© Copyright 2025 American Medical Association. All rights reserved.
An open cholecystotomy or cholecystostomy is a surgical procedure performed to address issues related to the gallbladder, specifically for exploration, drainage, or removal of gallstones (calculi). This procedure is particularly indicated for patients suffering from acute cholecystitis, a condition characterized by inflammation of the gallbladder, often due to the presence of gallstones. Patients who are critically ill and unable to tolerate more definitive surgical interventions, such as a cholecystectomy, may require this procedure as a temporary measure to alleviate symptoms and prevent further complications. During the procedure, a surgical incision is made in the gallbladder to access its contents. If gallstones are identified, they are extracted to restore normal function. The surgeon inspects the gallbladder to ensure that bile can flow freely; if any obstruction is detected, the cystic duct is explored to remove any additional stones. In cases where multiple stones are present, a cholecystostomy tube may be inserted to facilitate drainage. This tube allows for the continuous removal of bile and any remaining stones, and the gallbladder is then closed around the tube, with additional drains placed in the abdominal cavity to manage any excess fluid before the surgical site is closed.
© Copyright 2025 Coding Ahead. All rights reserved.
The open cholecystotomy or cholecystostomy procedure is indicated for the following conditions:
The procedure involves several critical steps to ensure effective treatment of the gallbladder condition:
Post-procedure care involves monitoring the patient for any complications related to the surgery. The cholecystostomy tube will require regular assessment to ensure proper drainage and to prevent infection. Patients may need to stay in the hospital for observation, especially if they were critically ill prior to the procedure. Follow-up appointments will be necessary to evaluate the effectiveness of the procedure and to determine if further surgical intervention, such as a cholecystectomy, is needed in the future. Pain management and supportive care will also be part of the recovery process.
| Short Descr | INCISION OF GALLBLADDER | Medium Descr | CHOLECSTOT/CHOLECSTOST W/EXPL DRG/RMVL ST1 SPX | Long Descr | Cholecystotomy or cholecystostomy, open, with exploration, drainage, or removal of calculus (separate procedure) | Status Code | Active Code | Global Days | 090 - Major Surgery | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 2 - Standard payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 0 - 150% payment adjustment for bilateral procedures does NOT apply. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 2 - Payment restriction for assistants at surgery does not apply to this procedure... | Co-Surgeons (62) | 1 - Co-surgeons could be paid, though supporting documentation is required... | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Inpatient Procedures, not paid under OPPS | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P1G - Major procedure - Other | MUE | 1 | CCS Clinical Classification | 99 - Other OR gastrointestinal therapeutic procedures |
| 22 | Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service. | 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 53 | Discontinued procedure: under certain circumstances, the physician or other qualified health care professional may elect to terminate a surgical or diagnostic procedure. due to extenuating circumstances or those that threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. this circumstance may be reported by adding modifier 53 to the code reported by the individual for the discontinued procedure. note: this modifier is not used to report the elective cancellation of a procedure prior to the patient's anesthesia induction and/or surgical preparation in the operating suite. for outpatient hospital/ambulatory surgery center (asc) reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use). | 58 | Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78. | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | 78 | Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.) | 79 | Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.) | 80 | Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s). | 81 | Minimum assistant surgeon: minimum surgical assistant services are identified by adding modifier 81 to the usual procedure number. | 82 | Assistant surgeon (when qualified resident surgeon not available): the unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code number(s). | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | CR | Catastrophe/disaster related | GC | This service has been performed in part by a resident under the direction of a teaching physician |
|
Date
|
Action
|
Notes
|
|---|---|---|
| 2011-01-01 | Changed | Long description revised. Guideline information changed. |
| Pre-1990 | Added | Code added. |
Get instant expert-level medical coding assistance.