Laparoscopic Cholecystectomy
47562
-
47563— With intraoperative cholangiogram -
47564— With common bile duct exploration
Symptomatic cholelithiasis / acute cholecystitis / biliary dyskinesia
Same
Laparoscopic cholecystectomy
[Attending name], MD/DO
[Resident/PA name]
General endotracheal
The patient is a [age]-year-old [male/female] with a history of [indication] presenting for elective laparoscopic cholecystectomy. The risks, benefits, and alternatives of the procedure were discussed with the patient, and informed consent was obtained.
The gallbladder was [distended/contracted/wall-thickened] with [clear/turbid/bilious] bile. [Pericholecystic inflammation was/was not] present. Critical view of safety was achieved, demonstrating two and only two structures entering the gallbladder. The common bile duct appeared [not dilated / dilated to ___ cm]. [Additional findings or none].
The patient was brought to the operating room and placed supine. General endotracheal anesthesia was induced without difficulty. A surgical timeout was performed confirming patient identity, procedure, operative site, allergies, and administration of prophylactic antibiotics.
The abdomen was prepped and draped in sterile fashion. A small infraumbilical incision was made and pneumoperitoneum was established with a Veress needle to 15 mmHg. A 12-mm umbilical trocar was placed under direct visualization. Three additional trocars were placed under laparoscopic guidance: a 5-mm epigastric port and two 5-mm right upper quadrant ports.
The patient was positioned in reverse Trendelenburg with left lateral tilt. The gallbladder fundus was retracted cephalad and the infundibulum laterally. The peritoneum overlying the hepatocystic triangle was incised anteriorly and posteriorly. Dissection proceeded until the critical view of safety was achieved, confirming two and only two structures entering the gallbladder.
The cystic duct and cystic artery were individually identified, clipped proximally (x2) and distally (x1), and divided. The gallbladder was dissected from the liver bed with electrocautery. Hemostasis was confirmed. The specimen was placed in an endoscopic retrieval bag and extracted via the umbilical port.
The operative field was irrigated and inspected. No bleeding or bile leak was identified. Trocar sites were inspected during desufflation. The umbilical fascia was closed with [0-Vicryl] figure-of-eight suture. Skin was closed with [4-0 Monocryl] subcuticular sutures. Sterile dressings were applied.
None
Gallbladder sent to pathology
Minimal (less than 20 mL)
None
The patient tolerated the procedure well and was taken to the post-anesthesia care unit in stable condition.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: ***
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Laparoscopic cholecystectomy
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General endotracheal
INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with a history of *** presenting for laparoscopic cholecystectomy. The risks, benefits, and alternatives of the procedure were discussed with the patient, and informed consent was obtained.
FINDINGS: The gallbladder was ***. *** pericholecystic inflammation. Critical view of safety was achieved, demonstrating two and only two structures entering the gallbladder.
DESCRIPTION OF PROCEDURE:
The patient was brought to the operating room and placed supine. General endotracheal anesthesia was induced without difficulty. A surgical timeout was performed confirming patient identity, operative procedure, operative site, allergies, and administration of prophylactic antibiotics per protocol.
The abdomen was prepped and draped in sterile fashion. A small infraumbilical incision was made and pneumoperitoneum was established with a Veress needle to 15 mmHg. A 12-mm umbilical trocar was placed under direct visualization. Three additional trocars were placed under laparoscopic guidance: a 5-mm epigastric port and two 5-mm right upper quadrant ports.
The patient was positioned in reverse Trendelenburg with left lateral tilt. The gallbladder fundus was retracted cephalad and the infundibulum laterally. The peritoneum overlying the hepatocystic triangle was incised anteriorly and posteriorly. Dissection proceeded until the critical view of safety was achieved, confirming two and only two structures entering the gallbladder.
The cystic duct and cystic artery were individually identified, clipped proximally (x2) and distally (x1), and divided. The gallbladder was dissected from the liver bed with electrocautery. Hemostasis was confirmed. The specimen was placed in an endoscopic retrieval bag and extracted via the umbilical port.
The operative field was irrigated and inspected. No bleeding or bile leak was identified. Trocar sites were inspected during desufflation. The umbilical fascia was closed with *** figure-of-eight suture. Skin was closed with *** subcuticular sutures. Sterile dressings were applied.
ESTIMATED BLOOD LOSS: ***
SPECIMENS: Gallbladder to pathology
COMPLICATIONS: None
DRAINS: None
DISPOSITION: The patient tolerated the procedure well and was taken to the post-anesthesia care unit in stable condition.
Signed: .ME, .MYDEGREE — .TODAYVariants
Converted to Open
After initial laparoscopic exploration, the procedure was converted to an open cholecystectomy due to [dense adhesions/unclear anatomy/bleeding]. A right subcostal (Kocher) incision was made and extended as needed for adequate exposure. The critical view of safety could not be safely achieved laparoscopically. The remainder of the procedure was completed in open fashion. Fascia was closed with running [0-PDS] suture.
With Intraoperative Cholangiogram
After proximal clipping of the cystic duct, a small cholecystotomy was made and a cholangiogram catheter was inserted and secured. Fluoroscopic imaging demonstrated [normal biliary anatomy with free flow of contrast into the duodenum and no filling defects / filling defect at the level of the common bile duct / CBD dilation to ___ cm]. The catheter was removed, the cystic duct was clipped distally and divided.
Acute Cholecystitis / Gangrenous Gallbladder
The gallbladder was acutely inflamed with [gangrenous changes/purulent pericholecystic fluid/omental adhesions]. Dense adhesions required careful dissection of the hepatocystic triangle. [A partial cholecystectomy was/was not] performed, leaving the [posterior wall/infundibulum] in place given concerns for [CBD injury/bleeding]. The cystic duct stump was [clipped/ligated/oversewn].
Charting Tips
- Critical view of safety must be documented explicitly — write that CVS was achieved with two and only two structures entering the gallbladder. This is the single most important medicolegal element of this note.
- If cholangiogram performed, document the specific result: confirm flow to duodenum, CBD diameter, and absence of filling defects. 'Cholangiogram performed' alone is insufficient.
- If converted to open, document the specific reason clearly — 'unclear anatomy' or 'inability to safely achieve CVS' is legally safer and clinically more precise than 'bleeding' without further context.
Billing Tips
- Bill 47562 for standard laparoscopic cholecystectomy (10.21 wRVU, 90-day global). Use this code when the gallbladder is removed laparoscopically without cholangiogram or CBD exploration.
- Upgrade to 47563 (11.18 wRVU) when intraoperative cholangiogram is performed. Document contrast flow to the duodenum, CBD diameter, and absence of filling defects — 'cholangiogram performed' alone is insufficient for billing support.
- Upgrade to 47564 (17.55 wRVU) when common bile duct exploration is performed. Document the indication (stone, dilation, IOC finding), technique (transcystic vs choledochotomy), and findings.
- 90-day global period: all routine postoperative visits within 90 days are bundled into the surgical fee. Do not bill a separate E/M for routine follow-up unless an unrelated new problem is addressed.
- If converted to open, bill the open cholecystectomy code (47600 or 47605) rather than 47562 — the laparoscopic attempt does not add a separate billable code.