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Code This!

Scenario Week of August 13, 2014:
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Assign the correct 2014 CPT and ICD-9-CM diagnosis codes for the following outpatient coding scenario.

Preoperative Diagnosis: Acute cholelithiasis, acute cholecystitis, elevated SGOT and SGPT

Postoperative Diagnosis: Acute cholelithiasis, acute cholecystitis, elevated SGOT and SGPT

Procedures: Laparoscopic cholecystectomy, laparoscopic wedge biopsy of liver

Estimated Blood Loss: Less than 50 cc

Anesthesia: General endotracheal anesthesia

Indications: This is a 39-year-old pleasant female patient admitted to the hospital emergency department with a history of severe right upper quadrant abdominal pain of acute onset. She had persistently elevated SGOT and SGPT, and previously had an ultrasound and MRI. The ultrasound showed cholelithiasis and cholecystitis. The magnetic resonance cholangiopancreatography showed no evidence of common bile duct stone. The patient was seen by gastroenterology and then cleared for surgery. Laparoscopic and possible open cholecystectomy techniques were discussed at length with the patient, including the options, benefits, and risks of the procedure. Risks were discussed including bleeding, infection, bile leak, injury to bile ducts, need for further surgery, possible ERCP, anesthesia risks, deep vein thrombosis, pulmonary embolism, morbidity, and mortality. I answered all of her questions, and the patient expressed understanding and consent for surgery.

The patient was taken to the operating room where she was placed supine on the operating table. An IV was established and antibiotics administered. General anesthesia was administered. Venodyne boots were applied to both lower extremities to prevent deep vein thrombosis. The abdomen was prepped and draped in the usual sterile fashion. Laparoscopic instruments were set up. Heparin, 4,000 units, was given subcutaneously.

The skin incision was made just below the umbilicus in a vertical fashion using the #15 scalpel blade. The subcutaneous tissue was dissected. Fascia was incised. The peritoneum was incised. The peritoneal cavity was entered. The Hasson trocar was inserted and pneumoperitoneum was established using carbon dioxide. Skin incisions were made in the subxiphoid area. A 1 mm port was inserted under direct vision. Two 5 mm ports were inserted in the right upper quadrant. Diagnostic laparoscopy was performed. The survey of the upper abdominal organs appeared to be grossly intact. The gallbladder was mildly inflamed and was distended. There was minimal fluid in the pelvis.

The gallbladder was held with retraction in the fundus and the Hartmann pouch, Calot triangle was dissected. The cystic duct was identified, isolated, ligated with three clips proximately and one clip distally and divided. In a similar fashion, the cystic artery was ligated and divided. The gallbladder was placed in traction. The gallbladder was entered and dissected off the liver bed. The gallbladder was placed in the endoscopic bag and removed through the umbilical port. Hemostasis was ensured in the bed using Bovie cautery and clips as appropriate. The specimen was handed to the scrub nurse and labeled for pathologic examination.

A wedge of the liver tissue was excised from the free edge of the liver using laparoscopic scissors. The biopsy was also removed via the umbilical port. The specimen was handed to the scrub nurse, labeled, and sent for pathologic examination. Hemostasis was secured using Bovie cautery.

The peritoneal cavity and liver bed were irrigated with normal saline and suctioned out. The #7 Jackson Pratt drain was brought into the right upper quadrant incision and placed in the liver bed. The trocars were removed. Carbon dioxide gas was expelled. Diagnostic laparoscopy did not reveal any other gross abnormalities. The fascia at the umbilical port was approximated with 0 Vicryl interrupted sutures. The skin was approximated with 4-0 Monocryl subcuticular sutures to all incisions. Marcaine, 0.5 percent, was infiltrated in the subcutaneous tissue. Steri-Strips were applied. Sterile dressings were placed. Sponge, instrument, and needle counts were correct times two.

The patient tolerated the procedure well and remained stable throughout the course of the operation. She was transferred to the recovery room in stable condition.

Assign the correct CPT and ICD-9-CM diagnosis codes for the procedure.


CPT Procedure Codes
47562 Laparoscopy, surgical; cholecystectomy
47379 Unlisted laparoscopic procedure, liver

CPT Rationale
The first procedure is a laparoscopic cholecystectomy. In the index of CPT 2014, Professional Edition, under the main term “Cholecystectomy” and subterm “laparoscopic,” the code range provided is 47562–47564. In reviewing this code range in the main section of the book, the code description for 47562 identifies a laparoscopy, surgical; cholecystectomy. The physician’s documentation supports reporting this procedure.

To code the second procedure or wedge biopsy of the liver, refer to the index main term “Biopsy” and subterm “liver.” This refers the user to codes 47000–47001, 47100, and 47700. A review of each of these procedures shows that the only reference to a wedge biopsy of the liver is through an open technique. However, the physician’s documentation indicates that the biopsy was performed laparoscopically; therefore, any of these codes would be inappropriate.

Per CPT Assistant, December 2007, Volume 17, Issue 12, pages 10–17 the coder is instructed to report the unlisted code 47379 Unlisted laparoscopic procedure, liver, for the wedge biopsy. Modifiers do not apply to unlisted codes because unlisted procedures do not include a description that specifies the components of the particular service. In the index of CPT 2014, under the main term “Liver” and subterm “unlisted services and procedure,” the codes 47379 and 47399 are provided. A review of these codes in the main section of the book shows that the code description for 47379 describes an unlisted laparoscopic procedure, liver.

ICD-9-CM Diagnosis Codes
574.00 Calculus of gallbladder with acute cholecystitis, without mention of obstruction
790.4 Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase (LDH)

ICD-9-CM Rationale
The “first listed” diagnosis is the main reason for the encounter, which in this scenario is the reason for the surgical procedure or the acute cholelithiasis with acute cholecystitis. In the ICD-9-CM alphabetic index under the main term “Cholelithiasis” and subterms “cholecystitis” and “acute” refer the coder to 574.0. An additional fifth digit is required, which would be either 0 without mention of obstruction or 1 with obstruction. The physician’s documentation makes no mention of obstruction, so the appropriate fifth digit would be 0. When code 574.00 is referenced in the tabular section of ICD-9-CM Volume 1, the code description states “calculus of gallbladder with acute cholecystitis without mention of obstruction”; therefore, this would be the correct code assignment.

The second diagnosis is elevated SGOT, also called aspartate transaminase and SGPT, also called glutamic-pyruvic transaminase. In the ICD-9-CM alphabetic index under the main term “Findings, abnormal” and subterms “SGOT” and “SGPT,” both subterms refer the coder to 790.4. When code 790.4 is referenced in the tabular section of ICD-9-CM Volume 1 the code description states “Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase (LDH)”; therefore, this would be the correct code assignment.

Note that it may be more advisable to hold the claim until the pathology report until the liver wedge biopsy is received and a more definitive diagnosis could be available.

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