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Code This!

Scenario Week of September 12, 2013:
View Current Scenario

Assign the correct codes for the following outpatient scenario using ICD-9-CM diagnosis codes, CPT & HCPCS procedure codes:

Preoperative diagnosis: Cholecystolithiasis with chronic cholecystitis
Postoperative diagnosis: Cholecystolithiasis with chronic cholecystitis

Procedure performed: Robotic assisted laparoscopic cholecystectomy

Anesthesia: General endotracheal anesthesia.
Complications: None

Indications: The patient is a 36-year-old white female with a history of cholecystolithiasis with chronic cholecystitis.

Procedure: After induction of anesthesia the patient was placed in the supine position, and pressure points were appropriately padded. The abdomen was prepped and draped.

The left and right robotic arms were placed at the side of the patient’s head. The third arm was placed beside the left hip. The robotic arms were attached to the operating table sidebars.

Local anesthesia with Marcaine and Lidocaine was injected into the periumbilical area.A Veress needle was inserted at the umbilicus, and the abdomen was insufflated to a pressure of 12mmHg, which was maintained throughout the procedure. A small infraumbilical incision was made and carried down through the subcutaneous tissue and fascia, and a 10-mm trocar was inserted. The laparoscope was inserted into this trocar. A 10-mm epigastric trocar and a 5-mm right lateral wall trocar were placed with deployment of a dissection clamp and grasper. The laparoscope, grasper, and dissection clamp were engaged with the three robotic arms and adjusted in a double 90 degree position.

Next the physician moves to the console to steer the robotic arms.The neck of the gallbladder was retracted and Calot’s triangle was visualized. The cystic artery identified and ligated with two separate clips and then sharply divided. The cystic duct was identified, freed, clamped and divided. A diathermy hook was used to free the gallbladder. The gallbladder was removed via the epigastric trocar.

The abdomen was irrigated, and no bleeding was detected.The robotic arms were disengaged. The laparoscope and trocars were removed under direct visualization. The umbilical fascia was closed with 0 Maxon. The skin of the epigastric and umbilical ports was closed with interrupted 3-0 Vicryl stitched. Dressings were applied, and the patient was released to the recovery room in good condition.

Please assign the correct CPT, HCPCS and ICD-9-CM codes for the procedure above.


Answers:

ICD-9-CM Diagnosis Code
574.10 Calculus of gallbladder with other cholecystitis, without mention of obstruction

Rationale:
The code for the diagnosis of cholecystolithiasis with chronic cholecystitis is found in ICD-9-CM index under the main term “Cholecystitis,” which lists subterms of “calculus, stones in bile duct or gallbladder.” Since the documentation calculus of the gallbladder (cholecystolithiasis), it is appropriate to select these subterms. The subterm “cholelithiasis” lists additional subterms “with cholecystitis acute or chronic.” In this case, the medical record documents “chronic.” Code 574.1 is listed for chronic cholelithiasis; an additional digit is required to complete the code. A fifth digit of 0 describes chronic cholelithiasis with obstruction, and a fifth digit of 1 indicates without obstruction. Since there is no mention of obstruction, the correct code for this case is 574.10.

The tabular listing for this code describes calculus of gallbladder with other cholecystitis, without mention of obstruction.

Procedure Codes
CPT Code
47562 Laparoscopy, surgical; cholecystectomy

HCPCS Code
S2900 Surgical techniques requiring use of robotic surgical system (list separately in addition to code for primary procedure)

Rationale:
The main term “Cholecystectomy” in the CPT index lists subterm “laparoscope,” which refers the coder to 47562. Since no other procedures are documented (i.e., cholangiography, choledochoenterostomy, or exploration of the bile duct), code 47562 is verified. It is important that in addition to other procedures that may have been performed, the approach also be noted since this can affect code assignment. In this case, the procedure used a robotic surgical system so it would be appropriate to report HCPCS Level II code S2900. Medicare, as well as some commercial payers, may not allow payment for robotic surgical systems when used in surgical procedures; however, regardless of the payment ramifications, code S2900 should still be reported for complete and accurate coding.

 
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