Single‑incision laparoscopic cholecystectomy

Clinical classification codes

Coding recommendations

Single port incision surgery for laparoscopic cholecystectomy is coded in the same way as multiple port incision laparoscopic cholecystectomy.

A code from category J18.- Excision of gall bladder below plus Y75.2 Laparoscopic approach to abdominal cavity NEC is assigned as appropriate:

J18.1 Total cholecystectomy and excision of surrounding tissue

J18.2 Total cholecystectomy and exploration of common bile duct

Includes: Cholecystectomy and exploration of common bile duct NEC

J18.3 Total cholecystectomy NEC

Includes: Cholecystectomy NEC

J18.4 Partial cholecystectomy and exploration of common bile duct

J18.5 Partial cholecystectomy NEC

J18.8 Other specified excision of gall bladder

J18.9 Unspecified excision of gall bladder

For example the OPCS-4 codes for single port incision surgery for laparoscopic cholecystectomy that is not further specified are:

J18.3 Total cholecystectomy NEC

Includes: Cholecystectomy NEC

Y75.2 Laparoscopic approach to abdominal cavity NEC

If both a laparoscopic cholecystectomy and an operative cholangiography are performed at the same time, then both procedures need to be coded. The OPCS-4 codes assigned are:

J18.- Excision of gall bladder

A fourth character is assigned as appropriate

Y75.2 Laparoscopic approach to abdominal cavity NEC

J37.2 Operative cholangiography through cystic duct.