Coding biliary procedures requires in-depth knowledge of anatomy as well as coding guidelines. This article outlines the correct coding for biliary procedures in outpatient and physician settings.
The biliary system consists of the organs and structures that secrete and transport bile, including the liver, gallbladder, and bile ducts. Interventional radiologists can perform diagnostic imaging of the biliary system as well as procedures for relief of biliary obstruction. Bile is secreted by the liver and drains into small ducts called intrahepatic biliary radicles. The radicles on the right and left sides of the liver drain into the right and left hepatic ducts.
The two hepatic ducts then join to form the common hepatic duct. The gallbladder is a sac-like structure that stores and concentrates bile. Bile drains from the gallbladder through the cystic duct. The cystic duct joins with the common hepatic duct to form the common bile duct, which empties into the duodenum. Obstruction of the biliary system can be caused by calculi gallstonescancer, infection, cirrhosis, trauma, or other factors. Biliary obstruction needs to be treated promptly because it can cause pain, jaundice, infection, and tissue damage.
Diagnostic imaging of the biliary system is performed by passing a needle through the liver into one of the intrahepatic bile ducts. Contrast is then injected into the bile duct under fluoroscopy. This procedure is known as a percutaneous transhepatic cholangiogram PTC.
It is reported with CPT codesInjection procedure for percutaneous transhepatic cholangiography, andCholangiography, percutaneous, transhepatic, radiological supervision and interpretation. Modifier 26, Professional component, econ lowdown answers quizlet be added to and all other supervision and interpretation codes discussed in this article when the supervision and interpretation code is reported by a physician who provided only the professional component; for example, when the exam is performed in the hospital setting.
Diagnostic imaging studies can also be performed on patients who have a biliary drainage catheter in place. For example, a surgeon may leave a T-tube a self-retaining drainage tube shaped like a T in place at the time the gallbladder is removed, and the interventional radiologist may be asked to perform an imaging study via the tube to confirm that there are no remaining gallstones.
In other cases an imaging study may be performed on a nonsurgical patient who has had a drainage catheter placed percutaneously due to biliary obstruction. In these situations the radiologist can perform a cholangiogram by simply injecting contrast into the existing tube or catheter. This procedure is often referred to as a T-tube cholangiogram. It is reported with codesInjection procedure for cholangiography through an existing catheter e.
External biliary drainage is performed by positioning a drainage catheter in the bile duct above the obstruction. The physician punctures the skin and passes a needle into one of the bile ducts. The needle is exchanged over a guidewire for a catheter, and the catheter is positioned and sutured in place.
All of the bile then drains out of the body through the catheter into a collection bag. Sometimes two separate catheters are used to drain the right and left biliary ductal systems. External biliary drainage is reported with codesIntroduction of percutaneous transhepatic catheter for biliary drainage, andPercutaneous transhepatic biliary drainage with contrast monitoring, radiological supervision and interpretation.
Internal-external biliary drainage procedures are performed to allow bile to drain past an area of obstruction. The physician punctures the biliary tract percutaneously and advances a catheter down the bile duct past the obstruction. The catheter is exchanged over a guidewire for a biliary drainage catheter, which is left to external gravity drainage. Often the external end of the catheter can be capped after a few days so that all the bile drains internally into the duodenum.
Internal-external biliary drainage is reported with codesIntroduction of percutaneous transhepatic stent for internal and external biliary drainage, andPercutaneous placement of drainage catheter for combined internal and external biliary drainage or of a drainage stent for internal biliary drainage in patients with an inoperable mechanical biliary obstruction, radiological supervision and interpretation.
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You are leaving this website for information purposes only.Currently, we are not permitting visitors into our facilities, with very limited exceptions. Read more. This information will help you prepare for having a biliary catheter thin, flexible tube placed at Memorial Sloan Kettering MSK and teach you how to care for it when you are at home.
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Bile is a fluid made by your liver. It helps break down food. Your bile flows from your liver through your bile ducts to your small intestine. When your bile duct is narrowed or blocked by scar tissue or a tumor, bile can no longer flow into the first part of your small intestine, called the duodenum see Figure 1. This causes the bile to collect in your liver. The build-up of bile in your liver can cause infection, nausea, vomiting, fever, itching, and jaundice when your skin and the whites of your eyes look yellow.
If your bile duct is blocked, your doctor may recommend that you have a biliary drainage catheter placed. This will allow the bile to drain from your liver. There are 3 different ways bile can be drained from your liver. Your doctor will discuss these with you before your procedure. Figure 3. Internal-external biliary drainage catheter. Your drainage catheter or stent will be inserted by an interventional radiologist. An interventional radiologist is a doctor who specializes in image-guided procedures.
After the procedure, if you had a drainage catheter placed, it will be attached to a bag to collect the drainage. Your doctor will give you an idea of how much drainage you should expect.
You may need to stop taking some of your medications before your procedure. Talk with your doctor about which medications are safe for you to stop taking. We have included some common examples below.
If you take medication that affects the way your blood clots, ask the doctor performing your procedure what to do.Biliary drainage is the insertion of a tube into the bile duct.
This is most commonly carried out when the bile ducts are blocked. The bile ducts normally allow bile a green-brown fluid that is produced by the liver to help with the digestion of fats to drain from the liver to the small intestine see Figure 1. When the bile ducts are blocked, bile cannot leave the body and builds up. This build-up produces a yellow colour in the skin called jaundice and can also cause itching and dark urine. Blockage of the bile ducts can occur for a number of reasons, including gallstones impacted in the ducts, narrowings in the bile ducts after previous surgery and involvement of cancer in the ducts.
The drainage tube is placed through the skin into one of the bile ducts in the liver to allow bile out. Another common name for this procedure is a percutaneous transhepatic cholangiogram PTC. Do not eat or drink for 4 hours before the procedure. This is because the procedure is carried out under sedation or general anaesthetic — if your stomach is full, stomach contents can inadvertently pass into your lungs, which can be harmful.
This can happen any time you have sedative medication or anaesthesia, not just with biliary drainage, and is the reason you are asked not to eat or drink. You may need to stop medications that thin your blood, as these will increase your risk of bleeding. Examples include warfarin often sold as Coumadin or Jantovenclopidogrel often sold as Plavixasasantin, heparin and enoxaparin sodium often sold as Clexane. If you think that you may be taking any of these medications, please discuss this with the radiology practice before the procedure.
It is also recommended that you bring any recent X-rays or scans with you if you have copies at home. A relative or friend must be available to drive you home after the procedure, as you will not be allowed to drive after sedation or anaesthesia.
It is also recommended that the relative or friend stay with you the night after the procedure in order to provide assistance.
This procedure is usually carried out with the assistance of either sedation medication to relax you or a general anaesthetic. Intravenous antibiotics are also routinely given before the procedure. The skin of your abdomen is washed with antiseptic and then a very fine needle is inserted through the skin to administer local anaesthetic. This may sting for a few seconds before numbing the area. A small cut is made in the skin and a thin needle is passed through the skin into the liver and then into a bile duct inside the liver.
X-ray pictures or images are taken to see the path of the bile ducts. A tube has been inserted into a bile duct through the liver. X-ray dye has been injected to outline the bile ducts. A narrow portion of the bottom end of the bile duct can be seen due to a cancer in this case ]. A thin wire is passed through the centre of the needle so that it lies in the bile duct. A thin drain tube is then inserted over the top of the wire and into the bile duct.
A drain tube which has a curled end has been placed. The curled tip lies in the small intestine. The tube has tiny holes along its length, which allow bile to drain past the narrowing. One end of the drain tube will remain in the bile duct and the other end sits outside the skin where it is attached to a bag into which the bile drains. It is therefore normal for this bag to fill up with green-brown bile.
After the procedure, you may need to recover from the effects of any sedation or anaesthetic medications that were used. There is usually some initial discomfort or pain where the tube passes through the skin. This is usually well managed with simple pain relieving medications. Sometimes the pain is severe and can go on for some days requiring strong analgesia.Bile is produced in the liver and stored in the gallbladder where it can be released into the small intestine to aid in digestion.
If the bile ducts become blocked, it may lead to inflammation or infection also known as sclerosis cholangitis. Biliary interventions may remove gallstones, drain excess bile or place a stent within a bile duct to treat your condition and restore the flow of fluids. Your doctor will instruct you on how to prepare based on your specific procedure and may prescribe an antibiotic.
Tell your doctor about any recent illnesses or medical conditions and whether you have any allergies, especially to anesthesia or iodinated contrast material. Discuss any medications you're taking, including herbal supplements and aspirin. You may be told not to eat or drink for several hours beforehand and advised to stop taking aspirin or blood thinner three days prior to your procedure.
Leave jewelry at home and wear loose, comfortable clothing. You may be asked to wear a gown. Ask your doctor if you will be admitted to the hospital. If not, you should plan to have someone drive you home. Biliary interventions are minimally invasive procedures performed to treat blockages or narrowing and injury of bile ducts.
In addition, minimally invasive techniques can be used to treat an inflamed or infected gallbladder. Bilea fluid that helps digest fat in foods, is produced in the liver and flows through ducts or tubular passageways leading to the gallbladder where it is stored.
When needed, the gallbladder contracts and releases bile through ducts into the small intestine. If the bile ducts become blocked, bile cannot pass into the intestine and this may result in jaundice in which the level of bile products in the blood becomes elevated.
If the jaundice becomes severe, the patient will appear to have a yellowish hue, particularly in the whites of the eye. If the duct that connects the gallbladder to the rest of the bile ducts becomes blocked usually due to gallstones in the gallbladderthis results in inflammation or infection cholecystitis.
This is generally treated by surgical removal of the gallbladder — either laparoscopically minimally invasive or by conventional open surgery. However, when patients are too ill to undergo surgical cholecystectomy, a percutaneous cholecystectomy placement of a small tube through the skin into the gallbladder may be performed by an interventional radiologist.
An interventional radiologist is a radiologist who performs minimally invasive procedures with imaging guidance.It's not clear how many people develop the frequent loose, watery stools that characterize diarrhea after surgery to remove their gallbladders cholecystectomy. The cause of diarrhea after gallbladder removal isn't clear. Some experts believe that it results from an increase in bile, especially bile acids, entering the large intestine — which may act as a laxative.
Treatments you and your doctor may consider for controlling your diarrhea after cholecystectomy include:. Talk to your doctor about your options and whether additional tests are recommended. Generally, mild diarrhea after cholecystectomy is not cause for concern, but speak to you doctor if you are losing weight; have bloody diarrhea, diarrhea that awakens you from sleep, fever or significant abdominal pain; or have diarrhea lasting more than a few weeks.
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Show references Kim SS, et al. Laparoscopic cholecystectomy. Feldman M, et al. Saunders Elsevier; Accessed Nov.Percutaneous transhepatic biliary drainage is a procedure where a small, flexible, plastic tube is placed through the skin into the liver in order to drain an obstructed bile duct system.
The liver produces bile which aids digestion of fats. The bile flows through a series of small tubes ducts that drain into one large duct called the common bile duct, which then empties into the duodenum, the first part of the small bowel after the stomach.
Bile is also stored in the gallbladder. If the bile duct becomes blocked, the bile cannot drain normally and backs up in the liver. Signs of blocked bile ducts include jaundice yellowing of the skindark urine, light stools, itching, nausea and poor appetite. This is a potentially serious condition that needs to be treated. T his relieves the congestion in the blocked duct by allowing the bile to drain externally into a collecting bag as well as draining internally in the normal way.
Sometimes the biliary drainage procedure may be extended with the placement of a permanent plastic or metal stent across the site of the bile duct blockage. Stents are usually inserted a few days after the initial drainage procedure and they keep the narrowed duct open without the need for a catheter. Stenting may be preceded or followed by biliary dilatation, which involves dilating a segment of bile duct with a balloon to open up the stricture.
The most common indication for biliary drainage is blockage or narrowing stricture of the bile ducts. There are several conditions that may cause this including:. Biliary drainage relieves obstruction by providing an alternative pathway to exit the liver. Biliary drainage may also be necessary if a hole develops in the bile duct, resulting in leakage of bile into the abdominal cavity. This leak may cause severe pain and infection. Biliary drainage stops the leak and helps the hole in the bile duct to heal.
Biliary drainage may be necessary in preparation for surgery or other procedure on the bile ducts, such as removal of a bile duct stone or tumour. The procedure is performed by interventional radiologists. They are doctors specializing in minimally invasive treatments using image guidance.
Interventional radiologists are trained to use diagnostic imaging equipment, such as x-ray and ultrasound, to guide various instruments during a procedure. The procedure will take place in the Interventional Radiology Department in a room especially adapted with x-ray and ultrasound equipment.
Although biliary drainage is a relatively safe technique, there are potential risks as with any procedure. Occasionally, it may not be possible to place the drain in the bile duct, in which case surgery may be required to relieve the blockage.
Sometimes the bile may leak around the catheter and form a collection in the abdomen that can cause pain and may require drainage. Occasionally, the procedure can cause a blood infection septicaemia but prophylactic antibiotics are given to reduce this risk. Occasionally, bleeding may be a problem that requires a blood transfusion.
Rarely, bleeding can be more severe and an embolisation procedure or surgical operation may be necessary.