patient's existing T-tube? The doctor used fluoroscopic visualization and water-soluble contrast. The clinical indication is ‘bile duct stone', however the impression states that there is no evidence of a retained stone.
Since the physician carried out this cholangiogram injection procedure through an existing T-tube, you should code 47505 (Injection procedure for cholangiography through an existing catheter [example., percutaneous transhepatic or T-tube]). What's more, according to CPT notes, you should report 74305 (Cholangiography and/or pancreatography; through existing catheter, radiological supervision and interpretation) with 47505. Both codes state they apply for services carried out through an existing tube.
ICD-9: If the doctor documented retained bile duct stones, the proper ICD-9 code would be 574.50 (Calculus of bile duct with no mention of cholecystitis; with no mention of obstruction).
However in this case, there's no evidence of a stone. If the patient had a recent cholecystectomy and/or common bile duct exploration ...
... (as evidenced by the T-tube in place), you should report V67.09 (Follow-up examination following other surgery). You can assign V12.79 (Personal history of diseases of digestive system; other) as a secondary diagnosis to indicate the gallbladder disease.
Good move: The radiologist should indicate in the dictation the type of surgery and the cause for the surgery. Some third-party payers will want to see a code showing the reason for the surgery (like cholecystitis or cholelithiasis) in place of the follow-up code.
For more on this and for other specialty-specific articles to assist your radiology coding, sign up for a good medical coding resource like Coding Institute.