AMA Clinical Examples in Radiology - 2011 Issue 3 (Summer)
Percutaneous Cholecystostomy
Percutaneous Cholecystostomy Clinical History 82-year-old woman with a history of enterocutaneous fistula and endocarditis who now presents with right upper quadrant tenderness and fever. Abdominal ultrasound reveals gallbladder sludge and pericholecystic fluid suspicious for cholecystitis. Sedation Moderate sedation was administered under the attending physician's direction. The patient was continuously monitored by a trained nurse specialist 99144 99145 who was independent from those performing the procedure. Total monitored sedation intraservice time was 46 minutes. Technique The risks, benefits, and alternatives were discussed with the patient's family members and informed consent was obtained. Prior to beginning the procedure, Universal Protocol was...
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Article Overview
This article explains a radiology coding scenario involving percutaneous cholecystostomy and related documentation elements. It is useful for coders, radiology practices, and compliance staff who need to understand the scope of the procedure, associated sedation reporting, fluoroscopy documentation, and how the example is discussed in relation to CPT and PQRS reporting. The article also places the example in the context of CPT code updates and bundled service considerations.
Why This Topic Matters
Percutaneous gallbladder drainage is often coded alongside other documented services and quality measures, so understanding the article helps readers recognize what is included in the primary procedure and what related reporting topics are discussed.
Article Sections
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Clinical History
Provides the patient scenario and the imaging findings that led to the procedure.
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Sedation
Summarizes the sedation context and documentation elements tied to the procedure.
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Technique
Describes the procedural setup, access approach, imaging support, and catheter placement workflow.
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Findings
States the immediate procedural findings and drainage outcome.
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Impression
Gives the overall procedural impression from the report.
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How to Code
Reviews the coding discussion, including procedure reporting, sedation reporting, fluoroscopy documentation, and related CPT update context.
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Discussion
Explains broader coding and documentation issues connected to the example, including CPT revisions and quality-reporting references.
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References
Lists source materials cited by the article.
What You Will Learn
- How the article frames a percutaneous gallbladder drainage case for coding review.
- What documentation topics are addressed in connection with sedation, imaging, and fluoroscopy.
- Which general coding and quality-reporting subjects are discussed alongside the clinical example.
- How the article situates the example within CPT update and procedural reporting context.
Who Should Read This
- Medical coders
- Radiology coding specialists
- Compliance staff
- Billing staff
- Radiology department personnel
Codes Discussed
Code Ranges Discussed
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