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2025 CPT code 47610

Cholecystectomy with exploration of the common bile duct.

Follow current CPT guidelines for surgical procedures.Proper documentation is crucial for accurate coding and reimbursement. Note that if biliary endoscopy is performed, an additional code should be used.

Modifiers may be applicable depending on the circumstances of the procedure (e.g., 51 for multiple procedures, 59 for distinct procedural service, etc.). Consult current modifier guidelines.

Medical necessity is established by symptoms consistent with cholecystitis (such as biliary colic, right upper quadrant pain, or nausea), along with imaging findings (such as ultrasound or CT scan) indicating gallstones or other biliary pathology. Exploration of the common bile duct is medically necessary if there is clinical suspicion of common bile duct stones or obstruction based on the clinical presentation or intraoperative findings.

The surgeon is responsible for all aspects of the procedure, including preoperative planning, performing the cholecystectomy and common bile duct exploration, postoperative care, and follow-up.

IMPORTANT:For cholecystectomy with exploration of the common bile duct and biliary endoscopy, use 47610 with 47550.

In simple words: The doctor removes the gallbladder, a small organ that stores bile, and checks the common bile duct for blockages or stones.

This procedure involves the surgical removal of the gallbladder and exploration of the common bile duct.The surgeon makes an incision, dissects the structures around the gallbladder, clips the cystic artery and duct, and then explores the common bile duct to check for stones or obstructions. The gallbladder is dissected from the liver bed, the site is irrigated, and a drain is often placed.The incision is then closed in layers.

Example 1: A 50-year-old female presents with acute cholecystitis and is scheduled for a laparoscopic cholecystectomy with common bile duct exploration. Intraoperatively, the surgeon finds no stones, but proceeds with exploration to ensure patency of the common bile duct., A 65-year-old male with a history of gallstones undergoes an open cholecystectomy. During the procedure, multiple stones are found in the common bile duct, which are removed using a basket., A 40-year-old female with recurrent biliary colic undergoes a laparoscopic cholecystectomy. The surgeon performs a common bile duct exploration to rule out any underlying causes for the symptoms.A small stone is removed.

Preoperative diagnosis, operative report detailing the procedure (including exploration of the common bile duct and any findings such as stones or other obstructions), pathology report if applicable (stones removed), any postoperative complications, and follow-up care notes.

** This code is used for open or laparoscopic cholecystectomy with exploration of the common bile duct.The exploration may involve the use of instruments such as a cholangiogram (to visualize the bile duct) or a basket (to remove stones). This code does not include any additional procedures performed during or after the exploration, such as sphincterotomy.

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