Cholecystectomy Coding

One of the most common surgeries performed in General Surgery is cholecystectomy. This can be done with a cholangiogram (a contrast dye X-ray study of the biliary ductal system) and / or a CBD (common bile duct) exploration to remove debris or stones in the common bile duct. These procedures can be performed using Open or Laparoscopic techniques. Careful attention to the work RVU values associated with each procedure reveals that an improperly coded procedure can lead to significant differences in revenue. To be honest, surgeons sometimes aren’t the best coders and sometimes dictate things that are not listed in the “Procedure Performed” section of the Op Note. A second set of eyes from a Professional Coder reviewing the Op Note may lead to more accurate coding and better revenue.

Also note that Robotic Laparoscopic Cholecystectomy is coded as a Laparoscopic Cholecystectomy. For surgeons, there is no difference in work RVU’s.

FOOD FOR THOUGHT: Laparoscopic Cholecystectomy from a patient standpoint allows for a speedier recovery. Robotic Laparoscopic Cholecystectomy does not generate more work RVU’s for a surgeon but usually takes more Operating Room time and results in more healthcare costs when you factor in the additional cost of the Robotic equipment. Do you discuss these pros and cons with the patient and let them decide?

Undoubtedly the Robotic Platform with evolve in the near future as competitors bring their products to the marketplace. This will most likely drive down costs and additional technology improvements may lead to faster surgery. We will just have to wait…