Common Bile Duct Exploration
4742047425wRVU: 21.75 — Choledochotomy with transduodenal sphincterotomy or sphincteroplasty (alternative primary code; 21.75 wRVU)47550wRVU: 2.94 — Biliary endoscopy, intraoperative (choledochoscopy add-on; 2.94 wRVU)47600wRVU: 17.04 — Open cholecystectomy, concurrent (17.04 wRVU)74300wRVU: 0.0 — Intraoperative cholangiogram (radiology code, billed separately)
Choledocholithiasis: [failed ERCP / intraoperative IOC showing retained CBD stone / bile duct obstruction]
Same
Open common bile duct exploration, choledochoscopy, stone extraction, and T-tube placement
[Attending name], MD
[Resident name]
General endotracheal
Patient presents with choledocholithiasis: [failed ERCP / stone identified on IOC during cholecystectomy / preoperative MRCP showing [X] mm stone in CBD]. [Jaundice / cholangitis / pancreatitis present.] [ERCP unavailable / failed; stone [X] mm not extractable endoscopically.] Open CBD exploration planned. Risks including bile leak, T-tube complications, cholangitis, and need for future ERCP discussed. Consent obtained.
CBD [dilated to [X] mm / normal caliber]. [Intraoperative cholangiogram demonstrated [X] filling defect(s) in the [mid / distal] CBD.] [X] stone(s) retrieved via [Fogarty catheter / stone forceps / choledochoscope]. Completion cholangiogram / choledochoscopy confirmed duct clearance: [no filling defects / duct clear to duodenum]. Sphincter of Oddi [patent; contrast passed freely into duodenum].
The patient was positioned supine. A [right subcostal / midline] incision was made. The hepatoduodenal ligament was exposed. The common bile duct was identified and [confirmed by intraoperative cholangiogram / palpation of stones / aspiration of bile].
A longitudinal choledochotomy was made on the anterior wall of the CBD with a [15-blade] scalpel, [1.5 cm] in length, between stay sutures of [4-0 Vicryl]. Bile was evacuated. The duct was explored proximally and distally with [Fogarty biliary balloon catheter / stone forceps / Randall stone forceps]. [X] stones were extracted: [largest stone [X] mm]. [A flexible choledochoscope was passed proximally and distally; [no residual filling defects / residual stone removed under direct vision].]
A completion cholangiogram confirmed [duct clearance with free flow of contrast into the duodenum / no residual filling defects].
A [14-Fr / 16-Fr] T-tube was trimmed and placed into the CBD with the horizontal limb directed proximally and distally. The choledochotomy was closed around the T-tube with interrupted [4-0 Vicryl / 4-0 PDS] sutures. The T-tube was brought out through a separate right flank stab incision and secured. T-tube flushed; no bile leak at the closure.
Hemostasis confirmed. A [Jackson-Pratt drain] was placed near the choledochotomy. Fascia closed. Skin closed. Patient tolerated the procedure well.
None
[Bile / stone(s) sent for culture and composition analysis]
Minimal
[T-tube to gravity drainage / Jackson-Pratt drain near CBD closure]
Patient to PACU / floor in stable condition. T-tube to gravity. T-tube cholangiogram planned at 4-6 weeks.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: Choledocholithiasis: [failed ERCP / IOC finding / preoperative MRCP]
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Open common bile duct exploration, choledochoscopy, stone extraction, and T-tube placement
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General endotracheal
INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with choledocholithiasis [failed ERCP / IOC showing *** mm CBD stone]. Risks including bile leak and T-tube complications discussed. Informed consent obtained.
FINDINGS: CBD dilated to *** mm. IOC: *** filling defect(s) in [mid / distal] CBD. *** stone(s) retrieved. Completion cholangiogram/choledochoscopy: duct clear. Sphincter patent; contrast to duodenum.
DESCRIPTION OF PROCEDURE:
Patient supine. [Right subcostal / midline] incision. CBD identified; confirmed by [IOC / palpation / aspiration]. Longitudinal choledochotomy *** cm between stay sutures. Bile evacuated. Duct explored with Fogarty catheter; *** stones extracted. [Choledochoscope passed proximally and distally; duct clear.] Completion cholangiogram confirmed clearance. [14-Fr / 16-Fr] T-tube trimmed and placed; choledochotomy closed with interrupted 4-0 Vicryl; T-tube brought out through right flank stab; flushed; no leak. JP drain placed near closure. Fascia and skin closed. Patient tolerated procedure well.
ESTIMATED BLOOD LOSS: Minimal
SPECIMENS: Bile and stones for culture and composition
COMPLICATIONS: None
DRAINS: T-tube to gravity; JP drain near CBD
DISPOSITION: Patient to [PACU / floor]. T-tube cholangiogram at 4-6 weeks.
Signed: .ME, .MYDEGREE
.TODAYVariants
Laparoscopic CBD exploration
Transcystic or choledochotomy approach under laparoscopic visualization. Fluoroscopic stone extraction with Dormia basket or balloon. Primary closure of CBD vs. T-tube. Requires laparoscopic skills and flexible choledochoscope. Bill 47564 (laparoscopic cholecystectomy with CBD exploration, 17.55 wRVU). 47563 = laparoscopic cholecystectomy with IOC only; 47564 = laparoscopic cholecystectomy with CBD exploration.
Primary CBD closure (no T-tube)
When duct is clearly cleared and sphincter is patent, some surgeons close the choledochotomy primarily over a biliary stent or with direct closure. Documents as 47420; document rationale for omitting T-tube and confirmation of complete stone clearance.
Charting Tips
- Document CBD diameter. A CBD ≥6 mm is generally considered dilated; CBD <7 mm is a relative contraindication to choledochotomy (SAGES guideline) due to stricture risk from closure. Document the measured diameter and the clinical indication supporting exploration (stone confirmed on IOC, cholangiogram filling defect, or palpable stone).
- State number and size of stones retrieved
- Confirm clearance with a completion cholangiogram or choledochoscopy before closing
- Document T-tube size, limb positions, and that it was flushed without leak
- Drain placement near the CBD closure is standard and documents bile leak monitoring
- T-tube cholangiogram at 4-6 weeks plan should be in the operative note
Billing Tips
- Bill 47420 for open choledochotomy with exploration, drainage, or stone removal (21.48 wRVU, 90-day global). Bill 47425 for the same with concurrent transduodenal sphincterotomy or sphincteroplasty (21.75 wRVU). Code selection is based on whether transduodenal sphincterotomy is performed, not on T-tube placement. T-tube drainage is included in 47420.
- Concurrent cholecystectomy: when open cholecystectomy and open CBD exploration are performed together, use 47610 (open cholecystectomy with choledochotomy, 20.40 wRVU) as the single combined code. Do not bill 47600 + 47420 separately, as 47610 bundles both components. For laparoscopic cholecystectomy with IOC only, use 47563 (11.18 wRVU); for laparoscopic cholecystectomy with CBD exploration (transcystic or choledochotomy), use 47564 (17.55 wRVU).
- Intraoperative cholangiogram (IOC): bill 74300 separately when an intraoperative cholangiogram is performed and interpreted. The cholangiogram guides the decision for CBD exploration and should be documented with findings.
- Choledochoscopy (flexible scope passed through the choledochotomy) is included in 47420-47425 when performed by the same surgeon through the same incision. Document choledochoscope use and findings.
- 90-day global: T-tube cholangiogram at 4-6 weeks and T-tube removal are bundled in the surgical fee. Delayed ERCP for retained stone after T-tube removal is a separate endoscopic procedure. Document T-tube size, position, and output at the end of the case.
General coding reference. Verify with your institution’s billing department before submitting claims.