Common Bile Duct Exploration

CPT 47420 · 21.48 wRVU · 90-day global
CPT47420
wRVU21.48
Global90-day
ApproachOpen
ComplexityComplex
Add-on / Variant CPTs
  • 47425 wRVU: 21.75 — Choledochotomy with T-tube drainage and exploration
  • 47600 wRVU: 17.04 — Open cholecystectomy (if concurrent)
  • 74300 wRVU: 0.0 — Intraoperative cholangiogram
Preoperative Diagnosis:

Choledocholithiasis: [failed ERCP / intraoperative IOC showing retained CBD stone / bile duct obstruction]

Postoperative Diagnosis:

Same

Procedure Performed:

Open common bile duct exploration, choledochoscopy, stone extraction, and T-tube placement

Attending Surgeon:

[Attending name], MD

First Assistant:

[Resident name]

Anesthesia:

General endotracheal

Indications:

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.

Findings:

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].

Description of Procedure:

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.

Complications:

None

Specimens:

[Bile / stone(s) sent for culture and composition analysis]

Estimated Blood Loss:

Minimal

Drains:

[T-tube to gravity drainage / Jackson-Pratt drain near CBD closure]

Disposition:

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
.TODAY
Variants

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 IOC and 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 (>8 mm is dilated; exploration is justified)
  • 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 choledochotomy or choledochostomy with or without exploration, drainage by T-tube, or choledochoscopy (14.97 wRVU, 90-day global). Bill 47425 for choledochotomy or choledochostomy, with T-tube drainage and exploration (17.53 wRVU) when a T-tube is placed. Use the higher code when T-tube is placed.
  • Concurrent cholecystectomy at the same session: bill 47600 (open cholecystectomy, 14.00 wRVU) or 47562 (laparoscopic) separately. CBD exploration and cholecystectomy are not bundled. Document both procedures.
  • 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.

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