Laproscopic Cholecystectomy: PCS and ICD-10 Codes Explained

In this blog post, we will learn about laparoscopic cholecystectomy, a minimally invasive surgical procedure used to remove the gallbladder. We will go through the detailed procedure note to understand how the surgery is performed and its benefits. We will also explore the different ICD-10 codes used for preoperative and postoperative diagnosis, as well as the PCS codes for the surgical procedure.

Laparoscopic cholecystectomy is a common surgical procedure used to remove the gallbladder in patients with gallstones, chronic cholecystitis, or other related conditions. This surgery involves making small incisions in the abdomen and inserting a laparoscope, a thin tube with a camera and light attached to it, to view the inside of the abdomen.

Here is a detailed procedure note for a laparoscopic cholecystectomy:

Preoperative Diagnosis: Chronic cholecystitis

Postoperative Diagnosis: Chronic cholecystitis

Procedure: Laparoscopic cholecystectomy with intraoperative cholangiogram

After induction of general anesthesia, the patient was prepped and draped in usual sterile fashion. A stab incision was made in the left subcostal position, and a Veress needle was inserted into the abdomen. The abdomen was insufflated with carbon dioxide, and ports were placed for the laparoscope and surgical instruments. The cystic duct was identified and clipped, and a cholangiocatheter was inserted for an intraoperative cholangiogram, which was normal. The cystic duct was then divided, and the gallbladder was dissected free from the gallbladder bed using electrocautery. The gallbladder was removed through the subxiphoid port with an Endo pouch that was irrigated with saline. Hemostasis was assured, and the fascia and skin incisions were closed with sutures.

ICD-10 codes used for this procedure are K81.2 (acute cholecystitis with chronic cholecystitis) for preoperative diagnosis and K81.1 (chronic cholecystitis) for postoperative diagnosis.

The PCS codes used for laparoscopic cholecystectomy with intraoperative cholangiogram are:

0FT44ZZ (Resection of Gallbladder, Percutaneous Endoscopic Approach) - this code represents the removal of the gallbladder using a laparoscope.

3BF141Z (Fluoroscopy of Gallbladder, Bile Ducts and Pancreatic Ducts using Low Osmolar Contrast) - this code represents the use of a cholangiogram during the surgery.

Laparoscopic cholecystectomy is a safe and effective surgical procedure with a shorter recovery time and less postoperative pain compared to open cholecystectomy. By understanding the procedure and the ICD-10 and PCS codes used, healthcare providers can accurately document the diagnosis and procedure, ensuring proper coding and billing.