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Official Description

Cholecystectomy with exploration of common duct;

© Copyright 2025 American Medical Association. All rights reserved.

Common Language Description

The procedure described by CPT® Code 47610 refers to a cholecystectomy with exploration of the common duct, which is a surgical operation performed to remove the gallbladder and investigate the common bile duct for any obstructions or stones. The gallbladder is a small organ located beneath the liver that stores bile, a digestive fluid produced by the liver. When the gallbladder becomes inflamed or contains gallstones, it may lead to pain and other complications, necessitating its removal. In this procedure, an open surgical technique is employed, which involves making a significant incision in the upper abdomen, typically in the right subcostal region. This approach allows the surgeon to gain direct access to the gallbladder and the surrounding structures, including the common bile duct. During the operation, the surgeon carefully dissects the tissue to visualize critical anatomical landmarks such as the hepatoduodenal ligament, the gallbladder, and the triangle of Calot, which is the area where the cystic duct and the common bile duct meet. The dissection continues to the cystic artery, which supplies blood to the gallbladder. Once the gallbladder is freed from its attachments to the liver, the cystic duct is ligated to prevent bile leakage. The exploration of the common bile duct is crucial, as it allows for the identification and removal of any gallstones that may have migrated into the duct, which can cause blockages and lead to further complications. The procedure concludes with the placement of a T-tube in the common duct to facilitate drainage and ensure proper healing. Overall, this surgical intervention is essential for treating gallbladder disease and preventing potential complications associated with bile duct obstructions.

© Copyright 2025 Coding Ahead. All rights reserved.

1. Indications

The cholecystectomy with exploration of the common duct, as described by CPT® Code 47610, is indicated for several conditions related to gallbladder and bile duct pathology. The following are the primary indications for this procedure:

  • Cholecystitis - Inflammation of the gallbladder, often due to gallstones, leading to severe abdominal pain and potential complications.
  • Cholelithiasis - The presence of gallstones in the gallbladder, which can cause pain, nausea, and digestive issues.
  • Common bile duct obstruction - Blockage of the common bile duct, which may occur due to gallstones, strictures, or tumors, leading to jaundice and other complications.
  • Pancreatitis - Inflammation of the pancreas that can be caused by gallstones obstructing the bile duct.
  • Jaundice - Yellowing of the skin and eyes due to bile duct obstruction, which may necessitate exploration of the common duct to relieve the blockage.

2. Procedure

The procedure for CPT® Code 47610 involves several critical steps to ensure the successful removal of the gallbladder and exploration of the common bile duct. The following outlines the procedural steps:

  • Step 1: Incision - An incision is made in the upper abdomen, typically in the right subcostal region, to provide access to the gallbladder and surrounding structures.
  • Step 2: Visualization - Retractors are inserted to hold the incision open, allowing the surgeon to visualize the hepatoduodenal ligament, gallbladder, and triangle of Calot.
  • Step 3: Dissection - Tissue is carefully dissected down to the level of the cystic duct at its junction with the common duct, continuing to the level of the cystic artery.
  • Step 4: Gallbladder Removal - The gallbladder is dissected free from the hepatic bed, and the cystic duct is ligated to prevent bile leakage.
  • Step 5: Common Bile Duct Exploration - The common bile duct is explored by first exposing the lesser omentum, retracting the right lobe of the liver upward, and moving the duodenum downward.
  • Step 6: Duct Exposure - The peritoneum over the common bile duct is divided, exposing the duct, which is then opened longitudinally to allow for the extraction of any calculi.
  • Step 7: Stone Extraction - A biliary balloon catheter is inserted into the common duct, passed into the right and left hepatic ducts, and inflated to extract any stones present.
  • Step 8: Lower Choledochal Sphincter - The catheter is passed into the lower choledochal sphincter, inflated, and withdrawn to remove any stones located there.
  • Step 9: T-tube Placement - A T-tube is placed in the common duct, which is then closed around the tube to facilitate drainage.
  • Step 10: Final Steps - The cystic artery is dissected, doubly ligated, and divided, followed by the removal of the gallbladder. The incision is then closed around the T-tube and drains.

3. Post-Procedure

After the completion of the cholecystectomy with exploration of the common duct, patients typically require monitoring for any complications related to the surgery. Post-procedure care may include managing pain, monitoring for signs of infection, and ensuring proper drainage from the T-tube. Patients are often advised to follow a specific diet as they recover, gradually reintroducing solid foods as tolerated. The expected recovery time can vary, but many patients can return to normal activities within a few weeks, depending on their overall health and the complexity of the procedure. Follow-up appointments are essential to assess healing and to remove the T-tube when appropriate.

Short Descr REMOVAL OF GALLBLADDER
Medium Descr CHOLECYSTECTOMY W/EXPLORATION COMMON DUCT
Long Descr Cholecystectomy with exploration of common duct;
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) P1C - Major procedure - cholecystectomy
MUE 1
CCS Clinical Classification 84 - Cholecystectomy and common duct exploration
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).
52 Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient 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).
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.
62 Two surgeons: when 2 surgeons work together as primary surgeons performing distinct part(s) of a procedure, each surgeon should report his/her distinct operative work by adding modifier 62 to the procedure code and any associated add-on code(s) for that procedure as long as both surgeons continue to work together as primary surgeons. each surgeon should report the co-surgery once using the same procedure code. if additional procedure(s) (including add-on procedure(s) are performed during the same surgical session, separate code(s) may also be reported with modifier 62 added. note: if a co-surgeon acts as an assistant in the performance of additional procedure(s), other than those reported with the modifier 62, during the same surgical session, those services may be reported using separate procedure code(s) with modifier 80 or modifier 82 added, as appropriate.
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).
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).
AQ Physician providing a service in an unlisted health professional shortage area (hpsa)
AS Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery
CR Catastrophe/disaster related
ET Emergency services
GC This service has been performed in part by a resident under the direction of a teaching physician
Q6 Service furnished under a fee-for-time compensation arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area
XS Separate structure, a service that is distinct because it was performed on a separate organ/structure
XU Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service
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2010-01-01 Changed Code description changed.
Pre-1990 Added Code added.
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