Reader Question: Account for Additional Lap Chole Work

Article Overview

This reader question and answer discusses general surgery coding for a laparoscopic gallbladder operation that included cholangiography and an open colon repair. It is aimed at coders, billers, and surgical documentation reviewers who need to understand how the case may be represented in CPT and when modifier 22 may come into consideration based on the operative record. The article focuses on the documentation elements that distinguish separately reportable work from the primary procedure and on the general type of supporting documentation needed for additional reporting.