Question

This is a 34-year-old white female who came in complaining of right upper quadrant abdominal pain and also had some elevated liver function tests consistent with choledocholithiasis. Endoscopic retrograde cholangiopancreatography was performed revealing only sludge within the common bile duct. After the endoscopic retrograde cholangiopancreatography was performed, a laparoscopic cholecystectomy was able to be performed and was performed without any trouble. The patient did very well postoperatively and no longer has any of the pain she previously had. She is eating well and ambulating well and ready for discharge. PRIMARY DIAGNOSIS: Acute cholecystitis and choledocholithiasis. PRINCIPAL PROCEDURES PERFORMED: Endoscopic retrograde cholangiopancreatography and laparoscopic cholecystectomy. SECONDARY DIAGNOSIS: Hypertension. ALLERGIES: No known drug allergies. ACTIVITY: As tolerated. No lifting greater than 15 pounds in the next two to three weeks. The patient is to follow-up with Dr. White in two weeks regarding gallbladder removal and follow-up with Dr. Gaul concerning her hypertension. MEDICATIONS: Darvocet-N 100 one to two tablets p.o. q 4 to 6 hours p.r.n. pain with 30 being given and Hyzaar as prescribed as a home medication. Please help having a difficult time with CPT codes, HCPCS and ICD-10 codes.

Answer 1

Endoscopic retrograde cholangpancreatography.

43268-Endoscopic retrograde with insertion of tube into bile or pancreas.

43269-Endoscopic retrograde with chane of tube or stunt or removal of forrigbbody.

Laparoscopic cholecystectomy.

47562-Cpt code for diagnosis of laparoscopy and surgical removal of gall bladder.

47563-Cpt code of diagnosis of laparoscopy and surgical removal of gall bladder and work of intraoperative cholangiography.

Primary diagnosis.

Acute cholecystitis-K81.2

Choledocholitthiasis-K80.40

Principle procedure.

Endoscopy retrograde-43260.