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The procedure described by CPT® Code 47612 involves a cholecystectomy, which is the surgical removal of the gallbladder, performed using an open surgical technique. This procedure is accompanied by an exploration of the common bile duct and the creation of a choledochoenterostomy, which is a surgical connection between the common bile duct and the intestine. The operation begins with an incision in the upper abdomen, typically located in the right subcostal region, allowing access to the gallbladder and surrounding structures. During the procedure, various anatomical landmarks such as the hepatoduodenal ligament, gallbladder, and triangle of Calot are visualized to facilitate safe dissection. The surgeon carefully dissects the tissue down to the cystic duct's junction with the common duct and continues to the cystic artery. After freeing the gallbladder from the hepatic bed and ligating the cystic duct, the common bile duct is explored to identify and remove any gallstones. This is achieved by inserting a biliary balloon catheter into the common duct, which is then manipulated to extract stones from both the common bile duct and the hepatic ducts. Following the exploration, a choledochoenterostomy is performed, which can be configured as either a side-to-side or end-to-side anastomosis, with the end-to-side configuration being the preferred method. This involves mobilizing the common bile duct and connecting it to the duodenum, ensuring proper drainage of bile into the digestive tract. The procedure concludes with the removal of the gallbladder and closure of the incision around any necessary drains.
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The procedure described by CPT® Code 47612 is indicated for patients who present with conditions affecting the gallbladder and common bile duct. These indications may include:
The procedure for CPT® Code 47612 involves several critical steps, each essential for the successful completion of the cholecystectomy with exploration of the common duct and choledochoenterostomy:
After the completion of the procedure, patients typically require monitoring for any complications related to the surgery. Post-procedure care may include pain management, monitoring for signs of infection, and ensuring proper drainage from any placed drains. Patients are usually advised on dietary modifications and may need to follow up with their healthcare provider to assess recovery and any further management of gallbladder-related issues. The expected recovery time can vary based on individual health factors and the extent of the surgery performed.
| Short Descr | REMOVAL OF GALLBLADDER | Medium Descr | CHOLECYSTECTOMY EXPL DUCT CHOLEDOCHOENTEROSTOMY | Long Descr | Cholecystectomy with exploration of common duct; with choledochoenterostomy | 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). | 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). | GC | This service has been performed in part by a resident under the direction of a teaching physician |
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| Pre-1990 | Added | Code added. |